sb/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzabdulla Blmn / M / 40 yrs.
Referred by : Dr. Abc Xyzoshi.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

Alleged H/O road accident on 00.00.00 with loss of consciousness.
Right fronto-parietal craniectomy done on 00.00.00. For follow up.
Now C/O right sided weakness.

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 a right temporo-parietal craniectomy with herniation of the brain parenchyma through the craniectomy site.

Ill-defined, hyperintense areas on the T1 Weighted images are noted in the inferior frontal regions bilaterally, left anterior temporal region and in the right frontal and temporal regions. These lesions remain hyperintense on the proton, T2 Weighted and Fast Scan (T2 *) images and represent haemorrhagic contusions. Diffuse, ill-defined, hyperintense signal on the proton, T2 Weighted and FLAIR images in the white matter in the right fronto-temporo-parietal region may represent edema. Resultant obliteration of sulcal space is noted in the right cerebral hemisphere.

A small, epidural hematoma is noted in the right frontal region with a maximum width of about 1.0 cm. This lesion is hyperintense on all the pulse sequences.


CSF intensity lesions on all the pulse sequences in the subdural space in the left fronto-temporal region and in the right parieto-occipital parafalcine region, most likely represent subdural effusions.

A very thin sliver of hyperintense signal on all the pulse sequences in the right temporo-parieto-occipital region may represent subdural haemorrhagic fluid.

There is mild fullness of both the lateral ventricles. The right antrium appears pulled towards the craniectomy site. The third and the fourth ventricles are normal. The basal cisternal spaces are unremarkable. There is slight shift of the midline structures to the right. No obvious vascular anomaly is identified on this study.

Undisplaced fracture of the right frontal bone, right temporal bone and diastasis of the sagittal suture is noted.

Soft tissue in the sphenoid sinus and in the mastoid air cells bilaterally, more on the right, may represent haemorrhage.

IMPRESSION :

1. Post-operative status with herniation of the brain parenchyma through the craniectomy site.

2. Altered signal in the inferior frontal regions bilaterally, left anterior temporal region and in the right frontal and temporal regions represents haemorrhagic contusions.

3. A small, epidural hematoma in the right frontal region with a maximum width of about 1.0 cm.

4. CSF intensity lesions on all the pulse sequences in the subdural space in the left fronto-temporal region and in the right parieto-occipital parafalcine region, most likely represent subdural effusions.

5. Undisplaced fracture of the right frontal bone, right temporal bone and diastasis of the sagittal suture.