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Section
of Neuroradiology
University of Rochester Medical Center
Sample Dictations for Residents
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| Sample CT
dictations for incoming residents |
Head CT scan without contrast
Clinical Information: Mrs. Baker is 63 years old and presents with new onset left-sided weakness. The onset was sudden and there is a clinical suspicion for an infarct. CT scan was requested to evaluate for a new right sided infarct (50).
Procedure (CT1): Axial CT scans were obtained from base to vertex without intravenous contrast. No prior studies are available for comparison at the time of this dictation.
Findings:There is an ill-defined area of low attenuation in the posterior limb of the right internal capsule.
The cortical sulci ventricles and cisterns are slightly prominent. There is not mid-line shift, abnormal intra- or extra-axial fluid collection and the brain parenchyma demonstrates no other areas of abnormal density.
The visualized portions of the paranasal sinus, orbits, and mastoids are normal.
Impression: Acute infarct in the posterior limb of the right internal capsule.
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CT
scan of Paranasal Sinuses
Clinical Information: Mr. Baker is 43 year old with a long history of nasal congestion, facial pain and failure to improve on antibiotic treatment. CT of the paranasal sinuses was requested to evaluate for acute/chronic sinusitis (20).
Procedure: Coronal thin sectioned CT scans were obtained through the paranasal sinuses without intravenous contrast. There are no prior cross-sectional image studies available for comparison at the time of this dictation.
Findings: The frontal sinuses are clear. The ethmoid sinuses show mucosal thickening on both left and right sides. The maxillary sinus shows mucosal thickening on both sides with an air fluid level on the right side. The osteomeatal complex on the right side is narrowed secondary to a Haller cell and the mucosal thickening. The osteomeatal complex on the left side is narrowed but patent. The sphenoid sinus shows a minimal air fluid level.
The nasal septum is deviated to the right with a nasal septum spur.
Impression: Acute and chronic sinusitis involving all paranasal sinuses.
Blockage of the right osteomeatal complex.
Narrowing of the left osteomeatal complex. |
CT
scan of Cervical Spine
Clinical Information: Mr. Jones is 43 years
old and presents to the Emergency Department after a car
accident
with injury to the head, neck and face. Plain films
were obtained but were not conclusive as to whether he has
a fracture of the cervical spine. Therefore, CT scan of the
cervical spine with 2D/3D reconstructions was requested (14).
Cervical spine CT Procedure (Spine 78): Contiguous axial tomographic
sections were obtained through the cervical spine without intravenous contrast.
2D Reconstruction: Sagittal and coronal 2D reconstructions
were performed to evaluate vertebral height and alignment, neural foramina,
and intervertebral disk spaces.
Findings: The alignment, vertebral body and disk
space height are normal. There are no subluxations.
Axial images through the spine demonstrate a fracture of a
small osteophyte anteriorly inferiorly at C6. This does not involve the spinal
canal or the neural foramina.
The soft tissues in front of the upper cervical spine are normal.
Impression: Minimal fracture of osteophyte anterior to C6. |
CT
scan of Lumbar Spine
Clinical Information: Mr. Garret is 46
years old
and presents after a car accident with injury to the lower
back. There is a clinical suspicion of a fracture
of
the lumbar spine since he has pain and neurologic symptoms (30).
Lumbar Spine CT Procedure (Spine 74): Contiguous axial tomographic sections were
obtained through the lumbar spine without intravenous contrast.
2D Reconstruction: Sagittal and coronal 2D reconstructions were performed to
evaluate vertebral height and alignment, neural foramina, and intervertebral
disk spaces.
Findings: The alignment is normal. The vertebral body and disk space height are
normal. There is a fracture of anterior lower endplate of L1 without significant
reduction in height. The posterior elements and the posterior wall of the vertebral
body is intact.
The soft tissues surrounding the lumbosacral spine are normal.
