sb/ke/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Palmn / F / 22 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

H/O seizures since 8 years.
H/O seizure and subsequent fall from a height of 1st floor, 10 days back.
H/O bifrontal craniotomy with drainage of large extradural hematoma done on 00.00.00.

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 6 mm thick T1 Weighted coronal images.

OBSERVATION :

There is evidence of a bifrontal craniotomy with post-operative changes in the subgaleal soft tissues in that region.

There is still seen an epidural hematoma overlying the left cerebral hemisphere with a maximum width of about 5.0 mms. This lesion is hyperintense on the T1 Weighted images but relatively hypointense on the T2 Weighted images suggesting early subacute blood. At the vertex, this epidural hematoma is seen to extend slightly to the right of the midline and lies between the skull vault and the superior sagittal sinus. The superior sagittal sinus however shows normal flow void signal on the spin-echo pulse sequences. Slight effacement of the cortical sulcal spaces in the left cerebral convexity is noted. Minimal haemorrhage is seen to extend into the anterior interhemispheric fissure.






There is an ill-defined, hyperintense signal on the proton, T2 Weighted and FLAIR images along the left temporal cortex. This lesion appears relatively hypointense to normal grey matter on the T1 Weighted images. Ill-defined, hyperintense signal on all the pulse sequences is also noted within this lesion which suggest late subacute haemorrhage.

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.

An undisplaced fracture of the left parietal bone is noted.

Inflammatory changes are noted in the left mastoid air cells.

IMPRESSION :

1. Post-operative status.

2. An epidural hematoma overlying the left cerebral hemisphere with a maximum width of about 5.0 mms.

3. A left temporal cortical haemorrhagic contusion.

4. Fracture of the left parietal bone.

As compared to the previous CT Scan dated 00.00.00, there is decrease in the size of the frontal epidural hematoma and decrease in the mass effect.