HEAD AND NECK IMAGING. James Chen (MS IV)

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1 HEAD AND NECK IMAGING James Chen (MS IV) Anatomy Course Johns Hopkins School of Medicine Sept. 27, 2011

2 OBJECTIVES Introduce cross sectional imaging of head and neck Computed tomography (CT) Review head and neck anatomy Major anatomical landmarks on imaging Bone Ventricles Brain Vessels

3 CROSS SECTIONAL VIEWS Sagittal Superior Coronal Superior Axial Anterior A P R L R L Inferior Inferior Posterior

4 INTRODUCTION TO CT: RULES OF LIGHT AND DARK Bright = high density Bone Axial

5 INTRODUCTION TO CT: RULES OF LIGHT AND DARK Bright = high density Bone Axial Calvarium appears bright (Bone)

6 INTRODUCTION TO CT: RULES OF LIGHT AND DARK Bright = high density Bone Blood Axial

7 INTRODUCTION TO CT: RULES OF LIGHT AND DARK Bright = high density Bone Blood Axial Parenchymal Hemorrhage (Blood)

8 INTRODUCTION TO CT: RULES OF LIGHT AND DARK Bright = high density Bone Blood Bullets (hardware) Axial

9 INTRODUCTION TO CT: RULES OF LIGHT AND DARK Bright = high density Bone Blood Bullets (hardware) Axial Dark = low density Air Water (fluids) Gray = in between Soft tissue Bullet note artifact from metal

10 INTRODUCTION TO CT: WINDOWING Image brightness/contrast adjusted to accentuate particular structures Bone Window Brain Window

11 INTRODUCTION TO CT: CONTRAST Intravenous contrast makes vessels bright Non-contrast Contrast

12 NECK IMAGING Cervical vertebrae Cross sectional anatomy Vasculature Carotid arteries Vertebral arteries

13 CERVICAL VERTEBRAE Sagittal (bone window)

14 CERVICAL VERTEBRAE Articulation allows head movement C1 - atlas C2 axis Protects vital neural and vascular structures Cervical spinal cord Vertebral arteries Sagittal (bone window) Damage can result in significant morbidity

15 Dens Sagittal Coronal

16 Which cervical vertebral level is this axial section? Sagittal Axial

17 Axial Dens Transverse Foramen Cervical Cord Level of Atlas

18 NECK IMAGING Cervical vertebrae Cross sectional anatomy Vasculature Carotid arteries Vertebral arteries

19 CERVICAL VESSELS Large vessels of the neck deliver blood supply to the brain Anterior and posterior circulations Anterior: Carotid arteries Posterior: Vertebral arteries Disrupted flow can result in significant morbidity

20 VASCULATURE: CAROTID ARTERIES Sagittal Coronal

21 VASCULATURE: COMMON CAROTID ARTERIES Sagittal Coronal

22 VASCULATURE: INTERNAL CAROTID ARTERIES Sagittal Coronal

23 VASCULATURE: EXTERNAL CAROTID ARTERIES Sagittal Coronal

24 VASCULATURE: VERTEBRAL ARTERIES Vertebral Arteries (coronal) Vertebrobasilar arteries (coronal)

25 VASCULATURE: VERTEBRAL ARTERIES Vertebral Arteries (coronal) Vertebrobasilar arteries (coronal)

26 VASCULATURE: AXIAL IMAGES Axial Coronal

27 VASCULATURE: AXIAL IMAGES Common Carotid Arteries Below carotid bifurcation

28 VASCULATURE: AXIAL IMAGES Vertebral Arteries Below carotid bifurcation

29 VASCULATURE: AXIAL IMAGES Axial Above carotid bifurcation

30 VASCULATURE: AXIAL IMAGES External carotid arteries Above carotid bifurcation

31 VASCULATURE: AXIAL IMAGES Internal carotid arteries Above carotid bifurcation

32 VASCULATURE: AXIAL IMAGES Vertebral arteries Above carotid bifurcation

33 CASE: ARTERIAL ABNORMALITY Axial Which vessels are these? Abnormal Normal

34 CASE: CAROTID ARTERIES Axial Calcifications in atherosclerotic plaques

35 CASE: CAROTID ARTERIES Axial Which vessels are affected by atherosclerosis A. Vertebral arteries B. Common carotid arteries C. External carotid arteries D. Internal carotid arteries Internal POSTERIOR to external carotid artery above bifurcation

36 HEAD IMAGING Paranasal Sinuses Bony walls and contents Ventricles Normal vs. Enlarged Parenchyma Basic anatomy and midline shift Vasculature Hemorrhage types

37 PARANASAL SINUSES Paired air-filled spaces around nasal cavity Frontal, ethmoid, sphenoid, maxillary Normal varies Development occurs prenatally and after birth Shape and size of sinuses can differ between people Things to look for: Are the bony walls intact? Is there anything in the sinus (air will appear black)?

38 SINUSES: SPHENOID Sagittal Coronal

39 SINUSES: SPHENOID Sagittal Coronal Axial

40 SINUSES: SPHENOID Sagittal Coronal Axial

41 SINUSES: ETHMOID Sagittal Coronal

42 SINUSES: ETHMOID Sagittal Coronal Axial

43 SINUSES: ETHMOID Sagittal Coronal Axial

44 SINUSES: MAXILLARY Sagittal Coronal

45 SINUSES: MAXILLARY Sagittal Coronal Axial

46 SINUSES: MAXILLARY Sagittal Coronal Axial

47 SINUSES: FRONTAL Sagittal Axial

48 SINUSES: FRONTAL Sagittal Axial

49 CASE: SINUS ABNORMALITY Axial Which sinuses do we see on this axial image? A. Frontal B. Ethmoid C. Maxillary D. Sphenoid

50 CASE: SINUS ABNORMALITY Sagittal Sagittal Left Maxillary Sinus Right Maxillary Sinus (Normal)

51 CASE: FACIAL FRACTURE Sagittal Axial What is the likely cause of the abnormality? A. Neoplastic B. Trauma C. Infection D. Endocrine Fracture in anterior wall of left maxillary sinus

52 HEAD IMAGING Paranasal Sinuses Bony walls and contents Ventricles Normal vs. Enlarged Parenchyma Basic anatomy and midline shift Vasculature Hemorrhage types

53 CEREBRAL VENTRICLES Superior Anatomy Lateral ventricles (paired) R L Third ventricle Fourth ventricle Inferior Cerebrospinal fluid Produced in choroid plexus (lateral + third ventricles) Approach on axial images Ventricles midline and symmetric? Ventricles normal size? Abnormal ventricle contents?

