MRI Brain Report Sample:

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PATIENT NAME:  David Jones
ID NUMBER:   123456
REFERRING PHYSICIAN:   Harry Richard, M.D.
REFERRING PHYSICIAN’S FAX:  305-123-4567
DATE OF SERVICE: 01/01/11
D.O.B.:  

MRI OF THE BRAIN WITH AND WITHOUT CONTRAST:

TECHNIQUE:  MRI was performed of the brain prior to and following the administration of IV gadolinium utilizing standard protocol.  No prior study is available for comparison.

CLINICAL INFORMATION:   The basilar cisterns, ventricular system and cortical sulci appear unremarkable for a 67-year-old patient. The visualized mastoid air cells and paranasal sinuses appear clear. There are multiple small foci of increased signal on T2 weighted and FLAIR images in the subcortical white matter, predominately in the frontal regions of both hemispheres. There is no evidence of mass effect, midline shift, extra-axial fluid collection or hemorrhage. There are no abnormal areas of contrast enhancement identified within the brain.

The pituitary is not enlarged. The cerebellar tonsils are in normal anatomic position. The VII-VIII nerve complexes have a symmetric and unremarkable appearance without evidence of abnormal contrast enhancement.

IMPRESSION:

1. Focal abnormalities in the white matter as described above are generally associated with ischemic microvascular disease.  A demyelinating process can have a similar appearance. Clinical correlation is suggested. See complete discussion above.