Findings
- Thin subdural collection along the interhemispheric falx measuring 2 mm in thickness
- Trace susceptibility artifact in the dependent aspects of the occipital horns of both lateral ventricles
- Additional small focus of susceptibility artifact in the right frontal white matter
- Remote lacunar infarcts in the left frontal periventricular white matter and left caudate body
- Generalized cerebral volume loss
- Patchy subcortical and periventricular T2/FLAIR white matter hyperintensities
- Bilateral subgaleal scalp fluid collections
- Left mastoid and middle ear effusion with possible asymmetric soft tissue in the left posterior nasopharynx
- Moderate mucosal thickening of the left maxillary sinus
- Bilateral pseudophakia
- Postsurgical changes in the upper cervical spine with abnormal signal centrally in the upper cervical spinal cord
Diagnosis
Subdural hematoma
Sample Report
Thin subdural hematoma along the interhemispheric falx measuring 2 mm in thickness without associated mass effect.
Trace susceptibility artifact in the dependent aspects of the occipital horns of both lateral ventricles represents age-indeterminate trace intraventricular hemorrhage.
An additional small focus of susceptibility artifact in the right frontal white matter likely represents sequela of prior microhemorrhage.
Remote lacunar infarcts in the left frontal periventricular white matter and left caudate body on a background of generalized cerebral volume loss and chronic small vessel disease.
Left mastoid and middle ear effusion with possible asymmetric soft tissue in the left posterior nasopharynx. Recommend correlation with direct visual inspection to exclude an obstructing mucosal neoplasm.
Postsurgical changes in the upper cervical spine with abnormal signal centrally in the upper cervical spinal cord possibly representing myelomalacia. Recommend correlation with dedicated MR imaging of the cervical spine.
Discussion