Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of a calvarial defect secondary to [prior trauma/neurosurgical intervention/congenital anomaly]. Chief complaints include [pulsatile sensation/cosmetic deformity/headache/neurological deficit]. Duration of defect is [X] months/years. Patient denies current signs of infection, CSF leak, or seizures.
Clinical Examination Findings
Physical examination reveals a palpable calvarial defect measuring [X] x [Y] cm, located at the [frontal/parietal/temporal/occipital] region. The overlying scalp is [intact/scarred/atrophic] with no evidence of erythema, fluctuance, or sinus tract formation. Neurological exam is non-focal; cranial nerves II-XII are intact. No evidence of intracranial hypertension or herniation.
Treatment Protocol
Recommended management involves cranioplasty for reconstruction of the calvarial defect. Surgical plan: [Autologous bone graft/Customized PEEK implant/Titanium mesh] fixation. Pre-operative CT scan with 3D reconstruction reviewed. Prophylactic antibiotics initiated. Post-operative care includes neuro-monitoring and wound care.