| NORMAL ROENTGEN VARIANTS THAT MAY | | SIMULATE DISEASE ee eat THeopore E. Krats, MD Charloresville, Virginia MAarK W. ANDERSON, MD RadiologyOrner Books By THFODORE E. Krats An Atlas of Normal Developmental Roemrgen Anawony SECOND Eornion, with Thomas A. Smith Emergency Raiolgy Stconp Faron Aula of Roenagenographic Measerement ‘SevenTit FoIHIGN, Radicgy of Muscabeskelcal Stes hjuryMOSBY TLSEVIER 14 Jobe Renn Ste Php, PA 1108-209 ATLAS OF NORMAL ROENTGEN VARIANTS SUN. oe THAT aL SIMULAT DEAS SEN 0.017.003 Gopeight © 2007, 2001, 1996, 1992, 198, 1979, 1973 by os. Ln, sate of hetero. All igh esered No gar af hi paiientien ma he eprced oF remit nay em oF ya seam cero or mania ding pais ing reed. an ners storage arenes jt, thot pes fam the ple Perms may be tc rom Far He Scenes Ri Deere n lpi, PA'USK pe) 215 25905, fn 1) 15.299 105 « al helpers een er Yu man ae complete our rapest ews he vier heaps tp wee selecing‘Casomer Sporn then “Ottaning Permian Notice ‘Nether the Paar one the Aas aan any npr any lens ny anor damage te piso fren tag te tee ea thea the materia eis book. is thtresponabiy of te teams poennonee ring em mapa eperae an kdelg fthe Fatene wn dcrmine detest enn sel net o pcan br te poe. ‘The Paiher itary af Congress Cataloging in Publication Data ‘eat. Teh (Thcoghne Ele) 12 ‘us of sora roentgen rs ty sie / Theodore F- Rea, Mar We Anders Shel, Pom Inti ind, SENOAS-ORID Medical Mss 2 Diagn ero-Allive 1 aera, Math, ‘3 at TDNENE 1 Radcerphy-Aanes. 2. Ariens. 8, Diggs roy Ales WH 17 B25 200) gH Ayan Fai: Meghan Mest inst dane Kuss Pasng Sore Vong: Lina Va Pee Pry onogr Pris Cre Ding Dre Fle Zee Working together to grow libraries in developing countries | wwweebeviercum | wwwehookaidong | wwwsabre.org ESAT eee Pei in China Laedgthte pin mai 9876 FATENORMAL ROENTGEN VARIANTS THAT May SIMULATE DISEASE esTo Dr: Jobn F. Holt— teacher, friend, and the source of inspiration for this work.FOREWORD 1, when, a a young +F Instructor in Ratlilogy, it was my duty ro intercept residents” filn-reading queries on the way to “The Chief,” hoping to save precious moments for our one and only professor, ‘who was swamped with countless administrative problems in those ays of severe: manpower shortage. Eventually I kept score and discovered tha, during one 3-mnth period, the guestions brought up hy residents and fellow staff members regarding anatomic and pense vr ounaerel has: cain pale ees ny thee ro one. Admired. afew ofthe aberratins tat we intially thought tn be variants eventually proved to be pathologic in nature, Just the converse was tre far more often so Tam reasonably certain tha ths ratio tat Teast as high today as it was 40 years ag When Caffeys chssc text, Pediatric X-Rey Dingrosi, appeared in 1945 with its novel emphasis on anatomic variations, my interest in the subject vas spmmed again. In ensuing conversations and corresponutence, Dr. Cafey repeatedly emphasized the great need for 3 comprehensive radioogie text on vanunts and arfacts in both children and adults, He urged me to undertake the project alone, rouse offering his own collection of pediatric variants for ry way Ta fit. Sus sons lecares, and instruction courses at rational mctines on. my part clearly support Cafley’sconictions. Prtininary plans forthe book were formulated ind the gathering of alitional material was begun. ‘Despite encouragement and suppor fom all sides, his projec dd oot reach fruition. There are a number of reasons why this was so, but one in particular stands out. As the election of variants progressed in the form of films, negatives, photographic print ane ‘countless notations in books anon cards ithecame fra steamvler and then an avalanche, resulting in eventual disorganization andl utter frustration. No catoft point ever came clearly into view, and the ‘hook became unaffectionately known as "Fhe Monster” ft was with 2 feeling of grat relief that I happily relinquished any claims had fon the hook to the eager and able hands of Ted Keats, former resident and longtime close friend, who had heen quiet assembling his own