Status post fall. Questionable loss of consciousness. Please evaluate. Positive headache. There is no evidence of intracranial hemorrhage, mass effect, edema or midline shift. Areas of hypodensity in the left superior frontal gyrus are unlikely related to the patient's trauma and may represent volume averaging. The cerebellar tonsils are low lying and appear at the level of the foramen magnum. Further imaging, such as with an MRI, is recommended.The ventricles and basal cisterns are normal in size and configuration.The calvaria and skull base are radiographically normal without evidence of fracture. The visualized paranasal sinuses and mastoid air cells are normally pneumatized.
No intracranial hemorrhage or calvarial fracture. There is an area of hypodensity in the left superior frontal gyrus and the cerebellar tonsils are low-lying. MRI imaging is recommended as clinically indicated.These findings were discussed with Dr. Paik at the time of interpretation.