Date : 00.00.00
Name of the Patient : Abc Xyzlmn / M / 35 yrs.
Referred by : Dr. Abc Xyzankhla.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O trauma.
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 a hyperintense area in the right inferior frontal lobe superior to the roof of right orbit and right temporal lobe on the STIR and Gradient coronal images (se/im:105/15, 16). This is isointense to white matter on the T1 Weighted images and may represent hemorrhagic contusion in the given clinical setting.
A small extracerebral (extradural) collection which is hyperintense on all the pulse sequences is noted in the right temporal region (se/im:102/10). This would represent a hematoma.
There is a suggestion of a fractures of the right frontal bone, right zygoma and spenoid bone and also the base of skull.
There is a break in the anterior and medial wall of the right maxillary sinus and lateral and medial wall of the right orbit.
Hyperintense signal is seen on the T2 Weighted and STIR images in the right maxilary sinus, ethmoidal air cells, sphenoid sinus, mastoid air cells may represent haemorrhage/inflammatory tissue.
Subcutaneous edema/contusion is seen adjacent to the right orbit and over the right side of face.
- 2 - Scan-15-75
Both the lateral, third and the fourth ventricles are normal. The basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
In a known C/O trauma, the MRI features are suggestive of :
1. Altered signal in the right inferior frontal lobe and right temporal lobe may represent hemorrhagic contusions in the given clinical setting.
2. A small extracerebral (extradural) collection in the right temporal region would represent a hematoma.
3. Fractures of the skull as described.
A 3D CT would be useful for better evaluation.