Skull Films Research Articles

Imagings of Skull Vault Lesions

Lesions of the skull vault are often incidentally encountered during in plain radiography, CT, and MR imaging of the brain and benign lesions are more common than primary malignancies. The usefulness of plain skull films is limited, but when combined with CT or MRI, there is a high probability of accurate diagnosis. The aim of this essay is to describe a wide range of cranial lesions and to illustrate their distinguishing features

Report of eight cases of occipital dermal sinus: an update, and MRI findings.

We report our experience with 8 patients who were ultimately diagnosed as having occipital dermal sinuses. Clinical presentation, imaging findings and outcome are discussed, along with a review of the literature. In eight patients with occipital dermal sinuses, we retrospectively collected the following data: time to diagnosis, presenting signs, dermal anomalies, location of bone defects, intraparenchymal extension, surgical techniques and clinical outcome. Conventional radiography was performed in all patients; computerized tomography (CT) scans and magnetic resonance imaging (MRI) in all but two. Time to diagnosis ranged from 3 months to 9 years. Presenting symptoms were: infection of a cutaneous mass (n = 4), occipital mass (n = 2), intracranial hypertension related to intra-cerebral abscess (n = 2). In all patients, dermal sinus was located near the external protuberance of the occipital bone. In all patients but one, a cutaneous orifice was associated. Other cutaneous anomalies were: hairy nevus (n = 2) and subcutaneous cysts (n = 4). One patient had associated cranio-facial malformations. Plain skull films revealed linear bony defects in all cases but one; CT scans revealed linear bony defects in all cases, osteitis and intra-parenchymal abscesses if present but they did not allow the delineation of the sinus tract. MRI performed in six patients allowed a better appreciation of the malformation revealing intracranial abscess (n = 1), the sinus tract (n = 2), inclusion cysts (n = 2), and associated venous anomalies (n = 1). Surgery was performed in all patients: a complete removal of the dermal sinus was obtained in all patients but one; inclusion cysts were found in six patients. Total recovery without sequelae was obtained in all patients, except one who suffered from developmental delay and a polymalformative syndrome. In newborns, a meticulous visual exploration of the midline skin along the craniospinal axis is necessary to detect congenital dermal abnormalities. Early surgery is required to prevent severe intracranial infection. MRI could help to determine the surgical approach by delineation of the sinus tract, its extension into deeper tissues and its association with cysts, abscesses or venous anomalies.

Usefulness of 3-D reconstructed images of the human cerebral cortex for localization of subdural electrodes in epilepsy surgery

Three-dimensional (3-D) images of 14 patients, in whom subdural electrodes were implanted for epilepsy surgery evaluation, were produced by fusing computerized tomography (CT) scans and magnetic resonance images (MRI) to determine the exact location of the electrodes. In 25% (198 of 806) of the subdural electrodes an exact location for resection strategy was not evident from the X-rays. The location of these electrodes (‘doubtful location’, DL) was compared to the 3-D images. Intraoperative inspection served as the gold standard. Concordance score was defined as good for 75–100% concordance, moderate for 50–75%, and poor for less than 50% concordance of the DL electrodes to the intraoperatively determined location. A comparative analysis of the 3-D images and X-ray films showed a highly significant difference ( P<0.0002) in favor of 3-D images. The concordance score for the DL electrodes in the 3-D images was good in 93% of the patients and moderate in 7%. In contrast, the concordance score was good in only 7% of the patients for the two-dimensional (2-D) skull films, moderate in 57%, and poor in 36%. Interobserver reliability was better for 3-D images (93%) than for the 2-D X-rays (43%). These findings suggest that 3-D images aid preoperative planning for resective epilepsy surgery.

Marinesco-Sjögren Syndrome: Neuroradiologic Findings

We report the neuroradiologic manifestations of Marinesco-Sjögren Syndrome, an autosomal recessive disorder characterized by cerebellar ataxia, congenital cataracts, mental and physical retardation, skeletal anomalies and myopathy. Our patient population included eight patients (five males and three females), aged 4 to 56 years, with mental retardation, cerebellar ataxia and myopathy. Clinical and genetic evaluations were performed in all patients. Four patients underwent muscle biopsies. Nine CT examinations, seven MR examinations and two lateral skull films were performed. All patients had absent lenses and hypoplasia of vermis and cerebellar hemispheres. All except one (who had a posterior fossa arachnoid cyst) had a small posterior fossa. The neuroradiologic hallmarks of the disease are cerebellar hypoplasia, small posterior fossa and absence of the lens secondary to early cataract extraction. The role of imaging is to suggest this syndrome in the differential diagnosis of small posterior fossa or hypoplastic cerebellum and congenital cataracts. The presence of characteristic clinical findings and history of consanguineous marriage help in reaching the final diagnosis.