Impression: L1 inferior endplate fracture. |
CT
of the Maxillofacial and Neck
Clinical Information: Mr. Derow is 78 years
old with
a history of nasopharyngeal carcinoma. He is post-surgery
and radiation
treatment and now presents for follow-up examination.
Maxillofacial CT Procedure: Maxillofacial
CT scan: Axial thin-section
CT scans were obtained through the maxillofacial region after
intravenous administration of contrast. There were no immediate
adverse reactions. The amount of contrast used can be found in
the IDX system.
Findings Maxillofacial CT scan: The visualized
portions of the brain, orbits and sinuses are normal. The soft
tissue in the
posterior nasopharynx is symmetric with no mass lesions. This
is unchanged compared to the prior study. There is no lymphadenopathy
at the skull base or around the nasal oropharynx.
Neck CT Procedure: Axial thin-section CT scans
were obtained through the neck after the administration of intravenous
contrast.
The amount of contrast can be found in the IDX system. There
were no immediate adverse reactions.
Findings Neck CT: The hypopharynx, larynx and
subglottic airway are normal. There are small lymph nodes in
the posterior triangle
(level 5) on the right side. These measures less than 1 cm and
are normal by radiographic criteria. The thyroid is normal and
the subglottic structures are normal. There is minimal atherosclerotic
calcification near the left carotid bifurcation but the vessels
are otherwise unremarkable. There is no evidence of recurrent
tumor.
Impression: CT scans of maxillofacial and neck
demonstrate no evidence of residual or recurrent tumor. |
Maxillofacial and Orbital CT Scan
Clinical Information: Mr. Chevy is 99 years old and was involved in a high-speed motor vehicle accident. Mr. Chevy was on his motorcycle when he was hit by a sports car earlier this afternoon. Mr. Chevy sustained injury to the face and orbit and CT scan has been requested to evaluate for traumatic injury to face and orbit.
Orbit CT Scan Procedure: Axial contiguous tomographic sections were obtained through the orbits without intravenous contrast.
Findings Orbital CT Scan: There is a fracture of the floor of the orbit on the left side with herniation of the orbital fat into the maxillary sinus. The inferior rectus muscle is also displaced into the fracture line. There is a second fracture of the medial wall on the left orbit (lamina papyracea) with minimal displacement into the orbital structures into the ethmoid sinus. The intracranial structures, the optic nerve, the remainder of the extraocular eye muscles (otherwise) as well as the globe are normal.
On the right side, there is a periorbital soft tissues swelling but no evidence of acute fractures.
Maxillofacial CT Scan Procedure: Axial contiguous tomographic sections were obtained through the maxillofacial structures without intravenous contrast.
Maxillofacial CT Findings: There is a left nasal bone fracture with a few millimeter displacement. In addition the interior nasal spine is fracture with posterior and inferior displacement. The mandible and maxilla are unremarkable. There is fluid in the left maxillary sinus and mucosal thickening in the right maxillary sinus. The frontal sinus is clear but there is mucosal thickening in the ethmoid sinuses.
Impression: CT scan of the orbit and maxillofacial regions shows a left blow-out fracture involving the floor and medial wall of the left orbit. There are fractures of the left nasal bone and anterior nasal spine.
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Head and Neck CT Scan with Head and Neck Angiography
Clinical Information:
Mr. Baker is a 75-year-old man presenting with new onset of left-sided weakness. The onset was sudden and there is a clinical suspicion for an acute infarct. CT scan of the head was requested to evaluate for this clinically suspected infarct, CT Angiography of the head was requested to evaluate for stenosis or occlusion of the intracranial vessels. CT Angiography of the neck was requested to evaluate for stenosis of the extra-cranial vessels.
Head CT Scan Procedure:
Axial CT scans were obtained through the base of the vertex without intravenous contrast. No prior studies are available for comparison at the time of this dictation.
Head and Neck Angiography Procedure: Following an injection of a standard dose of contrast material, axial thin-sections CT scans were obtained first through the neck and then through the head.
