ke/sb/rg//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 with subdural hematomas.
Multiple subdural tappings done with ventricle tapping on 00.00.0000.
Patient is still drowsy.
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 bloom on the Fast Scan (T2 *) images and would represent subacute blood/paramagnetic substance deposition. 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.
A burrhole is seen in the right posterior parietal region and in the left high frontal and right frontal regions.
There is dilatation of both the lateral and third ventricles.
Air fluid level is seen in the frontal horns of both the lateral ventricles and the temporal horn on the right side.
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.
Incidentally noted is an empty sella.
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. Mild dilatation of both the lateral and the third ventricles.
4. Air fluid level in the frontal horns of both the lateral ventricles and the temporal horn on the right side.
As compared to the previous MRI (study no:00000) dated 00.00.0000, there is,
a. Near complete resolution of the subdural collection (loculated) in the left fronto-parietal region.
b. Slight increase in the size of the ventricles with air fluid level seen in the frontal horns of both the lateral ventricles and the temporal horn on the right side.