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hs/sb
Date : 00.00.00

Name of the Patient : Abc Xyz B. lmn / F / 10 yrs.
Referred by : Dr. Abc Xyzrmar / Dr. Abc Xyzdar.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

C/O vehicular accident on 00.00.00, with head injury and altered sensorium since then.

EXAMINATION :

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.

5 mm thick T1 Weighted sagittal images.

FEW IMAGES SHOW PATIENT MOTION INSPITE OF SEDATION.

OBSERVATION :

Irregularly defined areas of hyperintensity on the proton, T2 Weighted and FLAIR images are seen to involve the cortical grey matter in the left fronto-temporal lobes and medial aspect of the right temporal lobe. These are iso to hypointense to normal grey matter on the T1 Weighted images and would represent cortical contusions in the given clinical setting. A speck of hyperintensity on the T1 Weighted images is seen within the lesion in the left frontal lobe and would represent blood.

Small hyperintense areas are seen in the left cerebellar hemisphere, right cerebral peduncle, corpus callosum, posteriorly
and adjacent to the third ventricle on the left side. These would represent contusions/diffuse axonal injury.

A sliver of hyperintensity on all the pulse sequences is seen to overlie the left frontal lobe and may represent subdural blood.


Small subdural effusion is also noted in the right frontal region.

Both the lateral, 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.

IMPRESSION :

The MRI features are suggestive of :

1. Cortical contusions in the the cortical grey matter in the left fronto-temporal lobes and medial aspect of the right temporal lobe (with a small haemorrhagic component in the left frontal lobe).

2. Contusions/diffuse axonal injury in the left cerebellar hemisphere, right cerebral peduncle, corpus callsum, posteriorly and adjacent to the third ventricle on the left side.

3. A sliver of subdural fluid in the left frontal lobe.
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