collection of variants over the ears. Keats has neatly and effectively sidestepped my dilemma in several ways: Rather than trying t present all posible variants of the paranasal sinuses, the sella turcia, or the small intestine just to cite {ree of many posible examples), he has wisely inlnded only those that truly simulate recognizable disease entities. In so doing he has avoided the impossible and, more important, as brought the subject into practical perspective al has spare the reader much irelevant twvia. His use ofthe atlas format in dealing with this mater is aso to be commended. ‘The old argument chat am atlas autornatially precludes true scholarly achievement ijust not valid in many aspects ‘of dagnasticroentgenology and isniely refuel hy this particular soluine. The carefully scleted soemtgenograms that have: heen s0 rmeticulousy reproduced herein speak for themselves ina most eloquent manner. ‘Congratulations, ‘Te, on a job well done. Jou E. Horr CoDinen Dvison of Por Ry (Retired) :8 Mert Childers Hepa! Univers of Macy Medial Comer tier, Micon viPREFACE Whar muare delivers ows ix mecer sale, Recnasezxhar marare creates bas eternity it sae Basnrvis Sincere N.. oun endless, anal our sudy of normal anatomic ‘aration confinas this. Iti this eorstant variation of anatomy that makes diagnostic radology such an exciting and challenging occupation. Tn this editan we present the products of ur recent experience and ave itloded CT'and MIR ampiiion of some ofthese entities. We hive also substituted better examples of variants previonly presented. ln our Preface to the lst eiton, we suggested that since plan {ilu radiography of eh skull was hecoming pase. it might beboove 1 to eliminate this section. Unfortunate as the art of pla film inerpretation of the sll is dininishing, there ts 2 correspond increase in errors of interpretation, particularly in the overdiggnos ‘of normal variation. To this end, we have decide! ro leave th section in place, We are pleased with the eontinucl enthusiastic receprion of this ‘work by our eolleagues and appresiate the contributions of physicians who have sent us case material fr inclusion inthis edition. We ene specal recognition to oar secretary, Denise Johnson, for ber help n assembling this edition and v9 our wives, Part and Amy, for thet interest in and support of this effort “Tutoporr E, Keats ‘Mang W. ANDERSONPREFACE TO THE SEVENTH EDITION ‘The scien ho callets and catalan the child bo snders Aarsfot throng the wood re eguatlyeciestenc y the ser profs of erestnres thet pepalae ths plane act, Bran and Phar VaNcey [ he ahove quotation states perfectly my awe of the infinite variety with which narre has prowided us. Despite my 28 years of zathenng nornal roentgen anatomic variants, scarcely a day oFa week foes by without my finding some variation that [have pot recognized previonsly. Forrunately, most of these are sufficiently obvions that they do not arouse any concern of pathology. Nevertheless, U have sell managed to accumlte a large number that do aise suspicion, and these constirate the new additions to this seventh edie In order wo keep the sizeof the buok manageable, Ihave seriously considered which entities I eonk! reasonably eliminate. 1 have rentoxed the variants demonsited by bronchography, since this teciniue has dsoppeared bt there ite es that rl applicable. I am abit saddened ro note that interpretation of ‘conventional euliography of the skull i rapidly becoming a lost art ‘because ofthe advent of CT. Perhaps this section might he re ‘or limited in future editions, but at present I have retained it, since in some less technically sophisticated societies it i tila frst line oF this edition 1 am introducing my friend and colleague, Dr. Mark We Anderson, Associate Professor of Radiology here at the University of Virgin, as co-author, Dr. Anderson isan accomplished musculoskeletal radiologist who will help carry on this work, His expertise in CT and MRI will hance future eitons with improsed explanatory spplementalstuies. Dr. Anderson atu Iserveas emergency