sb/hs/rg/nl
Name of the Patient : Abc XyzPantlmn / M / 78 yrs.
Referred by : Dr. Abc Xyzmpat.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Known C/O TIA. Multiple CVA with residual dysphagia.
Left frontal and parietal burrholes done on 00.00.0000. Left 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 coronal images.
OBSERVATION :
There is evidence of left frontal and parietal burrhole defects.
There is still seen a very small, subdural hematoma overlying the left cerebral hemisphere with a maximum width of about 3.0 mms. This lesion appears hyperintense to normal brain parenchyma on all the pulse sequences. There is no significant mass effect.
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 with subtle hyperintense signal within it on the T1 Weighted images. This most likely represents an ischemic lesion, with haemoglobin breakdown products.
Scan-00007
Lacunar infarcts (iso to hyperintense to CSF) 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 an ischemic lesion (hyperintense to white matter on the T2 Weighted images) 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, 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 very small, residual, subdural hematoma overlying the left cerebral hemisphere with a maximum width of 3.0 mms.
2. Altered signal along the cortex and subcortical white matter in the left temporo-parietal region most likely represents a subacute ischemic lesion with evidence of haemoglobin breakdown products within it.
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 an ischemic lesion in the right posterior parietal deep white matter.
4. Age related cerebral cortical and cerebellar atrophy with mild ventricular dilatation.
..3/.
- 3 - Scan-00007
The patient is status post-burrhole tapping for a subdural hematoma on the left side.
As compared to the previous MRI dated 00.00.0000 (scan no:00001), there is a decrease in the size of the left subdural hematoma and resultant mass effect. The ischemic lesion in the left temporo-parietal region is now a subacute lesion. The left lateral ventricle is a little full as compared to the previous study.