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ke/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc XyzMuthuslmn / M / 37 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

Alleged H/O fall from a height with injury to head and spine for which patient was operated in 0000.
Now C/O diplopia, giddiness, headaches and weakness from waist downwards.

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 coronal images.

5 mm thick T1 Weighted sagittal images.

OBSERVATION :

A right parieto-temporo-occipital craniotomy with post-operative changes is seen.

There is a hypointense area on the T1 Weighted images in the right temporo-occipital region. This is seen to follow CSF signal intensity characteristics on all the pulse sequences. Hyperintense areas at the periphery of this lesion on the proton, T2 weighted and Flair images appear hypointense to the white matter on the T1 Weighted images and would represent areas of gliosis. This lesion in toto would represent an area of cystic encephalomalacia (There is ex-vacuo dilatation of the right occipital horn).

There is slight prominence of the cerebellar folia bilaterally.

The cavernous sinuses on this scan are unremarkable.


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.

Inflammatory changes are seen in the mastoid air cells on the right side.

IMPRESSION :

1. Post-operative status.

2. Area of cystic encephalomalacia in the right temporo-occipital region.

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