raologstsin our departinent, aud the material from this source will abo provide ns with addtional bone and sof tise variants for fire inclusion. ‘Once agsin, [wish to express my thanks to the many radiologiss in the United States and ahroad who have submitted cases for ray review. ‘Their interest and gracious permission to include theit material in the bok is much appreciated Api ove seid eeogtion my seen, Pana Wet Steele, for many years step ty and dedication, and tony wife, Pat, for her long interest in and support of this work. Turonone E. KEATS,PREFACE TO THE SIXTH EDITION ‘The earn frm our srk et ete saison which that azrk rang you ad the world need of the work, Wit his if becen. or 45 near beasn you age F the most part, the stimulus for my continued interest the field of normal vatation comes from the many physicians who have Personally communicated their appreciation for the help they have received fom this atlas. ‘These comments were offered hy 2 wide spectrum of rudologsts ranging from residents toiling m emergency settings to senior radiologists who have found a variant that has larfed chinieal problem However. [ have concerns that the volume of materia that ‘continue to present may became so large that it may be dffclt to ‘contain ta single volume. Considering the wide range of experience ‘of my audience, it is 9 dificult decision to eliminate some en Ibcause of theie simplicity and others doe to their rarity. Tale this problem in part I have omitted the section on cholecystogra- phy since this technique has virtually disappeared. from current nical practice. Other changes included inthis edition area wide range of nex variations that maybe troublesome, betier examples of Wr.tiaw Lowen Burcmor Du Bows (1958) previously documents, andthe aon of MRT mages, Ua fo tccnplan the mee arama dover. bs i Pe eae es MT cc Tcould be reise in nr peintng rat thar some of the normal sera roves qreatond yop poor aia ee, The eaters CRA Aree oF Mie RAN Geslacsranl when stressed may become symptomatic. Some of these ure aa by Dr. Jock Lawson’ in a eas ae Taeltoapes suena perenne yeti world over who have sent me ee for inchusi hi ‘book and wvhn hve offered siggesions for improvement of the preseneaton, The wars recta oi wre ete resin bar beso fying in the satisfaction T have gained from this effort and in Sip tdicamriorte cic Tanve special recognition to my secretary, ef ayy delete andy in and support of ny work. atria West, for years at for hee long interest “Tarovone F ary “Lane P, Clea sgicare radia varan theses Aa J Rad 168290, 195,PREFACE TO THE FIFTH EDITION ‘Sy ot “This the tua” bt *So it scr tome 0 be as I ne see the things Tabi Ls.” Inscription above a doorway atthe sn Naval Otfiers Schoo! in Kiel, quoted by ‘Joun McPite in Rising Peo rhe Plains I he many expressions of acceptance of tis work have heen nost gratifying and have provid me with the stimulus to continue tocxllee and explain many of the normal phenomena tha we seein cour everyday work ‘Asi have collected normal euensgen variants ove the years Thave heard the repeated criticism that the material #8 unproven, and it say acs the cme te, Fxplrton of ing ha ae ‘unrelated o symptomatology is nota nsual undertaking, The quote above states the situation exiety. The inclusion of whar T present is ‘often based largely on the fat tha the findings are meidental and asjmpromati, or have been seen repeatedly in ether patents im a similar clinical seting. Inthe fie edition, I stated that ll entries are G subject to further serutiny and exclusion if ncessary. [am delighted to state thar over the years only a few have failed to survive the text of te, In this edition {have included! more CT images and some MR ‘examinations to establish the developmental nature of some of the new entries. Unfortunately. not many incidental findings are subjected to these kinds of evaminations, and only te will perrit further documentation ‘Mother Nature is ineshaustle in the infinite varieuy of human deselopment she provides. ince this edition has zone to pres. Lhave