Exam(s) CT STROKE PROTOCOL
Exam Status: Final
The imaging provider, XW, MD, reviewed your images and created this report to communicate with your care team. Your care team may not have yet reviewed this report but will discuss these results with you at your next visit, through telephone, or MyChart messaging. If you do not have a visit scheduled and wish to schedule one, please reach out to your practice through MyChart or by calling the practice directly.
CF STROKE PROTOCOL 8/21/2023 3:45 PM
INDICATION (as provided by referring clinician): Code Stroke
ADDITIONAL HISTORY: Patient presents with loss of balance at 12:00 AM today, fall with injuries to the ribs, falling towards the left per neurology. Describing feeling of balance difficulty and difficulty walking but no focal neurologic deficit, NIH stroke scale 0.
COMPARISON: 2/19/2014 CT brain 3/13/2015 PET/CT.
TECHNIQUE: Helical CT imaging of the brain without intravenous contrast. Perfusion was not performed. CTA imaging of the head and neck was performed. Coronal and sagittal reformatted images were obtained with multiplanar and MIP reconstructions.
MEDICATIONS: lohexol 350 - 70 mL -Intravenous
FINDINGS:
BRAIN:
No acute hemorrhage or large vascular territory hypodensity. No herniation. No hydrocephalus. No extra-axial collection.
VESSELS:
Intracranial vessels: No large vessel occlusions or high-grade stenoses within the anterior or posterior circulation. Diminutive right A1 ACA segment, likely developmental.
Cervical vessels: Bovine arch with mild tortuosity of the proximal left common carotid artery. No hemodynamically significant narrowing of either proximal ICA at the bifurcation. No other focal plaque or stenosis of the great vessel origins in the chest or neck.
OTHER FINDINGS:
Heart and lungs normal as visualized. Patulous partially fluid-filled esophagus. No suspicious lymphadenopathy in the neck. Multiple thyroid nodules measuring up to 1.1 cm do not meet size criteria for additional ultrasound follow-up.
Severe multilevel cervical spondylosis with mild retrolisthesis of C3 on C4. There is grade 1 anterolisthesis if C5 on C6 and grade 1/2 anterolisthesis of C7 on T1,
likely similar to 2015. Degenerative autofusion of the C6 and C7 vertebral bodies. Anterolisthesis, disc space uncovering, and degenerative disc/facet changes at C7-T1 are contributing to moderate to severe appearing stenosis of the bony spinal canal. Multilevel degenerative neural foraminal narrowing, severe at several levels, including on the left at C2-C3 and C3-D4, bilaterally at C4-C5 and C5-C6. No suspicious lytic or sclerotic lesions in the visualized spine.
Medialization of the right vocal cord with dilation of the ipsilateral pyriform sinus and the right laryngeal ventricle, nonspecific but can be seen within vocal cord paralyasis.
IMPRESSION:
1 No acute intracranial hemorrhage, hydrocephalus, or herniation.
2. No large vessel intracranial occlusion or significant arterial narrowing in the head or neck.
3. Multilevel cervical spondylosis, as described, with possibly severe narrowing of the bony spinal canal at C7-T1. The degree of bony canal stenosis is likely not significantly changed since 2015.
4.Findings possibly suggestive of right vocal cord paralysis, correlate with clinical symptoms.
//Noncontrast CT brain and CT angiography findings were discussed with Dr, G by BV, MD on 8/21/2023 at 1543 hours.
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