Date : 00.00.00
Name of the Patient : Abc Xyzama Slmn / M / 18 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O fall of a heavy object on head at 8.30 am on 00.00.00 with loss of consciousness.
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 and 4 mm thick T2 Weighted sagittal images.
There are ill-defined, hyperintense areas on the proton, T2 Weighted and Flair images in the subfrontal cortex and subcortical white matter bilaterally. These areas appear hypointense to normal grey matter on the T1 Weighted images.
Very thin sliver of altered signal is noted in the subdural space over the cerebral convexities bilaterally which most likely represent subdural haemorrhage. Very small, extracerebral (most likely extradural) hematomas in the left inferior frontal region and in the right high frontal region are noted. Subgaleal hematoma is also noted in the frontal regions bilaterally.
Undisplaced fracture of the frontal bone is noted in the midline. Probable fracture of the right superior orbital rim and the nasal bone is also noted (scans 103.9, 102.9).
The paranasal sinuses show evidence of soft tissue, bilaterally, which may represent haemorrhage in the given clinical setting.
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.
1. Altered signal in the subfrontal cortex and subcortical white matter bilaterally represent contusions, in the given clinical setting.
2. Very minimal subdural haemorrhage over the cerebral convexities bilaterally.
3. Very small, extracerebral (most likely extradural) hematomas in the left inferior frontal region and in the right high frontal region.
4. Undisplaced fracture of the frontal bone in the midline.
5. Probable fracture of the right superior orbital rim and the nasal bone.
6. Soft tissue in the paranasal sinuses bilaterally represent haemorrhage in the given clinical setting.