Diagnostic value of three-dimensional CT in pediatric calvarial pathologies

Transcription

1 Diagnostic value of three-dimensional CT in pediatric calvarial pathologies Poster No.: C-1263 Congress: ECR 2013 Type: Educational Exhibit Authors: Y. Pekcevik, E. Hasbay, R. Pekcevik; Izmir/TR Keywords: Trauma, Congenital, Computer Applications-3D, CT, Pediatric, CNS, Bones DOI: /ecr2013/C-1263 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 71

2 Learning objectives 1. To review the anatomy and embryology of the calvaria 2. To discuss the common normal, variant and pathological findings that threedimensional CT can aid the diagnosis 3. To explain the utility of three-dimensional CT in the diagnosis of calvarial pathologies Background In children with suspected cranial pathologies three dimensional (3D) CT is superior to other modalities. It can help differentiate actual pathology from normal or variant appearances. Sutures and fontanels, synostosis, abnormalities of head shape without craniosynostosis, congenital calvarial defects, cranial fractures, bone tumors and postoperative cranial vault can be assessed with 3D CT. Images for this section: Fig. 1: Development of the skull Page 2 of 71

3 Imaging findings OR Procedure details MDCT Scanning Technique All CT examinations were performed by a 64-slice CT scanner (Aquillon 64, Toshiba Medical Systems, Tochigi, Japan). The scanning parameters included 120 kv, ma, section thickness of 0.5 mm and reconstruction interval of 0.5 mm. The scan revolution time was 0.5 seconds. Three-dimensional reconstructions were generated on the CT scanner console and send to picture archiving and communication system (PACS). For patients that need detailed evaulation, 3D volume rendered (VR) and 3D MIP images were evaluated in a workstation (Aquarius workstation, TeraRecon, San Mateo, California, USA). Embryology and anatomy Fig. 1: Development of the skull References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR The development of the skull outlined in Figure 1. Calvaria is a Latin term and it means upper part of the head that surrounds brain and special sense organs. It is formed by pressure of the growing cerebral and cerebellar hemispheres. Dura has a regulatory role in this process (1). Page 3 of 71

4 Membranous bones of the vault are seperated by sutures that help vaginal passage and allow uniform growth of the calvarium by its fibrous connective tissue content. The growth of the skull is parallel to a fused suture (Virchow's law). If there is a premature fusion of a suture, the calvaria show no growth perpendicular to the affected suture (1). Anterior fontanelle is a space in the conjunction of sagittal, coronal and metopic sutures and closes typically by 12 months of age. Posterior fontanelle is in the conjunction of sagittal and lambdoid sutures and closes by about three months of age (1-3). The closure of the sutures and fontanels outlined in Table. Figure 2-4 showed normal calvarial 3D anatomy. Fig. 2: Normal 3D calvarial anatomy. (F: frontal bone, O: Occipital bone, P: parietal bone, Sp: sphenoid bone, Ts: temporal bone squamous portion). References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 4 of 71

5 Fig. 3: Normal 3D calvarial anatomy. (F: frontal bone, O: Occipital bone, P: parietal bone, Sp: sphenoid bone, Ts: temporal bone squamous portion). References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 5 of 71

6 Fig. 4: Normal 3D calvarial anatomy. (F: frontal bone, O: Occipital bone, P: parietal bone, Sp: sphenoid bone, Ts: temporal bone squamous portion). There is a linear fracture in the right parietal bone (double arrows). References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Table. Normal age of the fontanel/suture closure Fontanel/Suture Age of the closure Page 6 of 71

7 Anterior fontanel months Posterior fontanel 3-6 months Posterolateral fontanel (mastoid) 2 years Anterolateral fontanelle (sphenoidal) 3 months Metopic suture 9-11 months (may persist into adulthood) Sagittal suture years Coronal sutures years Lamdoid sutures years Squamosal sutures years Wormian bone (intrasutural bones) Wormian bones are accessory bones that occur within cranial suture and fontanels, most commonly within the posterior sutures (Figure 5). Usually they are normal variant but sometimes associated with cleidocranial dysplasia, pyknodysostosis, osteogenesis imperfecta, hypothyroidism, hypophosphatasia, acroosteolysis and Down Syndrome (4). Page 7 of 71

8 Fig. 5: Wormian bones. There are a lot of are accessory bones within lamdoid suture and posterior fontanel (arrows). References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 8 of 71

