& Technology Medical Radiological Sciences iagnostic Department

INIS-SD-141 HIP SD0000066

this Thesis for the ofB.S.C

Supervised By: UST.\ Abdel Samad Mo

PAGES ARE MISSING IN THE ORIGINAL DOCUMENT Table of Contents Page

Introduction A Dedication B Acknowledgment C Common Abbreviations D Chapter one: 1 - Introduction - The Significant of the study - Research problems - The rational^ of the study - The objectives of the study - The Hypotheses - Research Termonologies - Methodology of research sample - Obstacles Chapter Two: Anatomy of the Skull 4 Chapter Three : Research Procedure 22 Chapter Four : Results, Conclusion & Recommendations 53 Bibliography 54 Appendices introduction

Patterns recognition leading to differential diagnosis is the essence of imaging when face with specific finding on plain radiograph CT, MR. N.M and ultra sound and this research offer imaging of skulls related to the disease. Added to this lists are description of specific imaging finding to be expected for each diagnostic entity and help the technologist to choose the most suitable position when certain disease is suspected.

(A) Dedication

Our families

Our Friends

Our Colleagues...

(B) Acknowledgment

We would like to express our thanks to Dr Abdei Samad Mohammed Salih for his uniimited help in the completion of this work. Thanks are also extended to the New X- Ray section in Khartoum Hospital. Thanks are also to those who help directly or indirectly hi this research.

(C) Common Abbreviations

CJ.N.S Central Nervous System. C.S.O.M Chronic Suppurative Otitis Media C.T. Coronary thrombosis or Cerebral thrombosis or Computerize topography. C.V.A Cerebro Vascular Accident D.S. A Digital Subtraction Angiography F.O. Fronto Occipital I.A.M. Internal Auditory Meatus O.F. Occipito Frontal O.M. occipito Mental P.N.S. Post Nasal Space R.T.A. Road Traffic Accident S.A.H. Sub Arachnoid Hemorrhage S.IYLV. Sub Mento Vertical S.G.L. Space Occupying Lesion T.M.J. Tempro mandibular Joint

(D) Chapter One

Introduction: - This study stems from the primes that the skull is one of the most complicated for diagnostic faults. So, this study focuses on the technique of skull related to pathology. The aims behind this study is to achieve the.best way for the technique of skull by studying and searching reality analyzing the situations used. Not only for avoiding mistakes, problems and causes techniques, but also, to achieve the best way for patient safety and the accurate diagnosis in both the early and the lately diagnosis.

The Significant of the Study The significant of this study is to: - 1. Achieve the best way for the technique of skull to help in diagnosis diseases and its minor and negative effects bearing in mind the accurate anatomical parts, which build up this vital part. The Objectives of the Study: The objectives of this study are to :- 1 .Achieve accepted temporary bases for the various techniques to diagnosis various skull diseases. 2. A special aim of this study is to be a rich reference for the trainees, moreover to improve the performance of the technicians in carrying out their duties. The Rational^ of the study

)a$6 diagnosis te the skull is very dangerous because it contains sensitive and effective parts like the brain, which is the central processing unit for the body. Any defect in the brain affects the function of other parts in the body.

Research Hypotheses:

l.The additional pr4vatertechniques help in clarifying the skull independently and permit diagnosing the pathological situation. 2. The importance of the existence of accessory devices for skull diagnosis to confirm Angulation Rotation. 3. The importance of the existence of skull unit in any X-Ray department.

Methodology of Research

In this research, the researcher follows the experimental method..

Data Collection Data for this research was collected from 1. References. 2. Interviews and Observations with patients. Time Duration Five months.

Place:- Faculty of Radiological science, Khartoum, Sudan.

Reseach sample:- Hospital Patients. Obstacles:- There is a lack of references and literature. CHAPTER TWO ANATOMY AND PHYSIOLOGY OF THE CRANIUM

Anatomy of the Skull

The skull is the name given to the bones, which make up the skeleton of the head. The only bone of the skull, which is the moveable, is the mandible, or lower jaw. The skull is divided into an upper box -like portion called the calvarium, and lower irregular portion which constitute the skeleton of the face. The calvarium contains the brains. Its made up of eight bones, one frontal bone, two parietal bones, two temporal bones, one occipital bone, one sphenoid bone and ethmoid bone. The facial skeleton is made up of 14 bones, two zygomatic bones, two maxillae, two nasal bones, two lagrimal bones, two palatine bones, two inferior nasal conchae and one mandible.

