Endgames Picture Quiz

A case of head injury

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d4155 (Published 21 July 2011) Cite this as: BMJ 2011;343:d4155
  1. Benjamin R K Smith, specialist registrar in radiology,
  2. Aidan G Shaw, specialist registrar in radiology,
  3. David C Howlett, consultant radiologist
  1. 1Eastbourne District General Hospital, East Sussex Hospitals Trust, Eastbourne BN21 2UD, UK
  1. Correspondence to: B R K Smith brksmith{at}doctors.org.uk

An 82 year old man tripped on uneven paving and sustained a frontal head injury. A passer-by came to his aid and called an ambulance. The patient did not lose consciousness and was fully oriented at the scene.

On arrival at the emergency department he was fully oriented and remembered all events. He had been feeling nauseous in the ambulance and had vomited twice since his arrival. Apart from ongoing nausea and a mild headache he was feeling okay. Baseline observations were normal. Clinical examination showed no neurological deficit. He had extensive right periorbital swelling and a full thickness right forehead laceration that needed suturing.

The casualty officer was worried about the ongoing nausea and arranged for an urgent computed tomogram of the brain (fig 1).

Fig 1 Axial computed tomogram of the brain (soft tissue windows)


  • 1 What is the most likely diagnosis?

  • 2 What additional images would be helpful?

  • 3 What injuries and complications are associated with this pathology?

  • 4 How should this condition be managed?


1 What is the most likely diagnosis?

Short answer

Free intracranial air (pneumocephaly) is seen around the frontal lobes, sylvian fissures, and para-falcine region, with soft tissue swelling over the right frontal bone (fig 2). The combination of frontal head injury and extensive pneumocephaly suggests a frontal sinus fracture.

Fig 2 Axial computed tomogram of the brain (soft tissue windows) showing free air around the frontal lobes (white arrows), falx, and sylvian fissures (white arrowheads)

Long answer

This is a case of frontal sinus fracture with intracranial extension. The non-contrast computed tomogram of the brain shows extensive pneumocephaly with pockets of air seen around the frontal lobes, sylvian fissures, falx, and quadrigeminal cistern (fig 2). Soft tissue swelling is seen overlying the right frontal bone. The brain parenchyma has normal a …

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