9 A larger, single, centrally located intrasutural bone at the junction of the lambdoid suture and sagittal suture is called os incae (interparietal bone) (Figure 6). It is formed in a persistent mendosal suture (5). Fig. 6: Os incae (interparietal bone). A large, single intrasutural bone at the junction of the lambdoid suture and sagittal suture (arrows). References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 9 of 71

10 Lacunar skull, increased convolutional markings, copper beaten skull Lacunar skull, increased convolutional markings and copper beaten skull are confusing terms. Lacunar skull is a dysplasia of the membranous bone. The well-defined lucent areas in calvarium are represent nonossified fibrous bone and they are bounded by normally ossified bone (2). They usually present at birth and most prominent in the parietal and occipital bones. The inner table is more affected than the outer. The lacunae resolves spontaneously by age 6 months and is not related to the degree of hydrocephalus. Lacunar skull is usually associated with Chiari II malformation, and less commonly with encephalocele (2). Convolutional markings are inner table indentations that is caused by the cerebral surface of the growing brain in infants (Figure 6c). They occur later than lacunar skull, especially during periods of rapid brain growth, between age 2-3 years and 5-7 years. They become less prominent after approximately 8 years of age. Convolutional markings are now considered to be a reflection of normal brain growth. If they become prominent and seen throughout the skull rather tahan posterior parts, it reflects a pathologic condition so called copper beaten skull (6). Copper beaten skull is an indicator of chronic elevated intracranial pressure resulting from craniosynostosis, hydrocephalus and intracranial masses (Figure 8). Macrocrania, splitting of the sutures, skull demineralisation and erosion or enlargement of the sella turcica may be seen due to increased in intracranial pressure (6, 7). Abnormalities in head size (macrocephaly and microcephaly) Macrocephaly is a large head which is larger than two standard deviations from the normal distribution. There are three major causes of macrocephaly: Hydrocephalus (increased CSF fluid) (Figure 22), megalencephaly (enlargement of the brain due to neurocutenous syndromes or metabolic diseases) or thickening of the skull (anemia, rickets, hyperphosphataemia, osteopetrosis, osteogenesis imperfecta, cleidocranial dysostosis). It may be contitutional or due to benign causes such as benign enlargement of the subarachnoid space. CT is superior to skull radiograph because it can differantiate these major categories (8). Microcephaly is small head which is less than two standard deviations from the normal distribution. Head size is smaller in some ethnic groups. It can also be familial. But it is important to diagnose microcephaly and identify the cause. There are two major Page 10 of 71

11 causes of microcephaly: Primary ( chromosomal disorders, neurolation defects such as anencephaly and encephalocele, prosencephalisation defect such as agenesis corpus callosum and holoprosencephaly, migration defect) and secondary (intrauterine infection, toxins and vascular occlusions, severe hypoxic-ischemic injury and postnatal systemic diseases) (2,8). Due to the lack of brain growth, the force keeping the cranial bones separated does not exist and there may be early closure of the sutures or even overlapping of the skull bones (Figure 7). Page 11 of 71

12 Fig. 7: Microcephaly. Sutures are closed and overlapping (arrows) in 1 year-old patient due to severe hypoxic-ischemic injury. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Abnormalities in head shape There may be abnormalities in the shape of the neonatal calvaria due to pressure on the head during childbirth. This is called fetal or newborn molding and usually disappears after a few days. Faulty fetal packing means concave depressions in the calvaria due to extrinsic pressure of the limb or uterine leiomyoma (2). Plagiocephaly without craniosynostosis (posterior deformational, positional plagiocephaly) is associated with sleeping position (sleeping on back), congenital torticolis, abnormal vertebra and neurologic deficits. There is ipsilateral frontal and contralateral occipital bossing (parallelogram shape) and anterior displacement of ipsilateral ear (9).There is no significant distortion of the anterior-posterior axis of the skull base (10) (Figure 8-10). Craniosynostosis Premature fusion of the sutures are commonly isolated and sporadic (non-syndromic). Craniosynostosis may be associated with some syndromes, including Crouzon, Apert, Pfeiffer and Carpenter syndrome (1,11). Plagiocephaly, means skewed or oblique head (1). Unilateral coronal synostosis (anterior plagiocephaly) (Figure 11), unilateral synostosis of the lambdoid suture (posterior plagiocephaly) or asyncronous synostoses of multipl sutures (Figure 12-13). Page 12 of 71