The skull viewed from the above

Three important sutures can be seen:- 1. The coronal sutures. Anterioly which unites the frontal bone with right and left parietal bone. 2. The sagittal suture. In the midline which unites to to two parietal bones. 3. The lambdoid suture. Posterialy, which unites the right and the left paterial bones which the occipital bone. The junction of the coronal suture and the sagittal suture is called the bregma. The junction of the sagittal suture and the lambdoid suture is called the lambda. The skull

— Frontal bone

Coronal suture il^-%^^ ^i-^M\ T "•••"" " 1 Left parietal bone 1 > v . , l-- •- - • •- — Sagittal suture

Lambdoid suture

I'ig: 6.1. 'I'IIL' skull, seen from above. The Skull Viewed from the Front

When the skull is viewed from the front is wide above than t>elow. The upper portion is smooth and is made up of the frontal bone, the lower portion is irregular. The orbital openings one roughly quadri lateral. This margin bears on its midial third a notch called the supro orbital notch. The lateral side of the orbit the zygomatic process of the frontal bone project down words for a short distance to unite with the frontal process of zygomatic bone. The anterior opening of the nasal cavities is a roughly triangular. Below the orbits the two maillaes form a large of skeleton of the face. bone

Supraorbital nolch - - Zytjomalic process of frontal bone Frontal process of maxilla led nasaf bone Oight zygomalic bone Inftaorhital foramom Anterior nasal I.elt maxilla spine

Mandible

Fig. 6.2. The skull si-cn from the (Vont.

Infra orbital frame opening, which transmit vessels and nerves. The lower part of the facial skeleton consists r of the mandible which carrels the lower teeth.

The Skull Viewed from the Side When the skull is viewed from the side five of the bones, which make up the calvarium can be distinguished. Anterioly the frontal bone, which articulates posteriorly with the parietal bone at the coronal suture. The parietal bone articulates posteriorly with the 'occipital bone at the lambdoid suture, and inferiorly for most at its length with the temporal bone. Anteriorly vyith the temporal bone is form by the greater Wing of the sphenoid, the portion of the temporal bone is called the squamous part of the temporal bone. Extending forward from posterior part of the squamous portion of the temporal bone is the zygomatic process, which unites with the temporal process of the zygomatic bone to form the zygomatic arch.

, Coronal suture • Loll parietal hone Frontal bone — • Tempoial line

Supraciliary arch Great wing of Lanilnlun) suture sphenoid _ . Occipital hone Nasal bone I Squamous pait of tempotalbone Zygomatic process of ~ External acoustic temporal bone meatus Anterior nasal' Tympanic plate spine i - Mastoid process Left maxilla Slyloid process,

Fig. 6.4. The skull seen from the kit side. Just posterior to the root of the zygomatic process is -the external acoustic meatus. The anterior and inferior margins, of ;the meatus are form by a plate of bone called the rynipanie plate. Behind the external acoustic meatus is the'mastoid part of the temporal bone, and this project downward to form the mastoid process. In between the external acoustic meatus and the mastoid process is the styloid process, a slender process is attached to the hyoid' bone by the stylo-|iyoid ligament. The posterior border of the masoid temporal bone articulates with the occipital bone.

The skull viewed from Below ^—•••M^^^^^™^^^^^^^*™— I 1 1 1111 1 lima HIII ~m—mm q The bas of the skull is irregular and for convenient of description is divided into three areas: . .1. An interior parts which extents from the front teeth to the, Dosienor margin to the hard palate. 2. A middle part from the posterior,margin of the hard palate and anterior margin of the foramen magnum. 3. A posterior part behind the anterior margin of the foramen margin.

. Incisive fossa Palatine process of maxiila Palatine bone —' -• Inferior orljit.il Pterycjoid hamulus —/ fissure Posterior nasal Zyyornatic: arch spine - Foramen ovale Lateral pterygoid - Foramen plate spinosuirr Styloid process Foramen laceruiTi Occipital condyle -—• •— Carotid canal Mastoid process \-—/-' I ( Jugular foramen Stylomastoid foramen Foramen magnum External occipital - crest

Inferior nuchal line Superior nuchal line

External occipital •-• protuberance

Fig..6.5. Tin- Iwsr iil'-llu- skull

The Accessory Nasal Sinuses. The accessory nasal sinuses are cavities contained within certain of the bones of the'skull. These cavities communicate with nasal cavity and are lined with mucous membrane. The mucous secreted by this membrane is swept into the nose by cilia on its surface. The sinuses are found in the frontal bone, the maxillae, the ethmoid bone and the sphenoid bone. The are virtually absent at birth but gradually enlarge during childhood and puberty. Even so their size varies considerably in different*adult individuals. The Nasal Cavity

The nasal cavity is an irregularly- shaped cavity, which lies above the floor of the mouth and below the anterior cranial fossa. It is divided into right and left halves by the nasal septum. Each half of the nasal cavity has roof, floor and lateral and medial walls.

Anatomy of the Brain

The central Nervous System: - The central nervous system is composing of: - 1. The brain. 2. The spinal cord.

The brain: It lies within the cranial cavity and is composed of: the cerebrum, the midbrain, pons, the medulla oblongata and the cerebellum.(figure 1) i) The cerebrum: it is the largest part of the rain and is composed of the right and left cerebral hemispheres, which are incompletely separated by a deep midline cleft, called the longitudinal cerebral fissure. A fold of dura matter called the falx cerebri projects downward into this fissure. Below the longitudinal cerebral fissur the two cerebral hemspheres are connected by a mass of white matter, or nerve fibres called the corpus callosum. Within each cerebral hemisphere is a cavity called the lateral ventricle. Each cerebral hemisphere is composed of an outer layer of grey matter called the cerebral cortex. The surface of the cerebral cortex is arranged in a number of folds, called grey or convolutions which are separated by sulci or fissures.(figure 2).

