SKULL RADIOGRAPHY

NAMS BIR HOSPITAL

B.Sc.MIT 1ST YEAR
SURAJ SAH
ROLL NO :- 9
Skull anatomy
• The skull rests on the superior aspect of the
vertebral column .
• It is made up of 22 separate bones divided into
two distinct groups
1. Cranial bones ( 8)
2. Facial bones ( 14 )
Cranial bones
• The cranial bones are further divided into the
calvaria and the floor.
• The cranial bones form a protective housing for the
brain .
Namely :-
a) Frontal
b) Occipital
c) Parietal (2)
d) Ethmoid
e) Sphenoid
f) Temporal (2)
Facial bones
• The facial bones provide structure , shape and support for the face .
• They also form a protective housing for the upper ends of the
respiratory and digestive tracts and with several of the cranial bones
form the orbital sockets for protection of the organs of sight .
Namely :-
a) Nasal (2)
b) Lacrimal ( 2 )
c) Maxillary (2)
d) Zygomatic (2)
e) Palatine (2)
f) Inferior nasal conchae (2)
g) Vomer (1)
h) Mandible (1)
Superior aspect of cranial base
Cranial Dipole
• The bones of the cranial vault are composed of
two plates of compact tissue separated by an
inner layer of spongy tissue called dipole .
• The outer plate or table is thicker than the inner
table over most of the vault and the thickness of
the layer of the spongy tissue varies
considerably.
Fig :- Lateral aspect of inferior of cranium
Cranial sutures
• Except for the mandibles , the bones of the cranium
and face are joined by fibrous joints called sutures .
• The sutures are named :-
1. Coronal sutures :- found between frontal and
parietal bones.
2. Sagittal sutures :- located on the top of the head
between the two parietal bones and just behind the
coronal suture line .
3. Squamosal suture :- between temporal and
parietal bones .
4. Lamboidal sutures :- between occipital and
parietal bones .
Cranial sutures
• On the lateral aspect of the
skull , the junction of the
parietal bone , squamosal
suture and greater wing of the
sphenoid is the pterion ,
which over lies the middle
meningeal artery .
• At the junction of the occipital
bone , parietal bone and
mastoid bone portion of the
temporal bone is the asterion
.
Fontanel
• In the newborn infant
the bones of the
cranium are thin and
not fully developed .
• They contain a small
amount of calcium ,
are distinctly marked
and present six areas
of incomplete
ossification called
fontanels .
SKULL MORPHOLOGY
• Normal cranium is more or less oval in shape , being
wider in back than in front .
• The average cranium measures approximate
a) 6 inches (15cm) at its widest point from side to side
b) 7 inches (17.8cm) at its longest point from front to
back
c) 9 inches (22cm) at its deepest point from the vertex
to the sub - mental region.
• The thickness and degree of mineralization in normal
adult crania show comparatively little difference in
radiopacity from person to person , and the atrophy of
old age is less marked than in other regions of the
body.
• In typically shaped head ( mesocephalic skull ) the
pterous pyramids project anteriorly and medially at an
angle of 47’ from the midsagittal plane of the skull .

• In the brachycephalic skull , which is short from

front to back , broad from side to side and shallow
from vertex to base , internal sutures are higher with
reference to the infraorbitometal line (IOML) and
their long axes are more frontal in position . ( the
pterous pyramids lie at an average angle of 54’ .)

