Date : 00.00.00
Name of the Patient : Abc XyzNilmn / M / 35 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O head injury for which a right fronto-parietal craniotomy was done on 00.00.00.
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 and Fast Scan (T2 *) coronal images.
FEW IMAGES SHOW PATIENT MOTION.
There is evidence of a right fronto-parietal craniotomy.
There is seen a fairly large, approximately 3.8 x 7.8 x 4.2 cms sized mass lesion in the right deep fronto-temporo-parietal region. This lesion has a peripheral hyperintense rim with an intermediate signal intensity centre on the T1 Weighted images. On the proton and T2 Weighted images the peripheral rim remains hyperintense where as the centre of the lesion appears relatively hypointense. On the Fast Scan (T2 *) images the centre of the lesion appears significantly more hypointense. Perilesional white matter hyperintense signal on the T2 Weighted and FLAIR images may represent perilesional edema. Effacement of the sulcal spaces in the right fronto-temporo-parietal region is noted with indentation and compression of the right lateral and third ventricles, effacement of the suprasellar cistern and shift of the midline to the left.
- 2 - Scan - 00008
Hyperintense, fluid level is noted in the lateral ventricles bilaterally with evidence of haemorrhage in the fourth ventricle. Mild dilatation of the left lateral ventricle is noted when compared to the right.
There is a thin sliver of a hyperintense signal on all the pulse sequences over the cerebral convexity in the right fronto-temporo-parietal region which may represent subdural fluid, the sequelae of previous surgery.
No obvious vascular anomaly is identified on this study.
Inflammatory changes are noted in the paranasal sinuses and mastoid air cells bilaterally.
1. Post-operative status.
2. An approximately 3.8 x 7.8 x 4.2 cms sized mass lesion in the right deep fronto-temporo-parietal region as described follows the signal characteristics of a subacute hematoma . Intraventricular fluid level may either suggest dissection of the hematoma into the ventricles or may be the sequelae of previous surgery. Resultant mass effect is noted. It is difficult to differentiate the gel foam packing from a residual/recurrent hematoma on this study.
3. A sliver of subdural fluid over the cerebral convexity in the right fronto-temporo-parietal region is the sequelae of previous surgery.
As compared to the previous MRI (study no: 00007) dated 00.00.00, there is a slight decrease in the size of the hematoma and in the degree of the resultant mass effect. Haemorrhage is now noted in the lateral ventricles. The hematoma is now in the subacute stage. The patient is status post-operative.