sb/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyzh Blmn / M / 51 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
H/O RTA on 00.00.00.
C/O irrelevant talk since then.
Known hypertensive.
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 are ill-defined, hyperintense areas on the proton, T2 Weighted and FLAIR images in the high parietal cortex bilaterally. These lesions appear isointense to normal brain parenchyma on the T1 Weighted images.
Small bright foci on the proton and T2 Weighted images are noted in the subcortical white matter in the left high parietal region and may be ischemic in etiology.
The CSF space in the fronto-temporal regions bilaterally appears slightly prominent.
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.
A subgaleal hematoma is noted in the right fronto-temporo- parietal region and in the periorbital region.
An air-fluid level is noted in the right maxillary antrum and in the sphenoid sinus which may represent blood, in the given clinical setting of trauma. Hyperintense signal on the T2 Weighted images in the left middle ear may represent blood/inflammatory changes.
IMPRESSION :
1. Altered signal in the high parietal cortex bilaterally most likely represents cortical contusions, in the given clinical setting.
2. Prominent CSF space in the fronto-temporal regions bilaterally may represent subdural effusion in the given clinical setting.
3. A subgaleal hematoma in the right fronto-temporo-parietal region and in the periorbital region.
4. Air-fluid level in the right maxillary antrum and in the sphenoid sinus which may represent blood, in the given clinical setting of trauma.