collected a great ruraber of new variant for subsequent publicatiuns The task is endless, hut its a ahor of lore T would like to express appreciation to the many physicians ‘who have sent me material and have graciously granted permission to publish these images. I would like to particularly acknovskedge the invaluable expertise of Dr, Evan A. Lennon of Sydney, Australia, for biscarefil proofreading ofthe uanuseript. Thanks areal» due to my secretary, Patricia West ny eto asistat, Carol Chowdbry, Ph.Ds and my wife, Patt, for her encouragement in this work, ‘Tueovorr E, KEATSPREFACE TO THE FOURTH EDITION ‘Testy te phenomena of disease thant Boks isto sail an suncertered sex, lew seady books without parent snot ogo sea a al. Sin Wat OsteR I he pulication ofthis fourth edition reflets the praifsing response ae medical pion tthe exer eons Tove heen particularly rewarded by dhe comments of many radiologists who havendicated that the lusation of these mary normal variants has heen of grear help ie their clinical work 2nd in convincing their lial cleagues af the innocent nature ofthese fing. have ‘capi men ofthe new entries during de course of my day's work ‘when I can exantine and question patients and try to document the rane ofthe radingraphie findings. ‘Mest ofthe entities i the las edition have std the test of time. Thave removed the illustration of whar T helieved to be the nutrient foramen of the tiia since T became aware ofthe typical appearance ‘of the posterior vial runners sts fracture. This ilustranon has been replaced witha correct version. (have ade a great deal of new material on the cervical spine. [find this portion of the skeleton catremely difficult to interpret and full of pills for che unwary radiologst, not only because ofits anatomic structure, hut also as 2 result of faulty positioning and projection “The reader will also find some important new material concerning relationships of joints, particularly in the wrist and the aeromioclavieular joint, that violate accepted criteria T wish to express my appreciation 1 the many: physicians who have permitted me to publish material sent for consultation, T wish to express special appreciation w9 Dr, Christian Cimmino, ‘of Fredericksburg, Virginia, for his many. contributions and his iawaluableasistance in unraveling many anatomic riddles, Thanks are also de to my secretary, Paricia West, my’ elitr assistant, Carol Chowsdhry and my wife, Paty, for making my task easier ‘Tawovors F. Keats,PREFACE TO THE FIRST EDITION “Things eve seldom wh they sen. Skim ile masquerade os (GiupeeEr & SULLIVAN'S LMS. Pinfore | he prablem of normal variation is @ lifelong one for the radiologist, and the mark of his experience i often his ability to recognize a wide range ofthese entities. Cataloging and describing normal variants demonstrated by ruentgenalogy is of more than academic interes, for recognition of the abnormal first requires full Knowledge of the normal. Variation is inseparably related to the study of normal anatomy. In addition, the err of oventignosis of oral vation a evince of pathlogy may he more sous than Comission and may lead wo nels and Rannful therapy. ‘When one stiies the field of normal variation in deal, he i apt w he overwhelmed hy the seemingly infinite variety nature has provided, 4 detaled stady of all of these would te a valuable, fut limiless, underaking. Of more significance are those variations that may simulate diver in the radiograph, tis thse variations that form the substance ofthis initial Hort. Those that are shown here represent problems in diagnosis hase on my personal esperience, on that of my ascociares as well 5 on that of suecenive yeneratiuns of residents in traning. An interest inthe subject of normal variations scems to induce spontancons generation of ational entities 30 that, atthe time of this writing, there appears to be no end in sight, bor its necesury to make a start. I is anticipated that subsequent editions will add additional troublesome variants swells correct or amphi those herein 35 new information