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sb/ke
Date : 00.00.00

Name of the Patient : Abc Xyzl Nlmn / M / 49 yrs.
Referred by : Dr. Abc Xyzdar / 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.

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 coronal images.

SOME IMAGES SHOW PATIENT MOTION.

OBSERVATION :

There is still seen a subtle ill-defined, hyperintense signal on the proton and T2 Weighted images in the right occipital cortex and in the subcortical white matter in the high frontal deep white matter on the right (scan 105.16). These lesions appear nearly isointense to normal white matter on the T1 Weighted images.

There is mild dilatation of both the lateral, third and fourth ventricles. There is slight prominence of the cerebral cortical sulci, cerebellar folia and the basal cisternal spaces bilaterally. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.

Inflammatory changes are noted in the right maxillary antrum.










IMPRESSION :


1. Altered signal in the subcortical white matter in the right high frontal region and right occipital cortex may represent contusions/shearing injuries in the given clinical setting.

2. Mild dilatation of both the lateral, third and fourth ventricles with prominence sulcal spaces and basal cisterns.

As compared to the previous MRI (study no:00006) dated 00.00.00, there is reduction in the size and signal intensities of the previously described contusions/shearing injuries. There is also complete resolution in the previously identified subdural collections. There is however, mild dilatation of the ventricular system and prominence of cortical sulcal spaces and basal cisterns.


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