31-year-old man with seizure yesterday. Known seizure history. Fell with trauma and contusion to left eye. There is no evidence of intracranial hemorrhage, mass or edema. Right temporal encephalomalacia is present with ex vacuo dilatation of the trigone of the right lateral ventricle -- this finding has been previously evaluated with MRI and is stable. The ventricles and basal cisterns are otherwise normal in size and configuration.Findings of left orbit trauma are partially visualized including blowout fracture of the lamina papyracea with herniation of orbital fat into the left ethmoid air cells, thickening of the medial rectus muscle, and orbital emphysema. The visualized paranasal sinuses and mastoid air cells are otherwise normally pneumatized.
1. Partially visualized findings of the left orbit trauma including medial wall fracture. If clinically appropriate, consider dedicated orbital CT.2. No CT findings of intracranial traumatic injury.