—:—i Cerebrum

Midbrain. • • —

Pons '- Cerebellum

Medulla oblongata

The. parts of the brain.

Prpcentral gyrus Central sulcus Frontal lobe Poslc-entra1 gyrus Parietal lot:> Lateral sulcus Occipital I T«?mioral lobe —

•h-6. I lie I'.Uor.il aspect of the Ifi! it-rcbr.il

10 Within the white matter of the cerebral hemisphere, there are a number of collections of grey matter. The three collections of grey mater are as follows: LThe basal ganglia lie on the lateral wall of the anterior and central parts of the lateral ventricles. 2.The thalamas is a mass of grey matter, which lies below the corpus callosum, and forms the lateral wall of the cavity known as the third ventricle. The internal capsule separates the lateral side of each thalamus from the basal ganglia. The thalamus is mainly composed of nerve cells, which relay sensory impulses from the spinal cord towards the sensort cortex. 3. The hypothalamus The hypothalamus lies below the thalamus at the base of the brain and firms the floor of the third ventricle. Projecting downwards from the lower surface of the hypothalamus is the stalk which attaches the pituitary gland to the base of the brain. Just in front of the pituitary gland is the optic chiasma, which forms a communication between the two optic nerves. The hypothalamus contains centers, which are responsible for regulation of the body temperature, the regulation of sleep and the control of the metabolism of fat and carbohydrates. The hypothalamus also plays an important part in the control of the pituitary gland. ii) The midbrain The midbrain connects the cerebral hemispheres above the to pons below. Anteriorly it is composed of two cerebral peduncles, which are mainly formed by fibers passing to and from the cerebral hemispheres, and posteriorly it is composed of four rounded eminencies called the quadri-geminal bodies, which are reflex centers for sights and hearing. Within the center of the midbrain is a narrow canal called the cerebral aqueduct (aqueduct of sylvius), which connects the third ventricle above with the forth ventricle below. iii) The pons The pons lies below the midbrain in front of the cerebellum and above the medulla oblongata. It is composed mainly of nerve fibers passing between the cerebral hemispheres and the spinal cord, and of nerve fibres passing from one cerebellar hemisphere to the other. Lying deeply within the white matter are collections of grey matter which are nuclei for some of the cranial nerves. iv) The medulla oblongata The medulla oblongata has a rounded eminence, called the pyramid, which is composed of motor fibers passing downward from the cerebral cortex. The lower part of the medulla these motor fiber coss from one side to the other at the decussation of the pyramids and thus the fibbers from the right cerebral cortex pass to the left side of the body. Some of the sensory fires passing upward towards the cerebral cortex cross from one side to the other in the medulla. The medulla contains a number of collections of grey matter, which are: 1.Nuclei for certain of the cranial nerves. 2. Relay stations for some of the sensory fibers passing upward from the spinal cord. Also contained within the medulla are the so-called vital centers, which are the respiratory center, the cardiac center and the vasomotor center.

12 v) The cerebellum The cerebellum lies in the posterior cranial fossa behind the pons and medulla oblongata. It Is composed of two hemispheres, which are joined across the midline by a narrow strip called the vermis. Like the cerebrum, the cerebellum is composed of an outer cortex of grey matter and has white mater in its interior. The outer surface of the cerebellum is thrown into a large number of narrow folds, which are separated by deep fissures. The cerebellum is concerned with the maintenance of balance and posture, and the coordination of the voluntary muscular movement. The cerebellum receives from the muscles and joints sensory impulses, which are impulses from semicircular canals of the inner ear to maintain balance. Efferent impulses from the cerebellum pass to the basal ganglia and pass from there down the spinal cord. They exert controlling influence over voluntary impulses, which are initiated in the motor cortex. Impulses that pass to the cerebellum do not give rise to conscious sensation. The Blood Supply of the Brain The arteries of the head 1 .The common carotid arteries (CCA) i) Right common carotid artery arises from the branchiocephalic artery. ii) The left common carotid artery arises directly from the arch of the aorta. The common carotid artery is enclosed in a sheet of fascia together with the Internal Jugular Vein, which lies laterally to the artery, and the vagus nerve, which lies behind the artery and vein. At the level of the upper border of the thyroid cartilage the common carotid artery

13 divides into two branches: The internal carotid artery and the external carotid artery. 2.The external Carotid artery It runs upward in the line of the (CCA.) to end in the parotid gland, behind the neck of the mandible, by dividing into the superficial temporal artery and the maxillary artery. It supplies the superficial tissues of the head and neck. Each has the following branches: i. The superior thyroid artery ii. The ascending pharyngeal artery iii. The lingual artery iv. The facial artery v. The occipital artery vi. The posterior auricular artery vii. The superficial temporal artery viii. The maxillary artery It has two parts: 1 .infraorbital artery 2. Middle meningeal artery. (Fig.3)

