8  CT Brain Temp (Lesion)

8.1 Short Prelim

No

  • intracranial hemorrhage,
  • extra-axial collection,
  • acute large territorial infarction,
  • midline shift or brain herniation

identified.

8.2 Infarction

8.2.1 Lacunar

[A few | several] (small) well-defined hypodense lesions at

  • [anterior | posterior] limb of internal capsule

  • {side} lentiform nucleus,

likely chronic lacunar infarctions.

8.2.2 Small VV dz

(Mild) patchy hypodense changes involving at

  • [lt | rt | bilat] corona radiata
  • periventricular white matter of {lobe}

IMPRESSION:

  • (Mild) degree of small vessel disease.

8.2.3 Chronic Infarction

A wedge-shaped hypodense lesion at ___,

likely chronic infarction of the ___ artery territory.

8.3 Hemorrhage

8.3.1 SDH

[There is development of | New]

  • (+) [Acute | Subacute | Chronic] (on chronic) subdural hematoma (SDH) along [left | right] ___ convexity, measuring up to ?? cm in maximal thickness.

  • (+) crescent-shaped [isodense | hyperdense] lesion along ___ convexity, about ?? cm in maximal thickness; likely representing [Acute | Subacute | Chronic] (on chronic) subdural hematoma (SDH).

IMPRESSION:

  • [Increased | decreased] thickness of __ subdural hematoma (SDH) along __.

  • Thin (? mm) [Acute | Subacute | Chronic] SDH along ___.

8.3.2 SAH

SAH along

  • (+) [left | right | bilateral] cerebral sulci
  • (+) basal cistern
  • (+) [bilateral] MCA cistern
  • (+) [left | right | bilateral] Sylvian fissure.

8.3.3 Contusion

Hemorrhagic brain contusion at ___

8.4 Pressure Effect

Abbr: midline shift or brain herniation

Full

  • [left | right | bilateral] uncal herniations
  • descending transtentorial herniations
  • crowding of the foramen magnum
  • tonsillar herniation

8.4.1 No / Not change

No uncal herniation, descending transtentorial herniations, crowding of the foramen magnum, or tonsillar herniation is seen.

No significant change of pressure effects, seen as …

8.4.2 Yes

Pressure effect [causing | is seen as] …

  • (+) effacement of adjacent [left | right | bilateral] {lobe} ___ sulci,

  • (+) ?-mm rightward | leftward midline shift

  • (+) (impending) ___ herniation

IMPRESSION:

  • Increased pressure effects are seen as

8.5 Calcification

(Dense) calcification(s) [at | along]

  • [bilateral] globus pallidus.
  • falx cerebri

(is noted.)

8.6 Chronic lesion

(Chronological change of ___, now seen as…)

encephalomalacia/gliosis change

  • (+) with volume loss, and

  • (+) associated ex-vacuo dilatation of the ___ ventricles.

IMPRESSION:

  • Sequelae of old traumatic contusion seen as encephalomalacia/gliosis change at ___ and associated ex-vacuo dilatation of ??? ventricles.

8.7 Post Op

8.7.1 Craniotomy

Evidence of ___ craniotomy is noted,

along with post-operative changes seen as

  • (+) dural thickening with calcification along ___

  • (+) (small) extradural fluid collection, measuring up to __ mm in maximal thickness.

  • (+) [Increased | Decreased] degree of scalp swelling and soft tissue gas along surgical site.

IMPRESSION:

  • Post ___ craniotomy, with post operative changes seen as dural thickening and calcification. (small) extradural fluid collection is still noted.

8.8 Tube / Line

Feeding: Feeding tube placement via ___ nostril.