1 1 Brain and Cranial Nerves

Home , Lateral sulcus, Pericallosal cistern

1 1 Brain and cranial nerves

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c 3 Brain, 3D CT angiogram. (a) Lateral. (b) Occipitomental. (c) 4 Circle of Willis. 6 2 5 5 7 8 13 18 12 15 16

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For labels see page 4. 2 Vessels of the brain

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Brain, 3D CT angiogram. (a) Lateral. (b) Sagittal (posterolateral). (c) Occipitomental. (d) Circle of Willis. d

For labels see page 4. Vessels of the brain 3

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Brain, MR angiogram. (a) Sagittal rotation view. (b) Lateral view. (c) Coronal view. (d) Axial view.

For labels see page 4. 4 Vessels of the brain

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14 c Brain, MR angiogram. (a) Axial. (b) Frontal. (c) Frontal. (d) Cranial.

1. Internal carotid artery 7. MCA genu (bifurcation) 14. Vertebral artery 2. Horizontal (A1) anterior cerebral artery 8. Precommunicating (P1) posterior cerebral 15. Maxillary artery (ACA) segment artery (PCA) segment 16. Superficial temporal artery 3. Vertical (A2) ACA segment 9. Ambient (P2) PCA segment 17. External carotid artery 4. Anterior communicating artery 10. Quadrigeminal (P3) PCA segment 18. Carotid siphon 5. Horizontal (M1) middle cerebral artery 11. Posterior communicating artery 19. Superior and inferior terminal branches of (MCA) segment 12. Basilar artery middle cerebral artery 6. Insular (M2) MCA segment 13. Superior cerebellar artery

Numbers 1–19 are common to pages 1–4. Vessels of the brain 5

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9 7 b 3D CT venograms (a-f). (a) Left lateral view. (b) Left posterolateral view.

For labels see page 6. 6 Vessels of the brain

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3D CT venograms. (c) Right posterolateral view. (d) Anteroposterior view. (e) Right lateral view. (f) Left posterolateral view.

1. Superior sagittal sinus 6. Transverse sinus 11. Internal cerebral vein 2. Bridging vein 7. Sigmoid sinus 12. Superior petrosal sinus 3. Great cerebral vein (of Galen) 8. Confluence of sinuses (torcular Herophili) 13. Cavernous sinus 4. Straight sinus 9. Internal jugular vein 5. Sphenoparietal sinus 10. Superior jugular bulb

Numbers 1–13 are common to pages 5–6. Brain 7

1. Parotid duct 23 2. Masseter muscle Parotid gland 21 31 3. (superficial lobe) 4. Ramus of mandible 15 32 22 39 5. Pinna of ear 25 27 28 6. Retromandibular vein 19 2 33 7. Sternocleidomastoid muscle 34 20 1 18 4 18 8. Parotid gland (deep 19 36 37 42 lobe) Internal jugular vein 3 6 40 9. 13 35 8 11 10. Mastoid process 41 9 12 11. Internal carotid 5 24 artery 10 30 16 47 7 12. Occipital condyle 14 13. Longus capitis muscle 45 26 14. Foramen magnum 15. Hard palate 56 16. Vertebral artery 17 17. Occipital emissary a 46 vein 18. Medial pterygoid b muscle 19. Lateral pterygoid 61 muscle 62 Lateral pterygoid 48 61 20. 64 62 plate 65 48 21. Incisive foramen 50 74 68 63 22. Inferior concha 23. Nasal septum 50 24. Medulla oblongata 51 37 25. Tooth bony socket 57 67 49 66 26. Cerebellar tonsil 59 60 43 27. Coronoid process of 52 58 73 mandible 38 54 53 70 28. Temporalis muscle 44 55 29. Folia of cerebellar 69 hemisphere 30. Spinal cord 31. Nasolacrimal duct 29 32. Zygomatic arch 33. Mandibular condyle 34. Medial pterygoid 17 72 plate 71 c

Brain, axial T2-weighted MR images, from inferior d to superior.

