Date : 00.00.00
Name of the Patient : Abc Xyzl T. lmn / M / 54 yrs.
Referred by : Dr. Abc XyzAndar / Dr. Abc Xyzah.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O head injury at 8.00 pm on 00.00.00 with loss of consciousness, bleeding and vomiting.
Known hypertensive and diabetic.
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 Fast Scan (T2 *) coronal images.
5 mm thick T1 Weighted sagittal images.
There is thickening of the gyri which appears hypointense to the grey matter on the T1 Weighted images in the left anterior temporal lobe, right temporal lobe laterally and the left frontal lobe. These are seen to turn hyperintense on the proton, T2 Weighted and Fast Scan (T2 *) images. Few areas are hypointense on the Fast Scan (T2 *) images and might represent oxy/deoxyhemoglobin. There is effacement of the sulci in that region.
A sliver of small subdural collection is seen in the fronto-temporo-parietal regions bilaterally.
Suspicious fractures of the temporal bones bilaterally are noted with altered signal in the right mastoid air cells and right middle ear cavity.
Fluid level is seen in the maxillary sinuses bilaterally, left more than right.
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.
Note is made of subgaleal contusion/edema in the right occipital and left parietal region.
The MRI features are suggestive of :
1. Haemorrhagic contusions in the left anterior temporal lobe, right temporal lobe laterally and the left frontal lobe.
2. Small subdural collection in the fronto-temporo-parietal regions bilaterally.
3. Suspicious fractures of the temporal bones bilaterally with altered signal in the right mastoid air cells and middle ear cavity.