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Pictorial Essay

CT and MR Imaging of Focal Calvarial Lesions

Estanislao Arana1 and Luis MartI-BonmatI2

C alvarial
tally encountered
lesions
during CT and
are often inciden- Eosinophilic Granuloma
Cell Histiocytosis)
(Langerhans’ healing
and
lesions.
generally
Dural
appears
invasion
as dural
is uncommon
enhancement
MR imaging of the brain. To our The localized form of Langerhans’ cell on Tl-weighted images after contrast agent
knowledge, few studies have been published histiocytosis occurs almost exclusively in administration (Fig. 2).
regarding the CT and MR imaging findings children and young adults; at clinical presen-
of these lesions, and most seem to have no tation, patients canbe asymptomatic or have
distinctive imaging features I 1-7]. The mci- a palpable soft-tissue mass. The lesions are Osteoma
dence ofcalvarial lytic lesions revealed by ra- oval or round isolated lytic lesions that begin Osteomas are the most common benign tu-
diography is approximately 7% [8), with in the diplo#{235}
and involve the full thickness of mors of the calvaria. When symptomatic, they
benign skull lesions being more common the calvarium [4]. The margins appear cir- often appear as a painless swelling. On CT, os-
than primary malignancies. The increasing cumscribed, and the edges may be beveled. teomas are dense. smooth, well-demarcated le-
use of MR imaging makes guidelines to inter- Bony sequestrum is very characteristic (Fig. sions (Fig. 3) that commonly arise from the
pret the features of these lesions necessary. I ), but periosteal reactions are rarely encoun- outer table. Inner table osteomas can be misdi-
We reviewed the records of 185 patients tered. TI-weighted MR imaging depicts the agnosed as wholly ossified meningiomas (Fig.
with proven calvarial lesions who underwent lesions with low-to-intermediate signal in- 4). Unlike meningioma.s, osteomas show sig-
CT: 92 of these patients also underwent MR tensity (Fig. 2). Decreased signal intensity nal void and an absence of soft-tissue compo-
imaging. The most common lesions encoun- on T2-weighted images have been related to nent on all MR imaging sequences.
tered were Langerhans’ cell histiocytosis,
18.9%: osteoma, 15.1%: epidermoid and
dermoid cyst, 12.9%: metastasis, 12.4%;
meningioma, 10.8%: hemangioma, 9.1%; fi-
brous dysplasia, 6.4k: and miscellaneous
diseases, 14.4%. Excisional biopsy was con-
firmatory in I 34 patients, and 3 1 were diag-
nosed by aspiration biopsy. Twenty patients
with benign lesions had follow-up for 3 years
( I 0 had osteomas, six had epidermoid cysts,
and four had fibrous dysplasia). In this essay,
we describe a sampling of illustrative cases
drawn from the overall series to review char-
Fig. 1.-27year-old woman with tenderness in occipital area caused by eosinophilic granuloma.
A, CT scan shows button sequestrum of left occipital bone.
acteristic imaging features of the most fre- B, CT scan obtained 2 years later shows resolution of lytic lesion with only slight remodeling of outer table. Heal-
quently encountered lesions. ing is a frequent finding of isolated eosinophilic granuloma.

Received September 21, 1998; accepted after revision November 19, 1998.
1 Department of Radiology, Hospital Casa de Salud, Manuel Candela 41, E-46021 Valencia, Spain. Address correspondence to E. Arena.

2Department of Radiology, Hospital Universitario Doctor Peset, Av. Gaspar Aguilar 90, E-46017 Valencia, Spain.

AJR 1999;172:1683-1688 0361-803X/99/1726-1683 © American Roentgen Ray Society

AJR:172, June 1999 1683

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Fig. 2.-17-year-old girl with frontal-bone swelling caused by eosinophilic granuloma.

A, CT scan shows lytic lesion that contains bony sequestrum.
B, Axial fast spin.echo T2-weighted image (TRITE, 2000/108) shows bright signal intensity of lesion.
C, Coronal Ti-weighted image (400/16) obtained after gadolinium administration shows enhancement of lesion and lack of enhancement in bony sequestrum and adjacent
dura. At surgery, dura was seen to be invaded.

Fig. 3.-54-year-old woman with palpable parietal mass caused by osteoma. Axial CT scan shows outer table
osteoma with well-defined rim.

Fig. 4-59-year-old woman with chronic headaches and

incidentally discovered innertable parietal osteoma.
A, Axial CT scan shows inner table osteoma with lobu-
lated margins.
B, Axial fast spin-echo T2-weighted image (TRITE, 3000/
104) shows signal void in lesion (arrow).

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Fig. 5-63-year-old woman with frontal-bone tumor caused by epidermoid cyst.

