Date : 00.00.00
Name of the Patient : Abc Xyzarayanlmn / M / 35 yrs.
Referred by : Dr. Abc Xyzenoy.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O road accident on 00.00.00 with injury to the face and drooping of the left eyelid since then.
M.R.I of the brain was performed using the following parameters :
5 mm thick T1 Weighted, proton and T2 Weighted axial images.
4 mm thick T1 Weighted and STIR coronal images.
5 mm thick T1 Weighted sagittal images.
There is no focal area of altered signal intensity in the brain parenchyma per se
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.
Susceptibility artifacts are noted in the subgaleal soft tissues in the left periorbital region, the sequelae of previous injury.
Multiple comminuted fractures of the nasal bone, maxillary sinuses, orbits and the floor of the anterior cranial fossa are noted. The left globe is displaced inferiorly and posteriorly into the left orbit. The vitreous of the left globe is slightly more hyperintense with layering when compared to the right on the T1 Weighted images and appears more hyperintense on the proton and T2 Weighted images. No obvious displacement of the lens is noted on either side.
There is herniation of the intraorbital fat and the left inferior rectus muscle into the left maxillary antrum through the fracture in the floor of the left orbit. Altered signal in the left orbital fat may be the sequelae of previous injury. The left optic nerve is normal in its course and signal intensity. The left optic nerve is not well visualized in the left optic canal.
Slight inferior herniation of the right orbit into the right maxillary antrum, anteriorly, is also noted. The visualized right optic nerve is normal in its course and signal intensity without entrapment.
Soft tissue in the paranasal sinuses may represent ? old haemorrhage, ?? inflammatory tissue. Deviation of the nasal septum to the right is noted.
Fracture of the left zygoma is also noted.
1. No abnormality is detected within the brain parenchyma per se on this study.
2. Multiple comminuted fractures involving the orbits and paranasal sinuses on either side as described.
3. Herniation of the left orbital contents into the left maxillary antrum with injury to the left globe as described (most likely represents vitreous haemorrhage).
4. The left optic nerve in the left optic canal is not well visualized.