sb/bv/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyzkant P. Rellmn / M / 35 yrs.
Referred by : Dr. Abc Xyzwant.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Alleged H/O fall of a shutter on the head 1 month back with difficulty to eat or sign, blurred vision in both eyes and visual defect on the left side since 25 days.
EXAMINATION :
M.R.I of the brain was performed using the following parameters :
5 mm thick T1 Weighted, proton and T2 Weighted axial images.
3 mm thick FLAIR and 5 mm thick Fast Scan (T2 *) coronal images.
OBSERVATION :
There are ill-defined, hyperintense areas on the proton, T2 Weighted and FLAIR images in the white matter in the right cerebellar hemisphere, left middle cerebellar peduncle, right temporo-parietal region and in the right posterior parietal region. These lesions appear hypointense to normal white matter on the T1 Weighted images.
There is another similar lesion in the right inferior temporal region which is seen to involve the gray and white matter.
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.
IMPRESSION :
1. Altered signal intensity lesions in the white matter in the right cerebellar hemisphere, left middle cerebellar peduncle, right temporo-parietal region and in the right posterior parietal region is not specific for a single etiology. These most likely represent demyelinating lesions. The possibility of these lesions representing contusions as a sequelae of previous head trauma seems less likely.
2. Area of altered signal in the right temporal region involving the gray and white matter may represent a contusion in the given clinical setting.
However a contrast enhanced scan would be worthwhile.