sb/hs/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyz Jilmn / F / 35 yrs.
Referred by : Dr. Abc Xyz.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O vehicular accident with head injury on 00.00.00.
EXAMINATION :
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.
OBSERVATION :
There is an ill-defined, hyperintense signal on the T1 Weighted images along the right posterior temporal cortex. This lesion remains hyperintense on the proton, T2 Weighted and FLAIR images with a peripheral hypointense rim more pronounced on the Fast Scan (T2 *) images. The cortex along the right anterior temporal region also appears hyperintense on the proton, T2 Weighted and FLAIR images (hypointense on the T1 Weighted images). Very minimal subdural haemorrhagic fluid (hyperintense on all the pulse sequences) is noted in the right temporal region with a maximum width of about 2.0 mms.
There is a CSF signal intensity lesion on all the pulse sequences in the left anterior temporal cortex with perilesional hyperintense signal on the proton, T2 Weighted and FLAIR images (scans 103.6-7, 107.12-13).
A minimally displaced fracture of the left fronto-temporal bone is noted.
There is mild dilatation of both the lateral, third and the fourth ventricles. There is prominence of the cerebral cortical sulci and the basal cisternal spaces bilaterally. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
..2/.
Hyperintense signal on all the pulse sequences in the left mastoid air cells and in the sphenoid sinus may represent haemorrhagic fluid, in the given clinical setting.
IMPRESSION :
In a known C/O trauma, the MRI features are suggestive of :
1. Altered signal in the right temporal cortex would represent a haemorrhagic contusion with gliotic changes along the anterior temporal cortex, in the given clinical setting.
2. Minimal subacute, subdural, haemorrhagic fluid in the right temporal region.
3. Gliotic/encephalomalacic changes in the left anterior temporal cortex, most likely the sequelae of a previous contusion.
4. A minimally displaced fracture of the left fronto-temporal bone.
5. Mild communicating hydrocephalus.
6. Haemorrhagic collection in the left mastoid air cells and in the sphenoid sinus.