Date : 00.00.00
Name of the Patient : Abc Xyzndra D. Banlmn / M / 55 yrs.
Referred by : Dr. Abc Xyzndu.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O fight with fall and swelling over the mastoid region on 00.00.00 at 10.30 pm.
C/O inability to speak with 2 episodes of convulsions in the morning of 00.00.00.
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 seen a fairly large, approximately 4.3 x 4.5 x 3.5 cms sized ill-marginated, iso to slightly hyperintense lesion on the T1 Weighted images in the left inferior frontal and frontal regions. This lesion appears hyperintense on the proton, T2 Weighted and FLAIR images and shows a peripheral hypointense rim on the Fast Scan (T2 *) images. There is indentation on the frontal horn of the left lateral ventricle. Extension of this lesion is noted into the left lateral and third ventricles. This lesion represents a hyperacute to acute intracerebral hematoma/haemorrhagic contusion in the given clinical setting. Multiple smaller lesions of similar signal intensity are noted in the anterior temporal regions bilaterally, right inferior frontal region and bilateral hi-frontal parafalcine region. Extension of the haemorrhage into the subarachnoid space is noted in some places. Suspicious extracerebral haemorrhage is noted in the right high parietal region in the midline.
There is mild dilatation of both the lateral and the third ventricles. The fourth ventricle is normal. The basal cisternal spaces are unremarkable. There is mild bulge of the midline structures to the right. No obvious vascular anomaly is identified on this study.
Subgaleal hematoma is noted in the left periorbital region, left fronto-temporo-parietal region and in the high parietal regions bilaterally.
A probable fracture of the zygoma is noted anteriorly with a fairly large hematoma deep to the left zygomatic arch.
1. An approximately 4.3 x 4.5 x 3.5 cms sized intracerebral hematoma/haemorrhage contusion in the left inferior frontal and frontal regions, dissecting into the left lateral and third ventricles.
2. Multiple smaller haemorrhagic contusions/hematomas in the anterior temporal regions bilaterally, right inferior frontal region and bilateral hi-frontal parafalcine regions.
3. Subgaleal hematoma in the left periorbital region, left fronto-temporo-parietal region and in the high parietal regions bilaterally.
4. A probable fracture of the zygoma anteriorly with a fairly large hematoma deep to the left zygomatic arch.