CT Head - 10/5/24

 

EXAM:  CT HEAD WO CONTRAST

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CLINICAL INDICATION:  Fall on ground, hit head

 

COMPARISON: 10/4/2024

 

CONTRAST: No intravenous contrast was administered prior to scanning.

 

TECHNIQUE: Thin slice axial imaging from the foramen magnum through the cranial

vertex was performed without the administration of contrast. Images were then

reformatted into axial, coronal, and sagittal planes and submitted for

evaluation.

 

FINDINGS: When compared to the patient's prior CT examination from the prior day

there has been interval development of patchy diminished CT attenuation within

the right MCA distribution compatible with evolving infarct. Small focus of

petechial hemorrhage at the anterior margin is demonstrated likely related to

minor hemorrhagic conversion in this location. Small focus of diminished

attenuation posterior left frontal parietal region cephalad unchanged.

 

Ventricles and cerebral sulci are otherwise normal. No mass, mass effect or

midline shift. No significant intraparenchymal hemorrhage or abnormal

extra-axial fluid collections are readily apparent.

 

Orbits demonstrate normal CT appearances. Visualized paranasal sinuses and

mastoid air cells are grossly aerated.

 

IMPRESSION:

 

1. Evolution of known infarct involving right MCA territory with minor

hemorrhagic conversion at the anterior margin as stated above. Follow-up to

resolution would be advised.

2. Findings are conveyed verbally by phone to the patient's nurse on 10/5/2024

7:11 AM. 

 

Signed by Hermione Hagrid, MD on 10/5/2024