Date : 00.00.00
Name of the Patient : Abc Xyzlal Khlmn / M / 66 yrs.
Referred by : Dr. Abc Xyztrak.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O vehicular accident in January 0000 with drainage of a chronic right fronto-parietal subdural hematoma on 00.00.00 and 00.00.00.
H/O fever since 00.00.00. Memory impairment since 8 days.
H/O left sided hemiparesis.
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 coronal images.
Note is made of a burrhole in the right parietal region. There is slight meningeal thickening overlying the right cerebral hemisphere.
There are ill-defined, hyperintense areas on the proton, T2 Weighted and Flair images in the cortex/subcortical white matter in the inferior frontal and frontal regions bilaterally and in the bilateral temporal regions. These lesions appear hypointense on the T1 Weighted images.
A lacunar infarct (iso to hyperintense to CSF) is noted in the right cerebellar hemisphere.
There is mild to moderate dilatation of both the lateral and third ventricles. The temporal horns of the lateral ventricles are disproportionately dilated. There is mild fullness of the fourth ventricle. There is slight prominence of the cerebral cortical sulci and cerebellar folia bilaterally.
The basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
There is no evidence of a residual subdural hematoma on this study.
1. Status post-burrhole for evacuation of a right fronto-parietal subdural hematoma.
2. Altered signal in the cortex/subcortical white matter in the inferior frontal and frontal regions bilaterally and in bilateral temporal regions represents gliotic/ encephalomalacic changes, most likely the sequelae of previous contusions.
3. Mild to moderate dilatation of both the lateral and third ventricles with the temporal horns being disproportionately dilated.
4. Lacunar infarct in the right cerebellar hemisphere.