Skull Films Research Articles

Futility of skull radiography for nontraumatic conditions

Indications for post-traumatic skull radiographs have been well publicized, and "high-yield" criteria have been established. Such criteria have not been established for patients without trauma. We report a review of 157 consecutive skull series taken for nontraumatic conditions. Skull radiography was found to be extremely "low yield" in the evaluation of the nontraumatized patient--only 4.5% of the films showed significant abnormalities related to the patient's diagnosis. Moreover, regardless of radiographic results, skull films had little impact on further diagnostic workup or on patient management. Our results suggest that more stringent criteria should be considered in ordering skull radiographs for nontraumatic indications.

Primary radiographic diagnosis of fractures in the mandible

A retrospective study was performed to determine the reliability of primary radiography in evaluation of fractures in the mandible. In all, radiographic diagnosis was correct in 77% of 272 fractures. Panoramic tomography (PT) was superior compared with conventional methods (skull films and jaw projections) in the assessment of these fractures. Without PT, the diagnostic error rate increased to 40%, largely due to missed fracture lines. It is recommended that PT be performed in all cases of suspected jaw fractures, initially, when obtainable, or at least once during the treatment of a jaw trauma patient. Fractures in the dento-alveolar and condylar regions, particularly, presented repeated difficulties in initial radiography.

Anatomical Localization Schemes for Use in Positron Computed Tomography Using a Specially Designed Headholder

A headholder system is described for use in the correlation of images obtained with positron computed tomography (PCT) and other neuroradiological imaging modalities. Methods are described for defining brain anatomy from PCT images by the use of projection schemes from tomographic data. Cross-correlation of images between positron CT and standard lateral skull films, X-ray computed tomography (XCT), and two-dimensional rectilinear positron images are discussed. Such methods allow for improved reproducibility of head positioning and more precise cortical localization necessary in studies of normal brain function as well as in neuropathological conditions.

Increasing the diagnostic yield of portable skull films

A three-year retrospective analysis was conducted at a 280-bed suburban community hospital with 27,000 annual emergency department visits. All patients with a discharge diagnosis of skull fracture were studied. There were 72 patients with skull fractures. Thirty-two (44.4%) of these patients had basilar skull fractures, located predominantly in the occipital bone. Of these, 19 (59.3%) had normal antero-posterior and lateral views, with the skull fracture detected only on the Towne view. Five of these patients had depressed skull fractures and three had intracranial lesions requiring surgical intervention. We conclude that, when the decision is made to obtain portable skull films, a Towne view must be included, as well as the antero-posterior and lateral views, to increase the diagnostic yield of portable skull films in patients with skull fractures.

Pseudofontanelle in Multiple Myeloma

To the Editor.— Lytic bone lesions are commonly associated with multiple myeloma. In about 65% of patients, skeletal x-ray films will show bone lesions that are best seen on lateral skull and anteroposterior pelvic films. Less common are palpable plasmacytomas—which grow from areas of underlying bone destruction. These lesions occur in approximately 15% of patients and are usually seen in the skull, sternum, and clavicles where the skin is contiguous to the affected bones. We have seen two patients with palpable plasmacytomas of the skull, who during intensive treatment with high-dose cyclophosphamide for their systemic disease experienced a resolution of the plasmacytomas. The disappearance of the superficial mass resulted in the formation of a fontanelle-like lesion that was easily palpable on the patient's skull. Report of Cases.— Case1.—A 62-year-old woman with nonsecretory multiple myeloma had an elevated, firm, nontender 3×3.5-cm left-sided parietal plasmacytoma developed. On the second day of

Computed tomography in intracranial supratentorial osteochondroma.

A case of a huge intracranial frontoparietal osteochondroma in a 20-year-old man is reported. The presenting symptoms were headache, vomiting, and blurred vision. Apart from papilledema, no other abnormal neurological signs were present. A specific preoperative diagnosis could not be reached from the information provided by plain skull films, angiography, and radionuclide scan. The findings on computed tomography were those of a high density mass interspersed with small foci of lower densities, producing a honeycomb appearance, and surrounded by deposits of nodular calcification. The postcontrast scan showed a moderate degree of enhancement with preservation of the precontrast honeycomb pattern. These particular features may enable a correct preoperative histological diagnosis to be offered with a high degree of probability.