35. Contents of jugular foramen 49. Middle temporal gyrus 63. Lateral rectus muscle 36. Petrous temporal bone 50. Sphenoid sinus 64. Retro- orbital fat 37. Internal carotid artery 51. Temporal lobe 65. Temporalis muscle 38. Mastoid cells 52. Pons 66. Internal carotid artery (cavernous part) 39. Maxillary sinus (antrum) 53. Middle cerebellar peduncle 67. Body of sphenoid 40. Cochlea 54. Flocculonodular lobe of cerebellum 68. Medial rectus muscle 41. Posterior semicircular canal 55. Fourth ventricle 69. Superior cerebellar peduncle 42. Clivus 56. Cisterna magna 70. Superior semicircular canal 43. Basilar artery 57. Facial nerve (CNVII) 71. Calcarine cortex of occipital lobe 44. Labyrinthine artery 58. Vestibulocochlear nerve (CNVIII) 72. Torcular Herophili (confluence of sinuses) 45. Inferior cerebellar vermis 59. Internal acoustic meatus 73. Petroclinoid ligament 46. Inion (internal occipital protuberance) 60. Cerebellopontine angle 74. Optic nerve (CNII) 47. Foramen of Luschka 61. Lens 48. Ethmoid cells 62. Vitreous humour 8 Brain

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Brain, axial T2-weighted MR images, from inferior to superior.

1. Lens 17. Inferior colliculus 33. Interpeduncular cistern 2. Vitreous humour 18. Sylvian fissure (lateral sulcus) 34. Cerebral aqueduct (of Sylvius) 3. Lateral rectus muscle 19. Temporal horn of lateral ventricle 35. Folia of cerebellum 4. Medial rectus muscle 20. Superior rectus muscle 36. Insular gyri 5. Superior cerebellar vermis 21. Frontal sinus 37. Cerebral peduncle 6. Optic nerve (CNII) 22. Crista galli 38. Occipital horn of lateral ventricle 7. Infundibulum of frontal sinus 23. Olfactory tract 39. Anterior commissure 8. Lacrimal gland 24. Suprasellar cistern 40. Third ventricle 9. Pituitary gland 25. Bifurcation of internal carotid artery 41. Posterior commissure 10. Internal carotid artery (supraclinoid part) 26. Middle cerebral artery 42. Pineal gland 11. Uncus of temporal lobe 27. Anterior communicating artery 43. Trigone of lateral ventricle 12. Hippocampus 28. Optic chiasm 44. Basal vein (of Rosenthal) 13. Ambient cistern 29. Basilar artery bifurcation 45. Internal cerebral vein (of Galen) 14. Posterior cerebral artery 30. Quadrigeminal cistern 46. Claustrum 15. Straight sinus 31. Midbrain (mesencephalon) 47. Anterior cerebral artery 16. Superior sagittal sinus 32. Superior colliculus 48. Thalamus Brain 9

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Brain, axial T2-weighted MR images, from inferior to superior.

1. Interhemispheric fissure 16. Optic radiation 31. Body (atrium) of lateral ventricle 2. Posterior limb of internal capsule 17. Forceps major 32. Corona radiata 3. Thalamus 18. Genu of corpus callosum 33. Outer table of calvaria 4. Posterior commissure 19. Choroidal vessels 34. Diploë 5. Head of caudate nucleus 20. Splenium of corpus callosum 35. Inner table of calvaria 6. Frontal horn of lateral ventricle 21. Inferior sagittal sinus 36. Arachnoid granulation 7. Anterior limb of internal capsule 22. Temporal lobe 37. Precentral gyrus 8. Globus pallidus 23. Parietal lobe 38. Central sulcus (of Rolando) 9. Putamen 24. Occipital lobe 39. Postcentral gyrus 10. External capsule 25. Superior sagittal sinus 40. Grey matter 11. Body of caudate nucleus 26. Cingulate gyrus 41. White matter 12. Callosomarginal artery 27. Choroid plexus 42. Falx cerebri 13. Frontopolar artery 28. Anterior cerebral artery 43. Middle cerebral artery (second order 14. Frontal lobe 29. Cortical vein branch) 15. Forceps minor 30. Calvaria 44. Centrum semiovale 10 Brain

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33 c d Brain, sagittal T2-weighted MR images.

