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Name of the Patient : Abc Xyz lmn / F / 13 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

Alleged H/O RTA at 4.15 pm on 00.00.0000 with loss of consciousness.
For follow-up.

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 :

There are still seen small hyperintense areas on the FLAIR and T2 Weighted images along the grey matter in the frontal region and temporal lobes bilaterally. These are hypointense to the grey matter on the T1 Weighted images and would represent cortical contusions in the given clinical setting.

Small hyperintense areas are seen on the proton, T2 Weighted and Flair images in the splenium of the corpus callosum on the left side, the posterior part of the body of the corpus callosum, the posterior limb of the left internal capsule and frontal lobes bilaterally. These are isointense to white matter on the T1 Weighted images and would represent diffuse axonal injury.

A small sliver of subdural collection is seen in the right temporo-parietal region and left tentorial leaflet.

There is fullness of both the lateral ventricles. The 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. ..2/.





IMPRESSION :

1. Contusions along the grey matter in the frontal region and temporal lobes bilaterally.

2. Diffuse axonal injury in the frontal lobes bilaterally, posterior limb of the left internal capsule and corpus callosum.

3. A small sliver of subdural collections in the right temporo-parietal regions and left tentorial leaflet.

As compared to the previous MRI (study no:00001) dated 00.00.0000, there is regression of the lesions in the left internal capsule and left cerebral peduncle.

The lesion in the splenium of the corpus callosum on the left side and in the posterior part of the body of the corpus callosum
was not well-identified previously. Fullness of both the lateral ventricles is also noted.

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