i obtained. The distinction herween normal anatomic variation and 2 congenital anomaly isan arbitrary one. have tried ro avoid inclusion Of anoinalies of development, which are obvious in themselves 1nd often productive of signs and symptoms, but rather have tried fo concentrate on those alterations thar are essentially incidental Findings and significant onlin ther potential for misiterpretation, “The proof of the validry of the material presented s largely subjects, based on personal experience and on the published work of others. It consists Largely’ of having seem the entity many times and of cing secure im the knowledge that time bas proved the inovence ofthe lesions. In other eases follow-up studies indicated thar the lesion in question represents a phase of growth that is climinated by maturation. Still other variants were detected in ‘ciation uf the side opposite thar in question when a radiograph ‘vas made for purpuses of comparison. Further experience may prove sone ofthese concepts incorrect alla, therefore, considered subject to future modification or elimination, This book is arranged in atlas form with the concept that a phorgraphic reproduction of a normal variant i far superior tp 2 text gern. The ilrtive meri therefor, enphasied and the rex minimal and concise, Referens are melded where the subject i still considered controversial or where doc thought necessary. The interested reader is referred 0 t Pediatric X-Ray Diagnass by John Caey orkid ft Nera ed Er ag Sta! Recti These books represent pioneer effort in the fick! of Skeletal Roentgen variants. This atlas confines ise to roemgen viciams scen in conventional roentgenology with no attempt to include those encountered in the specialized fields of angiocardiography, ‘neuroradiology, or the other ratologie specialties. The later ill provide a frnfal source for future study Tac are 2 numberof nova entities tht simulate pathology by virae of growth, or projection, ot both. These are nor anatomic variations in the truc sense, but since they intredace, @ sitilar problem, they are included as well “The ath artanged by anatomic areas, Hewever, cern specific erties are repeated in more than one seetion, so the reader searching for 8 variant may encounter it not only in the anatomic area of is origin, bur alo in the anatomic section of the lesion it Simulates. Tt 1s hyped this repetitive arrangement wil fiitate recognition, particularly for the less experienced observer. Specie acknowledgment is de 1 Dr John F. Hot, Poker of Radiology at the University of Michigan, wha, ay my teacher, fist intrested me in the subject of normal variation. Throughout his profession career, he has been a student of the subject and hay raciously contributed his collection of variants for melasion inthis Work, He has sho generously contrihuted time and constructive Crt during the ekg iat, WViout i inpron and help this work could not have been accomplished. Tish to express tne appredation also to the eany unnamed physicians who have contributed to this eollection and, 9 parca, tw Dis. Chuistan Cimino and Donald Kenneweg of Fredenitsbug, Virginia, and Drs William R_ Newman and Clinton [. Rogers of ‘Cumberland, Maryland, for many valuable cases. My thanks, 10, to ‘Mis Anne Russell 1, P, ofthe Section of Medical Photography at the University of Vieginia, for her inaluable help inthe preparation ‘ofthe dhastrations an ro my secretary, Miss Ann Rute, foc er patience and id in manuserin preparation Timanonr E. Kear,CONTENTS Foreword, vit Preface in Preface to the Seventh Edivion xi Preface vo the Sixth Edition vit Preface to the Fifth Edition xv Preface ro the Fourth Edition wi Preface to the First Falition xix pxev QI THe Bones 1 1) Tue Sku 3 Uhe Calvaria 4 racranial Caleications. 25 The Occipital Bone 54 The Temporal Bone _ 83 The Mastoid 87 “The Petrous Pyramid 91 “The Sphenoxd Bone 96 ‘The Base of the Skull 101 ‘The Sella Turcica 111 20 THe Factat. Bones 119 “The Orbits 120 he Paranasal Simuses. 