13 Fig. 12: Plagiocephaly and copper beaten skull. Premature fusion of the sagittal suture (white arrow) and left coronal suture (double white arrows). There are multipl lucencies in the parietal and occipital bones due to increased intracranial pressure, copper beaten skull. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 13 of 71

14 Fig. 13: Plagiocephaly and copper beaten skull (the same patient as in Fig. 12). Premature fusion of the sagittal suture (white arrow) and left coronal suture (double white arrows). There are multipl lucencies in the parietal and occipital bones due to increased intracranial pressure, copper beaten skull. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 14 of 71

15 A radiologist should distinguish posterior plagiocephaly, which requires surgey, from positional plagiocephaly, which can be treated conservatively (10,11). There are some important clues: 1) Lamdoid suture synostosis; 3D VR images are very useful for quick assesment of the premature fusion. 3D MIP images, that can be easily done in workstations within seconds, can be added for further detailed evaluation (12). 2) Contralateral frontal and parietal bossing (trapezoidal shape) and posterior displacement of ipsilateral ear (9). In positional plagiocephaly there is ipsilateral frontal and contralateral occipital bossing with a parallelogram shape and anterior displacement of ipsilateral ear (Figure 8, 9). 3) In skull base view, posterior fossa axis line (central line from the basion to opisthion) will be away from the anterior fossa axis line (central line bisecting the cribriform plate) toward the site of the lambdoid fusion (9, 10). In positional plagiocephaly the lines are continuous with each other or have minimal deviation (2.3#±1.3#) (10) (Figure 9) Page 15 of 71

16 Fig. 8: Positional plagiocephaly. Parallelogram shape of the posterior calvaria with ipsilateral frontal bossing (white arrow) and contralateral occipital bossing (double white arrows) on vertex view. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 16 of 71

17 Fig. 9: Positional plagiocephaly. Skull base view in another patient shows minimum shift in midline lines (white; posterior fossa axis line, black; anterior fossa axis line). Long axis of the left temporal bone (black lines) is anterior than right, which clinically reflects anterior displacement of the left ear. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 17 of 71

18 Fig. 10: Positional plagiocephaly(the same patient as in Fig. 9). There is flattening of the posterior calvaria (white line), ipsilateral frontal bossing (white arrow) and contralateral occipital bossing (double white arrows) and parietal bone fracture paralel to the plane of the imaging (black arrows). Convolutional markings are seen as lucent areas in 3D VR in parietal and occipital bones. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 18 of 71

19 Scaphocephaly (or dolichocephaly) results from premature sagittal synostosis. There is an increased growth following the direction of the sagittal suture (Virchow's law). This is the most common form of the isolated synostosis (11). (Figure 14-16) Page 19 of 71

20 Page 20 of 71

21 Fig. 14: Scaphocephaly. Vertex view shows premature fusion of the anterior part of the sagittal suture (arrow). There are lucencies in the parietal and occipital bones due to increased intracranial pressure. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Fig. 15: Scaphocephaly. (The same patient as in Fig. 14) Increased AP diameter of the skull. There are lucencies in the parietal and occipital bones due to increased intracranial pressure. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 21 of 71

22 Fig. 16: Scaphocephaly. Increased AP diameter of the skull in another patient. Note the bony ridge (arrows). References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Trigonocephaly is a bulging of the forehead due to fusion of the metopic suture before 6 months of age (1). Metopic suture fuses from glabella to the anterior fontanel. Anterior fontanel ossification, hypotelorism, narrowing of anterior cranial fossa and compensatory increase of middle cranial fossa are seen (11). (Figure 17,18) Page 22 of 71

23 Fig. 17: Trigonocephaly. 3D images of premature fusion of the metopic suture. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 23 of 71

24 Fig. 18: Trigonocephaly. (The same patient as in Fig. 17) Axial MPR images of premature fusion of the metopic suture with hypotelorism, narrowing of anterior cranial fossa and compensatory increase of middle cranial fossa. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Oxycephaly, brachycephaly results from bilateral premature fusion of the coronal or lambdoid sutures. There is a flat and high forehead due to growth following the direction of the coronal suture. Transverse diameter of the skull is widened. Superior Page 24 of 71

25 displacement of the lesser wing of the sphenoid caused the characteristic "harlequin eye" (1,11). Brachycephaly is frequent in syndromic synostosis (e.g. Apert, Crouzon, Pfeiffer, craniofrontonasal syndrome etc.) (13). (Figure 19,20) Page 25 of 71

