Clinical question to be answered: Status post fall from 3 stories with low GCS upon arrival. Now with posturing. Examination redemonstrates extensive previously noted post traumatic findings of the skull fracture, small left frontal subdural and pneumocephalus. There is no evidence of parenchymal hemorrhage or definitive edema on the current exam. The ventricular size and basal cisterns remain similar and within normal limits to prior study and with no evidence of any compromise. No evidence of midline shift or hydrocephalus. No evidence of transtentorial herniation.Extensive scalp hematoma on the left is again identified. New since prior examination this placement of a intracranial pressure monitor with minimal adjacent pneumocephalus.Further evaluation for the extent of brain parenchymal injury with an MRI is again recommended.
1.No evidence of new hemorrhage or edema. Stable ventricular system and basal cisterns.2.Right frontal ICP monitor.