Date : 00.00.00
Name of the Patient : Abc Xyzahmed Uslmn / M / 72 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O road accident at 5.30 am on 00.00.00, with loss of consciousness and bleeding from the left ear.
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.
There is evidence of a biconvex, extracerebral lesion in the right fronto-temporo-parietal region. This lesion is hyperintense on all the pulse sequences and would represent an extradural hematoma. There is resultant indentation upon the underlying brain parenchyma. Also seen is mild compression upon the right lateral and third ventricles with mild shift to the left side. Smaller extracerebral collections with similar signal characteristics are seen to overlie both cerebral hemispheres and may represent subdural fluid/blood.
A fluid-fluid level is noted within the left occipital horn and this would suggest presence of subarachnoid blood with extension into the ventricular system.
Hyperintense areas on the proton, T2 Weighted and FLAIR images are seen to involve the cortical grey matter in the right temporal lobe. A smaller similar area is also noted in the left temporal lobe. These would represent cortical contusions in the given clinical setting of trauma.
Areas of hyperintensity on the proton, T2 Weighted and FLAIR images are seen within the periventricular white matter bilaterally and these are most likely ischemic in etiology. Foci with similar signal characteristics are noted in the white matter in the frontal lobes bilaterally.
There is mild fullness of both the lateral ventricles. Also seen is prominence of the cerebral cortical sulci, more so in the frontal regions. The fourth ventricle is normal. The basal cisternal spaces are unremarkable. No obvious vascular anomaly is identified on this study.
Subgaleal edema is noted in the left fronto-temporo-parietal region.
Hyperintense signal on the T2 Weighted images is noted within the sphenoid sinus and mastoid air cells/middle ear cavity, bilaterally and this may represent blood, in the given clinical setting of trauma.
Suspicious skull vault fracture is noted in the left fronto-parietal region.
The MRI features are suggestive of :
1. An extracerebral extradural hematoma in the right fronto-temporo-parietal region.
2. Subdural collection of fluid/blood overlying the cerebellar hemispheres, bilaterally.
3. Cortical contusions involving the cortical grey matter in the temporal lobes, right more than left.
4. Presence of blood in the ventricular system as described.