80 year-old male status post fall with head laceration. CT HEAD:There is a left parietal scalp hematoma with foci of subcutaneous air consistent with the patient's history of scalp laceration. No skull fracture underlying this location or elsewhere.There is no acute intracranial hemorrhage or extra-axial fluid collection. Ventricles and sulci are normal. There is no mass effect, midline shift, or basal cistern effacement.Again seen is an area of hypoattenuation in the right insular cortex and temporal lobe which appears grossly unchanged when compared to the MRI performed last month. There is no evidence of new intracranial mass. There is preservation of the gray-white matter interface. There is no evidence of acute territorial ischemia. Previously described small vessel ischemic disease is poorly seen on CT examination. Moderate calcification of the intracranial vessels. Small maxillary sinus retention cysts or polyps are present. The visualized mastoid air cells and remaining paranasal sinuses are clear. The visualized orbits are within normal limits. There is no evidence of retrobulbar hematoma. The lenses are not well visualized bilaterally consistent with the prior MRI findings of cataract surgery. CT CERVICAL SPINE:There is mild rightward curvature at the cervicothoracic junction. However, there is no evidence of acute malalignment or fracture. It should be noted that CT does not evaluate for ligamentous stability. There is moderate to severe degenerative disc disease affecting the cervical spine. There are multilevel disc osteophyte complexes most pronounced at the level of C5/6 and C6/7 with partial ventral thecal sac effacement. Severe facet arthropathy is present, greatest at left C4-C5 which appears nearly fused. There is severe uncovertebral joint hypertrophy at the levels of C5/6 and C6/7, associated with severe neuroforaminal narrowing at right C6/7.Redemonstrated bilateral pleuroparenchymal scarring, on the left with associated calcifications. The remainder of the lung apices are clear. There is diffuse heterogeneity of the thyroid gland without evidence of a dominant nodule. Severe left and mild right carotid bifurcation calcifications.
1. Left scalp laceration without skull fracture or acute intracranial hemorrhage. 2. Redemonstration of right temporal lobe mass characterized by recent MRI examination.3. No evidence of fracture or acute malalignment of the cervical spine. It should be noted that CT does not evaluate for ligamentous stability. 4. Moderate cervical spine degenerative changes.