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SB/HS/NL/NL

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.
Multiple subdural tappings done. Patient slightly more drowsy in the last one week.
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 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 represent gliotic/encephalomalacic changes, the sequelae of previous resolving hemorrhagic contusions. Resultant dilatation of the temporal horn of the right lateral ventricle is noted as compared to the left.

A small bright focus on the T2 Weighted images is noted in the left cerebellar hemisphere and in the left frontal deep white matter.



Minimal subdural haemorrhage is noted in the right temporo-parietal region. A burrhole is seen in the right posterior parietal region.

A concavo-convex lesion which is slightly hyperintense to CSF on all the pulse sequences is seen to overlie the left fronto-parietal lobe, with a maximum width of about 2.0 cms. A membrane is noted along the inner margin of the lesion. Resultant indentation on the underlying left fronto-parietal lobe and on the frontal horn of the left lateral ventricle is noted. 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. Post-operative status.

2. Gliotic/encephalomalacic changes within the right fronto-temporal lobes (involving the cortical gray and subcortical white matter), the sequelae of previous resolving haemorhagic contusions.

3. Minimal subdural haemorrhage in the right temporo-parietal region.

4. A loculated subdural collection in the left fronto-parietal region.
..3/.








- 3 - Scan-00002



5. Mild dilatation of both the lateral and third ventricles.

As compared to the previous MRI (study no:00002) dated 00.00.0000, there is,

a. Increase in the size of the subdural collection (loculated) in the left fronto-parietal region with mass effect.

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

c. Slight increase in the size of the ventricles.









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