Date : 00.00.00
Name of the Patient : Abc Xyzkumar lmn / M / 45 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O accident 4 months back.
C/O left sided hemiparesis and left UMN facial palsy.
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.
FEW IMAGES SHOW PATIENT MOTION INSPITE OF SEDATION.
There are diffuse areas of hypointensity on the T1 Weighted images involving the cortex and subcortical white matter in the right fronto-temporal lobes and left temporal lobe. In the given clinical setting of trauma, these most likely represent contusions.
A sliver of hyperintensity on the proton and T2 Weighted images is seen to overlie the right cerebral hemisphere and may represent a very small collection of fluid/blood.
A lacunar infarct (iso to hyperintense to CSF) is seen within the right lentiform nucleus.
There is mild fullness of the ventricular system.
The basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
Inflammatory changes are seen within the maxillary sinuses bilaterally and ethmoidal air cells.
The cervical and dorsal spines were screened with 4 mm thick T2 Weighted sagittal images and the lumbar spine was screened with 5 mm thick T1 Weighted sagittal images. A mild posterior disc bulge with small peridiscal osteophytes is seen at the D8-D9 level.
In the given clinical setting of trauma, the MRI features are suggestive of :
1. Contusions in the cortex and subcortical white matter in the right fronto-temporal lobes and left temporal lobe.
2. A very small collection of fluid/blood overlying the right cerebral hemisphere.
3. A lacunar infarct within the right lentiform nucleus.