Date : 00.00.00
Name of the Patient : Abc Xyzl Nlmn / M / 49 yrs.
Referred by : Dr. Abc Xyzdar / Dr. Abc Xyzla / Dr. Abc Xyzagwati.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O railway accident on 00.00.00, with altered sensorium since then.
C/O increased drowsiness for the last 2 days.
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 FLAIR coronal images.
SOME IMAGES SHOW PATIENT MOTION.
There is still seen a left fronto-temporo-parietal, subdural collection which follows CSF signal on all the pulse sequences. The maximum width of this lesion is about 1.5 cm. Resultant mild effacement of the cortical sulcal spaces is noted, with minimum indentation on the frontal horn of the left lateral ventricle.
A smaller, similar signal intensity lesion is noted in the right frontal region, measuring about 4.0 mms in width.
There are ill-defined, hyperintense areas on the proton, T2 Weighted and FLAIR images in the subcortical white matter in the right high frontal region (scan 103.13), right occipital cortex (scan no 107.2) and along the postero-lateral margins of the pons and the junction of the pons and midbrain, bilaterally (scan no 107.8). These lesions appear iso to hyperintense to normal white matter on the T1 Weighted images.
Both the lateral, third and the fourth ventricles are otherwise unremarkable. The basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
- 2 -
Fracture of the left zygomatic arch is noted.
Inflammatory changes are noted in the paranasal sinuses and mastoid air cells.
1. Left fronto-temporo-parietal and right frontal, subdural collections as described.
2. Altered signal in the subcortical white matter in the right high frontal region, right occipital cortex and along the postero-lateral margins of the pons and the junction of the pons and midbrain, bilaterally may represent contusions/shearing injuries in the given clinical setting.
3. Fracture of the left zygomatic arch.
As compared to the previous MRI (00000) dated 00.00.00, there is no significant change in the mass effect although there is a marginal increase in the size of the subdural