54 VENTRICLES SYMMETRIC? Sagittal Axial

55 VENTRICLES SYMMETRIC? Sagittal Axial Lateral ventricles symmetric

56 VENTRICLES IN MIDLINE? Sagittal Axial

57 VENTRICLES IN MIDLINE? Sagittal Axial Choroid plexus (lateral ventricles) bright from calcium

58 VENTRICLES IN MIDLINE? Sagittal Axial Ventricles equidistant from midline

59 NORMAL VENTRICULAR SIZE? Axial Axial Normal Enlarged (Hydrocephalus)

60 ABNORMAL VENTRICLE CONTENTS? Axial Axial Normal CSF (dark)

61 BLOOD IN VENTRICLES Axial Axial Intraventricular Catheter (helps reduce pressure by draining CSF) Normal CSF (dark) Intraventricular blood (bright)

62 HEAD IMAGING Paranasal Sinuses Bony walls and contents Ventricles Normal vs. Enlarged Parenchyma Basic anatomy and midline shift Vasculature Hemorrhage types

63 BRAIN PARENCHYMA Basic anatomy Cerebral hemispheres divided by falx cerebri

64 BRAIN PARENCHYMA Basic anatomy Cerebral hemispheres divided by falx cerebri Falx cerebri is dural fold separating left and right hemispheres

65 BRAIN PARENCHYMA Basic anatomy Cerebral hemispheres divided by falx cerebri Cerebral cortex superior to brainstem and cerebellum Ax Sag

66 BRAIN PARENCHYMA Basic anatomy Cerebral hemispheres divided by falx cerebri Brainstem and cerebellum inferior to cerebral cortex Ax Sag Cerebrum (temporal lobes) Cerebrum

67 BRAIN PARENCHYMA Basic anatomy Cerebral hemispheres divided by falx cerebri Brainstem and cerebellum inferior to cerebral cortex Ax Sag Brainstem Brainstem

68 BRAIN PARENCHYMA Basic anatomy Cerebral hemispheres divided by falx cerebri Brainstem and cerebellum inferior to cerebral cortex Ax Sag Cerebellum Cerebellum

69 BRAIN PARENCHYMA Normal changes with age Brain mass decreases Surrounding CSF spaces appear larger (enlarged sulci, ventricles) 20-years-old 80-years-old

70 BRAIN PARENCHYMA Elements to consider on imaging: Symmetry? Falx cerebri in midline? Abnormal mass (variable brightness) or edema (darker)? Hemorrhage (bright)?

71 CASE: BRAIN ABNORMALITY Axial Axial Abnormal Normal

72 CASE: BRAIN ABNORMALITY Axial What abnormalities are present? A. Compression of left lateral ventricle B. Intraventricular hemorrhage C. Midline shift D. A and C

73 CASE: BRAIN ABNORMALITY Axial What abnormalities are present? A. Compression of left lateral ventricle B. Intraventricular hemorrhage C. Midline shift D. A and C

74 CASE: INTRACRANIAL ABNORMALITY Axial What is the cause of the mass effect? A. Trauma B. Hemorrhage C. Congenital D. Tumor

75 CASE: INTRACRANIAL ABNORMALITY Axial What is the cause of the mass effect? A. Trauma B. Hemorrhage C. Congenital D. Tumor Large mass in left frontal lobe

76 CASE: INTRACRANIAL ABNORMALITY Axial What is the cause of the mass effect? A. Trauma B. Hemorrhage C. Congenital D. Tumor Significant edema related to mass

77 CASE: INTRACRANIAL ABNORMALITY Axial What is the cause of the mass effect? A. Trauma B. Hemorrhage C. Congenital D. Tumor Significant edema related to mass

78 HEAD IMAGING Paranasal Sinuses Bony walls and contents Ventricles Size and symmetry Parenchyma Basic anatomy and midline shift Vasculature Hemorrhage

79 INTRACRANIAL BLEEDING Common use of non-contrast head CT NEW blood appears BRIGHT (acute bleed) OLD blood can be DARK (old bleed) Different locations Epidural Subdural Subarachnoid Parenchymal Outside brain parenchyma

80 INTRACRANIAL BLEEDING Common use of non-contrast head CT NEW blood appears BRIGHT (acute bleed) OLD blood can be DARK (old bleed) Different locations Epidural Subdural Subarachnoid Parenchymal ARTERIAL hemorrhage

81 INTRACRANIAL BLEEDING Common use of non-contrast head CT NEW blood appears BRIGHT (acute bleed) OLD blood can be DARK (old bleed) Different locations Epidural Subdural Subarachnoid Parenchymal VENOUS hemorrhage

82 SUMMARY Rules of CT High density = Bright (Bone, blood, bullets) Low density = Dark (Air, CSF, edema) Normal anatomic landmarks on cross-sectional imaging Bone Brain/Ventricles Vessels

83 THANKS Questions? Good luck on the rest of anatomy!

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