Head CT Scan Post-Contrast:
Axial CT scans were obtained through the brain after contrast material had been injected.
3D Reconstructions:
3 dimensional reconstructions of the axial images were obtained from the original source images. The 3 dimensional images were medically necessary in order to visualize the vascular structure of both the head and the neck.
Head CT Scan With and Without Contrast Findings:
There is an ill-defined area of lower attenuation in the right frontal lobe with loss of gray-white matter differentiation and some swelling.
The remainder of cortical sulci ventricles and cisterns are normal. The mid-line shift is not displaced and there is no other area of abnormal density within the brain parenchyma. The visualized portions of the paranasal sinus, orbits, and mastoids are normal and the boney structures visualized in the head CT scan are normal.
Head CT Angiography Findings:
There is stenosis of the right middle cerebral artery just before the first trifocation (N1). The rest of the vascular structures are the intracranial vessel are normal. gPullmans perfusionh was performed and this shows decreased perfusion in the right middle cerebral artery territory corresponding to the area of lower attenuation seen on the non-contrast head CT scan.
Head W/Contrast CT Scan Findings:
There are no areas of abnormal enhancement. Brain parenchyma shows normal enhancement patterns.
Neck CT Scan Findings:
The cervical vessels including the common carotid artery bilaterally, the vertebral artery bilaterally, and the internal carotid artery bilaterally appears unremarkable. There is no stenosis or narrowing. The carotid specifically the carotid bifocation bilaterally appears normal.
Impression:
Acute right middle cerebral artery infarct with an associate middle cerebral artery stenosis.
No other acute abnormality in the brain.
CT Angiography of the neck is unremarkable.
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| Sample MR
dictations for incoming residents |
MR
Angiography of the Head
Clinical Information: Mr. John Johnson
is 92 years old
and presents with weakness of his right
arm. There was sudden onset of arm weakness this morning
which has not resolved. CT scan showed a small area of
acute infarction and this MR angiogram was performed
to evaluate for stenosis of the intracranial cerebral
vessels (66).
Procedure (MR 253): A coronal 2D face contrast angiographic
pulse sequence centered at the skull base was performed as well as axial
3D time of flight SPGR multi-slab angiographic sequence through the vessels
about the Circle of Willis.
Findings: There is a focal narrowing of the M2 segment of
the left middle cerebral artery. The right A1 segment is hypoplastic. The
remainder of the anterior circulation is unremarkable.
The basilar artery shows irregularities throughout. The posterior
cerebral arteries are patent bilaterally. There is fetal origin of the left posterior
communicating artery.
Impression: Focal stenosis of the left M2. |
MR
Angiograhy of the Carotid Arteries with and without contrast
Clinical Information: Mrs. Brown is 45 years
old with a recent episode of facial numbness and left leg
weakness.
She had a CT scan and an MR scan which were both
negative but there remains a question whether there is stenosis
of the carotid artery that could account for her recent episode.
MR angiography of the neck vessel was requested to evaluate
for carotid artery stenosis.
Procedure (MR 251): Axial 2D time of flight, and coronal and
sagittal 2D face contrast angiographic pulse sequences were obtained through
the neck. Additionally, an axial T1 weighted fat suppressed pulse sequence was
obtained through the neck. Moreover, a coronal 3D time of flight SPGR (elliptic)
multi-slab angiographic sequence was obtained of the neck vessels during infusion
of a Gadolinium-based contrast agent. The exact amount of contrast agent can
be retrieved from the IDX system.
Findings: There is a focal stenosis of the origin of the left
internal carotid artery. This amounts to approximately 50% stenosis. The remainder
of the left carotid circulation is unremarkable.
On the right side there is a 20% stenosis of the origin of
the right internal carotid artery. The vertebral and basilar arteries are unremarkable.
Impression: 50% stenosis of the origin of the left internal
carotid artery and 20% stenosis of the origin of the right internal carotid artery. |
MR Imaging of the Brain without and with Contrast
Clinical Information: Mrs. Bevelt is 83 years old and presents with weakness of her right arm and headache (14).
