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sb/hs/nl/rg.

Name of the Patient : Abc Xyz lmn / M / 47 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

H/O left occipital craniotomy with removal of extradural hematoma and left temporal craniotomy with evacuation of subdural hematoma on 00.00.0000.

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 is evidence of a left occipital and left temporo-frontal craniotomy.

There are ill-defined, hyperintense areas on the proton, T2 Weighted and FLAIR images in the right frontal and temporal cortex and subcortical white matter. These areas appear hypointense on the T1 Weighted images with subtle hyperintense signal in some places. Volume loss is also noted in the right frontal and temporal lobes.

There is a linear hyperintense signal on the proton and T2 Weighted images in the genu of the left internal capsule extending into the left lentiform nucleus. Minimal subdural fluid is noted in the left fronto-temporo-parietal region and in the right frontal region. Probable residual blood products are noted in the right frontal subdural space (se/im : 104.13, 14).


There is mild fullness 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.

IMPRESSION :

The MRI features are suggestive of :

1. Post-operative status.

2. Resolving haemorrhagic contusions in the right frontal and right temporal regions.

3. Minimal subdural fluid in the left fronto-temporo-parietal
region and right frontal region.

4. Altered signal in the genu of the left internal capsule would represent a resolving shearing injury.

As compared to the previous MRI (study no:00009) dated 00.00.0000, the epidural hematoma in the posterior fossa on the left is now not visualized. Resolving contusions and shearing injuries are noted as described. There is a decrease in the size of the subdural fluid collections in the fronto-temporo-parietal regions bilaterally as described.


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