A, CT scan shows lytic, well-defined epidermoid cyst in frontal bone.
B, Sagittal Ti-weighted MR image (TRITE, 500/iO) shows homogeneous low signal intensity (arrow).
C, Axial fast spin-echo T2-weighted image (3000/i04) with fat saturation shows well-defined, hyperintense cystic lesion, indicating fluid-filled lesion.

Epidermoid and Dermoid Cyst

Epidermal inclusion cysts are mainly lo-
cated around the midline, but any bone in the
cranial vault can be involved. Pressure ero-
sion causes remodeling and expansion of the
outer and inner tables. The lesion is typically
lytic and oval-shaped with a clearly sclerotic
margin. Calcification inside a dermoid cyst
represents saponification. Such lesions are
hypointense on T 1 -weighted images. but sig-
nal intensity varies depending on the lipid
content or hemorrhagic products [2] (Fig. 5).
Dermoid cysts contain elements of dermal
and epidermal origin. These cysts are pre-
dominately located periorbitally and in the
posterior fontanelle or occipital midline, with
or without including the dermal sinus (Fig.
6). Dermoid tumors are the largest group of Fig. 6-43-year-old man with long.course occipital tu- Fig. 7.-49.year.old man with frontal-bone metastasis
pediatric tumors with intracranial extension. mor caused by dermoid cyst. Axial CT scan shows well- from hepatocellular carcinoma. CT scan shows ragged
defined lytic lesion in occipital bone. Note air bubbles lytic lesion with soft-tissue mass.
They characteristically show high signal in- corresponding to dermal sinus (arrow).
tensity on all MR imaging sequences.

Metastasis
Most multiple abnormal radiolucencies in
the calvaria after the fifth decade of life are car-
cinoma metastases. These lesions are almost
exclusively lytic, with ragged margins or per-
meative destruction (Fig. 7). Exceptions to this
rule include prostate and breast tumors, which
often show osteoblastic reaction (but with less
hyperostosis than meningiomas) [3]. Charac-
teristically, a soft-tissue mass can be discovered.
Calvarial metastases are visualized on T2-
weighted images as areas of hyperintensity re-
placing the normal diploetic space and cortical
bone. Gadolinium-enhanced Ti-weighted im-
ages usually show marked enhancement (Fig. Fig. 8-66-year-old man with occipital lesion caused by metastasis from lung carcinoma.
A, Axial CT scan shows ill-defined lytic lesion.
8). Multiple radiolucencies with well-defined
B, Axial gadolinium-enhanced Ti-weighted MR image (TRITE. 490/il) shows marked enhancement with delimi-
borders but without reactive sclerosis are char- tation of intracranial and extracranial soft tissues.

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Fig. 9-48-year-old man with previously diagnosed myeloma.

A, Axial CT scan shows well-defined lytic lesion without sclerotic rim. Lesion involves inner table.
B, Axial fast spin-echo T2-weighted MR image (TRITE, 3000/104) shows hyperintense lesion in diploetic marrow (arrow).
C, Axial gadolinium-enhanced Ti-weighted image (490/il) shows homogeneous enhancement of myeloma lesion.

acteristic of multiple myeloma (Fig. 9). The di- ized hyperostosis of adjacent bone in 4.5-44% are extremely rare and are more aggressive. Pri-
agnosis of multiple myeloma should be of cases [3]. An osteobla.stic reaction is com- mary meningioma
intraosseous is also uncom-
strongly suspected when skeletal lesions are monly seen (Fig. 10); less commonly, mixed mon and has imaging features similar to those of
seen at other sites. Rarely, a focal lesion may be blastic and lytic reactions are present (Fig. 1 1). intracranial meningioma. The hallmark of the
due to a plasmacytoma. These lesions have Hyperostosis appears on CT as a whorl-shaped differential diagnosis of intraosseous meningi-
marked enhancement of the soft-tissue compo- inhomogeneous area with local disappearance of oma is the bone-centered soft-tissue component
nent after contrast agent administration. the bone laminar architecture [6, 7]. In addition depicted on MR imaging (6] (Fig. I 2).
to showing the dural, or carpetlike, tumor, MR
Meningioma imaging shows slightly increased signal intensity
Hemangioma
Meningioma.s are the most common nonglial of the hyperostosis on T2-, proton density-, and
intracranial tumors and typically produce local- TI-weighted images [7]. Purely lytic reactions Hemangiomas can present clinically as
palpable masses or can be incidentally de-
tected. These lesions are usually well-defined
and radiolucent, with an inner reticulation
that has a sunburst or honeycomb appear-
ance. Compared with radiography. CT better
depicts the radiating trabecular pattern result-
ing from simultaneous destruction and re-
modeling of bony architecture. Periosteal
reaction may be seen, but it is uncommon 151.
TI-weighted MR images characteristically
show hyperintensity in the diploetic space be-
cause of the presence of blood, thrombosis,
or fat (Fig. I 3). Focal areas of diminished sig-
nal intensity represent bony trabeculation.