1. Alveolar ridge 21. Genu of corpus callosum 42. Orbital cortex of frontal lobe 2. Anterior arch of atlas (first cervical 22. Globe 43. Pituitary gland vertebra) 23. Great cerebral vein (of Galen) 44. Pons 3. Anterior cerebral artery 24. Head of caudate nucleus 45. Posterior arch of atlas 4. Basilar artery 25. Massa intermedia 46. Superior rectus 5. Body of corpus callosum 26. Inferior colliculus 47. Spheno-occipital synchondrosis 6. Body of lateral ventricle 27. Inferior rectus muscle 48. Splenium of corpus callosum 7. Superior medullary velum 28. Internal carotid artery (in cavernous 49. Superior cerebellar peduncle 8. Cerebellar folia sinus) 50. Superior colliculus 9. Cerebellar hemisphere 29. Internal cerebral vein 51. Sylvian fissure (lateral sulcus) 10. Cerebellum 30. Interventricular foramen (of Monro) 52. Tegmentum of pons 11. Cerebral peduncle 31. Lateral ventricle 53. Temporal lobe 12. Cervical spinal cord 32. Lentiform nucleus 54. Tentorium cerebelli 13. Cingulate gyrus 33. Mandible 55. Pineal gland 14. Cingulate sulcus 34. Maxillary sinus (antrum) 56. Vertebral artery 15. Cisterna magna (cerebellomedullary 35. Medulla oblongata 57. Anterior ethmoidal cells cistern) 36. Middle cerebellar peduncle 58. Middle ethmoidal cells 16. Corona radiata 37. Middle cerebral artery 59. Posterior ethmoidal cells 17. Cortical vein 38. Nasopharynx 60. Prepontine cistern 18. Foramen magnum 39. Odontoid process (dens) 61. Hard palate 19. Fourth ventricle 40. Optic chiasm in suprasellar cistern 62. Incisive canal 20. Bulbus oculi 41. Optic nerve Brain 11

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Brain of child mid-sagittal T2-weighted MR image.

1. Anterior arch of atlas (first cervical 16. Foramen magnum 33. Pituitary gland vertebra) 17. Confluence of sinuses (torcular Herophili) 34. Pons 2. Anterior cerebral artery 18. Fourth ventricle 35. Posterior arch of atlas 3. Superior sagittal sinus 19. Frontal sinus 36. Posterior commissure 4. Aqueduct (of Sylvius) 20. Genu of corpus callosum 37. Prepontine cistern 5. Basilar artery 21. Great cerebral vein (of Galen) 38. Quadrigeminal cistern 6. Body of corpus callosum 22. Internal cerebral vein 39. Quadrigeminal plate (tectum) of midbrain 7. Cerebellar folia 23. Interventricular foramen (of Monro) 40. Sphenoid body (non-pneumatised) 8. Cerebellar tonsil 24. Lamina terminalis 41. Splenium of corpus callosum 9. Cerebellum 25. Lateral ventricle 42. Superior medullary velum 10. Cerebral peduncle of midbrain 26. Mammillary body 43. Tegmentum of pons 11. Cervical spinal cord 27. Massa intermedia 44. Tentorium cerebelli 12. Cingulate gyrus 28. Medulla oblongata 45. Third ventricle 13. Cisterna magna (cerebellomedullary 29. Laryngopharynx 46. Anterior ethmoidal cells cistern) 30. Odontoid process (dens) (unfused) 47. Middle ethmoidal cells 14. Diploë of calvaria 31. Parieto-occipital fissure 48. Posterior ethmoidal cells 15. Optic chiasm 32. Pineal gland 12 Brain

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Brain, mid-sagittal T1-weighted MR image, contrast enhanced.

1. Anterior arch of atlas (first cervical 15. Cingulate sulcus 31. Parieto-occipital fissure vertebra) 16. Foramen magnum 32. Pineal gland 2. Anterior cerebral artery 17. Confluence of sinuses (torcular Herophili) 33. Pituitary gland 3. Superior sagittal sinus 18. Fourth ventricle 34. Pons 4. Aqueduct (of Sylvius) 19. Frontal sinus 35. Posterior arch of atlas 5. Basilar artery 20. Genu of corpus callosum 36. Cingulate gyrus 6. Body of corpus callosum 21. Great cerebral vein (of Galen) 37. Quadrigeminal cistern 7. Cerebellar folia 22. Rostrum of corpus callosum 38. Sphenoidal sinus 8. Cerebellar tonsil 23. Anterior commissure 39. Splenium of corpus callosum 9. Cerebellum 24. Subparietal sulcus 40. Tegmentum of pons 10. Cerebral peduncle of midbrain 25. Lateral ventricle 41. Tentorium cerebelli 11. Cervical spinal cord 26. Pericallosal cistern 42. Third ventricle 12. Optic chiasm 27. Inferior nasal concha 43. Anterior ethmoidal cells 13. Cisterna magna (cerebellomedullary 28. Medulla oblongata 44. Middle ethmoidal cells cistern) 29. Nasopharynx 45. Posterior ethmoidal cells 14. Diploë of calvaria 30. Odontoid process (dens) Brain 13

