Presentation
Previous admission with fall/head injury. Right parietal skull fracture managed conservatively.
Patient Data
Comminuted depressed right parietal skull fracture with overlying hematoma and associated pneumocephalus.
No acute hemorrhage. Significant cerebral atrophy. Moderate small vessel disease and established right thalamic and pontine infarcts.
New admission with focal neurology - left sided hemiparesis and neglect, gaze deviation to right, variable conscious level. Also pyrexial.
Acute onset of symptoms (witnessed by family), no recent history of falls or trauma.
Open wound over area of previous skull fracture.
Intraparenchymal hyperdensity in right parietal lobe. Collection is lying under existing skull fracture. Pneumocephalus more prevalent than on previous imaging. No significant mass effect.
No evidence of hematoma or bony injury other than poorly healed right skull fracture.
The right parietal hyperdensity was managed as hemorrhage however with no overt history of trauma, but an exisiting skull fracture, antibiotic therapy was commenced for possible abscess formation.
An MRI was planned (with contrast and DWI sequences) to further characterize this, however the patient deteriorated and underwent further CT imaging.
No worsening of hemorrhage nor new acute bleeds.
Marked extension of of pneumocephalus with evidence of spread to lateral ventricles, basal cisterns and pre-pontine spaces.
Case Discussion
This case was managed conservatively in a neurosurgical center and eventually the patient was palliated.
The onset of the latter presentation is unclear but from the collateral history it did sound like an acute deterioration with associated neurology so a bleed is more likely than an abscess. However, it was suspected that the wound was poorly healing or may have been disturbed since the initial presentation which may have contributed to the eventual findings.
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