CURRENT NEUROIMAGING OPTIONS

1. Skull X-ray
a. AP
b. Lateral
Skull AP-lateral view standard view
c. Caldwells view
Occipito frontal view
This position is ideally suited for studying frontal sinuses. In this position the frontal sinuses
are in direct contact with the film hence there is no chance for any distortion or geometric
blur to occur.
To get a caldwell view the patient is made to sit in front of the film with the radiographic
base line tilted to an angle of 15 - 20 degrees upwards. The incident beam is horizontal and
is centered 1/2 inch below the external occipital protruberance. This view is also known as
the frontal sinus view.
d. Townes view
Patient is in an erect position, either standing or sitting
Position the patient so that their back and posterior skull are touching the bucky/grid
Bring the patients chin down until the radiographic baseline orbitomeatal line (OML) is
parallel to the floor, therefore perpendicular the bucky. If the patient is not able to do this,
the central ray angle may have to be increased caudally so that there is a 30 degree angle
between the radiographic baseline (OML) and the central ray.
Ensure the midsaggital plane is perpendicular to the bucky
Ensure the interpupillary line is parallel to the floor
e. Waters' view
also known as the Occipitomental view
is a radiographic view, where an X-ray beam is angled at 45 to theorbitomeatal line.
The rays pass from behind the head and are perpendicular to the radiographic plate.
It is commonly used to get a better view of the maxillary sinuses.
f. Submentovertex view (SMV)
For this projection the neck is maximally extended and the film casette touches the top of
the head.
The x-ray beam enters the head under the chin (near the mental tubercle of the mandible)
and exits at the vertex.
The direction of the beam is perpendicular to the cantho-meatal line.
This view is used in conjunction with other projections, and allows direct visualization of the
base of the skull.
2. Computed Tomography (CT)
a. Axial
b. Sagittal
c. Coronal
3. Magnetic Resonance Imaging (MRI)

4. Ultrasound

5. Angiogram
 CT/MRI

CRANIOFACIAL TRAUMA RADIOLOGY

SKELETAL TRAUMA

Concerns on radiograph of trauma are:

High index of suspicion

Two radiographs at 90 degree to each other in every case
Once a fracture is identified, do not forget to look at the rest of the film

SKULL

Demonstration of skull fractures does not indicate presence of intracranial injury or the other
way around.
Indications in plain film
Shift in the calcified pineal
Depressed skull fracture
Types of fracture
Linear sharp, dark, translucent line, irregular or jagged, branching character
Oftens extend into the base
Versus vascular groove: smooth, curving course
Versus suture lines: serrated edges
Depressed stellate with multiple fracture lines radiating outward from a central point
Secondary to severe trauma
Diastatic linear fracture extends into the suture and separates it
Infancy and children most commonly seen
Lambdoid and sagittal suture most commonly involve

TEMPORAL BONE FRACTURES

Types:

a. Longitudinal temporal bone fracture

b. Transverse temporal bone fracture
c. Mixed oblique fracture type

FACIAL

NASAL FRACTURES

- most common fracture of the facial skeleton

ORBITAL TRAUMA FRACTURES

 - BLOW-OUT FRACTURES
o Orbital floor fracture
o Tear drop sign
o Air-fluid level

Le Fort 1
Guerin fracture
Transverse fracture that transects the inferior aspect maxilla, nasal septum and most
inferior portions of the pterygoid plate
Floating palate
Le Fort 2
Fracture produces pyramidal in shape
Nasal bone, frontal process of maxilla, medial orbital wall, inferior orbital wall, maxillary
sinus, pterygoid plate
Floating maxilla
Le Fort 3
Produces craniofacial separation
Horizontal fracture that transects the nasofrontal suture, medial, inferior and lateral
orbital walls, zygomatic arches and pterygoid plate base
Floating face

Zygomaticomaxillary fracture (tripod)

Zygoma 2nd most commonly fractured bone of the midface (nasal bones most
commonly fractured bone of the mdiface)
Zygomatic sutures separation
Zygomaticosphenoidal
Zygomaticofrontal
zygomaticomaticotemporal
HEAD TRAUMA:
Imaging:

Skull x-ray
Not sensitive for detection of intracranial pathology
For medicolegal purposes
Patients at low risk for intracranial injury based on history and physical exam should be
observed while patients at high risk should be imaged by CT scan
The absence of skull fractures on conventional radiography does not exclude significant
intracranial injury
CT scan:
Quick, widely available
Accurate in detection of acute intra and extraaxial hemorrhage
Accurate in detection of skull, facial and orbital fractures
MRI:
Traditionally less desirable than CT in acute setting because
longer exam time
difficulty in managing life support and monitoring equipment
inferior bone detail
comparable or superior to CT in detection of acute epidural and subdural hematoma and
non-hemorrhagic brain injury
modality of choice for subacute and chronic head injury and in patients with acute head
trauma with neurologic findings unexplained by CT

Skull fractures

non-displaced linear fracture most common type

no surgical management required
depressed fracture usually associated with underlying contusion
pneumocephalus may be seen in compound fractures and those involving the paranasal
sinuses

Classification of head injury:

Primary lesions
Occur as a direct result of blow to the head
Epidural, subdural, subarachnoid and intraventricular hemorrhage, diffuse axonal injury
Secondary lesions
Occur as a consequence of primary lesions
Often preventable
Cerebral swelling, brain herniation
Hydrocephalus, ischemia, infarction
EPIDURAL HEMATOMA:

Usually arterial in origin and often results from fractures that disrupt the middle meningeal
artery
 May occur from stretching and tearing of meningeal arteries without associated fractures
Skull fractures are seen in 85-95% of cases
Most are temporal or temporoparietal
CT: acute epidural hematoma appear as well-defined high attenuation lenticular or biconvex
extraaxial collections
Frequently with associated mass effect with sulcal effacement and midline shift
Bone window usually demonstrates overlying skull fracture
Does not cross sutures where the periosteal layer of the dura is attached firmly

SUBDURAL HEMATOMA:

Typically venous in origin

Often due to stretching and tearing of cortical veins that traverse the subdural space
May also be due to disruption of penetrating branches of the superficial cerebral arteries
Extends over a much larger space than in epidural hematoma because the inner dural layer
and arachnoid are not firmly attached as the dura and the inner table of the skull
Commonly seen after acute deceleration injury from a motor vehicle accident or fall
CT:
Acute
Acute crescentric extraaxial collections of high attenuation
Most are supratentorial
Does not cross the falx cerebri and tentorium but can cross sutural margins
Chronic
Low attenuation value similar to CSF
Rebleeding
Heterogeneous appearance from a mixture of fresh blood and partially liquefied
hematoma
Sediment level or hematocrit level

SUBARACHNOID HEMORRHAGE:

Results from disruption of small subarachnoid vessels or direct extension into the
subarachnoid space by contusion or hematoma
May be due to trauma or ruptured aneurysm
CT:
Linear areas of high attenuation within the cisterns and sulci
If due to ruptured aneurysm, CT angiography with 3D reformation should be done at
once before vasospasm sets in
MRI:
Isointense to T1W and T2W
FLAIR
More sensitive in detecting acute subarachnoid hemorrhage
High signal intensity

DIFFUSE AXONAL INJURY:

Widespread disruption of axons at the time of an acceleration/deceleration injury

Usually not seen on imaging
 Better seen by MRI than CT
Most commonly due to high speed motor vehicle crashes
Loss of consciousness starts immediately after injury and more severe than in patients with
cortical contusions or hematoma
If patient has decreased sensorium (poor GCS) but CT scan is normal suspect DAI
CT:
Subtle or absent findings
Most common small petechial hemorrhages at the gray-white matter junction or corpus
callosum
Ill-defined areas of decreased attenuation may occasionally be seen
MR:
Small foci of increased signal within the white matter, multiple as many as 15-20 lesions
in severe head injury
Mild
Usually confined to frontal and temporal white matter
Typically involves the parasaggital regions of the temporal lobes
More severe trauma
Involves lobar white matter as well as corpus callosum
Most severe trauma
Involves the dorsolateral aspect of the midbrain and upper pons in addition to the lobar
white matter and corpus callosum

CORTICAL CONTUSION:

