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Dx for cpt 70545 impression

she803

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cpt 70545 Report denied icd-9 780.97, 437.1

Examination: MRA neck with and without contrast.

Clinical indication: Altered mental status.

Technique: Multiplanar multi sequence MR imaging of brain was performed without administration of intravenous contrast material. 3-D time-of-flight MRA images of brain were obtained without administration of contrast material. 2-D time of flight MRA images of neck were obtained without contrast. Contrast enhanced MRA of the neck was also performed. Multiplanar reformats and maximum intensity projections were obtained. There is no prior MRI study for comparison.

Findings: There is no restricted diffusion to suggest an acute infarct. There is extensive encephalomalacia and gliosis in the posterior frontal lobes, bilateral parietal lobes and occipital lobes probably due to chronic infarcts. Multiple chronic cerebellar infarcts are identified. There are periventricular and subcortical foci of FLAIR signal abnormality consistent with microvascular ischemic disease. There is no intracranial hemorrhage, mass lesion or abnormal extra-axial fluid collection. There is cerebral and cerebellar atrophy. There is no hydrocephalus.

There is a right frontal extracranial lipoma measuring 14 x 6 mm. A polyp or a mucous retention cyst is seen in the right frontal sinus.

MRA head and neck:

The aortic arch and origin of great vessels are normal. The left vertebral artery arises from the proximal aspect of the left subclavian artery in close proximity to the aortic arch.

The left common carotid artery is normal in caliber and bifurcation pattern. The cervical segment of the left internal carotid artery is normal in caliber. There is irregularity of the cavernous segment of the left internal carotid artery probably due to atherosclerotic disease. The left middle cerebral artery, posterior communicating artery and anterior cerebral artery are normal.

There is an irregular plaque at the right carotid bulb for a length of 9 mm resulting in approximately 20% stenosis by NASCET criteria. The remaining cervical segment of the right internal carotid artery is normal. There is irregularity of the right cavernous internal carotid artery consistent with atherosclerotic disease. The right middle cerebral artery, posterior communicating artery and anterior cerebral artery are normal.

The vertebral arteries and basilar artery are normal. The right vertebral artery is dominant. There is diminished flow-related signal in the P2 segments of bilateral posterior cerebral arteries with normal flow-related signal distally; given the symmetry of these findings an artifactual etiology is likely however severe stenosis is also considered.

Impression:

No acute infarction.
Extensive chronic infarcts.
Microvascular ischemic disease.
Diffuse cerebral and cerebellar atrophy.
20% stenosis of the right carotid bulb.
Decreased flow related signal in P2 segments of posterior cerebral arteries which are probably due to artifact however severe stenosis is also considered.
 
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