Clinicopathological study of the arachnoid cyst (author's transl)

Twenty-one cases of arachnoid cysts were experienced in the last 5 years. Craniotomy and extirpation of the arachnoid cysts were performed on 20 cases. Clinical features and histological findings of these cases were investigated. Ages of these patients ranged from 7 months to 70 years. Twelve cases (57%) were under the age of 20 years and the other nine cases (43%) were over 20 years old. The cysts were located in the middle fossa in 12 cases, in the frontal lobe in five cases, in the posterior fossa in three cases and in the left-sided hemisphere in one case. Symptoms were generally rather mild. Among the 12 cases of middle fossa arachnoid cysts, only six cases showed bony changes such as elevation of the sphenoid wing in plain skull films and of the 11 cases which underwent angiographic studies, only five cases showed poor visualization of the superficial middle cerebral veins on the affected side. Arachnoid cysts were readily diagnosed by CT examination as watery low density areas with a clear-cut margin which showed no enhancement by intravenous injection of contrast media. Metrizamide-CT and RI-cisternography were utilized in nine cases. Eight cases showed non-communicative cysts surrounded by metrizamide acummulation in the adjacent arachnoid space. Histological examinations of the cystic membrane were performed in eight cases by taking specimens from the covering part as well as from the bottom where the membrane adhered to the cortical surface. Seven out of eight cases showed duplicated normal arachnoid membrane. This finding indicated that the cysts could be regarded as “intraarachnoid cysts”, as pointed out by Starkman. Normal arachnoid membrane was examined histologically by taking specimens from lobectomized cortex as well as autopsied brain for comparison with the cystic membrane. These examinations revealed an interesting arachnoidal structure which might be termed “micro-intraarachnoid cysts” in certain instances. The etiology of the primary arachnoid cyst has been considered as congenital or developmental in nature. Starkman advocated that the structure of the intraarachnoid cyst itself indicated congenital malformation of the arachnoid membrane. However, this series included so many unexpected adult cases and also a case of posttraumatic arachnoid cyst in one identical twin. Therefore, one course of pathogenesis of the arachnoid cysts, can be postulated as a “microintraarachnoid cyst” existing in normal people starting to grow and becoming a large arachnoid cyst, triggered by some enlarging forces in head traumas or other unknown factors.

Evaluation of head trauma: efficacy of skull films.

A retrospective review of 1,845 patients was performed to evaluate the efficacy of skull films in acute head trauma. The implications of efficacy included effects on diagnosis, therapy, and ultimate outcome. Seventy-nine patients had skull fractures. Thirty-three patients sustained significant intracranial sequelae from their injuries, but only seven of these also sustained fractures. Twenty-six patients had significant intracranial sequelae but no skull fracture. In none of the 33 patients with significant intracranial sequelae was management or outcome affected by skull film findings. Of 1,845 patients, seven (0.38%) had basilar fractures requiring antibiotics. These were the only patients whose treatment and outcome were apparently altered by radiographic findings. Skull fractures alone seldom indicate more serious internal head injury. Routine skull films after head trauma are not effective contributors to the evaluation, management, or outcome of acute intracranial injury. "High--yield" clinical criteria are offered for predicting patients at risk for significant intracranial sequelae. If any of the "high-yield" features for significant intracranial sequelae are present, computed tomography should be considered as the primary, noninvasive diagnostic procedure of choice. The poor correlation of skull fracture with significant intracranial sequelae suggests that, for a select subgroup of patients, skull fracture may protect against significant intracranial sequelae.

Fractures of the Sella Turcica

Five recent cases of sella turcica fracture examined at the Medical Center Hospital of Vermont are reported. These fractures are most commonly associated with frontal or maxillofacial trauma and are complicated by cranial nerve palsies, chiasmatic injury, and cerebrospinal fluid rhinorrhea and otorrhea. The mortality rate with these fractures is high because of the associated brain injury. The importance of a detailed endocrine evaluation to detect developing pituitary abnormalities is also emphasized. The accuracy of radiographic diagnosis of these fractures utilizing plain skull films, tomography, and computed axial tomography is reviewed. the importance of cerebral angiography to evaluate the intracavernous internal carotid arteries and the basilar artery is also emphasized, as is the theoretical basis of the pathological findings associated with these fractures.

