Date : 00.00.00
Name of the Patient : Abc Xyz R. Nlmn / M / 20 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O railway accident on 00.00.00 with loss of consciousness for 1/2 an hour.
Now C/O memory loss and disorientation.
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.
There is a well-marginated approximately 3.2 x 2.4 x 4.0 cms sized hyperintense lesion on T1 Weighted images in the left fronto-temporal cortex. This lesion shows a mixed signal on the T2 Weighted images with part of the lesion remaining hyperintense and part of the lesion turning hypointense. Perilesional white matter hyperintense signal on the proton, T2 Weighted and FLAIR images may represent perilesional edema/contusion.
A thin sliver of extracerebral haemorrhage is noted in the left occipital region and in the interhemispheric fissure in the high posterior parietal region. There is an ill-defined, hyperintense signal on the proton, T2 Weighted and FLAIR images in the subcortical white matter in the left high posterior parietal region and in the right frontal region. This lesion appears hypointense on the T1 Weighted images.
An undisplaced fracture of the left temporal bone is noted. The overlying subgaleal soft tissues in that region shows altered signal and appears slightly swollen due to subgaleal hematoma.
Air is also noted in the subgaleal soft tissues.
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.
Mucosal thickening is noted in the left frontal sinus.
1. Altered signal in the left fronto-temporal cortex represents a haemorrhagic contusion.
2. Altered signal in the subcortical white matter in the right frontal region and right high posterior parietal region may represent Shearing injuries in the given clinical setting.
3. A thin sliver of extracerebral haemorrhage in the left occipital region and in the interhemispheric fissure.
4. Undisplaced fracture of the left temporal bone.
5. Subgaleal hematoma and air in the left temporal region.