From the Guidelines
The patient can be safely discharged with no need for further CT scans or medical intervention, given the normal CT head findings and no evidence of neurologic deterioration, as supported by the American College of Radiology's 2021 update on head trauma 1. The CT scan of the head shows normal findings with no evidence of any abnormalities. The brain tissue appears healthy with no signs of bleeding, tumors, or stroke. The ventricles (fluid-filled spaces) and surrounding structures are normal in size and position. There is a retention cyst or mucosal polyp in the sphenoid sinus, which is unchanged from a previous CT scan from April 2025. This is a common, benign finding that typically requires no treatment. The skull bones are intact with no concerning lesions. The sella turcica, which houses the pituitary gland, is normal in size. Some key points to consider in this case include:
- The risk of deterioration with a normal CT and neurologic examination is very low (0.006%) 1.
- Patients with a normal CT but with an abnormal neurologic examination are typically admitted for observation 1.
- The necessity of routine repeat CT in the presence of a normal initial CT and in the absence of neurologic deterioration is controversial, with some guidelines recommending against it 1.
- The risk of delayed traumatic intracranial hemorrhage in patients with coagulopathy and a normal initial CT is low, even on anticoagulant or antiplatelet medication 1. Overall, this is a completely normal CT scan of the head with no concerning findings that would require medical intervention or follow-up, and the patient can be discharged with no need for further evaluation, as the current evidence suggests that the risk of complications is very low 1.
From the Research
CT Head Findings
- The brain parenchyma demonstrates no focal finding, with no intracranial hemorrhage, mass, or infarct 2
- The ventricles and basal cisterns are normal in caliber, with no mass effect or midline shift
- The gray-white differentiation is preserved
- Mastoid air cells and extracranial soft tissues are unremarkable
Sphenoid Sinus Findings
- Retention cyst/mucosal polyps in the sphenoid sinus, similar to CT performed April 9,2025
- Studies have shown that sphenochoanal polyps are solitary masses of low attenuation on computed tomographic (CT) scans that arise from the sphenoid sinus 3
- The incidence of sphenoid sinus cysts has apparently increased in recent years, with common symptoms including headache and ocular disturbance 4
Diagnostic Approaches
- CT, MRI, and nasal endoscope provide the greatest diagnosis information and guide management of sphenoid sinus cysts 4, 5
- Nasal endoscope plays an important role in the treatment of sphenoid sinus cysts, allowing for safe and minimal blood loss surgery 4, 6
- Routine follow-up CT scans are beneficial in patients with minimal brain injury and may lead to higher levels of medical management or neurosurgical intervention 2