Maazo's Y2K TBI: MaazoEtsoh 1999 TBI Brain Surgery ICU 002

Magnetic Resinance Imaging

Diagnostic Report:
(PROCEDURE) AT 1020 HOURS Diagnosis: Montrose Memorial Hospital Medical Imaging Services 800 South Third Street Montrose, CO 81401 970-240-7314 Patient: PETERSEN,MARVIN D Date: 12/12/11 MR #: M000385902 Adm MD: DOB: 03/16/nyofb Acct #: V00001267689 Att MD: HEHMANN,MICHAEL F MD Age: 60 Req #: 11-0034671 Ord MD: HEHMANN, MICHAEL F MD Rm/Bed: Status: REG CLI Pt Phone#: (970)399-7170 Birad Code: Reason for visit: SEIZURES Patient Letter: 1212-0002 MRI/BRAIN W/O CONTRAST REASON FOR EXAMINATION: Recent seizure activity. Fall with a head injury in 1999. Previous left-sided parietal surgery with placement of a plate. MRI BRAIN WITHOUT CONTRAST. TECHNIQUE: Sagittal and axial T1 SE, axial fat saturated T2 FSE, axial FLAIR, axial gradient recall echo, and axial DWI with ADC map. FINDINGS: Comparison studies would be critical in thorough evaluation of today's examination. If they can become available, direct comparison can be made to determine the stability of many of the findings described below. If a comparison study cannot be obtained, contrast is recommended to evaluate some of the lesions, for example the left inferior frontal lesion, as described below. There is moderate volume loss with compensatory expansion of the ventricles and extra-axial spaces. There is gliosis and encephalomalacia within the right frontal lobe, compatible with the patient's prior head injury. In addition, there is cystic change with volume loss and ex vacuo expansion of the temporal horn of the left lateral ventricle as seen on coronal image 14 of series 10. There is a small rounded cystic focus within the left posterior frontal lobe, image 16 of series 4.If this is a new finding, contrast would be useful in excluding a primary glial tumor. There is no intracranial hemorrhage. There is no deviation of the midline. There is no extra-axial collection. The orbits and globes are normal. The paranasal sinuses and mastoid air cells are clear. IMPRESSION: Multiple findings as described in detail in the above report. Comparison examination would be very useful in further evaluation. These findings include: 1. A rounded cystic focus within the posterior left frontal lobe. This measures 5 mm in size and may be chronic in nature, but if it is a new finding, contrast would be important to exclude a primary neoplasm. 2. Postsurgical changes and volume loss within the inferior left temporal lobe. 3. Posttraumatic gliosis and encephalomalacia right frontal lobe. Dictated by: RAZIANO, RANDALL M MD Signed by: Transcribed By: Approved By:Radiologist:

Maazo's Y2K TBI

Wednesday, August 11, 2010

MaazoEtsoh 1999 TBI Brain Surgery ICU 002

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