Name of the Patient : Abc XyzMalmn / M / 45 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O vehicular accident on 00.00.00 with head trauma. Bilateral temporal bone flap removal on 00.00.00. Bilateral temporal craniotomy with haemorrhagic contusion evacuation on 00.00.00. Burr hole on 00.00.00.
H/O right cranioplasty in February on 00.00.0000 and 00.00.0000.
For follow up.
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.
There is H/O cranioplasty in February 0000.
There are ill-defined, hyperintense areas on the proton, T2 Weighted and FLAIR images in the inferior frontal regions bilaterally, right fronto-temporal region, bilateral high parietal, parafalcine region and in the left temporal region. These lesions appear relatively hypointense on the T1 Weighted images. Some areas in the above described lesions follow CSF signal on all the pulse sequences. Residual haemoglobin breakdown products are noted in the right fronto-temporal and left temporal regions.
A small, hyperintense focus on the proton and T2 Weighted images is noted in the left middle cerebellar peduncle which appears hypointense on the T1 Weighted images. A similar lesion is noted in the left temporo-occipital region.
The left cerebellar hemisphere appears slightly hypoplastic with a mega cisterna magna and prominent left sided retrocerebellar cistern.
Small bright foci on the proton, T2 Weighted and FLAIR images are noted in the subcortical white matter in the frontal regions bilaterally and in the right posterior parietal region.
There is mild fullness of both the lateral ventricles. The third and the fourth ventricles are normal. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
A polyp is noted in the left maxillary antrum.
1. Post-operative status.
2. Altered signal in the inferior frontal regions bilaterally, right fronto-temporal region, bilateral high parietal parafalcine region and in the left temporal region are the sequelae of previous haemorrhagic contusions.
4. Altered signal in the left middle cerebellar peduncle,
left temporo-occipital region and in the subcortical white matter in the frontal regions bilaterally and in the right posterior parietal region as described may represent shearing injuries, in the given clinical setting.
5. Hypoplastic left cerebellar hemisphere with a mega cisterna magna and prominent left sided retrocerebellar cistern.
As compared to the previous MRI (study no:00000) dated 00.00.0000, the resolving haemorrhagic contusions show evidence of encephalomacic changes.
The patient is status post-cranioplasty in February 0000. There is no significant change in the size of the ventricles.