Clinical and biochemical phenotype of familial anterior hypopituitarism from mutation of the PROP1 gene.

We have investigated the largest family with PROP1 deficiency reported to date. Eight patients, aged 17-40 yr, in two sibships with possibly related mothers but no parental consanguinity were 109-137 cm in height (-8.8 to [minus]5.9 SD score) and sexually immature. None had received hormonal therapy. Affected individuals had similarities to and significant differences from patients with insulin-like growth factor I (IGF-I) deficiency due to GH receptor deficiency (GHRD) and normal thyroid function and sexual maturation. The differences from patients with GHRD include normal hand and foot length in seven of eight, normal arm span with relatively long legs, and persistence of extremely low levels of IGF-I into adulthood; similarities include the degree of growth failure, frequent but not uniform increased body weight for height or body mass index, and the presence of limited elbow extensibility and blue scleras in six of eight. Three patients had markedly increased sella turcica area for height age and bone age, determined from lateral skull films. The degree of sellar enlargement is variable in these two sibships. Serum GH concentrations were 0.1 ng/mL or less after clonidine ingestion. Other results were: IGF-I, 3-11 ng/mL (normal, 114-492); IGF-II, 185-299 ng/mL (normal, 358-854); IGF-binding protein-1 (IGFBP-1), 12-200 ng/mL (normal, 13-73); IGFBP-2, 60-384 ng/mL (normal, 55-480); and IGFBP-3, 400-600 ng/mL (normal, 2000-4000). The very low IGF-I and normal IGFBP-1 and -2 levels differ from findings in adults with GHRD. The GH-binding protein concentration was 58-799 pmol/L, with two patients above the normal range of 66-306. LH and FSH levels were very low, with no sex differences between serum levels of estradiol (3-6 pg/mL) and testosterone (3-10 ng/dL). PRL levels all were below normal. Serum concentrations of cortisol were normal. Serum T4 levels were uniformly low (<0.2-0.5; normal, 0.8-2.7 ng/dL), free T3 values were less than normal in seven of eight subjects, and total T3 concentrations were below normal in five of eight, but TSH levels were normal (0.58-2.18; normal, 0.4-4.2 mU/L). DNA specimens from affected individuals in each sibship were homozygous for a 2-bp deletion in exon 2 of the PROPI (Prophet of Pit-I) gene, which causes a shift of reading frames and results in a translational stop signal at codon 109. The mutant protein, when expressed in vivo lacks DNA-binding and transcriptional activation functions. The consequences of the PROPI abnormality in this and other kindreds include gonadotropin deficiency as well as the expected deficiencies in products of Pit-I-dependent somatotrophs, lactotrophs, and thyrotrophs. The severity of the hormone deficiency phenotype is compatible with the complete loss of PROP1 activity.

Extracranial soft-tissue swelling: a normal postmortem radiographic finding or a sign of trauma?

To determine if extracranial soft-tissue swelling is an expected postmortem finding or a sign of trauma. Extracranial soft-tissue thickness was measured at 5 standardized locations on postmortem skull films obtained of 18 infants with no evidence of trauma on autopsy. The same measurements were performed on the skull films of 100 living children, all less than 3 years old and without clinical history of trauma. Extracranial soft tissues measured only slightly greater in the postmortem group than on films of living children; however, the difference did achieve statistical significance. Minimal extracranial soft-tissue swelling is a normal finding on a postmortem skeletal survey. The presence of substantial or asymmetric extracranial soft-tissue swelling should be viewed with suspicion for trauma.

The management of minor traumatic brain injury.

Minor traumatic brain injury accounts for the majority of the one million head trauma attendances at A&E departments in the United Kingdom. Guidelines have been established listing criteria for skull...

