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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