Radiological Report

Patient Name / Age : Mr. Michael Lesser, 36 y/o.

No. Medical Record : 56-98-00/MC
No. Radiology : MR/NC/09/06/011
Referring Doctor : Dr. Ruby, Neurologist
Date : 01 June 2009
Examination : MRI + MRA of the head
Clinical Diagnosis : Neuropatic pain DD/ occlusive disease

Dear Dr. Ruby,

MRI and MRA of the head without application of contrast agent was performed using
head coil, DWI, Flair and FSE sequences and PCA-3D technique for MRA, T1-, proton
density and T2-weighted images, axial section with following results :
No deviation of the midline structures. Cortical sulci and ventricle system of bilateral cerebral
hemispheres show no dilatation or narrowing and appear symmetrical bilaterally, particularly
no signs of displacement or increased intracranial pressure are noted.. Supratentorial cerebral
structures show normal brain tissue with well differentiation of the anatomical structures and
normal intensity of the brain tissue, especially no tumor mass, vascular malformation or other
pathological intensities in bilateral cerebral hemispheres and basal gangliae, but small focal
chronic hemorrhage is noticed in the left cerebral peduncle with diameter of + 3 mm showing
relatively sharp border and slight perifocal gliosis. Sella, parasellar region and orbitae on both
sides without any abnormalities, particularly no tumor mass is seen. Infratentorially the
cerebellum and the brain stem show normal appearance, particularly no tumor formation or
ischemia lesion are evident .
On the MRA no pathological finding is seen on vascular structures of the circle of Willis,
including bilateral internal carotid arteries, anterior and medial cerebral arteries and also
bilateral anterior and posterior communicating arteries. In the vertebrobasilar basilar system,
basilar artery, bilateral vertebral and posterior cerebral arteries show no further abnormalities.
In the paranasal sinus no signs of sinusitis are noted.

Impression : - MRA shows no abnormalities on vascular structures of circle of Willis and

vertebro-basilar system, particularly no significant vascular stenosis,
aneurysm or other vascular malformation / anomaly are seen, while
supratentorial cerebral structure show small focal chronic hemorrhage is
noticed in the left cerebral peduncle with diameter of + 3 mm showing
relatively sharp border and slight perifocal gliosis ( e.c. cavernoma ? ). No
further pathology is noted on the other cerebral / intracranial structures,
particularly no tumor mass, hydrocephalus or acute ischemic lesion either in
the supra- or in the infra-tentorial compartment.
No signs of paranasal sinusitis or mastoiditis are seen bilaterally.

Thank you for referring this patient.

Dr.med. Luqman Adji Saptogino

Consultant Radiologist and Nuclear Medicine Physician