Diagnostic: Intraventricular and brainstem hemorrhage. Due to head injury. (September 1993).

Patient's current situation

1. Cognitive function (Intelligence): In good condition. Currently following university program. Studying via copied books and cassette recorded lectures.

Visual function (Eyesight and hearing): Good (100% ability).

Speaking ability: No clear pronunciation (lisp), no repeating, and no stammering. Having approximately 70% of normal speaking ability.

2. Movements:

• Right hand can move rather freely, can write, bend, and stretch. Fingers and move well and have good sense. Overall assessment: right hand has approximately 50 - 60% normal ability. Left hand is much less capable than right hand, can bend and stretch but is unable to hang horizontally or higher. Overall assessment: left hand has 15% of normal ability.
• Legs keep enshrined and have good sensation. Arthreses are in normal condition. Unable to stand. Right leg is in better condition than left leg. When lying, patient can bend and stretch legs but with hard efforts.

General assessment:

Right leg has 20% of normal ability

Left leg has 10% of normal ability

Vetebral column: Normal . Patient can sit (with fixing belts) for 4 - 5 hours.

3. No sphincter disturbance

4. Eating and drinking: Patient can eat and drink but slow and easy choke when drinking.

5. Sleeping: Normal . 6 hours per night.

6. Heart and lung:

Normal heartbeat frequency. Blood pressure: 110/70 mmHg.

7. Urinary tract: Normal .

REPORTS OF CT-SCANNER AND MRI

• 6-9-1993

CT Scanner without intravenous application of contrast media.

In the pons, there is a hyperdensity zone of a hemorrhage, which seems to be communicated with the 4 th ventricle. The hemorrhage is seen also in occipital horns of two lateral ventricles, which are discretely dilated

The cerebral edema is not seen. There is no fracture seen on the skull

Impression: hemorrhage in the pons and ventricles.

• 1-4-1997

There is a small porencephalia (4 x 10 mm) in the center of the pons. Citernes peripedoncular and ponto-cerebellar are dilated.

Sizes and shapes of the 3 rd and lateral ventricles are normal

Impression: porencephalia post-traumatic.

• 6-3-2000

MRI without intravenous application of Gadolinium

There is a dilatation of peripedoncular pons-cerebella and great citerne associated with a hypotrophia and porencephalia in the center of the pons

There no abnormality of the cerebral and cerebrally parenchyme

Impression: hypertrophy and porencephalia posttraumatic in the pons