Mild head injuries: A source of excessive radiography? (Analysis of a series and review of the literature)

A retrospective study of 130 consecutive patients referred from the accident and emergency department for skull radiography is presented. It is concluded that there was a misuse of radiography, in that 76% of the patients had additional X-ray examinations of an area other than the site of injury. Many of these extra radiographs are requested not because an injury is suspected in these areas, but because a combination of examinations is often regarded as routine procedure. The application of clinical guidelines would reduce the number of X-ray films requested, but review of the literature suggests that the uselessness of skull radiography has been overstated. Firstly, a depressed fracture may be impossible to detect clinically and a skull radiograph is essential if intracranial infection is to be prevented in some of these patients. Secondly, some authors have mistakenly applied the findings in paediatric patients to adults. Nearly 90% of adult patients with an intracranial haematoma have a fracture, whereas the converse is true in children. This fact suggests that consideration should be given to the clinical use of skull films as an aid to reducing the number of adults with mild injuries admitted to hospital for observation. In marked contrast with other reports, only 3% of the skull examinations in this series were technically inadequate. Problems relating to poor quality skull films, and any difficulty that casualty officers may have in detecting fractures, should in any case by overcome by proper supervision and instruction from radiologists.

Skull X-rays after recent head injury

The frequency and significance of skull fracture after both mild and severe injuries are discussed by reference to large series of patients. Important management decisions depend on the finding or exclusion of a fracture. Inadequate treatment of an open injury frequently results in intracranial infection, and this is most often due to failure to take a skull X-ray, but sometimes the result of missing the fracture on the film. Failure to detect a linear fracture of the vault is a common reason for delayed diagnosis of intracranial haematoma, with resultant mortality and morbidity. Inability reliably to exclude a skull fracture in accident and emergency departments results in thousands of unnecessary admissions to hospital in Britain, causing inconvenience to patients and wasteful use of Health Service resources. Detection of fracture is also important in selecting patients for CT scanning, which can be made available only to a minority of patients. Skull films taken in accident and emergency departments are sometimes of poor quality and this is more often due to poor technique than to lack of co-operation by the patient. Not only is there need to improve technical standards of skull radiography in these departments, but clinicians there should be trained by radiologists to interpret the skull films, and to recognise when these are not of diagnostic quality. This need for more and better skull X-rays stems from the demands of good clinical practice rather than medicolegal considerations.

Stereotactic Aspiration of Deep Cerebral Abscesses after CT-Directed Labeling

Multiple, deep cerebral abscesses were treated in 2 patients by stereotactic aspiration after CT-guided needle labeling of single cavities. Separation of labeling from stereotactic manipulations avoids CT artifact generated by standard frame components; the technique will, therefore, accommodate most stereotactic instruments in current use. Alignment of CT and stereotactic coordinates hinged upon coidentification of the Pantopaque-labeled cavity on CT scans and on routine skull films with the stereotactic frame in place. Proximity of the label to targets eliminated the need for special head fixation or complex baseline correction.

Experimental Brain Stem Displacement

6 dogs were anesthetized and a silver clip attached to a cotton plug as surgically placed in the aqueduct of Sylvius. An immediate postoperative lateral skull film was obtained to demonstrate the position of the clip. The animals developed signs of hydrocephalus within hours after the procedure. 2 weeks after placement of the aqueduct plug, the animals received a permanent ventriculostomy. Immediate pre- and postoperative ventriculostomy lateral skull films were taken again to indicate position of the silver clip. Finally, a lateral skull film was taken 2 weeks after ventriculostomy and just prior to sacrifice. Radiological techniques were standardized. In this experimental setting downward brain stem herniation predominated and upward herniation of the brain stem was an infrequent occurrence.