26 Fig. 19: Craniofrontonasal syndrome, brachycephaly. Bilateral coronal synostosis with bony ridge (double arrows). Central defects between frontal bones (arrows). The calvarium is broadened in the transverse plane. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Fig. 20: Craniofrontonasal syndrome, brachycephaly.(the same patient as in Fig. 19)the calvarium is shortened in the sagittal and broadened in the transverse plane. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 26 of 71

27 Congenital calvarial defects Parietal foramina are paired parasagittal defects that result from delayed or incomplete ossification of the parietal bone (2). They are generally isolated but may be part of a syndrome. They are usually considered benign. Parietal foramina associated with an atretic cephalocele and symmetrical parietal meningoceles with abnormal venous anatomy have been described (14). (Figure 21). Page 27 of 71

28 Fig. 21: Parietal foramina seen as paired parasagittal defects in parietal bones. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 28 of 71

29 Open sutures and anterior fontanel can be due to elevated intracranial pressure (Figure 22) or hypothyroidism and skeletal dysplasia, e.g. cleidocranial dysplasias, pycnodysostosis and osteogenesis imperfecta. Fig. 22: Large sutures and anterior fontanel due to hydrocephalus. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Large anterior fontanel can be associated with achondroplasia, congenital hypothyroidism, Down syndrome, rickets and increased intracranial pressure. Anterior fontanel size is the average of the anteroposterior and transverse diameters. The average size of the anterior fontanel is 2.1 cm, and the median time of closure is 13.8 months. (15). (Figure 23) Page 29 of 71

30 Fig. 23: Large anterior fontanel in a 2 year-old boy. Measurement of the fontanel size (a+b/2). References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Calvarial bone fractures Page 30 of 71

31 Cranial fractures that are parallel or nearly parallel to the section orientation may be missed at interpretation of CT. Pediatric calvarium with multipl sutures and fontanel make diagnosis more diffucult. 3D VR and 3D MIP images are very useful in these patients and fractures and their extension can be assessed easily (12). (Figure 10, Figure 24,25). Page 31 of 71

32 Fig. 24: Bilateral parietal bone fractures (arrows), posterior view. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Cephalohematoma is subperiosteal hematoma of the calvaria (2). They do not cross the midline. They generally resolves spontaneously and may calcify periferally (Figure 26,27). If they are not absorbed they can ossify over the surface. Ossified cephalohematoma is a rare entity and it needs surgical management (16). It can mimic osteoma in 3D images. Page 32 of 71

33 Fig. 26: Cephalohematoma. 3D image show periferally calcified subperiostal hematoma. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 33 of 71

34 Fig. 27: Cephalohematoma. Axial MPR image show periferally calcified subperiostal hematoma (the same patient as in Fig. 26). References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Calvarial bone tumors 3D CT may help to evaluate litic and sclerotic bone tumors. 3D CT is useful for preoperative and postoperative assessment of these patients. Osteomas are the most common primary benign tumors of the calvaria, They are solid nodular sclerotic lesions and they usually arise from the outer table (17). (Figure 28,29) Page 34 of 71

35 Fig. 28: Osteoma. 3D image show left parietal osteoma (arrows). References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 35 of 71

36 Fig. 29: Osteoma. Axial MPR image (the same patient as in Fig. 28) show left parietal osteoma. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Langerhans' cell histiocytosis, epidermoid and dermoid cyst, meningioma, hemangioma, fibrous dysplasia and metastases are other most common lesions of the calvaria. Postoperative cranium Page 36 of 71

37 3D CT is valuable in postoperative evaluation of surgery for craniosynostosis (Figure 30,31). Burr holes, cranioectomy defects and bone grafts may be evaluated with 3D VR images. Fig. 31: Preoperative images of the patient in Fig. 29. Anterior plagiocephaly due to fusion of the right coronal suture (arrows). Preoperatively there is increased convolutional markings in parietal and occipital bones result from increased cranial pressure. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Page 37 of 71

38 Fig. 30: Ppostoperative images (1 year after) of the anterior plagiocephaly due to fusion of the right coronal suture. References: Radiology, Izmir Tepecik Training and Research Hospital - Izmir/TR Images for this section: Page 38 of 71

39 Fig. 1: Development of the skull Page 39 of 71

40 Fig. 2: Normal 3D calvarial anatomy. (F: frontal bone, O: Occipital bone, P: parietal bone, Sp: sphenoid bone, Ts: temporal bone squamous portion). Page 40 of 71

41 Fig. 3: Normal 3D calvarial anatomy. (F: frontal bone, O: Occipital bone, P: parietal bone, Sp: sphenoid bone, Ts: temporal bone squamous portion). Page 41 of 71