Endometrial Hyperplasia with Atypia in an Adolescent with Primary Amenorrhea: A Case Report

Background Endometrial hyperplasia with atypia is an uncommon occurrence in adolescents. It is usually seen in the postmenopausal age range, but it has been reported to be a precursor for endometrial cancer in both premenopausal and postmenopausal patients. Case A 16 year old morbidly obese, hirsute, and developmentally delayed white female presented for evaluation for primary amenorrhea. She received a complete endocrinologic evaluation which showed her to be in the pre-menarchal range with serum estradiol of 1.9 ng/dl, FSH of 8.4 mlu/ml, LH of 5.9 mlu/ml, testosterone of 9.9 ng/dl, DHEA-S of 45 ug/dl, TSH of 1.1 mlu/ml, T3 of 140 ng/dl, Free T4 of 1.0 ng/dl, and prolactin of 21.4 ng/ml. Skull films and a CT of the head were normal. Because she was unable to tolerate any physical exam in the office, she underwent a pelvic exam and transvaginal ultrasound under anesthesia. On pelvic exam, her vaginal mucosa appeared atrophic and slightly friable, but her cervix appeared normal. Her obesity precluded obtaining any information from bimanual exam. The ultrasound showed that she had a thickened endometrium of 1 cm with grossly normal appearing ovaries. The patient then underwent dilation and curettage (D&C) which showed her to have endometrial hyperplasia with focial mild atypia. Medical treatment to reverse the hyperplasia was then planned. Conclusion Endometrial hyperplasia with atypia is a rare event in adolescents since it is usually seen in the postmenopausal age group. This patient presented with primary amenorrhea and was subsequently found to have endometrial hyperplasia with atypia. To the author's knowledge, after extensive review of the literature, this has never previously been reported. Clinicians should be aware of the possibility of atypical endometrial hyperplasia in morbidly obese adolescents with primary amenorrhea.

Eikenella corrodens skull infection: A case report with review of the literature

Subgaleal abscesses and skull osteomyelitis are very uncommon since the introduction of antibiotics. Eikenella corrodens infection is extremely rare in childhood and has never been reported in calvarial osteomyelitis. We present a previously healthy 9-year-old boy, with a history of frontal contusion without injury, who developed E corrodens osteomyelitis of the skull. The radiographic findings are reviewed, including skull films and computed tomographic scans. The patient underwent surgical debridement of the lesion, as well as systemic medical therapy with amoxicillin. We review the medical and surgical therapy for such lesions. The differential diagnosis of a posttraumatic scalp swelling is also reviewed. Good resolution after debridement and antibiotic therapy is reported. Surgical intervention is emphasized for the removal of bony sequestrum and nonviable bone while maintaining an intact dura.

Primary intraosseous meningiomas.

A retrospective study was performed to evaluate the clinical, radiological and histological findings of 14 intraosseous meningiomas. 14 histologically proved intraosseous meningiomas were studied with plain skull film and CT. Pathological records were reviewed. We found 9 calvarial cases and 5 spheno-orbital ones. The most common symptom in the calvarial cases was a lump in the scalp, and in the spheno-orbital lesions it was exophtalmos. Hyperostosis was present in all 5 spheno-orbital cases and in 3 out of the 9 calvarial ones; in the other 6 cases it had a mixed pattern. Enhanced dura was present in 3 calvarial cases and in 2 sphenoidal ones. Dura was involved in 5 cases: 2 with inflammatory changes, 2 with a minimal intradural tumour and one with a subdural tumour. CT better detected both the bony reaction and the intraosseous extension of the tumour. The dural changes were not specific of tumoural involvement. The differential diagnosis comprises: fibrous dysplasia, osteoma, blastic metastasis and mainly meningioma en plaque (MEP). Comparing our findings with other series, we noticed that in some cases the term MEP was used for similar cases. As the name MEP is merely descriptive and both entities share a larger number of similarities than differences, we believe that a differentiation between hyperostotic en plaque meningioma and intraosseous meningioma can hardly be made.