Procedure (MR 202): Sagittal T1]weighted, axial T1, diffusion, T2]weighted, and FLAIR images were obtained through the brain. After intravenous administration of a standard dose of Gadolinium based contrast agent, coronal T1]weighted 3D SPGR and axial T1]weighted spin echo images were obtained. The exact amount of contrast agent given can be retrieved from the IDX system.
Findings: The cortical sulci and ventricle systems are prominent.
There is a wedged shaped area of increase T2 and FLAIR signal on the left side corresponding to a vascular territory of one of the major branches (specify if you can) of the right middle cerebral artery. The area has increased diffusion signal with low signal the ADC (apparent diffusion coefficient) map. The abnormal area involves both the cortex and the white matter. The wedge-shaped area has minimal mass effect. On T1 weighted images the abnormal area shows decreased signal and on post-contrast enhanced images there is no abnormal contrast enhancement.
The pituitary gland, corpus callosum and cerebellar tonsils are normal. There is normal flow void in the major arteries of the circle of Willis. There is no midline shift and no abnormal intra- or extra-axial fluid collections. The brain parenchyma shows no other areas of abnormal signal intensity.
Impression: Left middle cerebral artery acute infarction.
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MR
Imaging of the Lumbar Spine
Clinical Information: Mr. Whitney is 46
years old
with right L5 radiculopathy. MRI was requested to evaluate
for disk herniation or neural foramina stenosis
(14).
Procedure (MR 321): Sagittal T1 and T2-weighted images were obtained through
the lumbosacral spine as well as axial proton density and T2-weighted images.
No prior studies are available for comparison.
Findings: The vertebral body and disk heights are normal. The alignment of the
lumbar sacral spine is normal.
T12/L1: No stenosis of the neural foramina or central canal.
L1/L2: Minimal narrowing of the right neural foramina secondary to facet hypertrophy.
The left neural foramina and central canal are normal.
L2/L3: No narrowing of the central canal or neural foramina.
L3/L4: Moderate narrowing of the right neural foramina secondary to facet hypertrophy
and a diffuse disk bulge. The central canal is mildly narrowed secondary thickening
of the ligamenta flavum and a diffuse disk bulge. The left neural foramen is
patent.
L4/L4: Mild narrowing of the right neural foramina secondary to facet hypertrophy
and a diffuse disk bulge. The central canal is mildly narrowed narrow secondary
thickening of the ligamenta flavum and a diffuse disk bulge. The left neural
foramen is patent.
L5/S1: Significant narrowing of the right neural foramen secondary to marked
facet hypertrophy and a right paracentral disk herniation. The central canal
is within normal limits and the left neural foramen is normal.
Impression:
L5/S1: Significant narrowing of the right neural foramen secondary to marked
facet hypertrophy and a right paracentral disk herniation. |
MR
Imaging of the Cervical Spine without contrast
Clinical Information: Mrs. Aura is 55 years old
and presents with neck pain and neurologic symptoms indicating
a left C6 radiculopathy. MRI was requested to
evaluate for an anatomic explanation for her signs and symptoms (14).
Procedure (MR 301): Sagittal T1- and T2-weighted images were obtained through
the cervical spine, as well as axial proton density and T2-weighted images.
Findings: The alignment, vertebral body and disk space height are normal. There
is decreased signal from the C3/C4, C4/C5 disks indicating dissecation. The signal
intensity from the remainder of the disks and vertebral bodies are normal.
C2/C3: No stenosis of the neural foramina or central canal.
C3/C4: Mild narrowing of the right neural foramina secondary to facet hypertrophy
and uncovertebral arthropathy. The central canal is normal and the left neural
foramen is normal.
C4/C5: No narrowing of the neural foramina or central canal.
C5/C6: Moderate to severe narrowing of the central canal secondary to a posterior
spondylotic ridge. There is moderate to severe narrowing of the right neural
foramina secondary to uncovertebral arthropathy and facet hypertrophy. The left
neural foramen is patent.