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(a)–(p) Brain, coronal T2-weighted MR images, from anterior to posterior.

1. Superior sagittal sinus 12. Greater wing of sphenoid 23. External capsule 2. Falx cerebri 13. Nasopharynx 24. Insular gyrus 3. Anterior cerebral artery 14. Temporalis muscle 25. Sylvian fissure (lateral sulcus) 4. Callosomarginal artery 15. Hard palate 26. Putamen 5. Genu of corpus callosum 16. Oropharynx 27. Middle cerebral artery 6. Frontal horn of lateral ventricle 17. Masseter muscle 28. Supraclinoid part of internal carotid artery 7. Cingulate gyrus 18. Frontal lobe 29. Lateral wall of cavernous sinus 8. Temporal lobe 19. Body of corpus callosum 30. Internal carotid artery 9. Anterior clinoid process 20. Septum pellucidum 31. Pituitary gland 10. Olfactory cortex 21. Head of caudate nucleus 32. Optic chiasm 11. Sphenoidal sinus 22. Anterior limb of internal capsule

Numbers 1–129 are common to pages 13–16. 14 Brain

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(a)–(p) Brain, coronal T2-weighted MR images, from anterior to posterior.

33. Suprasellar cistern 43. Trigeminal ganglion in Meckel’s cave 53. Maxillary nerve (CNV second division) 34. Globus pallidus 44. Body of sphenoid 54. Abducens nerve (CNVI) 35. Body (atrium) of lateral ventricle 45. Inferior alveolar vessels 55. Infratemporal fossa 36. Lateral pterygoid muscle 46. Inferior alveolar nerve 56. Parietal lobe 37. Medial pterygoid muscle 47. Head of mandible 57. Hippocampus 38. Tongue 48. Coronoid process of mandible 58. Temporal horn of lateral ventricle 39. Soft palate 49. Parotid gland 59. Middle cerebral artery (second order 40. Choroid plexus 50. Oculomotor nerve (CNIII) branch) 41. Corona radiata 51. Trochlear nerve (CNIV) 60. Third ventricle 42. Optic tract 52. Ophthalmic nerve (CNV, first division)

Numbers 1–129 are common to pages 13–16. Brain 15

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78 k l (a)–(p) Brain, coronal T2-weighted MR images, from anterior to posterior.

61. Prepontine cistern 71. Thalamus 82. Cerebral peduncle vestibulocochlear (CNVIII) 62. Basilar artery 72. Hypothalamus 83. Massa intermedia nerves 63. Posterior cerebral artery 73. Mammillary body (of 84. Trochlear nerve (CIV) in 93. Vestibule of vestibular 64. Superior cerebellar artery hypothalamus) ambient cistern apparatus 65. Retromandibular vein 74. Cochlea 85. Interpeduncular cistern 94. Arcuate eminence 66. Tragus of auricle 75. Pharyngobasilar raphe 86. Trigeminal nerve (CNV) 95. Superior semicircular canal 67. Basiocciput 76. Basisphenoid 87. Internal jugular vein 68. Spheno-occipital 77. Anterior arch of C1 88. Body of caudate nucleus synchondrosis 78. Vertebral artery 89. Odontoid process of C2 69. Auriculotemporal nerve 79. Lateral mass of C1 90. Body of C2 70. Interventricular foramen (of 80. Sternocleidomastoid muscle 91. Internal acoustic meatus Monro) 81. Pons 92. Facial (CNVII) and

Numbers 1–129 are common to pages 13–16. 16 Brain

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o p (a)–(p) Brain, coronal T2-weighted MR images, from anterior to posterior.