125 he Manilary Sinuses, 125 ‘The Frontal Sinuses 131 ‘The Ethnaid Bone and Fihmoidal Sinuses 137 ‘The Sphencidal Sines 139 The Zygomatic Arch 142 The Mandible 14 The Nose. 151 Tue Sprr 155 “The Cervical Spine 156 The’ Thoratc Sine 286 ‘The Lumbar Spine. 307 ‘The Sacrum 349 “The Coceye 364 ‘The Sucroiiac Joins 367 “DHE PELvic GIRDLE 373 ‘The Mivm 374 ‘The Pubis and Ischium 388 ‘The Acctabulum 41 ‘THE SHOULDER GIRDLE AND THoRAcIC CacE 45 “The Scapula 16 The Clavicle 451 The Sternum 465 The Ribs 478 THE UPPER EXTREMITY 507 ‘The Humerus 508 The Proximal Porton of the Humerus 508 ‘The Distal Portion of the Humerus 530 ‘The Forearm 546 ‘The Proximal Postion of the Forearm. S46 ‘The Distal Portion of the Forearm 360 ‘The Hand 577 The Carpuls. 577 The Aecsory Ossices 57 ‘The Carpets in General 586 ‘The Capitate and Lamate Bones 588 The Haman Bone 597 Toe Trapein and Trpecuid Bones GOL The Navicaler Hone 603 ‘The Triguerrem Home 613. The Pisform Bone 616 ‘The Meracarpals 421 ‘The Sessinoid Bones 634wwii F Contents Tur Lower EXTREMITY 655 ‘The Thigh 656 ‘The Femoral Head and Lip Joint 656 ‘The Femoral Neck 667 ‘The Fruchanters. 681 “The Shak of the Fermur 683 ‘The Distal Fad of the Femur 697 The Paella 743 The Lee 71 The Proximal Ends of the Tibis and Fibula 771 “The Shafts ofthe Tibia and Fibula 800 ‘The Distal Fn of the Tia and Fibula 810 “The Foot B38 The Tirals 838 The Accsory Osides $38 The Tales ¥95 The Caeaneus 871 he Tira Neveaer. 890 The Canifrns 905 The Culead 918 “The Mettarsals. 923 The Sesamoid Bones, 956 The Toes 968 1 EE THe Sort Tissues 9» ‘Tur Sorr Tissurs OF THF NECK 981 ‘THE SOFT TIssuES OF THE THORAX [009 ‘The Chest Wall 1010 ‘The Pleura 1028 The Lungs 1042 he Mediastinum (063 The Heart and Great Vessels 1088 ‘The Thymus 1118 10 u 12 13 ‘THe Diariracm 131 ‘Tur SOFT TISSUES OF THE ABDOMEN 1141 ‘The Abdomen in General 1142 ‘The Gastroimestinal Tract_ 1162 ‘The Esophagus. 1162 The Stomach 1168 ‘The Duodenum 1185 The Small lnestine 1193 The Colon 1199 ‘The Liver and Biliary Tract 1220 ‘Tur SOFT ‘Tissues OF THE PELVIS 1227 ‘Tue GENrrourINaRy TRACT. 1239 The Kidneys 1240 The Dees The Bladder ‘The Urethra, “The Genital Tract 1277 Index 1281THE SKULL 41024 The Calvaria 11 t0 165 25034 Physiologic Intracranial Calcifications 1-66 to 1-95 35t046 ‘The Frontal Bone 1-96 to 1-129 47:53 The Parietal Bone 1-130 to 1-149 54t0.82 "The Occipital Bone 1-150 t0 1-235 31086 ‘The Temporal Bone 1-236 to 1-246 87 1090 The Mastoid 1-247 to 1-258 195 ‘The Petrous Pyramid 1-259 10 1-273 96t0 100 “The Sphenoid Bone 1-274 to 1-288 101110 ‘The Base of the Skull 1-289 to 1-323 1t1t0 117 The Sella Tun 1324 to 1-348SSeS The Calvaria HicuRe 1-1, The relate propertions ofthe cranial vault sive wo face sie in dhe infant fer skingy fram those i the ada Applying adult standart the inf may suggest 3 isprpetianae increase val sire, Ax bith, the head 40-tice ‘ain s approximately 4 in adulhaed, his ato 32. {Ref Watson EH, Lowrey GI: Growth and Development of ‘Chilklren, Sebel. St. Lous, Men, 1967) (From Keats TE Pesiare rally Some poteiily misleading variations fram he adult. VA Mle 9-630, 1966.) 1-2, Overlapping sutures ins neonate secondary to molding of labor. 1-4, Sealy folds in a neonate producing an unas appearance in the pata ein‘The Calvarias Tur SKULL 5 Ficune 1-4. Occipital skin fll FiGURE 1-6. Hair raids producing an unusual shadow ae vere of hl GUE 1-5. Scalp fo in the ocala region that eld be maken fora fracture ict 1-7, Strations ever the parietal aca couse by hat FicURE 1-8. Tair brads with surrounding casic hands, sinmlating| sclerotic si6 Tue SKULL » The Calvaria‘The Calvaria = Tur SKULL 7 12. Localized prominent diplie parer in the parietal bone (A) prodocs a striking appearance in Waters’ projection (B) FiceRs 1-13, Irregularities and trations in the vertex of the parietal bone caused by the seratons of dhe sagittal satu. A Neonat B, 10-year-old man (Ret Sarwar M, eal Nature of vertex stations on lateral skal algaphs. Railay 14690, 1988)8 Tur SKULL + ‘The Calvaria FiGUHE 1-14, Prominent digital markings. The prominence of elaral liga markings vates widely, paciculy bereeen the fourth and tenth years. They do notin themselves necessarily let increase itraranial pres. (Ref: Marsuay D: Digital markings nthe agape. Bir] Radial QHR647, 1951) Ke should be notes tha infnes may ‘ccasonally he horn without neurologie dsease hut wih Iscuntr skulls, which sre spontaneous: (Ref: Taylor B. Barat I1B, Seber]: Neonatal Fecunar sll without neural isease. South Med} 753875, 1982.) FIGURE. 