The Arteries of the Brain: - For large arteries entries the cranial cavity to supply the brain. They are: - • The right and left internal carotid arteries, which enter the cranial cavity through the upper part of the foramen lacerum. • The right and left vertebral arteries, which enter the cranial cavity through the foramen Magnum. l.The Internal Carotid Arteries :- They are supplying a large part of the cerebral hemispheres, the eye and its associated

14 structures, and they send branches to the skin of the forehead and the anterior part of the scalp. The Ophthalmic artery arise from the internal carotid artery closed to the anterior clinoid process anf runs forward to enter the orbit, together with the optic nerve, through the optic canal. It supplies the eyeball and other structures in the orbit and gives off the supraorbital artery, which leaves the orbit through the supraorbital foramen or notch. The internal carotid artery ends by dividing into the anterior and the middle cerebral arteries and the anterior communicating artery. 2.The Vertebral Arteries:- They are entering the cranial cavity through the foramen magnum. Soon after their entrance into the cranial cavity the two vertebral arteries unite in the midline to form the Basilar artery. The basilar artery passes upwards in the middle on the basal part of the occipital bone and at the upper border of the pons it divides into the two Posterior Cerebral arteries. The posterior cerebral arteries each give off a branch called the Posterior Communicating artery, which communicate with the anterior cerebral arteries. Before uniting, the vertebral arteries give off branches to the spine, the cerebellum and the medulla oblongata. The basilar artery gives off branches to the cerebellum and the midbrain.

15 Supefficial temporal artery — Occipital artery • Maxillary artery Posterior auricular artery

Facial artery Internal carotid ' Lingual artery artery Si/perior thyroid External carotid •artery artery

Common carotid artery

The superficial arteries of the head.

Anterior cerebral artery — Internal carotid communicating artery . - yrtery Middle cere-lirai Posterioi . . communicating artery ~ Posterior cerobral artery i. 8asiU)f artery

Vertebral artery

l'l\c hast-of the brain, sliiming tlic-Cirtlc ol' \Villis.'

16. THE CIRCLE OF WILLS:- The two internal carotid arteries, the basilar arteries and the anterior and posterior communicating arteries form an arterial circle at the base of the brain. This arterial circle is called the Circle of Willis (Fig 4) The following branches arise from the Circle of Willis on each side:- The anterior cerebral artery which passes upwards and backwards in the midline over the corpus callosum. It supplies the anterior and medial parts of the cerebral hemisphere. The middle cerebral artery, which is the other terminal branch of the internal carotid. It runs laterally and then upwards in the lateral cerebral sulcus and supplies a large part of the lateral surface of the cerebral hemisphere. The posterior cerebral artery is one of the terminal branches of the vertebral artery. It runs laterally, gives off the posterior communicating artery and then runs on the inferior surface of the cerebral hemisphere. It supplies the temporal and occipital lobes of the cerebral hemisphere.

The Veins return from the brain:- The superficial veins of the scalp accompany the branches of the external carotid artery, which supply the scalp and they receive the same names. They all unite just behind the angle of the mandible to form the external jugular Vein. l.The external Jugular Vein:-

17 It runs downwards in front of the sternomastoid muscle to enter the subclavian vein behind the clavicle. The superficial veins of the face, however, drain into a vein called the Facial vein. The facial vein starts close to the inner angle of the eye, runs downwards to the cross the mandible in front of the angle, and enters the internal jugular vein. 2. The Venous Sinuses of the Cranial Cavity:- The venous blood from the brain drains into special channels called the venous sinuses. These are sinuses, which are formed between the layer of the dura matter, which is the outer membrane lining the brain. The sinuses are lined by endothelial tissue. The most important venous smuses are: - (Fig 6)

i) The superior Sagittal Sinus:- Lies in the upper margin in the falx cerebri, a fold of dura matter which lies between the right and left cerebral hemispheres. The superior sagittal sinus.commence s above the crista galli of the ethmoid bone and passes backward in the midline of the skull vault to reach the internal occipital protuberance, where it opens into one of the transverse sinuses. It drains the blood from the superior part pf the brain. ii) The Inferior Sagittal Sinuses:- Lies in the lower margin of the falx cerebi and runs backwards to drain into the straight sinus.

18 (5)

Superficial temporal Maxillary vein /— 'vein • '

Posterior auricular Facial vein vein

- External jugular-vein Internal jugular vein

The venous return from the head and neck.

Superior sagittal •• sinus Fal.x cerebri Inferior sagittal sinus : .Great cerebral vein Straight sinus Transverse sinus Tentorium cerebelli Commencement . of sigmoid sinus The venous sinuses. 19 iii) The straight Sinus:- it runs downwards and backwards in the junction of the falx cerebi with the tentorium cerebelli, which is a fold of dura matter which almost completely roofs in the posterior cranial fossa. The straight sinus opens into ones of the transverse sinuses. A vein, the great cerebral vein, opens into the anterior end of the straight sinus. iv) The Cavernous sinuses: - Lies on either side of the sella turcica. They communicate with the sigmoid sinus, the internal jugular vein and the veins of the face by small venous channels. v) The transverse Sinuses:- Are large sinuses . the right transverse sinus is usually the continuation of superior sagittal sinus, and the left transverse sinus the continuation of the straight sinus. They commence at the internal occipital protuberance and then run latrally and forwards round the upper margin of the posterior cranial fossa, in the attach margin of the tentorium cerebelli. Near the posterior margin of the lateral ends of the petrous parts of the temporal bones they are continuos with the sigmoid sinuses. vi) The Sigmoid Sinuses:- run downwards and medially, from the end of the transverse sinuses, to reach the jugular foramen, where they are continuous with the internal jugular vein.

