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Name of the Patient : Abc XyzN. Pantlmn / M / 78 yrs.
Referred by : Dr. Abc Xyzmpat / Dr. Abc Xyzla.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

H/O subdural collection in the left cerebral convexity on 00.00.0000.
Left frontal and parietal burholes on 00.00.0000.
Left subdural taping done on 00.00.0000.
Slight dysarthria still persist.
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.

OBSERVATION :

There is evidence of left frontal and parietal burrhole defects.

There is seen a subdural hematoma over the left cerebral convexity with a maximum width of about 9.0 mms. This lesion appears hyperintense to normal brain parenchyma on all the pulse sequences. Resultant slight effacement of the cerebral cortical sulci on the left is noted with minimal indentation on the left lateral ventricle.

There is a hyperintense signal on the proton, T2 Weighted and FLAIR images along the cortex and subcortical white matter in the left temporo-parietal region. This lesion appears relatively hypointense to normal grey matter on the T1 Weighted images and most likely represents an ischemic lesion.



Lacunar infarcts are noted in the external capsular regions bilaterally, right lentiform nucleus and right corona radiata, bilateral centrum semiovale and in the left posterior parietal deep white matter, with ischemic lesion in the right posterior parietal deep white matter.

There is mild dilatation of both the lateral and third ventricles. The fourth ventricle is normal. There is prominence of the cerebral cortical sulci in the right cerebral hemisphere, cerebellar folia and the basal cisternal spaces bilaterally.

There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.

IMPRESSION :

1. A left cerebral convexity hematoma with a maximum width of 9.0 mms.

2. Altered signal along the cortex and subcortical white matter in the left temporo-parietal region most likely represents a ischemic lesion.

3. Lacunar infarcts in the external capsular regions bilaterally, right lentiform nucleus and right corona radiata, bilateral centrum semiovale and in the left posterior parietal deep white matter, with ischemic lesion in the right posterior parietal deep white matter.

4. Age related cerebral cortical and cerebellar atrophy with mild ventricular dilatation.

The patient is status post-burrhole tapping for a subdural hematoma on the left.

As compared to the previous MRI dated 00.00.0000 (scan no:00006), there is decrease in the size of the left cerebral convexity hematoma and resultant mass effect. The ischemic lesion in the left temporo-parietal region is better appreciated on the present study.

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