Fibrous Dysplasia
Fibrous dysplasia is most frequently seen in
childhood and adolescence. The skull is in-
volved in both the monostotic and polyostotic
form of the disease. The most common type has
Fig. 1O.-6i-year-old woman with gait disorder caused by frontal-bone meningioma.
a ground-glass appearance with well-defined
A, Axial CT scan shows osteoblastic response in inner cortex of frontal bone.
B, Axial fast spin-echo T2-weighted image (TRITE, 2850/104) shows low signal intensity of osteoblastic response margins (Fig. I 4). There is expansion of the
(arrow) and accompanying edema. diploe with bulging of the outer table and thin-

1686 AJR:172, June 1999

 Focal Calvarial Lesions
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Fig. 11.-65-year-old man with headache, pain, and palpable mass caused by menin9ioma.
A, Axial CT scan shows mixed lytic and blastic reaction in frontal bone caused by underlying meningioma.
B, Axial contrast-enhanced CT scan shows dural tumor with intracranial and extracranial extension.
C, Axial gadolinium-enhanced Ti-weighted MR image (TRITE, 490/il) shows marked enhancementwith delimitation of dural and calvarial mass. Note high signal intensity
of subdural collection.

Fig. 12-41-year-old man with palpable mass caused

by intraosseous meningioma.
A, Coronal unenhanced CT scan shows both lytic and
blastic bone reaction in vertex with soft-tissue corn-
ponent.
B, Coronal Ti-weighted MR image (TRITE, 500/14)
shows soft-tissue mass on both sides of calvariurn.

Fig. 13-42-year-old man with palpable left parietal

scalp mass caused by hemangioma.
A, Coronal CT scan shows coarse trabeculated lesion
in left parietal bone. Note slightly eroded inner table
(arrow) and thickened outer table.
B, Coronal Ti-weighted MR image (TRITE, 400/14)
shows mixed hyperintensity in lesion.

Fig. 14.-28-year.old woman with long-standing calvarial tumor due to fibrous dysplasia. CT scan
shows detail of left parietal lesion with both lytic and blastic appearance and outward bulging.

AJR:172, June 1999 1687

 Arana and MartI-Bonmati

Fig. 15-32-year-old woman with palpable mass

caused by fibrous dysplasia of occipital bone.
A, CT scan shows ground-glass lesion with erosion of
internal table.
B, Axial proton density-weighted MR image (TRITE,
2850/il) shows heterogeneous signal intensity of lesion.
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ning of the inner table, which characteristically Acknowledgment 4. David R. Oria RA, Kurnar R, et al. Radiologic fea-
does not protrude inwardly [31. Thickening and turns of eosinophilic granuloma of bone. AiR 1989:
We are grateful for the support of Fran-
153: 102 1-1026
increased density of the normal bone is present cisco Menor in the preparation of this paper.
5. Bastug D, Ortiz 0. Schochet SS. Hemangioma.s in the
at the margins. The second most common type
calvaria: imaging findings. AiR 1995:164:683-687
is the diffusely sclerotic form, mostly found in References 6. Amna E, Diaz C. LitOfl FE et a]. Piimaiy intra()sseou.s
the skull base. The rarest form is a cystic lytic I . Wecht DA, Sawaya R. Lesions of the calvaria: sur- meningiomas. Aetti Radio! 1996:37:937-942
lesion surrounded by bony sclerosis. MR imag- gical experience with 42 patients. Ann Surg Oncol 7. Terstegge K. Schomer W, Henkes H, Heye N. Hos-
ing shows decreased signal on all pulse se- 1997:4:28-36 ten N. Lanksch WR. Hyperostosis in meningiomas:
2. Arana E. Latorre FF, Revert A, et al. tntradiploic epi- MR findings in patients with recurrent meningioma
quences with occasional hyperintense areas and
dermoid CySts. Neumradio1og 1996:38:306-311 ofthe sphenoid wings. AJNR 1994:15:555-560
contrast enhancement (Fig. 15) and also reveals 3. Hodges E Pathology ofthe skull. In: Taveras J. Fenucci 8. Thomas J. Baker H. Assessment of roentgenographic
absence of soft tissue, a cardinal difference from J. eds. Radiolog: (IkigliOsiS, i,nagin,s’. intenention, lucencies of the skull: a systematic approach.
other sclerotic lesions. 2nd ed., vol. 3. Philadelphia: Lippincoti. 1989:1-21 Neurology 1975:25:99-106

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