20 3.The internal Jugular vein :- It runs downwards in the neck from the base of the skull. It passes deep to the sternomastoid muscle and unites with the subclavain vein behind the clavcle to form the brachiocepholic vein. In its course its joined by the facial vein and small veins from the pharynx and thyroid gland. CHAPTER THREE 3.1 Trauma The value of plain films following the head injury

Although the fracture is a valuable sign of a head injury, the appearances of a fracture often bears little correlation to the underlying damage, and serve brain damage and subdural hiamatormas can occur in-patients with normal skull films. Plain film signs which indicate significant head injuries are:- L Shift of the pineal from midiine. This is an important sign as it often indicates an extradual or subdural haematoma. Swelling of one hemisphere due to contusion of the brain can also cause pineal displacement. 2. Fluid levels in the sinuses "or air in the subarachnoid space or ventricles indicate a fracture with a tear of the dura. Antibiotic treatment is often advocated with this type of injury to prevent meningitis. As with the detection of all fluid levels, its necessary to take the lateral film with horizontal ray. Computed Tomography in Head Injuries

1. Extracerebral lesions:- Haematomas (External & Subdural) 2. Fracture of the skull base or vault. 3. Intercebral lesions. Oedema, contusion and heamatomas. In most neuroligical disorder, the plain film are either normal or abnormalities are too non-specific for

22 MKl of the Brain The routine techniques used for magnetic resonance imaging vary from center to center. Axial, coronal and sagittal projections are all considered standard and two of these are usually chosen for a routine examination. This multiplier capability is particularly useful for assessing the extent of pituitary tumours and for visualizing structure in the posterior fossa and craniovertebral junction. A variety of signal sequences are used to create the images: usually Tl-weighted, T2- weighted and balanced (Proton Density) images. No signal is produced from bone, so there is no bone artefact, which means that the posterior fossa structures are more clearly demonstrated than with CT. it is possible to recognize flowing blood and therefore, the larger arteries and veins stand out clearly without the need for contrast medium. The characteristic of grey and wiiite matter are different, and the both are clearly different from the CSF in the venticular system and subarachnoid space. Therefore, the anatomy of the brain can be exquisitely displayed.

24 3.2 Pathology Occurring in the Skuli And Related Technique

1.Acoustic Neuroma: a tumour of the 8th cranial nerve there may be enlargement of the internal auditory meatus technique I) AP skull with 25, 30, and 35 caudad II) Stenver's projection III) Lateral skull IV) Submento vertical V) CT with contrast enhancement because the an abnormality not seen on precontract scan may be visible following contrast enhancement and this is due to the contrast accumulating in large blood scale, but more commonly due to break down of the blood brain barrier allowing the contrast to enter the lesion. VI) MRJ it is more useful modality than the CT because there is no artifact which mean that the posterior fossa structure are more clearly demonstrated than with CT. An (MRI) contrast agent must have magnetic properties. The first agent introduced for intravenous administration was "gadolinium DTP A" like intravenous iodinated agent used for CT. gadolinium is excluded from normal brain substance by the blood -brain barrier it accumulatein the site of lesion because the tumour destroy the blood- brain barrier that mean the contrast will accumulate at the site of tumour.

25 A)

B)

A coustic neuroma a) Antroposterior(Town£ projection), b) postero anterior view of another patient

A coustic neuroma C.T scan

26 2. Acromegaly

Over activity of the eosinophil call of the anterior lobe of the pituitary gland usually due tumour, it arises in the adult life after completion of bone growth causing some bone enlargement technique: I) Lateral skull to show enlarged frontal and mandible with separation of teeth. II) CT with contrast. III) MRI with contrast.

3. Anencephaly

Failure of fetal brain to develop with associated lake of formation of the vault of the skull. Techniques Neurosonography: - with ultra sound it is simple to scan heals neonates and young babies to obtain image of verticular system and the adjacent brain, scanning is the best done to impade the transmission of ultra sound little discomfort is caused to the baby and produce is rapidly carried out even on ill babies in intensive care unit.

4.CaIcif!ed choroid plexus:-

Calcification may occur in choroid plexuses of the lateral ventricls. The radiographic appearance is that small number of clacified point gathered together, and of less density than pineal calcification it's usually bilateral lying approximately 2cm behind and below pineal shadow. Technique: - i). PA skull ii) lateral skull iii) Town's view iv) CT v) MRI.

27 neurosonography a) normal croiiai section b) cronai section.

Calcified choroid Plexus- lateral view 5. Calcified pineal body Calcification laid down in the central part of the body usually with advancing age. Calcification alone is of little significant, but the fact that the pineal is demonstrated is an aid diagnosis in space occupying lesion. Techmque:- I) AP skull with 35 caudad ii) Lateral skull iii) C.T.

