Name of the Patient : Abc XyzMalmn / M / 45 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O vehicular accident on 00.00.00 with head trauma. Bilateral temporal bone flap removal on 00.00.00. Bilateral temporal craniotomy with haemorrhagic contusion evacuation on 00.00.00. Burr hole on 00.00.00.
No complaints at present. For follow up.
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.
There is evidence of fronto-temporo-parietal craniectomy bilaterally.
There are ill-defined, hyperintense areas on the proton, T2 Weighted and FLAIR images in the inferior frontal regions bilaterally, right fronto-temporal region, bilateral high parietal parafalcine region and in the left temporal region. These lesions appear relatively hypointense on the T1 Weighted images. Residual haemoglobin breakdown products are noted in the right fronto-temporal and left temporal regions.
A very thin, sliver of subdural fluid is noted in the left fronto-temporo-parietal region. This lesion appears loculated in the left frontal region with a maximum width of about 8.0 mms.
Hyperintense signal along the gyri in both fronto-temporal regions on all the pulse sequences represents subarachnoid blood.
A small, hyperintense focus on proton and T2 Weighted images is noted in the left middle cerebellar peduncle which appears hypointense on the T1 Weighted images. A similar lesion is noted in the left temporo-occipital region.
A burr hole is noted in the left temporo-occipital region.
The left cerebellar hemisphere appears slightly hypoplastic with a mega cisterna magna.
Small bright foci on the proton, T2 Weighted and FLAIR images are noted in the subcortical white matter in the frontal regions bilaterally and in the right posterior parietal region.
There is mild fullness of both the lateral ventricles. The third and the fourth ventricles are normal. The rest of the basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
A polyp is noted in the left maxillary antrum.
1. Post-operative status.
2. Altered signal in the inferior frontal regions bilaterally, right fronto-temporal region, bilateral high parietal parafalcine region and in the left temporal region are the sequelae of previous haemorrhagic contusions.
3. A very thin, sliver of subdural fluid in the left fronto-temporo-parietal region with a loculated pocket in the left frontal region with a maximum width of about 8.0 mms.
- 3 - Scan-00000
4. Altered signal in the left middle cerebellar peduncle,
left temporo-occipital region and in the subcortical white matter in the frontal regions bilaterally and in the right posterior parietal region as described may represent shearing injuries, in the given clinical setting.
5. Hypoplastic left cerebellar hemisphere with a mega cisterna magna.
As compared to the previous MRI dated 00.00.00, there is slight decrease in the size of the ventricles. The left frontal extracerebral collection is smaller in size but appears loculated. Resolving haemorrhagic contusions are still noted as described.