53 David Sutton

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

• Fig. 53.1 The four standard skull proiections: (A) lateral; (B) PA; ( C) Towne's; (D) basal.

• Fig. 53.2 (A) X-ray film of skull taken in standard lateral projection.

• (B) Diagram to illustrate the standard lateral view. 1 = coronal suture;

• 2 = meningeal vascular marking, anterior branch; 3 = anterior border of

• middle fossa; 4 = lambdoid suture; 5 = dorsum sellae; 6 = clivus; 7 = lateral

• sinus; 8 = squamoparietal suture; 9 = external auditory meatus.

• Fig. 53.3 (A) X-ray film taken in standard AP projection. (B) Diagram to illustrate (A) 1 - crista galli; 2 = lesser sphenoidal wing; 3 = zygomaticofrontal suture; 4 superior orbital fissure; 5 nasal septum; 6 innominate line formed by inner wall of temporal fossa; 7 = superior margin of petrous ridge; 8 = maxillary antrum.

• Fig. 53.4 (A) X-ray film taken in standard Towne's projection. (B) Diagram to illustrate (A) 1 = lateral sinus; 2 = foramen magnum; 3 = dorsum sellae; 4 = internal auditory meatus; 5 = acuate eminence; 6 = superior semicircular canal; 7 = lambdoid suture.

• Fig. 53.5 (A) X-ray film taken in standard basal view. (B) Diagram to illustrate (A) 1 = greater sphenoidal wing; 2 = sphenoidal sinus; 3 = foramen ovale; 4 = foramen spinosum; 5 = foramen lacerum medium; 6 = foramen magnum; 7 = internal auditory meatus.

• Fig. 53.6 Structures seen in optic foramen view. a = optic foramen; b = frontal sinuses; c = roof of orbit; d = ethmoid sinuses. See also Fig. 53.54.

• Fig. 53.7 Structures seen in oblique (Stockholm C) view of petrous bone. a = internal auditory meatus; b = internal ear and semicircular canals; c = mastoid air cells; d = temporomandibular joint.

• Fig. 53.8 Internal auditory meatuses as seen in the Towne's view. a = dorsum sellae; b = internal auditory meatus; c = internal ear; d = mastoid air cells.

• Fig. 53.9 Internal auditory meatus as seen in transorbital view. a = internal auditory meatus; b = internal ear and semicircular canals; c = frontal sinuses; d = ethmoid sinuses.

• Fig. 53.10 Two vascular markings on the outer surface of the skull which may resemble fractures and are due to: (1) the middle temporal artery; (2) the supraorbital artery. The meningeal vascular markings are shown by dotted lines. (After Schunk and Maryana 1960).

• Fig. 53.11 (A) Diagram of normal sella. a = anterior clinoids; b = posterior clinoids; c = cortex or 'lamina dura' of dorsum and floor of sella. (B) J-shaped sella. d = sulcus chiasmaticus.

• Fig. 53.12 Neonate skull. Note the wide fontanels and sutures.

• Fig. 53.13 (A) Heavily clacified Pineal Gland (arrow). (B) Calcification in the habeneular commissure. (arrow)

• Fig. 53.14 Calcified choroid plexuses. (A) Lateral view. (B) Towne's view.

• Heavily calcified Falx.

Fig. 53.16 Neonatal skull showing features of note. (A Frontal view. 1 = coronal suture; 2 = lambdoid suture; 3 = sagittal suture; 4 = metopic suture; 5 = anterior fontanel; 6 = posterior fontanel. (B) Lateral view. 1 = coronal suture; 2 = lambdoid suture; 3 = mendosal suture; 4 = anterior fontanel; 5 = posterior fontanel. (C) Towne's view. 1 = interparietal bone; 2 = supraoccipital bone; 3 = exoccipital bone; 4 = foramen magnum; 5 = posterior fontanel; 6 = mendosal suture; 7 = synchondrosis between supraoccipital and exoccipital.

• Fig. 53.17 Oxycephaly due to premature fusion of the coronal sutures. Note increased convolutional markings.

• Fig. 53.18 Hand of the same patient as Fig. 53.1 7, showing syndactyly. The combination of oxycephaly and syndactyly comprises Apert's syndrome.

• Fig. 53.19 Lacunar skull in an infant. Note the wide sutures.

• Fig. 53.20 (A) Chamberlain's line (arrow). (B) Normal relationship between digastric grooves and atlanto-occipital joint. The distance between the arrowheads normally measures 1.1 cm (± 0.4 cm).

• Fig. 53.21 (A) Lateral and (B) PA films of child with raised intracranial pressure and marked suture diastasis involving the coronal and sagittal sutures.

• Fig. 53.22 Diagram of the sellar changes in raised intracranial pressure in the adult. (a-f) show progressive changes from slight (b) to gross (f).

• Fig. 53.23 Advanced changes due to chronic raised pressure. The dorsum sellae has become ill defined. The anterior clinoids are also affected and the floor of sella is indistinct.