29 6. Chromophobe adenoma A tumour arising in the anterior lobe of the pituitary gland often causing radiological changes in the appearance of sella turcica. Technique : -1) AP skull with 35 caudad Town's view iv) Lateral skull. v) CT with contrast. vi) MRT with contrast. 7. Cranio stenosis The premature closing of cranial structures resulting in a small skull, this term embraces various skull deformaties, which arises from the above cause, and include oxycephly scaphocephaly craniofacial dysotosis and plagiocephaly this condtion is thought to be congenital abnormality. Technique :- i) PA skull ii) Lateral.

8. Craniotabes A condition occurring infancy. It is the formation of conical areas in bone substance, which are small and shallow, mainly in frontal and parietal bones of the skull. It is usually result from rickets naramus or syphilis. Technique :-1) PA skull ii) Lateral skull. 9. Giomus Jugular tumour: A tumour arising from small masses of epitheiiod tissue in the region of the Jugular bulb it may invade the petrous bone and the floor of the posterior fossa. Technique I) Pa skull with 10 caudad. ii) AP skull with 35 caudad(Town's view). iii) Rt and Lt lateral skull iv) Tomography.

Gloomus jugulare tumourTi-wieghted image coronal contrast - enhanced

10. Hydrocephalus An excessive accumulation of cerebrospinal fluid within the cranium causing gross enlargement and thinning of the vault of the skull with enlarge fontanel. Technique:-1) PA skull iii) Lateral skull iv) Neurosonography v) CT vi) MRI

3i 11. Hyperostosis Cranial An increase in bone mass usually due to the invasion or endocrine disturbance. Technique 1) SP skuil with 35 caudad. II) PA skuil with 20 caudad IV) Lateral skull V) Tangential views.

12. Hypertelorism (Grig's disease) A deformity of the frontal region of the cranium resembling mongolism and associated with mental deficiency it is also shows abnormal growth of the cartiligenous base of the skull, and radiologicaly enlarge lesser wings of and diminished greater wings of the sphenoid are demonstrated. Technique:-1) PA skull with 10 caudad ii) Lateral skull iii) submentovertical.

13. Meduiioblestoma

A malignant tumour of the brain- stem occurring in children, as the tumour seldom calcifies the only radiological evidence is that of raised intracrnial pressure, technique:-1) PA skull ii) Lateral skull Hi) CT with contrast iv)MRI

32 A)

B)

Meduiioblastoma A) non- contrast scan B) after intavenous injection of contrast material 14. Meningioma A slow growing benign tumor of cebbral meninges, radiologicaly it may sometimes be localized be bone sclerosis and increased blood supply, causing more visual vascular channels. Technique:-1) PA skull with 10 caudad ii) AP skull with 30 caudad (Town view) iii) Lateral skull iv) CT with contrast v) MRI with contrast.

A) B)

Meningioma A) frontal and B) lateral views of the skull

34 Meningioma hypomtense Ti - wiegfated image cronal scan A) hyperintense on T2 - wieghted image B).

15. Maningiocele A protrusion of the cerebral or spinal meninges through defect in the skull or vertebral column. It forms a cyst filled with cerebrospinsl fluid and possible protrasion of nervous tissue. Technique cerebral I) PA skull II) lateral skull III) CT with contrast. IV) MRI with contrast. 16. Mastoditis An information of the mastoid air-cells follows infection of the middle ear. Technique :- I) Rt and Lt PA oblique to demonstrate the mastoid tip. II) Kt and Lt lateral oblique-pinna of the ear folded for word. III) Fronto occipital with 30 caudad Towners view.

Mastoditis lateral oblique

17. Microcephaly A congenital defective development of the cerebrum with a thick skull an early closure of the fontanelles, resulting in small skull. Technique :- i) PA skull ii) Lateral skull. 18. Mucocale An encysted accumulation of mucus in a galand, sinus or organ such as the gall bladder. Radiologicaiy the most common site are ethmoid and frontal sinuses and lacrimal sac. Technique for sinuses:- i) Occipto frontal with 10 caudad. ii) Lateral skull, iii) Rt and Lt optic Jbrmina veins. Mucocele A) T! wieghted MR image if) Tl wieghted MR image. 19. Multiple Myeiomatosis. A malignant growth of plasma cwlls usually radioiogicaiy evident as multoiple defect of the bone it may affect vertebral bodies and pelvis. The distal parts of the extremities are rarely involve. Technique :- Lateral skull.

Multible myeloma- lateral view of the skull. 20. Ostespetrosis (Marble Bones) Disturbance in bone formation which usually stork during the foetal period. All bones are affected, showing marked increase in density, but with this comes marked fragility and there for fractures are often associated with the disease owing to increase density in the base of the skull the foramen tends to become occluded. Technique :- i) PA skull with 10 caudad ii) Lateral skull. iii) Submentovertical skull 21. Osteosclerosis The stapes (innermost of the ossicles) becomes fixed to the bony margin of the opening between the middle and inner ear. As result there is ossification of the fenstra rotunda causing deafness. Technique I) Rt and Lt lateral oblique of the mastoid air-cells pinna of the eatr floded forward, ii) Fronto occipital with 35 caudad. 22. Paget's Disease (Osteitis Deformans) A skeletal disease.of unknown origin, characterized by a slowly spreading changes in one or more bones. In early stages the bones are protic, but as the disease progresses there is complete or partial obliteration of the marrow cavity, the bone trabecuiation widens and becomes coarser. The bone softens, and bowing and bowing and flattering particularly is weight-bearing areas, occur technique. i) AP skull, ii) Lateral skull. ii) Lateral skull.