42 Fig. 4: Normal 3D calvarial anatomy. (F: frontal bone, O: Occipital bone, P: parietal bone, Sp: sphenoid bone, Ts: temporal bone squamous portion). There is a linear fracture in the right parietal bone (double arrows). Page 42 of 71

43 Fig. 5: Wormian bones. There are a lot of are accessory bones within lamdoid suture and posterior fontanel (arrows). Page 43 of 71

44 Fig. 6: Os incae (interparietal bone). A large, single intrasutural bone at the junction of the lambdoid suture and sagittal suture (arrows). Page 44 of 71

45 Fig. 7: Microcephaly. Sutures are closed and overlapping (arrows) in 1 year-old patient due to severe hypoxic-ischemic injury. Page 45 of 71

46 Fig. 8: Positional plagiocephaly. Parallelogram shape of the posterior calvaria with ipsilateral frontal bossing (white arrow) and contralateral occipital bossing (double white arrows) on vertex view. Page 46 of 71

47 Fig. 9: Positional plagiocephaly. Skull base view in another patient shows minimum shift in midline lines (white; posterior fossa axis line, black; anterior fossa axis line). Long axis of the left temporal bone (black lines) is anterior than right, which clinically reflects anterior displacement of the left ear. Page 47 of 71

48 Fig. 10: Positional plagiocephaly(the same patient as in Fig. 9). There is flattening of the posterior calvaria (white line), ipsilateral frontal bossing (white arrow) and contralateral occipital bossing (double white arrows) and parietal bone fracture paralel to the plane of the imaging (black arrows). Convolutional markings are seen as lucent areas in 3D VR in parietal and occipital bones. Page 48 of 71

49 Fig. 11: Plagiocephaly, trapezoid shape on vertex view due to single suture synostosis. Page 49 of 71

50 Fig. 12: Plagiocephaly and copper beaten skull. Premature fusion of the sagittal suture (white arrow) and left coronal suture (double white arrows). There are multipl lucencies in the parietal and occipital bones due to increased intracranial pressure, copper beaten skull. Page 50 of 71

51 Fig. 13: Plagiocephaly and copper beaten skull (the same patient as in Fig. 12). Premature fusion of the sagittal suture (white arrow) and left coronal suture (double white arrows). There are multipl lucencies in the parietal and occipital bones due to increased intracranial pressure, copper beaten skull. Page 51 of 71

52 Page 52 of 71

53 Fig. 14: Scaphocephaly. Vertex view shows premature fusion of the anterior part of the sagittal suture (arrow). There are lucencies in the parietal and occipital bones due to increased intracranial pressure. Fig. 15: Scaphocephaly. (The same patient as in Fig. 14) Increased AP diameter of the skull. There are lucencies in the parietal and occipital bones due to increased intracranial pressure. Page 53 of 71

54 Fig. 16: Scaphocephaly. Increased AP diameter of the skull in another patient. Note the bony ridge (arrows). Page 54 of 71

55 Fig. 17: Trigonocephaly. 3D images of premature fusion of the metopic suture. Page 55 of 71

56 Fig. 18: Trigonocephaly. (The same patient as in Fig. 17) Axial MPR images of premature fusion of the metopic suture with hypotelorism, narrowing of anterior cranial fossa and compensatory increase of middle cranial fossa. Page 56 of 71

57 Fig. 19: Craniofrontonasal syndrome, brachycephaly. Bilateral coronal synostosis with bony ridge (double arrows). Central defects between frontal bones (arrows). The calvarium is broadened in the transverse plane. Page 57 of 71

58 Fig. 20: Craniofrontonasal syndrome, brachycephaly.(the same patient as in Fig. 19)the calvarium is shortened in the sagittal and broadened in the transverse plane. Page 58 of 71

59 Fig. 21: Parietal foramina seen as paired parasagittal defects in parietal bones. Page 59 of 71

60 Fig. 22: Large sutures and anterior fontanel due to hydrocephalus. Page 60 of 71

61 Fig. 23: Large anterior fontanel in a 2 year-old boy. Measurement of the fontanel size (a+b/2). Page 61 of 71

62 Fig. 24: Bilateral parietal bone fractures (arrows), posterior view. Page 62 of 71

63 Fig. 25: Bilateral parietal bone fractures(arrows), lateral view (the same patient as in Fig. 24). Page 63 of 71

64 Fig. 26: Cephalohematoma. 3D image show periferally calcified subperiostal hematoma. Page 64 of 71

65 Fig. 27: Cephalohematoma. Axial MPR image show periferally calcified subperiostal hematoma (the same patient as in Fig. 26). Page 65 of 71

