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sb/hs/nl/rg.

Name of the Patient : Abc Xyzlal Kaplmn / M / 70 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

Alleged H/O RTA on 00.00.00 with loss of consciousness since then.
Subdural tapping done on 00.00.0000.
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 and Fast Scan (T2 *) coronal images.
5 mm thick T1 Weighted sagittal images.

OBSERVATION :

There are still seen areas of hypointensity on the T1 Weighted images which turn hyperintense on the proton, T2 Weighted and FLAIR images within the right fronto-temporal lobes (involving the cortical grey and subcortical white matter). Also seen are areas of subtle hyperintensity on the T1 Weighted images within these areas which would represent subacute blood. These lesions in toto would represent resolving haemorrhagic contusions.

A small bright focus on the T2 Weighted images is noted in the left cerebellar hemisphere.

Concavo-convex hyperintense lesions on all the pulse sequences are seen to overlie the right temporo-occipito-parietal region having a maximum width of 5.0 mms. and would represent subacute subdural hematomas. A burrhole is seen in the right posterior parietal region.
Scan-00002


A small concavo-convex lesion which is isointense to CSF on all the pulse sequences is seen to overlie the fronto-parietal lobes bilaterally and may represent a subdural hygroma. A burr hole is noted in the left high frontal and right frontal region.

There is dilatation of both the lateral and third ventricles. The fourth ventricle is normal. The basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.

Areas of altered signal in the paranasal sinuses may represent blood/inflammatory changes.

IMPRESSION :

In a known C/O trauma, the MRI features are suggestive of :

1. Resolving haemorrhagic contusions within the right fronto-temporal lobes (involving the cortical gray and subcortical white matter).

2. Subacute subdural hematoma in the right temporo-parieto-occipital lobe.

4. Subdural hygromas overlying the fronto-parietal lobes bilaterally.

5. Post-operative status.

As compared to the previous MRI (study no:00001 dated 00.00.0000, there is,

a. Decrease in size of the subdural hematoma in the right temporo-parieto-occipital region.

b. Near complete resolution of the diffuse axonal injury in the body of the corpus callosum.

c. The size of the ventricles is unchanged.


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