Meningioma in the Pineal Region

A case of meningioma in the pineal region is reported. The patient, a 40 year-old male, was referred because of a slight headache and the presence of a calcified lesion in plain skull X-rays. A neurological examination revealed a slight memory disturbance, minimum hemiparesis and a sensory disturbance on the left side. Plain X-rays and tomography of the skull showed large calcification 3 cm in diameter in the pineal region. A 99mTc pertechnetate brain scan showed an area of increased activity in the same region. Angiography showed no tumor stain in any phase. In the venous phase, upward displacement of the vein of Galen and the straight sinus was demonstrated. Pneumoencephalography revealed that the size of the mass corresponded exactly to the size of the calcification. It was also demonstrated that the mass was free from the edge of the tentorium. Right parietooccipital craniotomy was performed and the tumor in the pineal region was removed subtotally. This tumor was considered to have originated from the velum interpositum. The postoperative course was uneventful. Preoperative symptoms and signs improved except for the left lower quadrant hemianopsia which was produced by surgical manipulation. The pathological diagnosis was meningothelial meningioma with psammoma bodies. A review of the previously reported 35 cases can be summarized as follows. The origin of the meningiomas in the pineal region was either the velum interpositum (12 cases) or the junction of falx and tentorium (21 cases). This series of 36 cases including the present case consisted of 11 males, 21 females and four undescribed cases. In comparison with germinoma, characteristic clinical signs of meningioma in the pineal region were as follows. 1) The incidence of upward gaze palsy was much lower than that in germinoma cases. 2) Cerebellar signs, pyramidal signs and mental disturbances were found more commonly in meningioma cases than in germinoma cases. 3) Dysarthria and hypoglossal nerve palsy were seen only in meningioma cases. In seven cases (22.6%), characteristic calcifications were demonstrated on plain skull films. However, tumor stains were found by angiography in only a few cases. The prognosis of this tumor was generally poor. Only four cases were reported to be cured without neurological defects by total removal. Improvements in preoperative symptoms were obtained in nine of the cases. The overall mortality was 60.6% and operative mortality was 27.3%. When removing meningioma in the pineal region, considerable attention must be paid to preventing damage in the deep cerebral veins and surrounding structures.

Estrogen-Induced Galactorrhea in Man

A 36-year-old man had estrogen-induced galactorrhea and oligospermia. He had been taking an unknown amount of estrogen for a year. While hypogonadism, manifested by decreased libido and potency, was apparent at the time of estrogen administration, galactorrhea appeared two months after estrogen was discontinued. Normal skull film, tomogram views of the sella turcica, and computerized axial tomography scan suggested that long-term estrogen administration caused sustained hyperprolactinemia with levels that ranged between 21 and 83 ng/mL throughout the ensuing year. Prolonged thyroid-stimulating hormone and prolactin luteinizing hormone response to luteinizing hormone-releasing hormone were believed to be evidence of a derangement in the hypothalamic control of pituitary hormone secretion. A year after he stopped taking estrogen, the patient gradually regained his potency, his prolactin level declined, the galactorrhea disappeared, and spermatogenesis returned to normal.

Emergency Radiology of the Acutely III or Injured Child

The author promises in his introduction to concentrate on evaluation of the plain film, which is a mainstay of diagnosis in emergency medicine. In general, he holds true to his promise but cannot resist the temptation to include examples of computerized axial tomography used in the assessment of the condition of an emergency patient. For this he can be forgiven, since the number, clarity, and relevance of his other illustrations are genuinely helpful to the practitioner of emergency medicine. Particularly relevant are his discussion and illustrations of typical traumatic injuries to the extremities, spine, and head—the bread and butter of emergency medicine. Recent risk-factor analyses of emergency medical practices indicate that the most common claim against emergency physicians involves missed fractures. No competent emergency physicians would be expected to overlook a fracture of serious clinical importance. However, when interpreting scores of extremity, spine, and skull films during a night's duty

Benign intracranial hypertension in pregnancy

Benign intracranial hypertension, an unusual case of headaches, was associated with pregnancy in a gravid female with the chief complaint of headache. Symptoms resolved after three days of prednisone therapy. In benign intracranial hypertension, the possibilities of intracranial mass lesions, intracranial infection, obstruction of the cerebral ventricles, and hypertensive encephalopathy are excluded by evaluation with skull films, computerized axial tomography, electroencephalography and lumbar puncture. The only symptom may be headache and the only physical sign, papilledema. Therefore, neurological examination must include visualization of the fundi.

