Date : 00.00.00
Name of the Patient : Abc Xyz Dlmn / F / 64 yrs.
Referred by : Dr. Abc Xyzmpat.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O head injury in August 0000 with a subdural collection. Patient was conserved.
C/O headaches since 3-4 months with right focal findings.
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 coronal images.
There is a well-defined area measuring approximately 1.2 cms in diameter located in the left lentiform nucleus and head of the left caudate nucleus and is seen to extend into the body on the left side. This area is nearly isointense to CSF on the T1 Weighted images and turns more hyperintense from the proton to the T2 Weighted images and represents a lacunar infarct. Surrounding hyperintense areas are seen on the FLAIR images and represent gliotic changes (scans 102.12, 13, 104.12, 13, 105.12, 13).
The left cerebral peduncle appears smaller in size as compared to the opposite side and is suggestive of Wallerian degeneration.
There is a small hyperintense area located on the proton density, T2 Weighted and FLAIR images in the grey matter in the left temporal lobe (scans 103.7, 8, 104.7, 8, 102.7, 8, 105.11, 12). This area appears hypointense on the T1 Weighted images and represents an area of gliosis, probably the result of previous head injury.
The left frontal horn is more prominent as compared to the opposite side. There is slight fullness of the rest of the lateral ventricles and the third ventricle. The fourth ventricle is normal. There is prominence of the cerebral cortical sulci and cerebellar folia bilaterally. The basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
Metallic susceptibility artifacts are seen at the base of the skull on the left side probably as a result of fixed dentures.
1. Lacunar infarct in the left lentiform nucleus and head of the left caudate nucleus extending into the body.
2. An area of gliosis in the left temporal lobe, probably the sequelae of previous head injury.