66 Fig. 28: Osteoma. 3D image show left parietal osteoma (arrows). Page 66 of 71

67 Fig. 29: Osteoma. Axial MPR image (the same patient as in Fig. 28) show left parietal osteoma. Page 67 of 71

68 Fig. 30: Ppostoperative images (1 year after) of the anterior plagiocephaly due to fusion of the right coronal suture. Page 68 of 71

69 Fig. 31: Preoperative images of the patient in Fig. 29. Anterior plagiocephaly due to fusion of the right coronal suture (arrows). Preoperatively there is increased convolutional markings in parietal and occipital bones result from increased cranial pressure. Page 69 of 71

70 Conclusion The major teaching points of this exhibit are: 1.Three-dimensional CT can aid to differantiate normal and anormal calvarium 2.Three-dimensional CT is particulary superior in diagnosis craniosynostosis 3.Three-dimensional CT aids and makes easy diagnosis of common calvarial pathologies References 1. Kirmi O, Lo SJ, Johnson D, Anslow P. Craniosynostosis: a radiological and surgical perspective. Semin Ultrasound CT MR Dec;30(6): Glass RB, Fernbach SK, Norton KI, Choi PS, Naidich TP. The infant skull: a vault of information. Radiographics Mar-Apr;24(2): Aviv RI, Rodger E, Hall CM. Craniosynostosis. Clin Radiol Feb;57(2): Sanchez-Lara PA, Graham JM Jr, Hing AV, Lee J, Cunningham M. The morphogenesis of wormian bones: a study of craniosynostosis and purposeful cranial deformation. Am J Med Genet A Dec 15;143A(24): Wu JK, Goodrich JT, Amadi CC, Miller T, Mulliken JB, Shanske AL. Interparietal bone (Os Incae) in craniosynostosis. Am J Med Genet A Feb;155A(2): Tuite GF, Evanson J, Chong WK, Thompson DN, Harkness WF, Jones BM, Hayward RD. The beaten copper cranium: a correlation between intracranial pressure, cranial radiographs, and computed tomographic scans in children with craniosynostosis. Neurosurgery Oct;39(4): van der Meulen J, van der Vlugt J, Okkerse J, Hofman B. Early beatencopper pattern: its long-term effect on intelligence quotients in 95 children with craniosynostosis. J Neurosurg Pediatr Jan;1(1): Behrman RE, Kliegman RM, Jenson HB, eds. Nelson textbook of pediatrics. 16th ed. Philadelphia, Pa: Saunders, 2000; Kadom N, Sze RW. Radiological reasoning: a child with posterior plagiocephaly. AJR Am J Roentgenol Mar;194(3 Suppl):WS Sze RW, Hopper RA, Ghioni V, Gruss JS, Ellenbogen RG, King D, Hing AV, Cunningham ML. MDCT diagnosis of the child with posterior plagiocephaly. AJR Am J Roentgenol Nov;185(5): Page 70 of 71

71 11. Kotrikova B, Krempien R, Freier K, Mühling J. Diagnostic imaging in the management of craniosynostoses. Eur Radiol Aug;17(8): Epub 2006 Dec Medina LS, Richardson RR, Crone K. Children with suspected craniosynostosis: a cost-effectiveness analysis of diagnostic strategies. AJR Am J Roentgenol Jul;179(1): Binaghi S, Gudinhecth F, Rilliet B. Threedimensional spiral CT of craniofacial malformations in children. Pediatr Radiol 2000; 30: Fink AM, Maixner W. Enlarged parietal foramina: MR imaging features in the fetus and neonate. AJNR Am J Neuroradiol Jun-Jul;27(6): Kiesler J, Ricer R. The abnormal fontanel. Am Fam Physician Jun 15;67(12): Guclu B, Yalcinkaya U, Kazanci B, Adilay U, Ekici MA. Diagnosis and treatment of ossified cephalhematoma. J Craniofac Surg Sep;23(5):e Yalçin O, Yildirim T, Kizilkiliç O, Hürcan CE, Koç Z, Aydin V, Sen O, Kayaselçuk F. CT and MRI findings in calvarial non-infectious lesions. Diagn Interv Radiol Jun;13(2): Personal Information Page 71 of 71