23. Raised interaeranial pressure when the intracrenial pressure is raised forfor any length of time, there is engorgement of emissary veins enlarging the channels where they perforate the skull near the occipital protubrance. The meningeal vessels may also enlarge increasing the size of the foramen spinosum. There is also erosion of the posterior clonoid processes an increase in size of pituitary7 fossa and loss of the floor. In children there is diastasis of the suture technique. I) AP skull with 35 caudad. II) PA skull with 10 caudad. III) Sub mento vertical view. IV) Lateral skull

24. Sarcoma of the skull Rapidly growing malignant tumour. New7 spicules of bone are laid down at right angles to the bone surface and not always visualize with standard penteration. Technique :-

i) Rotino skull view ii) Tangential niew with the soft radiation.

25. Taxoplasmosis An infection disease caused by a prasite carried by animals. It occurs mainly in children and may affect the brain, causing convulsions. Specks of calcification may occur. This disease is transmitted in utero . Technique:- Cerebral sarcoma A) non contrast scan B) after intravenous contrast Infusion

Toxopiasmosis A) contrast- enhenced

40 26. Meningitis Collection of small not very dense amorphous calcific nodules. In frequent following bacterial ortubercular maningitis. Technique: - i) AP 30 caudad Towns view ii) Lateral skull. 27. Osteoma Various pattern of sclerosis osteoma Technique:- i) Lateral skull, ii) Tangertial. 28. Aneurysm curvilinear or complete ring of calcification, most commonly in arteriosclerosis aneurysm of cavernous portion of internal carotid artery may eroded the sidwall of the sella turcica and margins of the superior orbital fissure.

A) B) Giant aneulfylln A) axial B) coronal images

41 29. Enlargement erosion or Destruction of the Sella turcica. Pituitary a cienoma Balloonied sella with erosion backed ward bowing or complete destruction of the dorsum selli. Also anterior displacement of sellar floor it usually arises in the anterior lobe chromophobe adenomas and esnophitic adenoma is causing acromegly. The rare carcinomas of the pituitary produce extremely rapid sellar enlargment and destruction. Technique :- i) Lateral skull, ii) CT with contrast. Hi) MRI with contrast.

30. Hemorrhage Hemorrhage into the cisterns usually produces a thin layer of higher- density tissue adjacent to the teritrorium or in the pontine cistern. Technique: - i) Lateral" skull, ii) CT without contrast, iii) MRI without contrast.

42 ii) In direct catherization is carried out by passing a shaped catheter about meter long on guide wire retrogradly up the aorta from femoral artery or or occasionally from auxiliary artery using fmoroscopy which is essential the catheter may be farther advanced into the branchio cephalic artery and then into right carotid artery or into left carotid artery exposure in both lateral and AP project are necessary, and it is usually take series of film Eigutor more in each projection and rapid film changes is needed AP done with tube angeled 25 cephalad. A neurysm of anterior cerebral artery often more clearly seen in oblique or perorbital views when it may be preferable to take single film with guide cassette.

Carotid angeography lateral view Radionuclide imaging has been almost entirely replaced by (C.T) and (MM).

44 Radio-isotope imaging of the brain

Radio pharmaceutical Tc 99 m DTP A a suitable alternative to DTPA. DTP A is giucoheptonate some centers used sodium per technetate Dose 10 mci straight from the generator but in these cases the Pt must have sodium or potassium percholorate orally in order to to block up take of the pertechnetate by the thyroid plexuses, the detection of tumour and vascular abnormalities in the brain relies on the local disturbance of microcirculation at the site of the lesion Dynamic stubies may be performed to demonstrate relative circulation between the two hemisphere and static studies are routinely made in five projection approximately 30 minute after injection, although delayed films at 2-3 hours may demonstrate lesions not adequately visualized earlier, i) Dynamic Studies':- Computer is often used for these series it is not absolutely essential and good visual impression gained from direct micro dot series, the exposure should last over period of sec commencing from injection which should be as rapid as possible and preferable chased by about 10-20 mi saline. A suggested series would be of 16-14 film of 1.5 -2 sec each. The Ft may be in either the posterior or, vertex position, the posterior is useful for detecting sub dural heamatomas and other vascular lesion and the vertex position for comparing cerebral perfusion. ii) Static Study: Five projection are routinely taken- exposure may be determined either by count or time in the absence of converging collimator which will enable only the skull with minimum facial area to be include in the film. Suggested 3-5 min preview although in the case of uncooperative Pt it may be necessary to reduce this probably 1.5 min is least time in which satisfactory image can be built up.