• Fig. 53.24 Displacement of the calcified pineal by a right hemisphere tumour. The displacement measures 5 mm on the original film. T = midpoint; .f = pineal.

• Fig. 53.25 Mottled calcification in a slow-growing frontal glioma.

• Fig. 53.26 Sinuous calcification in a frontal glioma. Note the evidence of raised pressure in the sella, which shows loss of definition of its surrounding cortex (arrowhead).

• Fig. 53.27 Hazy amorphous calcification in a glioma of the occipital lobe.

• Fig. 53.28 Irregular calcification in a craniopharyngioma (arrowheads). Note the bowed shape of dorsum sellae.

• Fig. 53.29 Heavily calcified craniopharyngioma growing upward and forward from the sella.

• Fig. 53.30 Calcified craniopharyngioma. The calcification in the upper part appears to be outlining a cyst (arrowhead) and the tumour is actually encroaching on the sella.

• Fig. 53.31 (A,B) Heavily calcified parasagittal meningioma. The site and type of calcification, which outlines the whole tumour, are characteristic.

• Fig. 53.32 Calcified meningioma. Calcification is less typical but again the site, with the base of the tumour against the vault in the parasagittal region, is characteristic. The presence of a local hyperostosis and prominent frontal vascular markings also help to confirm the diagnosis.

• Fig. 53.33 Calcified dermoid in the posterior fossa. Note ring calcification (arrowheads).

• Fig. 53.34 Lipoma of corpus callosum, showing 'bracket' calcification.

• Fig. 53.35 Calcification (arrowhead) in a chordoma growing from the clivus

• Fig. 53.36 Large calcified aneurysm of the anterior communicating artery (arrowheads). The lesion is unusually large, but the marginal calcification is typical. Most calcified aneurysms are under 1 cm in diameter. (A) Lateral view. (B) PA view.

• Fig. 53.37 Multiple flecks and specks of calcification in an angiomatous malformation (arrow).

• Fig. 53.38 Flecks of calcification associated with a calcified ring shadow in an angioma (arrowheads).

• Fig. 53.39 Calcification in the margins of chronic bilateral subdural haematomas (arrowheads).

• Fig. 53.40 Unusually heavy calcification outlining the whole of the carotid siphon and shown to be bilateral in the frontal projection.

• Fig. 53.41 Calcified basal exudate above the sella in a patient with healed tuberculous meningitis (arrowheads).

• Fig. 53.42 Toxoplasmosis. Note characteristic multiple flecks of calcification.

• Fig. 53.43 Cysticercosis. There are multiple small calcified lesions 2-3 mm in diameter (arrowheads).

• Fig. 53.44 Heavy calcification in the basal ganglia and dentate nuclei. (A) Lateral View. (B) Townes View.

• Fig. 53.45 Tuberous sclerosis. There are nodules of calcification in the posterior fossa, in the frontal region, and in the parietal region. The last is nearly superimposed on the pineal.

• Fig. 53.46 Calcified occipital cortex in Sturge-Weber syndrome.

• Fig. 53.47 Enlarged meningeal and diploic vascular markings associated with a parasagittal meningioma. There is also a localised hyperostosis (arrowheads). (A) Lateral view. (B) PA view.

• Fig. 53.48 Bilateral hypertrophy of the middle meningeal vascular markings in a patient with a large angiomatous malformation.

• Fig. 53.49 Nasopharyngeal carcinoma producing erosion of the floor of the middle fossa on the left (arrows).

• Fig. 53.51 Multiple lytic deposits in the skull vault in a patient with carcinoma of the breast.

• Fig. 53.52 (A) Pituitary adenoma, showing ballooning of the sella and backward bulging of the dorsum. (B) Pituitary adenoma showing ballooning of the sella with undercutting of the anterior clinoids, backward bowing and thinning of the dorsum (arrowhead).

• Fig. 53.53 Craniopharyngioma without calcification. The shape of the sella, which is elongated, and the dorsum, which is slightly bowed forward, are suggestive of the cause.

• Fig. 53.54 Glioma of the left optic nerve. The left optic foramen (arrow) is markedly expanded compared with the normal right.

• Fig 53.55 Extensive erosion of the skull vault along the sagittal and coronal sutures. This was due to unrecognised chronic osteomyelitis following a minor scalp wound which was sutured.

• Fig. 53.56 Parietal thinning. The Towne's or PA projections show clearly that the external table and diploe are affected while the internal table remains (arrowheads).

• Fig. 53.57 Small parasagittal hyperostosis in the parietal region associated with a meningioma (arrowhead). Note the prominent vascular channels leading to the lesion.

• Fig. 53.58 Meningioma growing through the skull vault. Note the sunray spiculation and the enlarged vascular channels of the skull vault. (A) Lateral view.

• Fig. 53.59 Transverse linear fracture of the skull vault showing as a translucency ( ). There is also a vertical fracture showing as an increased density ( ).

• Fig. 53.60 Brow-up film showing pneumocephalus following frontal fractures. Note the air-fluid level, best seen in brow-up lateral films.