穿通外傷による頭蓋内異物の４症例

Four cases of intracranial foreign bodies are reported. The first patient was a 58-year-old male who drove nine nails into his head while drunk. On admission the patient was drowsy, and a plain skull film revealed the nails to be embedded intracranially on both sides of the frontal and temporal regions. Carotid angiography showed no vascular injury. The second patient was a 44-year-old male. The patient had fallen from the third floor of a building under construction, to the ground and a steel rod on the ground had pierced his face. On admission the patient was semi-comatose. The rod had penetrated from the right maxilla to the ipsilateral parietal vertex. The third patient was a 9-year-old boy. He had a fallen while running and his left upper orbit had been penetrated by a wooden chopstick which he had been holding in his hand. On admission the patient wasdrowsy. His left eye was intact but blind, extraocular movement was completely impaired, and there was no sensation in the left upper quadrant of the face. Computed tomography (CT) revealed a fragment of the chopstick extending from the orbit to the middle and posterior cranial fossa through the superior orbital fissure. Carotid and vertebral angiography showed no vascular abnormalities. The fourth patient was a 48-year old male. His head had been penetrated by a nail in a nail-gun accident. On admisson he was fully alert and had no neurological deficits. Only head of the nail was seen beside the occipital midline. CT showed that the tip of the nail was located in the right cerebellar hemisphere and vertebral angiography revealed the nail piercing the right transverse sinus. In all four cases, the foreign bodies were removed by the “open and see” policy. After craniotomy and intradural exploration, the foreign bodies were removed from the injured brain and penetrated major dural sinuses under visual control. The second patient, who had been seriously injured, died of encephalo-meningitis. Good recovery was obtained in the other three cases.

The Value of Skull Radiography in Ophthalmology

Skull radiographs and special views are still requested in ophthalmology despite the increasing availability of other radiological investigations such as CT, MR imaging and ultrasound. In order to assess the value of skull radiography in ophthalmology we retrospectively studied the use of skull radiographs and CT images in our department. In only one instance was patient management based purely on skull radiograph findings. Over 50% of CT examinations had been preceded by skull films which made no contribution towards management. In some cases the skull films had been misleading by not showing significant pathology and had consequently created considerable delay before diagnosis was reached. It is therefore unjustifiable to use skull films as a method of screening for orbital or intracranial disease and there is little indication for skull radiography in ophthalmology, except in detection of intraocular foreign bodies, facial and orbital fractures and simple sinusitis.

The Value of Skull Radiography in Ophthalmology

Skull radiographs and special views are still requested in ophthalmology despite the increasing availability of other radiological investigations such as CT, MR imaging and ultrasound. In order to assess the value of skull radiography in ophthalmology we retrospectively studied the use of skull radiographs and CT images in our department. In only one instance was patient management based purely on skull radiograph findings. Over 50% of CT examinations had been preceded by skull films which made no contribution towards management. In some cases the skull films had been misleading by not showing significant pathology and had consequently created considerable delay before diagnosis was reached. It is therefore unjustifiable to use skull films as a method of screening for orbital or intracranial disease and there is little indication for skull radiography in ophthalmology, except in detection of intraocular foreign bodies, facial and orbital fractures and simple sinusitis.

Fibro-osseous lesions of the jaws

In the first volume of the Journal of Oral Surgery, Dr G. Victor Boyko presented a case of osteofibroma of the mandible associated with leontiasis ossea of the skull (Boyko GV: J Oral Surg 1:100, 1943). The patient was a 32-year-old white woman who had complaints of right mandibular enlargement and a prominence of the right frontal and temporal areas of uncertain duration in August 1939. Mandibular radiographs showed an area of reduced radiodensity. Skull films showed a marked increase in density of the inferior part of the right temporal region and of the frontal bone, with evidence of both bone destruction and proliferation in the inferior frontal and orbital regions. A mandibular biopsy was reported as osteofibroma. The patient was kept under observation for 8 months after the biopsy, with little change in her condition. A course of deep x-ray therapy was then delivered to the mandibular lesion. She subsequently developed a pathologic fracture that was treated by maxillomandibular fixation. The fracture stabilized and at the last clinical examination, in June 1942, the patient had a union with good functional occlusion and was reported to be in good mental and physical condition.

Cryptococcal Skull Infection

A CASE OF cryptococcal osteomyelitis of the skull is presented. The patient was an immunocompetent host with skull and skin involvement without central nervous system or pulmonary extension. The radiographic findings are reviewed to include skull films, bone scan, and computed tomographic and magnetic resonance imaging scans. The patient underwent surgical debridement of the lesion as well as systemic medical therapy with amphotericin B and flucytosine. The medical and surgical therapy for such lesions is reviewed. Surgical intervention is emphasized for the removal of bony sequestrum and nonviable bone while maintaining an intact dura.