• In the dolichocephalic skull , which is long from

front to back , narrow from side to side and deep from
vertex to base , and the internal sutures are lower with
reference to the IOML and their long axes are less
frontal in position . ( the pterous pyramids form an
average angle of 40’ . )
Depending on its shape the atypical cranium requires more or less rotation of the
head or an increase or decrease in the angulation of the central ray compared with
the typical skull .
CRANIAL FOSSAE
• Internally the cranial floor is
divided into three regions the
anterior , middle and
posterior cranial fossae .
1. Anterior cranial fossae
:- extends from the anterior
frontal bone to the lesser
wings of the sphenoid .
2. Middle cranial fossae :-
extends from the lesser
wings of the sphenoid to the
apices of the pterous
portions of the temporal
bones .
3. Posterior cranial fossae
:- deep depression posterior
to the pterous ridges .
ORBIT
• Each orbit is made up of seven different bones .
• Three of these are cranial bones ( frontal , sphenoid and ethmoid ) and
other four bones are the facial bones ( maxilla , Zygomatic , lacrimal and
palatine ) .
• The circumference of the orbit , or outer rim are made up of three of the
seven bones ( frontal , Zygomatic and maxilla ) and the remaining four
bones make up most of the posterior aspect of the orbit .
PATIENT POSITIONING
• Whether the radiographer elects to perform the
examination with the patient in the recumbent
or upright position depends on four variables .
1. The equipment available ,
2. The age and condition of the patient ,
3. The preference of the radiographer and / or
radiologist
4. Whether upright images would increase
diagnostic value , such as showing air-fluid
levels in Para-nasal sinuses .
• Uncomfortable body positions resulting in
rotation or other motion is responsible for the
majority of repeat examination .
RADIOGRAPHIC TECHNICAL CONSIDERATIONS
• To prevent later rotation of the head , place and patients body so that its long axis,
depending on the image, either coincides with or is parallel to the midline of the
radiographic table.

• To prevent superior or inferior pull on the head, resulting to longitudinal angulation

or tilt, place the patients body so that the long axis of the cervical vertebrate
coincides with the level of the midpoint of the foremen magnum.

• Support any elevated part, such as the patients shoulder or hip on a pillow or
sandbag to relieve strain

• For examination of hyposthenic or asthenic patients, elevate the patients chest on a

small pillow to raise the cervical vertebral to the correct level for the lateral, PA and
obliged projections when the patient is recumbent.

• For examination of obese or hypersthenic patients, elevate the patients head on a

radioparent pad. To obtain the correct part – IR relationship if needed.

• While adjusting the body stand in a position that facilitates estimation of the
approximate part position . For example stand so that the longitudinal axis of the
radiographic table is visible as the midsagittal plane of the body is being centered
Anatomical terminology

All radiography of the skull is undertaken

with reference to a series of palpable
landmarks and recognized lines or planes
of the skull .
Landmarks
 Outer canthus of eye :- the point where the upper and lower eyelids
meet laterally.

 Infra-orbital margin / point :- the inferior rim of the orbit , with the
point being located at its lowest point .

 Nasion :- the articulation between the nasal and frontal bone .

 Glabella :- a bony prominence found on the frontal bone immediately

superior to the Nasion .

 Vertex :- the highest point of the skull in the median sagittal plane .

 External occipital protuberance ( inion ) :- a bony prominence

found on the occipital bone , usually coincident with the sagittal plane .

 External auditory meatus (EAM) :- the opening within the ear that
leads into the external auditory canal .
 Lines
Inter-orbital (inter-pupillary) line :- Joins the
center of the two orbits or the center of the two pupils
when the eyes are looking straight forward .

Infra-orbital line :- Joins the two infra-orbital points

.

Anthropological baseline ( Frankfurter line ) :-

passes from the infra-orbital points to the upper border
of the external auditory meatus .

Orbito-meatal ( radiographic ) baseline :- extends

from the outer canthus of the eye to the center of the
external auditory meatus .
Angle difference

OML & IOML = 7’

OML & GML = 8’
OMBL & ABL = 10’
 Planes
Median sagittal plane (MSP) :- Divides the skull into
the equal right and left halves ; landmarks on this plane
are the Nasion anteriorly and inion posteriorly .

Coronal plane :- These are at right angles to the MSP

and divide the head into anterior and posterior parts .

Anthropological plane :- A horizontal plane containing

the two , anthropological baselines and the infra-orbital
line . It is an example of axial plane . Axial planes are
parallel with this plane .

