sb/bv/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Mlmn / M / 20 yrs.
Referred by : Dr. Abc Xyzhru / Dr. Abc Xyzankhla.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

H/O road traffic accident at 4.30 pm on 00.00.00 with injury to the head.

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 coronal images.

SOME IMAGES SHOW MOTION ARTIFACTS.

OBSERVATION :

There is seen a very thin sliver of hyperintense signal on the proton and T2 Weighted images in the subdural space in the left fronto-temporal region. This lesion follows CSF signal on the T1 Weighted images and may represent a very small, subdural effusion.

There is a small hyperintense focus in the left parietal region (scans 106.8, 106.9) in the cortex best appreciated on the FLAIR images and represents a cortical contusion.

Both the lateral, third and the fourth ventricles are normal. The basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.






Probable fractures are noted in the lateral wall of the left orbit and the left zygomatic arch.

Fluid level is noted in the sphenoid sinus and left maxillary antrum, which may represent haemorrhage in the given clinical setting.

Susceptibility artifacts are noted in the soft tissues in the left fronto-temporo-parietal region, the result of the accidental injury. Altered signal in the subgaleal soft tissues in the left posterior parietal region, left temporal region and in the left periorbital region represents soft tissue contusions/hematoma.

IMPRESSION :

1. A very small, subdural effusion along the left fronto-temporal convexity.

2. Cortical contusion in the parietal lobe.

3. Subgaleal soft tissue injury as described with probable haemorrhage in the left maxillary antrum and sphenoid sinus.

4. Probable fractures in the lateral wall of the left orbit and left zygomatic arch

A 3D CT would be useful.