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CT Head Super

TECHNIQUE: 5 mm helical CT images were obtained through the brain without the use of contrast. Sagittal and coronal reconstructions were obtained. Findings:

NORMAL: There is no acute intracranial pathology. Normal gray-white matter differentiation is preserved. There is no hydrocephalus. The ventricles and sulci are normal for age. There is no hemorrhage, infarct, edema, mass effect, midline shift or herniation. No neoplastic changes are identified. There is no abnormal extra-axial fluid collections. The osseous structures are normal. There is no skull fracture. The calvarium is otherwise unremarkable. There is normal aeration of the mastoid air cells and paranasal sinuses. Soft tissues are normal.

EPIDURAL HEMATOMA, COUNTRECOUP, SUBDURAL: The brain parenchyma demonstrates right-sided temporoparietal hyperdensity of lenticular shape measuring 1.6 x 4.0 cm in axial plane, consistent with an epidural hematoma. An adjacent nondisplaced linear fracture traverses the squamosal portion of the right temporal bone and right parietal bone. Left cerebral hemisphere demonstrates contralateral contrecoup temporal lobe contusion. Hypodensities in the bilateral anterior temporal lobes and orbital frontal cortex bilaterally are suspicious for contusions in these locations. Thin subdural hematoma is noted along the left frontal and parietal lobes. There is mild mass effect from the contusions with mild diffuse sulcal effacement however there is no significant herniation at this time. Ventricles and subarachnoid cisterns are unremarkable. The skull base foramina are unremarkable.

MASS: There is a 3 cm rounded mass isodense to gray matter in the right temporal lobe. There is significant surrounding vasogenic edema involving [the majority of the right temporal, occipital and parietal lobes] nearly the entire right cerebral hemisphere, with significant surrounding mass effect and effacement of all of the CSF spaces including the right lateral and third ventricles, the basilar cisterns and Sylvian fissure and with leftward displacement of the uncus and brainstem. [There is significant mass effect on the atrium and temporal horn of the right lateral ventricle.] There is no acute hemorrhage associated with the mass.

MCA Stroke: The right MCA is hyperdense. The right insular ribbon is hypodense as compared to the left. There is obscuration of right basal ganglia. Increased right sulcal effacement is seen.

F/U MCA Stroke: The patient is status post right MCA distribution stroke. Continued hypodensity is seen in the MCA distribution with obliteration of the frontal horn of the right lateral ventricle and sulcal effacement. There is no evidence of hemorrhagic transformation or herniation. Otherwise, the remainder of the examination is unchanged in the interval. Again noted is a dense right MCA with a large, geographic distribution of low-attenuation within the expected distribution of the right middle cerebral artery. The decreased attenuation has become more prominent in the interval. Increased right sulcal effacement is seen.There has been slight decrease in size in the frontal horn of the right lateral ventricle. No herniation is seen. There is no hemorrhage seen. There has been no significant change in the degree of mass effect on the right lateral ventricle or midline shift since the recent comparison, secondary to continuing evolution of a large right MCA infarct. Sulcal effacement within the area of infarct with otherwise no effacement of the basilar cisterns is identified. Hypodensity within the caudate head and along the medial aspect of the right frontal lobe likely represent infarct in a watershed distribution involving the right anterior cerebral artery. This finding also remains stable from the recent comparison. There is no intracranial hemorrhage or evidence of obstructive hydrocephalus.

THROMBUS: The hyperdensity in the right internal carotid artery near the skull base as well as the hyperdense thrombus near the right insular ribbon remain unchanged.