Auricular plane :- Perpendicular to the anthropological

plane ; passes through the centre of the two external
auditory meatuses . It is an example of coronal plane .
The median sagittal
, anthropological
and coronal plane
are mutually at
right-angles to each
other .
 Positioning terminology

To describe a skull projection , it is

necessary to state the relative positions of
the skull planes to the image receptor and
to give a centering point or area to be
included within the beam .
OCCIPITO-FRONTAL (OF) PROJECTION
• Projection in which
the central ray is
parallel to the sagittal
plane .
• CR enters the skull
through the occipital
bone and exists
through the frontal
bone .
FRONTO-OCCIPITAL (FO) PROJECTION
• CR enters the skull
through the frontal
bone and exists
through the occipital
bone .
Beam angulation
• Many OF & FO projections will require the CR to
pass along the sagittal plane at some angle to the
Orbito-meatal plane .
• If the beam is angled towards the head , the beam is
then said to be angled caudo-cranially ( usually
shortened to cranial angulation and written in
short form as )
• If the beam is angled towards the feet , the beam is
then said to be angled cranio-caudally ( usually
shortened to caudal angulation and written in short
form as )
FO 30’
Lateral Right lateral

• CR passes along a coronal

plane at right angles to
the median sagittal plane .

• It is named according to
the side of the head
nearer to the image
receptor .
• In fig. right lateral the
beam enters the head on
the left side , passes along
a coronal plane , and
exists the head on the
right side .
Lateral with angulation
• If the CR passes along
a coronal plane to the
median sagittal plane
then the degree of
angulation is stated .
• Fig :- R Lat 30’
Oblique projection
• An oblique projection is obtained when the CR is
at some angle to the MSP & the coronal plane .
• Two factors that determine the name of
projection are
1. Whether the anterior or posterior portion of
the head is in contact with the cassette .
2. Whether the left or right side of the head is in
contact with the cassette .
40’ Left anterior oblique

Head is rotated to
the right , such that
the MSP is at 40’ to
the cassette and the
left side of the head
is in contact with
the cassette
Complex oblique projection

• Oblique projection may become more

complex when there is an additional caudal
or cranial angle added in relation to a
specified baseline .
• Such projection is achieved either by raising
or lowering the chin or tube can be angled .
55’ left anterior oblique with 35’ caudal angulation

• Head has been rotated

such that the right side of
the face is in contact with
the cassette and median
sagittal plane makes an
angle of 55’ to the Bucky .
• The CR has 35’ caudal
angulation or by raising
the Orbito-meatal plane
by 35’ whilst using a
horizontal beam .
Same above
projection has been
achieved with a
combination of tube
and orbital-meatal
plane angulation. In
this case , the plane
has been raised 20’
and the tube has
been given a 15’
caudal angulation ,
in effect producing a
total beam
angulation of 35’ to
the orbital-meatal
plane.
Thank you 
Patient preparation , Accessories ,Radiation
protection & Radiographic equipment

NAMS , BIR HOSPITAL

B.Sc.MIT 1ST YEAR
SANJAY KUMAR SHAH
ROLL NO :- 5
PATIENT PREPARATION
• Ensure that all metal objects are removed from the
patient e.g. :- hair clips and hair pins
• Bunches of hair often produce artifacts and this
should be untied.
• If the area of interest include the mouth , then false
teeth containing metal and metal dental bridges
should be removed .
• Patient should be provided with a clear explanation
of any movements and film positions associated
with the normal operation of the skull unit .
CLEANLINESS
• The hair and face are naturally oily and leave a
residue , even with the most hygienic patient's . If
the patient is sick , the residue is worse .
• During positioning of the skull , the patients hair ,
mouth , nose and eyes come in contact with the
vertical grid device , tabletop , or IR .
• For medical asepsis , a paper towel or a cloth sheet
may be placed between the imaging surface and
patient .
• As part of standard procedure the contacted area
should be cleaned with a disinfectant before and
after positioning .
Useful Accessories
• Foam pads are available in range of sizes to
accommodate different age groups , which aid in
immobilization.

