Date : 00.00.00
Name of the Patient : Abc Xyzal G. lmn / M / 65 yrs.
Referred by : Dr. Abc Xyzankhla / Dr. Abc Xyzin.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O vehicular accident on 00.00.00, with vomiting and bleeding from left ear, pain in the left shoulder and pain in the left side of chest.
M.R.I of the brain was performed using the following parameters :
5 mm thick T1 Weighted , proton and T2 Weighted axial images.
5 mm thick Fast Scan (T2 *) coronal images.
There is no focal area of altered signal intensity within the brain parenchyma.
Small sliver of hyperintense signal is seen in the right temporal region and right parieto-occipital region (subdural in location) on the T1 Weighted images which is seen to remain hyperintense on the proton, T2 Weighted and Fast Scan (T2 *) images and may represent haemorrhage in the given clinical setting. There is a suggestion of fracture of the right temporal bone anteriorly. Hyperintense areas are seen in the right fronto-temporal subgaleal region and left temporo-parietal subgaleal region on the proton and T2 Weighted images and would represent contusion/subgaleal edema/hematoma. Susceptibility artifacts are seen in the right fronto-parietal region.
Hyperintense signal seen on all the pulse sequences within the left mastoid region and left external auditory canal would represent haemorrhage, in the given clinical setting.
Both the lateral, third and the fourth ventricles are normal. The basal cisternal spaces are unremarkable. There is no midline shift. There is slight prominence of the cerebral cortical sulcal spaces in the fronto-parietal regions bilaterally. No obvious vascular anomaly is identified on this study.
- 2 -
Incidental note is made of pansinusitis.
1. Sliver of small subdural collection/hematoma in the right temporal region and right parieto-occipital region.
2. Probable fracture of the right temporal bone with right fronto-temporal and left temporo-parietal subgaleal contusion/edema/hematoma.