Areas of focal brain injury primarily involving the superficial gray matter
Less likely to have loss of consciousness and with better prognosis than in patients with
diffuse axonal injury
Well seen on CT
Tend to be multiple and bilateral
Occur near bony protuberance
Common sites:
temporal lobes above the petrous bone or posterior to the greater sphenoid wing
frontal lobes above the cribriform plate, planum sphenoidale and lesser sphenoid
wing
can also occur at the margins of depressed skull fractures
hemorrhagic lesions
foci of higher attenuation within superficial gray matter which may be surrounded by
larger area of low attenuation secondary to edema
MR:
Poorly marginated areas of increased signal on T2W in the characteristic locations
Hemorrhage heterogeneous signal intensity that varies depending on age of lesion
PNS
Head and Neck - term used collectively to describe the extracranial structures

Sinonasal cavity
Skull base

Pharynx

Oral cavity

Larynx, neck, orbit and temporal bone

IMAGING METHODS

Both multislice helical CT and MR can provide exquisite imaging of the normal and pathologic
anatomy of the head and neck.
CT is the modality of choice when looking for calcifications/lithiasis or for detection of fractures.

MR provides outstanding sensitivity for soft tissue discrimination. It often demonstrates full
extent of the pathology.

PET (Positron Emission Tomography) - increased the sensitivity and specificity in the evaluation
of primary and recurrent malignancies in combination with either CT or MR imaging.

PARANASAL SINUSES AND NASAL CAVITY

SINUSITIS
Most common pathology: Inflammatory disease

Findings include:

Mild mucosal

thickening, primarily within the maxillary and ethmoid sinuses.

ACUTE SINUSITIS CHRONIC SINUSITIS

Characterized by presence of air-fluid levels Mucoperiosteal thickening and osseous thickening
of the sinus walls
Foamy appearing sinus secretions
Soft tissue findings best detected on T2WI: high Secretions are desiccated no signal
signal
Caused by viral upper respiratory tract infection
Common complications of sinusitis

Inflammatory polyps

Mucous retention cysts

Mucoceles

Cavernous sinus thrombosis

Inflammatory polyps

Result of chronic inflammation resulting to muscosal hyperplasia

mucosal redundancy and polyp formation

Most often blend imperceptibly with mucoperiosteal thickening and

cannot be clearly differentiated.

Antrochoanal polyp antral polyp expands to the point where it

prolapses through the sinus ostium.

Soft tissue mass extending from the maxillary sinus to fill the ipsilateral
nasal cavity and nasopahrynx.

Mucous retention cysts

Represent obstructed mucous glands within the mucosal lining.

Have a characteristic rounded appearance, measuring one to several

centimeters in diameter.

Maxillary sinus most commonly involved

Mucocele

Similar to mucous retention cysts, but instead of being confined to the

single mucous gland, the lesion expands to the point where the entire
sinus becomes obstructed.

Typically occurs because of a mass obstructing the draining ostium.

Characteristic: Frank expansion of the sinus with associated sinus wall

bony thinning and remodelling.

Frontal sinus most commonly affected

Cavernous sinus thrombosis

Most commonly results from contiguous spread of infection from the

sinuses or middle third of the face, or less commonly dental abscess or
orbital cellulitis.

Staphylococcus aureus -- most common infectious microbe, found in 50-

60% of the cases.

MRI with contrast - modality of choice to confirm its presence

Tumor and tumor-like diseases

Inverting papilloma

Neoplastic nasal epithelium inverts and grows into the underlying

mucosa.

These papillomas are not believed to be associated with allergy or

chronic infections because they are almost invariably unilateral in
location.

Occur exclusively on the lateral nasal wall, centered on the hiatus

semilunaris.

Increased association with squamous cell carcinoma.

JUVENILE NASOPHARYNGEAL ANGIOFIBROMAS

Typically seen in male adolescents presenting with epistaxis.

Tumor arises from fibrovascular stroma of the nasal wall adjacent to the
sphenopalatine foramen.

Benign, but very locally aggressive

Classically, tumor fills the nasopharynx and bows the posterior wall of
the maxillary sinus forward.

Retromaxillary pterygopalatine fossa location is a hallmark feature.

Enhances markedly with contrast administration.

Malignancy

Squamous cell carcinoma most common (80- 90%)

often clinically silent until it is quite advanced.

Early symptoms are related to obstructive sinusitis

Imaging findings: opacified sinus with associated bony wall destruction.