• 45’ triangular pads are extremely useful for

immobilizing children. They can be held by the parent
and support the head without the parent placing their
hands in the primary beam .

• Velcro straps are of great use when immobilizing a

patient on a skull unit .

• Individual side markers are essential for skull

radiography , as the clip type side markers are easily lost
in the collimation , particularly when using a skull unit .
Radiation Protection
• Lead shields should be used to reassure the patient .

• Infants and children should receive radiation shielding of the

thyroid and thymus glands and the gonads . This protective
lead shielding also assist in immobilizing the pediatric patient
.

• The most effective way to protect the patient from

unnecessary radiation is to restrict the radiation beam by
using proper collimation .

• Whenever possible , use an occipito - frontal rather than a

fronto – occipital technique , since this vastly reduces the
doses to the eyes.
Image Quality Guidelines
• Image should have a visually sharp reproduction of
all structures , such as outer and inner lamina of the
cranial vault , the trabecular structure of the
cranium , the various sinuses and sutures where
visible , vascular channels , pterous part of the
temporal bone and the pituitary fossa .
• Image details should be in the 0.3 – 0.5 mm range .
• A 400 regular speed imaging system is
recommended .
• Use 70-85 kV tube voltage .
• 24*30 cm cassettes are used.
Radiographic Equipment
• Radiography of the skull can be carried out using a
specialized skull unit or with an ordinary Bucky ,or
simply with a stationary grid and tube .
• Problems arise for the radiographer as the different
methods use slightly different imaging techniques ,
which in turn utilize different planes and beam
angulations to achieve the same projection .
• Images taken on skull units yield the highest quality
skull images .
Types of skull unit
Isocentric skull unit
• Most widely available unit
• Image receptor plate and
primary beam are always
perpendicular to each other the
eliminating distortion .
• Point around which the tube
pivots is always adjusted so that
it is at the Centre of the object of
interest .
• Technique used by each
manufacturer will vary slightly ,
but all use the
anthropological baseline
when describing projections .
Lysholm skull unit
• Point around which the tube
pivots is always in the same
plane as the film .
• This has the potential to
produce distorted image if large
angulations are used.
• Technique used to operate these
units are very similar to those
for skull radiography carried out
with a simple tube and bucky
and utilize the radiographic
baseline when describing
technique .
• This type of skull unit not used
in modern imaging department .
Skull unit
Advantages of skull unit
• Reduction in distortion
• High resolution images resulting
from a grid with a large number of
gridlines per unit length ( grid
lattice ) and very fine focal spot on
the tube anode ( 0.3 – 0.4 mm^2 )
• Projections that are accurate and
consistent as the patient is placed in
one or a limited number of positions
and the tube is then positioned
around the head once this position
is achieved .
• It can be more comfortable for the
patient , as only one position has to
achieved .
• Purpose designed circular
collimators allow close collimation
to the head , reducing the dose and
minimizing secondary radiation .
Disadvantages of skull unit
• The tube on which the patient
lies is often quite narrow and
difficult to get on to , this may
make it unsuitable for patients
who are unable to co-operate ,
since they may fall off .
• Most units are accompanied by
their own technique manual
requiring the radiographer to
acquire set of skills unique to
one piece of equipment .
• Units are expensive .
• Units can be lacking in
versatility for sick patients and
patients with conditions such as
thoracic kyphosis .
• The importance of plain radiography of the skull
has diminished in recent years due to the wide
spread availability of imaging modalities such as
computed tomography (CT) and magnetic
resonance imaging (MRI) .
• Plain radiography does , however still play
significant role in the management of patients
with certain skeletal condition and to a limited
extent in trauma e.g. :- when a depressed or
penetrating injury is suspected or if the patient
is difficult to asses .
Thank you 