Increased expansion and pneumatization of the frontal sinuses with a depression deformity involving the left frontal sinus along with soft tissue scarring is suggestive of remote trauma. Mild right to left midline shift is present measuring approximately 4 mm. There is mild medial displacement of the right temporal lobe however no significant uncal herniation is noted at this time. There is 5 mm of subfalcine herniation. There is no herniation of the cerebellar tonsils inferiorly through the foramen magnum. Central hypodensity in the right posterior temporal occipital junction may be secondary to necrosis. There is mild dilatation of the left lateral ventricle. There is a focus of hypodensity in the right posterior caudate. There is no effacement of the right gyri. There is a 6 mm focus of encephalomalacia within the white matter adjacent to the right frontal horn of the right lateral ventricle. A larger focus of encephalomalacia is seen in the right frontal lobe extending to the inner table of the calvarium (series 300B image 24). There is mild global volume loss with concomitantly increased intra and extra-axial CSF-containing spaces. Periventricular white matter chronic microvascular ischemic changes are noted. Atherosclerotic calcifications are seen in the cavernous carotids and vertebrobasilar arteries. Mild degenerative changes are seen between the anterior arch of C1 and the dens of C2. There is near complete opacification of the right maxillary sinus. The calvarium is otherwise unremarkable. There is a fracture of left anterior and posterior maxillary sinus wall with air-fluid level and fat entrapped within the sinus. There is also left zygoma fracture and minimally displaced inferior orbital floor fracture extending through the infraorbital canal. There is mild diffuse enlargement of ventricles and extra axial CSF spaces. Scattered hypodensities in the periventricular white matter are consistent with small vessel ischemic change. There are mild diffuse periventricular white matter hypodensities, compatible with chronic ischemic small vessel disease. Mild diffuse periventricular white matter hypodensities in association with mild cerebral atrophy is likely secondary to chronic small vessel ischemic disease. There are mild chronic microvascular ischemic changes in the supratentorial white matter, as well as mild brain parenchymal atrophy. Ocular lenses are surgically absent bilaterally. Degenerative changes are noted at the C1-C2 level. 5 mm hypodensity in the right anterior thalamus is likely unchanged from prior study and may represent an old lacunar infarct. There is a 5 mm hypodensity seen within the left caudate head, putamen, globus pallidus, thalamus consistent with prominent perivascular space versus old lacunar infarct. Stable atherosclerotic calcifications are seen in the distal internal carotid arteries and vertebrobasilar system. Dense atherosclerotic calcifications are identified in the superficial scalp arterial branches. [Dense atherosclerotic calcifications are noted in the superficial and intracranial vasculature.] Mild circumferential mucosal thickening involving the ethmoid and frontal sinuses with small bilateral air-fluid levels within the maxillary sinuses are demonstrated. There is near-complete opacification of the bilateral maxillary sinuses, sphenoid and ethmoid sinuses secondary to pansinus disease, which has slightly worsened since the recent comparison. There is bilateral soft tissue density seen within the external auditory canal with complete occlusion of the left external auditory canal. This finding is probably secondary to cerumen. Incidentally noted is a nasopalatine duct cyst. The patient is status post right-sided decompressive craniotomy and left-sided ventriculostomy tube placement. The patient is status post left posterior fossa craniotomy. Postoperative craniectomy changes are stable. The ventriculostomy tube terminates within the body of the left lateral ventricle. There is minimal increased hemorrhage within the right cerebral hemisphere as compared to the prior exam. Diffuse right-sided sulci effacement, slightly increased from the prior exam is noted with interval expected evolution of the previously described blood product. There is stable to minimally increased right to left subfalcine shift. Prominent right frontal scalp hematoma is noted. Intraventricular hemorrhage is unchanged. Previously described pneumocephalus has improved. There are stable postsurgical changes consisting of a right frontal parietal ventriculostomy catheter which terminates in the right lateral ventricle near the foramen of Monroe. There is partial visualization of an endotracheal tube and nasogastric tubes in the oropharynx. Orbits and globes are unremarkable by noncontrast CT appearance. Staples are identified in the right parietal scalp. There is a dense pack of coils seen in the region of the left posterior communicating artery secondary to recent aneurysm coiling which results in mild streak artifact. Ventricles are stable to minimally decreased in size since the recent comparison with a newly developed small left frontal convexity subdural hygroma, of uncertain etiology, question over shunting. There has been expected mild interval decrease in the amount of subarachnoid and intraventricular hemorrhage seen layering in the atria of the lateral ventricles and along the sulci of the left hemisphere. The subdural fluid and soft tissue changes have resolved. There has been minimal interval decrease in the size of the right infraorbital subcutaneous hematoma, which is incompletely visualized on this head CT field-of-view. The surrounding right facial soft tissue swelling is almost completely resolved. There are no calvarial lesions. There is chronic left apex nasal septum deviation. Impression: Large area of vasogenic edema involving the right temporal, occipital and parietal lobes suspicious for underlying