Date : 00.00.00
Name of the Patient : Abc Xyz Plmn / M / 42 yrs.
Referred by : Dr. Abc Xyzidhungat.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
C/O headaches since 2 months.
C/O right UMN facial palsy with decreased hearing on the right side.
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.
There are hyperintense areas in the frontal periventricular and deep white matter bilaterally, right more than left, on the proton, T2 Weighted and FLAIR images. These are iso to hypointense to normal white matter on the T1 Weighted images and are suggestive of areas of ischemia/infarction.
There is mild fullness of both the lateral ventricles. The third and the fourth ventricles are normal. The basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
Note is made of gross inflammatory changes in the frontal sinuses and mild inflammatory changes in the ethmoidal air cells and maxillary sinuses. The frontal sinuses appear large. There is an approximately 1.5 x 1.0 x 2.5 cms sized mass lesion in the left frontal, epidural space, just superior to the left frontal sinus. Probably erosion of the left frontal bone at that site is noted with slight swelling of the subgaleal tissues in the left frontal region, overlying the erosive lesion in the bone. It is difficult to evaluate erosion of the roof of the left frontal sinus.
1. Altered signal in the frontal periventricular and deep white matter bilaterally, right more than left is suggestive of areas of ischemia/infarction.
2. Inflammatory changes in the paranasal sinuses bilaterally. Mucocele of the frontal sinuses is a likely possibility.
3. An approximately 1.5 x 1.0 x 2.5 cms sized epidural lesion in the left frontal region, with suspicious erosion of the left frontal bone and overlying soft tissue swelling is most likely an inflammatory lesion in the given clinical setting.