Date : 00.00.00
Name of the Patient : Abc Xyzn Ghlmn / M / 60 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O fall on 00.00.00 with right sided hemiplegia since then.
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.
5 mm thick T1 Weighted sagittal images.
There is seen an approximately 3.0 x 3.5 x 3.2 cms sized mass lesion in the left thalamus extending into the left corona radiata. This lesion is of mixed signal characteristic and is predominantly hypointense on the T1 Weighted images with a central, slightly hyperintense signal. On the proton and T2 Weighted images, the central area appears significantly hypointense whereas the peripheral segment of the lesion turns mildly hyperintense. There is perilesional edema. There is mild indentation of the third ventricle with minimal bulge of the midline to the right. The above described lesion represents an acute/early subacute intracerebral hematoma. Fluid-fluid level is noted in the occipital horn of the right lateral ventricle which suggests intraventricular extension of the lesion.
Lacunar infarcts (iso to hyperintense to CSF) are noted in the lentiform nuclei and thalami bilaterally and in the pons.
Ill-defined, hyperintense areas on the proton, T2 Weighted and FLAIR images are noted in the periventricular white matter bilaterally and bilateral corona radiata and centrum semiovale. These are most likely ischemic in etiology.
There is mild dilatation of both the lateral and third ventricles. The fourth ventricle is normal. There is prominence of the cerebral cortical sulci, cerebellar folia and basal cisternal spaces bilaterally.
Slow flow is noted in the right transverse and sigmoid sinuses.
An antrochoanal polyp is noted on the left side.
1. An approximately 3.0 x 3.5 x 3.2 cms sized mass lesion in the left thalamus extending into the left corona radiata and into the ventricular system as described represents an acute to early subacute hematoma.
2. Lacunar infarcts in the lentiform nuclei and thalami bilaterally and in the pons.
3. Altered signal in the periventricular white matter bilaterally and bilateral corona radiata and centrum semiovale most likely represents ischemic changes.