Positioning - Lateral Pt prone sagittal plane parallel to the detector. - AP Pt seated or prone the nose and forehead rest on detector with sagittal plane perpendicular to it. - AP Pt seated or supine the occiput rest on the detector with sagittal plane perpendicular to the detector. - Vertex Pt supine with the head rest against the detector, the sagittal plane perpendicular and the radiographic box line parallel to it. A lead rubber cap is placed around the neck and over the shoulder to minimize radiation from the rest of body reaching the detector.

•to 3. (C i )&(MR1) 1N1MAG1NG OF SINUSES,

Sinuses On plain radiograph the normal sinuses are translucent because they contain air. Because of the contrast afforded by the air, plain films still have an important role in sinus disease. It so happens that on an occipitomentai view the maxillary antra are approximately the same translucency as the orbits. The frontal sinuses are often aymmetrical and part or all of them may be absent. The mucosa lining the normal sinus is too thin to be visualized. Thickened mucosa can be recognized on plain films providing there is some air in the sinus, by noting the soft tissue density between the air in the sinus and the bony wall. The mucosal thickened may be smooth in outline or it may be polypoid. Polyps may be sufficiently large to extend into the nasopharynx. Allergy and infection both causes mucosal thickened and it is impossible to say radiologically which condition is responsible. Fluid in the sinuses is recognized by the presence of a fluid level. With the patient erect, a

47 tiuid level appears as a horizontal line across the sinus, which remains horizontal even when the patient's head is tilted. Fluid levels are seen with infection in the sinus and aiso with trauma, when a fracture allows blood or (CSF) to collect in the sinus.

Sinusitis water's view Both (C.T)&(MRI) provide an excellent view of the sinuses. The bony wails are clearly displaced and any mucosai thickening can be readily detected.

48 The Opaque Sinus:

The sinus becomes opaque when all the air is replaced and it then appears as dense or denser than the adjacent orbit. The causes of an opaque sinus are: - i) Infection or Allergy:- Fluid or a combination of the two replaces the air in the sinus. ii) Mucocele :- Are obstructed sinuses. Secretions accumulate and the sinus becomes expanded. A frontal sinus mucocele may erode the roof of the orbit and cause exophthalamos. CT clearly shows the size and extent of a mucocele. iii) Carcinoma of the sinus or nasal cavity:- In all opaque sinuses, particularly the antra, special attention should be paid on both plain films and CT. to the bony margins, because if these are destroyed, the diagnosis of carcinoma becomes almost certain. C.T. is superb at visualizing bone tumour invasion, by showing the extent of any soft tissue mass, which may extent beyond the sinus cavity. The same features can also be seen with (MRI). (C.T) and (MRI) have an important role in treatment planning and hi assessing the response to radiotherapy. Carinoma of the annum Ci scan

Carcinoma of the ethmoid sinuses

50 Nasopharynx

The adenoids are normally seen on the iaterai film in children as a bluge projecting into the nasophararyngeal air passage. CT and MRI gives excellent visualization of the nasopharynx and can demonstrate the presence of tumour together with any spread into the skull base.

Nasopharyngeai carcinoma A) CT scan if) MRI in another patient. Orbits: - (C i), and (MKi) clearly demonstrate the anatomy of the orbits. Imaging is mdicated in all patients with exophthalamos since it is possible to distinguish between masses arising outside the orbit with an intraorbital mass its relationship to the optic nerve can be determined. The main cause of intraorbital masses includes various tumours, including tumours of the optic nerve, vascular malformation and granulomas. The most common orbital masses originating outside the orbit are tumours or mucoceles of the frontal or ethmoid sinuses and a meningioma arising from the sphenoid ridge.

Optic nerve glioma

52 Chapter Four Conclusion and Recommendation Conclusion; rpi-j Th1 e study came out with the hereinafter conclusion: - 1. One of the most important benefits of this research is following the angles and the degrees in techniques, which should be taken whenever a specific disease is suspected. 2. Plain films are still the initial investigation for disorders of the bones of the skull particularly fracture, but otherwise have limited uses. 3. The nerve imaging modalities have had a greater impact on the diagnosis of the diseases of the (CNS) than on any other body system. CT and MRI have become the standard investigations for most disorders of the brain. Recommendations - The necessity of the existence of skull unit in any X-Ray section. . -The necessity of the existence of CT and MRI machines in any X-Ray section because they help in the situation of accidents for imaging the brain damage. - The necessity of the existence of the Mobile Unit machine in any X-Ray section. - Hospitals containing accessory devices should be exist across the high ro&ds.

53 References:- i. L. Eisenberg9Ronald (1994), "Skull and Spine Imaging". An Atlas of Differential Diagnosis. Pavan press, NewYork.

2." Peter Armstrong & Martin L-Wastie" " Diagnostic Imaging" Third Edition. 3. "Glenda J.Bryan" Diagnostic Radiography" Third Edition. 4. " MRI Dean TET West55 "Basic Anatomy and Physiology for Radiographers" Third Edition. 5." M,A, Clifford and A.E Drummond" " Radiographic Techniques Related to Pathology" Second Edition.

54