Cryptococcal Skull Infection

A case of cryptococcal osteomyelitis of the skull is presented. The patient was an immunocompetent host with skull and skin involvement without central nervous system or pulmonary extension. The radiographic findings are reviewed to include skull films, bone scan, and computed tomographic and magnetic resonance imaging scans. The patient underwent surgical debridement of the lesion as well as systemic medical therapy with amphotericin B and flucytosine. The medical and surgical therapy for such lesions is reviewed. Surgical intervention is emphasized for the removal of bony sequestrum and nonviable bone while maintaining an intact dura.

斜台脊索腫例

A giant chordoma originating in the clivus was found in a 26-year old female. At 13 years of age she had had polyneuritis after chickenpox, and a tumor of the nasopharynx was found coincidentally, but a definitive pathological diagnosis was not made even after repeated examinations in our clinic.In March, 1991 at 26 years of age, she visited our clinic again with a complaint of bilateral nasal obstruction. A giant cystic tumor was found in the nasopharynx, and she was admitted. Pathological examination in tissues obtained from a second operation revealed chordoma. The origin was considered to be the clivus because of its location on plain skull films, CT and MRI. The tumor had destroyed the apex of the pyramidal bone and invaded the intracranial space, showing severe kinking of the ponto-medullary junction of the brainstem. The tumor was partially removed by a transoral, and transpharyngeal approach and retromastoid craniectomy. The pathological diagnosis was typical chordoma, but it was considered to be unusual because the patient had not had symptoms of cranial nerve disturbance for 13 years.

The treatment of severe 'gummy' Class II division 1 malocclusion using the maxillary intrusion splint

This paper describes a modified Maxillary Intrusion Splint (M.I.S.) system which incorporates a near vertical pull headgear, and its use in the management of severe 'gummy' Class II division 1 malocclusion. The appliance was designed to reduce the visibility and vulnerability of the maxillary incisors in this difficult clinical situation by achieving the intrusion of maxillary teeth, restraining maxillary growth, and encouraging an element of subsequent forward mandibular rotation. The authors' initial experience using this system is presented in a retrospective cephalometric analysis of the lateral skull films of 26 treated patients contrasted with a similar number of comparable controls. The results showed that the principal effects of the M.I.S. were on the maxillary teeth giving decisive overjet control and incisor retraction with actual maxillary incisor intrusion. There was a similar effect on the maxillary molar and the M.I.S. provided effective en masse vertical control of the maxillary dentition. There was some degree of maxillary restraint in the M.I.S. group, but no noticeable difference in the change of mandibular position between the groups at the end of treatment. The possible reasons for this are discussed and suggestions made to improve this aspect of treatment in these patients.

Radiological findings in Hallermann–Streiff syndrome: Report of five cases and a review of the literature

Hallermann-Streiff syndrome (HSS) is a rare disorder with an associated constellation of radiological findings that may aid in the diagnosis of affected individuals. We reviewed the skeletal surveys of 5 affected individuals and noted some characteristic and constant findings. Radiological findings can include a large, poorly ossified skull with decreased ossification in the sutural areas. There was an increase in the number of Wormian bones. Severe mid-facial hypoplasia was present along with a prominent nasal bone. The skull films also showed an abnormally obtuse or nearly straight gonial angle. The teeth appeared small. The long bones were thin and gracile in appearance and often showed poor demarcation of the cortex from the medullary portion. Abnormal bowing of the radius and ulna was seen neonatally in 2 cases. There was widening at the metaphyseal ends of the long bones. The ribs were thin, but normal in length. The vertebral bodies were noted to be small and 3 cases had platyspondyly. There was a decreased number of sternal ossification enters. The metacarpals were also thin and gracile in appearance with metaphyseal widening. We conclude that these characteristic radiological findings in the newborn with HSS can aid in the diagnosis, and a skeletal survey in suspected individuals may be valuable in confirming the diagnosis.

Radiologic Evaluation of the Child with Craniosynostosis

The radiologic diagnosis of craniosynostosis is made in most instances based on routine skull films, because each suture closure produces characteristic changes. Computed tomography (CT) was originally used only to evaluate the intracranial contents. In the last 5 years changes in morphology at the skull base and in the calvarium have been better demonstrated with three-dimensional CT. This article describes and illustrates the appearance of craniosynostosis on skull radiographs and CT.