96. Lateral semicircular canal (of Sylvius) 115. Superior cerebellar 124. Dentate nucleus of 97. Posterior semicircular canal 107. Spinal cord peduncle cerebellum 98. Midbrain (mesencephalon) 108. Foramen magnum 116. Inferior cerebellar peduncle 125. Nodule of cerebellum 99. Medulla oblongata 109. Mastoid cells 117. Cerebellar hemisphere 126. Cisterna magna 100. Middle cerebellar peduncle 110. Trapezius muscle 118. Trigone of lateral ventricle 127. Lateral foramen (of 101. Cerebellar folia 111. Tectum (quadrigeminal 119. Great cerebral vein (of Luschka) 102. Pineal gland plate) of midbrain Galen) 128. Medial foramen (of 103. Internal cerebral veins 112. Tentorium cerebelli 120. Basal vein (of Rosenthal) Magendie) 104. Superior colliculus 113. Uncus of temporal lobe 121. Fourth ventricle 129. Quadrigeminal cistern 105. Inferior colliculus 114. Splenium of corpus 122. Cerebellar tonsil 106. Cerebral aqueduct callosum 123. Inferior sagittal sinus

Numbers 1–129 are common to pages 13–16. Pituitary fossa 17

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T1-weighted MR images of pituitary fossa (a) and (b) coronal, (c) sagittal, (d) sagittal post gadolinium.

1. Anterior cerebral artery 12. Medial pterygoid muscle 24. Temporal lobe 2. Anterior horn of lateral ventricle 13. Nasopharynx 25. Temporalis muscle 3. Bifurcation of internal carotid artery 14. Optic chiasm 26. Anterior pituitary gland 4. Branch of middle cerebral artery in lateral 15. Optic tract 27. Posterior pituitary gland sulcus (Sylvian fissure) 16. Parietal lobe of brain 28. Mammillary body 5. Cingulate gyrus 17. Pituitary gland 29. Thalamus 6. Corpus callosum 18. Pituitary stalk 30. Prepontine cistern 7. Insula 19. Posterior clinoid process 31. Fourth ventricle 8. Interhemispheric fissure 20. Septum pellucidum 32. Cisterna magna 9. Internal carotid artery in cavernous sinus 21. Sphenoidal sinus 33. Interpeduncular cistern 10. Lateral pterygoid muscle 22. Supraclinoid carotid artery 11. Lateral sulcus (Sylvian fissure) 23. Suprasellar cistern 18 Posterior fossa and midbrain

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c d (a)–(h) Axial MR images, from inferior to superior.

1. Glossopharyngeal nerve (CNIX) 5. Fourth ventricle 9. Pons 2. Basilar artery 6. Vagus nerve (CNX) 10. Abducens nerve (CNVI) 3. Jugular foramen 7. Cerebellar hemisphere 11. Facial nerve (CNVII) 4. Medulla oblongata 8. Internal carotid artery 12. Vestibulocochlear nerve (CNVIII)

Numbers 1–47 are common to pages 18–21. Posterior fossa and midbrain 19

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e f

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23 g h (a)–(h) Axial MR images, from inferior to superior.

13. Cochlear nerve 17. Meckel’s cave 21. Clivus 14. Vestibular nerve 18. Middle cerebellar peduncle 22. Facial nerve in stylomastoid foramen 15. Semicircular canals 19. Foramen of Luschka 23. Superior sagittal sinus 16. Cochlea 20. Anterior inferior cerebellar artery 24. Vermis

Numbers 1–47 are common to pages 18–21. 20 Cranial nerves

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c d Cranial nerves, MR images of (a) olfactory and optic nerves, (b) oculomotor nerve, (c) trochlear nerve, (d) trigeminal nerve, (e) and (f) abducens, facial and auditory nerves, (g&h) glossopharyngeal and vagus nerves.

25. Internal acoustic meatus 29. Oculomotor nerve (CNIII) 33. Trochlear nerve (CNIV) 26. Superior cerebellar peduncle 30. CNIII in oculomotor cistern 34. Interpeduncular cistern 27. Cisternal segment of CNV (trigeminal) 31. Pituitary gland 35. Eyeball 28. CNV enters Meckel’s cave 32. Ambient cistern 36. Midbrain

Numbers 1–47 are common to pages 18–21. Cranial nerves 21

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g h Cranial nerves, MR images of (a) olfactory and optic nerves, (b) oculomotor nerve, (c) trochlear nerve, (d) trigeminal nerve, (e) and (f) abducens, facial and auditory nerves, (g&h) glossopharyngeal and vagus nerves.

