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19999987-RR-18

RR

2145-11-03 04:35:00

2145-11-03 10:46:00

INDICATION: ___ female intubated for head bleed, who presents for evaluation of pneumonia. COMPARISONS: Chest radiographs from ___. TECHNIQUE: Single AP portable exam on the chest. FINDINGS: The ET tube terminates approximately 2.9 cm from the carina. The NG tube courses below the diaphragm with the tip out of the field of view of the film. There has been interval worsening of the right linear opacification likely secondary to atelectasis. No pneumothorax or definite pleural effusion is seen. The hilar and mediastinal contours are normal. There is mild cardiomegaly, stable compared to the preior exam. IMPRESSION: Slight interval worsening of right lower lung atelectasis.

19999987-RR-19

RR

2145-11-03 16:40:00

2145-11-04 08:36:00

HISTORY: ___ woman with left occipital hemorrhage of unclear etiology. Assess for infarct or underlying mass lesion. COMPARISON: CTA head and CTA neck on ___. TECHNIQUE: Multiplanar, multisequence T1- and T2-weighted images were acquired through the head before and after administration of IV gadolinium contrast. Diffusion-weighted images and ADC maps were also obtained for evaluation. FINDINGS: Again noted is a large intraparenchymal hemorrhage centered at the left occipital lobe. There is ___ edema with moderate mass effect on to the adjacent parenchyma. No shift of normally midline structures is noted. There is no definite evidence of intraventricular hemorrhagic extension. There is evidence of a developmental venous anomaly (DVA) traversing in the vicinity (image 10:16). An additional focus of susceptibility artifact is noted in the left temporal lobe (image 6:10). The ventricles remain normal in size and symmetric in configuration. The gray-white matter differentiation is well preserved in the remaining parenchyma. There is mild superimposed periventricular T2/FLAIR hyperintensity, nonspecific but could represent mild chronic microvascular ischemic disease. Allowing for the obscuration of the intrinsic T1 hyperintensity from the hemorrhage, there is no abnormal post-contrast enhancement. Major vascular flow voids are present. There is no slow diffusion to suggest acute infarction. There is moderate amount of retained fluid in the right mastoid air cells. The remaining visualized paranasal sinuses and left mastoid air cells are clear. The globes are symmetric. IMPRESSION: 1. Large left occipital intraparenchymal hemorrhage, unchanged and with persistent mass effect on to the adjacent parenchyma. No midline shift or intraventricular hemorrhagic extension. No acute infarcts or definite postcontrast enhancement. 2. A small DVA traversing in the vicinity of the left occipital intraparenchymal hemorrhage. The presence of a nearby DVA favors the differential of cavernous malformation (hemangioma cavernoma) which hemorrhaged. 3. A punctate susceptibility artifact in the left temporal lobe, could represent either a second cavernoma or an old microhemorrhage. Consider short-term follow-up after resolution of acute hemorrhage to better assess the underlying pathology.

19999987-RR-20

RR

2145-11-04 05:10:00

2145-11-04 08:58:00

PORTABLE CHEST OF ___ COMPARISON: ___ radiograph. FINDINGS: There has been interval extubation and improved lung volumes compared to the recent radiograph. Bibasilar atelectasis has nearly resolved with residual patchy atelectasis remaining in the right lower lobe and only minimal residual linear atelectasis in the left lower lobe. Apparent rightward deviation of the trachea is likely due to mild patient rotation and curvature of the spine, as there is no evidence of a discrete paratracheal mass on recent neck CTA of ___. Cardiac silhouette is stable in size. No pleural effusion or pneumothorax.

19999987-RR-21

RR

2145-11-07 15:18:00

2145-11-08 16:44:00

DATE OF SERVICE: ___. PRE-OPERATIVE DIAGNOSIS: Left occipital hemorrhage. INDICATION: Rule out vascular malformation. ATTENDING PHYSICIAN: ___, M.D. ASSISTANT: ___, N.P. ANESTHESIA: Moderate sedation was provided by administering divided doses of fentanyl and Versed throughout the total intraservice time of 45 minutes, during which the patient's hemodynamic parameters were continuously monitored. PROCEDURES PERFORMED: Right internal carotid artery arteriogram, right external carotid artery arteriogram, left internal carotid artery arteriogram, left external carotid artery arteriogram, left vertebral artery arteriogram, right common femoral artery arteriogram and Angio-Seal closure of right common femoral artery puncture site. DETAILS OF THE PROCEDURE: The patient was brought to the angiography suite. IV sedation was given. Following this, both groins were prepped and draped in a sterile fashion. Access was gained to the right common femoral artery and a 5 ___ vascular sheath was placed in the right common femoral artery. We now catheterized the above-mentioned vessels and AP, lateral filming was done. This did not show evidence of brain aneurysm. At this point, the right common femoral artery arteriogram was done and a 6 ___ Angio-Seal was used for closure of the right common femoral artery puncture site. FINDINGS: Right internal carotid artery arteriogram shows filling of the right internal carotid artery along the cervical, petrous, cavernous, and supraclinoid portion. The anterior and middle cerebral arteries fill well. The PCA is seen to be fetal in origin. There is a vascular blush in the lateral aspect of the orbit; however, there is no evidence of a dural AV fistula. The ophthalmic artery is also seen to give rise to a large branch which seems to course superiorly through the superior orbital fissure most likely anastomosing with the middle meningeal artery. Right external carotid artery arteriogram shows no evidence of dural AV fistula. Left internal carotid artery arteriogram shows filling of the left internal carotid artery along the cervical, petrous, cavernous, and supraclinoid portion. The anterior and middle middle cerebral arteries are seen normally with no evidence of arteriovenous malformation or dural AV fistula. There is a prominent posterior communicating artery; however, this is not fetal in nature. Left external carotid artery arteriogram shows no evidence of dural AV fistula. Left vertebral artery arteriogram shows filling of the left vertebral artery with reflux into the right vertebral artery. The left PCA is seen; however, the right PCA is not seen because of the hypoplastic nature of the right P1. The superior cerebellar arteries are seen well. There is mass effect on the distal branches of the left PCA; however, there is no definite evidence of an arteriovenous malformation. One cortical vein draining into the superior sagittal sinus is seen early, but there is no definite evidence of a nidus. Right common femoral artery arteriogram shows widely patent right common femoral artery. IMPRESSION: ___ underwent cerebral angiography which failed to reveal a source of hemorrhage in the left occipital lobe. There was a vein which appeared slightly early in the left vertebral artery injection draining into the left superior sagittal sinus; however, this was not consistent with an AVM and angiogram should be repeated in a month's time after the mass effect from the hematoma has resolved.