neoplasm, either primary or metastatic. This finding will be better evaluated with MRI which is already ordered. Right temporal lobe mass with surrounding vasogenic edema and pronounced mass effect causing effacement of the basilar cisterns and subfalcine herniation. Differential considerations include neoplasm such as metastatic or primary brain and infection. Right-sided temporal epidural hematoma with nondisplaced fracture of the right temporal and parietal bones. Right hypodense insular ribbon, hyperdense MCA, sulci effacement and obscuration of the right posterior caudate likely represent an early right-sided infarct. Evolving right M1 distribution MCA stroke. Cytotoxic edema appears slightly worsened in the interval, given the greater prominence of the geographic low attenuation, worsened sulcal effacement, and decreased ventricle size. No hemorrhage is seen. No CT evidence of acute intracranial pathology. Senescent changes without CT evidence of acute intracranial pathology. Chronic ischemic and senescent changes of the brain. If there is continued concern for infarct, recommend repeat head CT in 12 to 24 hours vs MRI. Resolving subarachnoid and intraventricular hemorrhage status post left posterior communicating artery aneurysm rupture with overall stable exam from the recent comparison. Occlusion of the left external auditory canal by soft tissue density, likely cerumen. Recommend correlation with physical exam. Status post decompressive right-sided craniectomy and hematoma evacuation with expected interval evolution. As compared with the prior exam, there has been mild increased hemorrhage with increasing sulcal effacement and right to left-sided shift. Large right frontal scalp hematoma. Senescent changes without acute intracranial pathology. Multiple contusions as described above. Small left frontal and temporal subdural hematomas. Comparison with prior exams is suggested. Stable to mild interval decrease in size of the lateral ventricles with newly developed small left frontal convexity subdural hygroma. Findings could be related to over shunting. Expected interval evolution of intraventricular and subarachnoid hemorrhage in this patient status post aneurysm coiling. The right infraorbital subcutaneous hematoma is minimally smaller, and there has been interval improvement in the right facial post traumatic edema since the comparison study. The patient is status-post resection of the right petrous bone and placement of and metallic mesh plate. There is a right carotid stent. There is diffuse erosive change of the skull base, not significantly changed from prior. There is mucosal thickening of the left sphenoid sinus. Discussed with Dr. [] at 1334 hours. *********************************** Comparison: CT head on October 16, 2008. Technique: Helical CT mages were obtained through the head without contrast. Sagittal reformations were obtained. Findings: There has been no significant change since the prior CT. The bilateral lateral ventricles have slight decreased in size from the 2008 examination, right greater than left. The ventriculoperitoneal shunt tip is located in the right lateral ventricle and is unchanged in position. There is no midline shift or intracranial hemorrhage. There is no change in appearance of the patient's known Chiari 2 malformation. The orbits and calvarium are unremarkable. Impression: 1. Stable appearance of the VP shunt with its tip in the right lateral horn. 2. Appearance of the bilateral lateral ventricles appear decreased in size compared to the 2008 examination, with right ventricle appearing much smaller than the left. ****************** Comparison: CT head performed one day ago. Technique: Helical CT images were obtained through the head without contrast. Sagittal reformations are available. Findings: There is a right thalamic hemorrhage which appears stable in size and density since yesterday's exam. There is minimally decreased surrounding edema, stable from prior. Hyperdense blood layering within the occipital horns of the lateral ventricles is resolving in the interim. There is no evidence of new infarct or hemorrhage. There is no hydrocephalus or midline shift. The remainder of the exam is unchanged. Impression: Stable appearance of the right thalamic hemorrhage with associated areas of vasogenic edema and with decreased intraventricular blood in the interim. ************************* Findings: There is no hemorrhage, mass effect, hydrocephalus, pathologic fluid collection or herniation. A wedge-shaped region of encephalomalacia in the right frontal lobe is unchanged. There is diffuse periventricular white matter hypodensity compatible with chronic microvascular ischemic disease. There is also mild diffuse brain parenchymal volume loss with commensurate mild prominence of the CSF-containing spaces. The calvarium is intact with the exception of stable-appearing craniotomy sites along the right parietal and occipital skull. There are no calvarial lesions. The paranasal sinuses are clear. Enteric and endotracheal tubes are incompletely visualized. Impression: 1. No acute intracranial pathology. 2. Chronic, postsurgical and senescent changes; see comments above. ******************************** Subcentimeter hypodensities in the periventricular white matter most likely represent a smaller lacunar infarcts. Dystrophic calcifications are again noted in the right medial cerebellum. There is mild global volume loss with concomitantly increased intra and extra-axial CSF-containing spaces. Periventricular microangiopathic ischemic changes are noted. There is no hemorrhage, edema, mass effect, hydrocephalus, herniation, or pathologic fluid collection. Atherosclerotic calcifications are seen in the cavernous carotids, left MCA, and vertebrobasilar arteries. Degenerative changes are seen between the anterior arch of C1 and the dens of C2. The calvarium is unremarkable. The right ocular lens is surgically absent.