Liquido cefalorraquiano na cisticercose encefalica

Cerebrospinal fluid (CSF) changes in brain cysticercosis have long been known. Its characteristic features are a mild or moderate pleocytosis with eosinophils, a slight or moderate protein increase with an elevated gammaglobulin concentration, and a positive complement fixation test. Unfortunately all these abnormalities are not always present together and difficulties may be encountered in the diagnosis. This paper presents a study based on the experience acquired in the CSF Laboratory of the Neurological Department of Escola Paulista de Medicina (São Paulo, Brasil) after 35 years' work, and 120.000 CSF specimens examined. The material consists of 147 cases of brain cysticercosis confirmed by necropsy, surgery, subcutaneous or intraocular cysticercus, x ray of the skull, and of 509 clinical observation with suggestive CSF changes. It is the purpose of this paper to appreciate the importance of each of the CSF tests and to observe the CSF abnormalities during the course of this disease. The results of the study of the 79 cases varified by necropsy or surgery showed that the characteristic CSF changes that make the diagnosis of brain cysticercosis were observed in 54 percent of the cases. The eosinophils were present in 82 percent, protein changes in 78 percent, complement fixation test in 70 per cent, hypertension in 55 per cent, and decreased sugar content in 27 per cent of the cases. In two cases the CSF was normal. As the eosinophils and the protein abnormalities may be seen in several other diseases, the complement fixation test for cysticercus should be regarded as the most important CSF test in the diagnosis of brain cysticercosis. The successive CSF specimens withdrawn of 40 patients during the course of this disease have shown that the abnormalities went on for 4 to 18 years observation, suggesting that the parasites were alive. On the contrary, in 11 other cases it was varified the final CSF normalization after 5 to 14 years, suggesting that the parasites were dead. The CSF was normal in 31 out of 42 patients with opaque nodules visible in skull films (calcified cysticercus). In the remaining 11 cases, the characteristic CSF findings were observed in 3, but in 8 cases the only abnormalities were positive complement fixation test or eosinophils. In 14 out of 26 patients with subcutaneous or introacular cysticercus there were the usual CSF changes but in the other remaining cases the CSF was normal. The absence of treatment for brain cysticercosis is consistent with the persistence of CSF abnormalities in the specimens examined during the course of this disease. This calls for an integrated prophylactic to all Latin-American countries in order to exterminate this serious disease for the well-being of the next generation.

Malignant external otitis: a radiographic-clinical correlation.

Malignant external otitis is an infectious process of the ear which may cause marked destruction of the surrounding bony structures. After evaluation of the plain skull films, mastoid series, temporal bone tomography, arteriography, and venography in nine cases of malignant external otitis, we divided the disorder into an early stage and late stage. The early stage is manifested by a soft tissue mass within the external canal or clouding of the mastoid air cells with no bone destruction. In the late stage, bone destruction may extend to the middle ear cavity, temporomandibular joint, and/or base of the skull. A correlation can be made between the clinical findings and these radiographic stages. Complex motion tomography is essential to appreciate the bone destruction in patients with late stage disease.

Pituitary fossa size and facial type

T he pituitary fossa is a depression in the superior surface of the body of the sphenoid and is limited anteriorly by the middle clinoid processes and posteriorly by the dorsum sella which carries the posterior clinoid processes on either side of its superior margin. All of the pituitary body, with the exception of the base of the infundibulum, lies within the confines of this bony area. It is necessary to be familiar with this osteology to appreciate the structure of the sella turcica as depicted on a lateral x-ray film of the skull. Numerous studies have been undertaken to determine whether a relationship exists between the size of the pituitary fossa and other body dimensions. Gordon and Bell4 studied the sellae of 104 normal children and found a marked variation in the size of the sella for any particular age and no definite relationship between the shape of the sella and skull size. They divided the sellae in these children into three general groups according to shape, namely, circular, oval, and flat. The oval sellae were the most common and were seen in 67 percent of the children, while the flat type was the rarest and was always found in small heads. Not all small heads, however, exhibited this type of fossa. Gordon and Bell5 subsequently studied 228 abnormal children and found that the sellae of these children were morphologically similar to those which they had described in their normal group. The size and shape of sellae did not appear to be influenced by any of the diseases studied, which included mongolism, anterior pituitary deficiency, mental retardation, and hyperand hypothyroidism. Silverman16 studied the sellae of 320 children and associated hypothyroidism with enlargement of this fossa. He established normal ranges for pituitary fossa size in North American children from birth to 16 years of age and also showed that the lateral radiographic area of sella bears a reasonable relationship to its volumetric size. Israel’ reported that the pituitary fossa increases in size throughout life and that the average annual increment varies between 0.2 and 1.1 percent. Haas found the normal adult pituitary area on a lateral skull film, when the target-to-film distance is 3 feet, to be 86 sq. mm. (Standard deviation, 15 sq. mm.). According to Haas, measuring the sellar area is more satisfactory than measuring its diameters, and he described a method for accomplishing this. Hurxtha17 also believed that this method has merit, especially when one is undertaking longitudinal studies of sellar size. The present study was undertaken, first, to determine the average size of sella as seen in lateral cephalographic radiographs and, second, to determine whether any correlation exists between the size of the pituitary fossa and some facial dimensions.