1-15. Vascular channels in the parietal hone simulating botcon segues, FIGURE 1-16, Vascular channels the fetal bone simulating hurton sequesta‘The Calvaria « THe SkuLL 910 Tur SKULL + The Calvaria Ficur 1-23. Vasculeyenove (phenopariea sina) slang Factare‘The Calvaria » Tur SKULL 11 0 Ficeer 1-24. Venous vaculie groove in the frontal bane which maybe FIGURE. 1-28, Lucent depression uf a pacchicnian granulation witha rms for frat lange desing vein vkry inthe feral projection. (Ref: Branan R, 533, 1976) ather poorly defined pacchionian depression smmating a destrvtve lesion, pa Wikon CB Arschoid granulations simulating ostelytic sins of he colar. AJR Am J Reengenal FrcuRt 1-27. Deep but ype pechionian depressene.‘The eternal thle uf the eri bowed, and the intemal tbl s apparently absent Failure vo appreciate these Features may lead to an erroneous thaynoss of erosion ofthe inner table ofthe skull= ~ < Ficus: 1-29. Pacchionian depressions in che ccipitl bone an unusual leston for this normal entity‘The Calvaria » THE SKULL 13 Ficunt 1-30, Pacchionian depression with 2 central area of density. This appearance is often mistaken fr a significant Kson such as. an exsiapile ‘wanuloma. (Ref Branan R, Wilson CD: Arachnoid granulations simulating oseeytic lesions of the colvaram, AJR Am J Roentgenol 127.823, 1974) “= «+ ica 1-31. Large pocchionan granulation ofthe vertex of skull hat evan urns configuration ro the verte. Ficune 1-32, Auesioefamne bone14 Tue Skutt. « The Calvacia 1 1-33. Huge anterior fontare bone in year-old child Jet 1-34, Fusing anterior fontanel hone in a3 year-old hoy This appearance may be confused with tha f depressed Factre inthe Ize projection. (Ref Girdany BR, Blank F: Anterior fontane bones, Am) Roentgenol Raum Ther Nucl Mes 95:14H, 1965) Ficusa, 1-35, Anterior fineanel bone erste appearance in Towne preston.‘The Calvaria » Tue SKULL 15 Bi 36, Cling nteroefranel bone i an U1 -yene ol bey. Pict 1-47, Remnants ofthe mero fomnanel boae in SO.yea 2 ai% » Sb Ficere 1-38, Wormian (tra) bane in 7-year hil. Thee my Bigg 1-39, Woman bons in 49-year boy fe sens a nora ara a well sn estengenesis pects and deidocranial dsestoss16 Tur SKULL the Calvaria hres in a 19 year od man. FioURE 1-41, ‘The sygumaticfrontal sure i 3 neonate ree 1-42. Wormian bones a the base of te coronal suture ina newborn (epiperic bane.d FPicume 1-45, Simulated spread of the coronal sutures ina $-yenold boy Stural prominence is extremely variable, panticulty from ages 4 o 8, and shoul! not be mistaken fr emdence of increased intracranial peesore Such early pensurral sclerosis scents the prominence of the suas, icuxe 1-45. Normal squires suture projected tanga, simulating 2 Guerre ‘The Calvaria Tur SKULL 17 Simulated ed surures in an & year-old by FicuRe 1-46, tangential projection of the squsmosa stare pacing Les obvious simulated eset.18 Tue SKULL « ‘The Calvaria ‘J Mh J ofthe corona suture Ficekt 1-48, Normal stural squamosa suture Fic 1-50. Farlysutural skeenThe Calvaria « "Tne SkuTL 19 io o acu 1-1, Thick but =a Fictne 1-82. Normal unc, empora, aa wii hcencies seen inthe aging catia Striking cept! radilucency ins 32-year-old woman, These inal rabohucencies shoul! not he mtshes fr the osteoporiss. carcunsripta of Paget sense20 Tue kurt + The Calvaria ev ail yperortsis ina 68-year-old woman, Diffie thihening of the ealbri is present as well sleaze’ ineeralbyperostesis of the frontal and parietal bones. Ficumr 1-56, Frontal and tempor benign cranial hyperostosisin an 8-year old woman‘The Calvaria » THe SKULL 21 ws intracranial oman, The raohacencies deposits erin right, CT scan shows the radiolucencies caused by intrveing