Date : 00.00.00
Name of the Patient : Abc Xyzant lmn / M / 76 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
C/O intracranial bleed.
H/O V.P.Shunt done in August 0000.
For follow up.
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 still seen an approximately 2.0 x 2.6 x 2.2 cms sized well-marginated hyperintense lesion on the T1 Weighted images in the region of the head of the right caudate nucleus, extending into the frontal horn and body of the right lateral ventricle. This lesion remains hyperintense on the proton, T2 Weighted and FLAIR images with a peripheral hypointense rim more pronounced on the proton and T2 Weighted images.
A hypointense focus on all the pulse sequences is noted in the right globus pallidus which may represent residual haemosiderin.
Ill-defined hyperintense areas on the proton, T2 Weighted and FLAIR images are noted in the periventricular white matter, more pronounced in the frontal regions and in the centrum semiovale.
A hyperintense signal, best appreciated on the proton density images is noted in the occipital horn of the right lateral ventricle (scans 106.9).
A burr hole is noted in the left posterior parietal region with a shunt tube traversing in the left posterior parietal lobe and extending into the left lateral ventricle with its tip lying in the body of the left lateral ventricle.
There is mild to moderate dilatation of both the lateral and the third ventricles. The fourth ventricle is normal. There is prominence of the cerebral cortical sulci, cerebellar folia and the basal cisternal spaces bilaterally. There is no midline shift. No obvious vascular anomaly is identified on this study.
Inflammatory changes are noted in mastoid air cells bilaterally.
The cervical spine was screened with the help of 4 mm thick T1 Weighted sagittal images which show mild degenerative changes at the C3-C4 and C4-C5 levels with posterior peridiscal osteophytes.
1. Post-shunt status with the tip of the shunt tube in the body of the left lateral ventricle.
2. An approximately 2.0 x 2.6 x 2.2 cms sized well-marginated lesion in the region of the head of the right caudate nucleus, extending into the frontal horn and body of the right lateral ventricle would represent a residual hematoma.
3. Altered signal in the periventricular white matter, more pronounced in the frontal regions and in the centrum semiovale would represent ischemic changes.
- 3 - Scan-00006
4. Altered signal in the occipital horn of the right lateral ventricle would represent residual intraventricular haemorrhage.
5. Mild to moderate dilatation of both the lateral and the third ventricles.
As compared to the previous MRI dated 00.00.00, (Study No.00004)
there is a decrease in the size of the right sided intracerebral hematoma and also the size of the ventricles. The patient is post-shunt status.