37. Mammillary body 41. Optic nerve, intraocular segment 45. Cerebral peduncle 38. Infundibulum 42. Optic nerve, intracanalicular segment 46. Olfactory tract and bulb (CNI) 39. Optic chiasm 43. Red nucleus of midbrain 47. Posterior cerebral artery 40. Optic nerve, intracranial portion 44. Substantia nigra

Numbers 1–47 are common to pages 18–21. 22 Brain and cranial nerves

Bonus e-materials

Cross-sectional image stack slideshows: Axial CT Midline sagittal T1-weighted MRI of the brain with Tutorials: Tutorials 2c, 2d, 2e, 2f of the head (unenhanced), Axial PD-weighted MRI intravascular contrast medium Single best answer (SBA) self-assessment of the head Selected pages from Imaging Atlas 4e questions Multi-tier labelling in slideshow/test yourself:

Intracranial variations (vascular and non-vascular)

The increasing use of arteriographic procedures Middle cerebral artery bifurcates in 71% of Mega cisterna magna 1% >10–12 mm mid has disclosed the presence of such morphological cases, trifurcates in 20% of cases and divides into sagittal dimension – not to be confused with variants more frequently and has aroused four branches in 9% of cases. arachnoid/epidermoid cysts, cerebellar atrophy, speculation in respect to their role in clinical Dandy Walker continuum (with vermian atrophy), Posterior cerebral artery originates from an disease: Blake’s pouch cyst – can be associated with enlarged PCOM artery and is connected only by a enlargement of the posterior cranial fossa. Circle of Willis hypoplasia 24%/duplication 12% slender vessel with the basilar artery on the right – the circle of Willis is present in 90% and a well- in 5.5%, on the left in 4.5% and bilaterally in 2%. Embryonic origin of posterior cerebral artery developed and symmetric circle is found in 50% from ICA/persistent primitive trigeminal artery Right transverse sinus hypoplasia 5.5%/aplasia of cases. In 60%, at least one component of the 0.1–0.6% – usually unilateral and associated 0.7% – not to be confused with thrombosis circle is hypoplastic, altering the predisposition with developmental saccular aneurysm on (bilateral transverse sinus hypoplasia 1.6%). and severity of symptoms and treatment the ICA where the PCOM would normally arise options for stroke and aneurysm disease. Their Superior sagittal sinus variations 2.3% – not (no associated specific clinical neurological knowledge can help avoid iatrogenic injury, guide to be confused with thrombosis (atresia anterior syndrome). In utero the trigeminal artery supplies neurosurgical vascular shunting and patient third 0.9%, hypoplasia middle third 0.7%, the basilar artery before the development of selection. Developmental saccular aneurysms hypoplasia of anterior one third 0.4%, hypoplasia the PCOM and vertebral arteries and normally are often associated with variants of the circle of of anterior 2/3rd 0.2% and hypoplasia of anterior involutes. Willis. A hypoplastic PCOM artery (17%), a fetal half 0.1%). Straight sinus hypoplasia 0.2% – not to be origin of the PCA (11%) and PCOM absence (7%) Prominent arachnoid granulations on confused with thrombosis. are the most common variants. MRV/CTV 2.8% – not to be confused with Absence of corpus callosum <0.01% – not Left transverse sinus hypoplasia 21%/aplasia localised thrombosis or intrasinus neoplasia really a normal variant (congenital insult between 4% (commonest locations: lateral aspect of left 3–12 weeks of pregnancy) and associated with transverse sinus 1.3%, left sigmoid sinus Anterior cerebral artery – duplicated A2 colpocephaly (enlargement of occipital horns of 0.7%, lateral aspect of right transverse sinus segment in 13%; 10% of the A1 segments are the lateral ventricles) – not to be confused with 0.6% and middle part of superior sagittal sinus hypoplastic/1–2% complete absence of one A1 hydrocephalus – associated with a myriad of 0.5%). segment. craniofacial conditions/clinical syndromes.