C7/T1: No narrowing of the central canal or neural foramina.
Impression:
C5/C6: Moderate to severe narrowing of the central canal and moderate to severe
narrowing of the right neural foramina secondary compressing the right C6 nerve. |
MR Imaging of the TMJ
Clinical Information: Mrs. Glad is 20 years
old with right TMJ pain and dysfunction. She had clicking in
the right TMJ until
recently when the clicking stopped and she got pain and limitation
on opening. MRI was requested to evaluate for internal derangement
of the right TMJ.
Procedure: Axial T2 localizer, proton-density oblique sagittal
and T2-weighted images were obtained at the closed-mouth position.
Proton density and T2-weighted oblique sagittal images were also
obtained at the open mouth position followed by closed-mouth
coronal proton-density and T2-weighted images. No intravenous
contrast was used.
Findings: Right TMJ: The condyle and temporal component are normal.
The disk is anteriorly displaced at the closed and open-mouth
position suggesting anterior disk displacement without reduction.
There is a small amount of joint effusion in the upper and lower
joint spaces. The disk is not significantly deformed but there
is a slight lateral component displacement. The bone marrow of
the condyle shows increased T2 signal suggestive of bone marrow
edema.
Left TMJ: The condyle and temporal components are normal. The
disk is anteriorly displaced at the closed-mouth position but
reduces to normal on opening. The disk is not deformed and there
is no abnormal joint effusion. The bone marrow of the condyle
is normal.
Impression: Right TMJ: Anterior disk displacement without reduction.
Left TMJ: Anterior disk displacement with reduction. |
MRI of Lumbosacral Spine with and without Contrast
Clinical Information: Mr. Nickels is 74 years old with a lower back pain and left L-4 radiculoapathy. MRI is requested to evaluate for spinal stenosis and/or disc herniation.
Procedure (MR324): Sagittal T1-, STIR- and T2-weighted images were obtained through the lumbosacral spine as well as axial T2-weighted images. After I.V. administration of a standard dose of Gadolinium based contrast agent fat saturated axial, sagittal, and coronal T1-weighted images were obtained.
Findings: The alignment of the vertebral bodies and disc space heights are preserved. The signal intensity from the discs and vertebral bodies is normal.
T12-L1 shows a minimal posterior spondylolytic ridge but no narrowing of the central canal or neural foramina.
L1-L2 shows facet hypertrophy on the left side and causing mild stenosis of the left neural foramen. The central canal and right neural foramina are normal.
L3-L4 is normal.
L4-L5 shows marked right sided facet hypertrophy and it diffused disc bulge which is excentric to the right. This results in severe stenosis of the right neural foramen. The disc also extends towards the lateral recess causing stenosis of the right L4 lateral recess. The central canal and left neural foramen are normal.
L5-S1 is normal.
Impression:
L1-L2 Mild stenosis of left neural foramen.
L4-L5 Severe stenosis of right neural foramen and stenosis of right lateral recess.
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Thyroid Nodule Comment
Multiple and/or solitary thyroid nodules are seen on routine CT and MRI examinations done for purposes other than evaluating the thyroid gland in about 15 to 60% of this otherwise unselected population. This incidence tends to increase with age. In general such incidental thyroid nodules should be evaluated and followed. The risk of malignancy is very low. It is not, according to recent reports, affected in a predictable way by size of individual nodules or the number of nodules. The risk of malignancy in an individual nodule tends to be higher the younger the patient. The need for further work-up and follow-up is controversial (Raymond AJNR 2006; 27: 1163-1164) but a baseline ultrasound is often suggested to evaluate these incidental nodules. The need for evaluation beyond ultrasound for additional follow-up should be carried out based on the ultrasound characteristics of the nodule(s), the clinical situation, and the desires of the patient. (Mancuso A: AJNR 2005; 26: 2445)
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