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in Encephalomalacia by
My ENT sent me for MRI due to multiple falls without explanation as to why.

"MRI BRAIN WO W CONTRAST - Details  About This Test Study Result Impression
1. No abnormality at the level of the internal auditory canals.
2. Focal encephalomalacia in the right basal ganglia and corona radiata related to a chronic [more than 6 weeks after incident] infarct or chronic hemorrhage. This is new compared to 11/25/2013.
3. Tiny sclerotic focus in the left basal ganglia, likely related to a tiny chronic lacunar infarct [A separate class of infarcts related to hypertension are found in the basal ganglia and pons. These infarcts are termed “lacunar infarcts” and by definition are less than 1.5 cm in diameter. These infarcts are typically multiple and represent small areas of infarction. Lacunar infarcts are frequently hemorrhagic]. [See Brain Ischemic Disease doc in docs to go - An ischemic stroke happens when a blood vessel (artery) supplying blood to an area of the brainbecomes blocked by a blood clot. About 80 out of 100 strokes are ischemic strokes.]
4. No acute intracranial abnormality.

West Reading Radiology Associates

Dictation By:
Gregory Chandler, MD
This report has been electronically signed by:
Gregory Chandler, MD
12/14/2015 2:13 PM Narrative Clinical history:
Hearing loss, conductive [H90.2 (ICD-10-CM)]
Sensory hearing loss, bilateral [H90.3 (ICD-10-CM)]
Vertigo [R42 (ICD-10-CM)]

Comparison: CT head 11/25/2013.

Technique: Multisequence, multiplanar MR images of the brain were acquired before and after administration of intravenous contrast. Thin slice axial T2 images through the internal auditory canals are provided for detailed characterization.


Brain: Focal T2/FLAIR hyperintense lesion in the right corona radiata causing negative mass effect upon the right lateral ventricle consistent with encephalomalacia. The lesion extends into the right basal ganglia. No evidence of contrast enhancement or diffusion restriction to suggest an acute process. The lesion measures approximately 7 x 11 mm and is slitlike in configuration. This likely represents a chronic focal infarct or resorbed chronic focal parenchymal hemorrhage [A hemorrhagic stroke happens when an artery in the brain leaks or bursts (ruptures)]. No definite communication with the right lateral ventricle to suggest porencephalic change. There is an additional tiny T2 hyperintensity within the left basal ganglia which may represent a focal chronic infarct. (Image 19 series 4).

No evidence of an extra-axial fluid collection or evidence of an acute intracranial hemorrhage. No additional FLAIR/T2 abnormalities elsewhere. No evidence of abnormal intracranial enhancement.

The ventricles are normal in size. Focal ex vacuo dilatation of the right lateral ventricle is new since 11/25/13 and is related to the area of focal encephalomalacia described above. No evidence of midline shift. The basal cisterns are patent. Vascular flow voids are present.

The calvarium is within normal limits in signal. The intraorbital contents are unremarkable. There is mucosal thickening involving the right maxillary sinus with right maxillary sinus volume loss compared to the left. This likely represents chronic maxillary sinusitis. Mastoid air cells are clear.

IAC: At the level of the internal auditory canals, there is normal course and contour of the cranial nerve VII and VIII complexes bilaterally. Incidental note of a tortuous vessel at the level of the right porus acoustics, a normal variation. No abnormal cranial nerve enhancement is seen.

The intracranial trigeminal nerve roots are within normal limits. Meckel's cave within normal limits. The visualized inner ear structures are intact bilaterally. Component Results There is no component information for this result. General Information Collected: 12/14/2015 1:49 PM" [email protected] Thank you.

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