sb/hs/nl/rg.
Date : 00.00.00
Name of the Patient : Abc XyzJ. Perlmn / M / 40 yrs.
Referred by : Dr. Abc Xyzi.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O being hit by an iron rod in the left fronto-temporal region 00.00.00 with semiconsciousness, vomiting and nasal bleed.
Now C/O loss of vision of the left eye.
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.
3 mm thick T1 Weighted and STIR coronal images and 3 mm thick T2 Weighted axial images through the optic nerves.
OBSERVATION :
There is an ill-defined, hyperintense signal on the proton, T2 Weighted and FLAIR images in the left inferior frontal cortex and subcortical white matter. This lesion appears predominantly hypointense on the T1 Weighted images with a subtle hyperintense signal within.
There is a very small, epidural lesion in the left anterior temporal region which is hyperintense on all the pulse sequences and represents a very small epidural hematoma, in the given clinical setting.
Both the lateral, third and the fourth ventricles are normal. The basal cisternal spaces are unremarkable. There is slight prominence of the cerebellar folia bilaterally. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
The optic nerves on either side are normal in their course and calibre and show normal signal.
No obvious entrapment of the optic nerves is noted.
IMPRESSION :
1. Altered signal in the left inferior frontal region represents a haemorrhagic contusion, in the given clinical setting.
2. A very small, epidural lesion in the left anterior temporal region represents a very small epidural hematoma, in the given clinical setting.
3. No significant abnormality is detected along the optic nerves on either side.