sess Iherwean the hypersteses 8, Loclied thickening ofthe parietal bone, a noma22 The SKULL + The Calvaria Ie 1-59. Pareto occipital hyperostsis Flcvne 1-60, Localized thickening ofthe expt bone, normal Picune 161, Cr the midline ofthe skull in a 7-yearold destructive procs. Such closire defects nay be unssiciated with bone dysplasia ce Figs. 1-100 1 1-103) (Ref Ineve ¥, eal Cranium bifidum ovcultm, Neuroradiology 25:217, 198, ot tebe mistaken foraThe Cabaria = THe SKULL 23 Fic. 1-62. localize palpable thinning of the outer table of the skull in an asypternatc 21-year-old woman. This probably represents an incomplete form of cranium bifidum ocaliun(ee Fig. 1-6), icine 1-65, Congenital depresions ofthe clvaria cused by faulty fetal packing. Such depresscns manifest ar bith aud, when not asoaed with edna or hemorrhage of the everying sof sss, te usualy de to faulty postion he worn with lorgtending presi fram the fetal fet or the matemal sacral promontory (Refs: Cafiey J Padiatic X-Ray Diognoss Sth ed. St.Louis, Mosby 1985; Even D, Kitehner SG, Peer EC, Neva a slul depresions unassocia with bith trauma. AJR Aun J Roentgsol 143.1063, 1984)24 Tur $xurt « The Calvaria a JAE Ficone 64, Sliphe cabarialdepresionsn an 1R-monih ol ci, probably representing residua of flty feral packing. These depressions usally regres pontanewsly without treatment 4, a we nt 1-65. Three examples of doughnut lesions.” These ane not cally significant atl maybe seen in any parc ofthe eavara inelding juvenile hal. They nay oF may not contin a central area of sleross, (Ref Keats TE, Holt JE: The caharial “doughnut lesion”: presiously ‘undeseribed end. Am J Roenegenol Rowan Ther Nucl Med 1053314, 1949.)7 a . Physiologic Intracranial Calcifications cue 1-66. The haluae corns sland). Ficunr 1-67. Large gsi26 Tue SKULL + Physiologic Intracranial Caleifications Figur: 1-69. Perrclinidcaefeation in the half axial projection, FIGURE 1-68, Petrotinoid ligament wth heavy ealifeation Fant 1-70, Parotid ignnent wth regu cin Tioune 4-71. Pevotini gamene with an wns pater heloaen ae. Frau 1-72, Tio examples of eacfcation bxxween the middle and posterior clini processesPhysiologic Intracranial Calcifications « The SkULL. 27 FicuRE 1-73. Unusual dra eakfieations ane anterior and posterior clini processes. Ficiah 1-74. The oc supra petrosan af Mecke, apy silage ‘okaistion under, or adherent abe dra onthe errepesteno srfice ‘ofthe petro bone, ner it tp. Note its postion in the tral ecko, superimps on the sels rurcea, which permits is differemta from petrohinoi ligament easton, (Refe Carraro G, Weinberg A: Os . supra petro of Meck. Am J Roentgenol Radium Ther Nucl Med 121189, 1974, Keats TF: The os spra petrosan of Mickel and alae petoctinl ligament eaksfcation. VA Med WHEI14, 1977)Ficure 1-75 Mckel seen on pyemography.Physiologic Intracranial Calcifications = THE SKULL 29 FicuRF 1-79. Mulople focal ars of dural caetcation ina 71-year-old man Peas Galatea eae seen FiGU: 1-82, Heavy eiifiation ofthe a ere30 THE SKULL + Physiologic Intracranial Calcifications w, ae FFiGunt 1-83. Heny ciation inthe fabs cere inthe frontal nd literal projections. Fugue 1-84, Three types of physolope cleifstion. Demonstrated are petrclined ligament (¢-),heay califesion ofthe entoraun cerebel (+), aun ax cere (4) eAwe 1-85. Minar cakafication ofthe tenteritan cerebelli 6). Calefcation sake present in the fa (6+) and the pineal plan (6) (Ref Sain RM, Di Chino GTentonaleakifetion. Radiology 111:207, 1974)Physiologic Intracranial Calcifications « THF SKULL 31 ictie 1-87. Cabfcaion inthe glomus of the ehoridplenus (boomerang canfigaration), ‘PloURE 1-88, Norma asyramety of the calcified glomera of the choroid pleas. These cannot be reliably wed for evince of intracranial abner32 Tue SkULL « Physiologic Intracranial Calcifications FicUne 1-90, Califcaion ofthe internal card arteries.Physiologic Intracranial Calcifications « Tue SKULL 33, « ~ hd Fictme 1-91, Calefistion ofthe internal carotid arcetes with very dense calefiaton in dhe lateral projection. FuceRe 1-93, Large34 THF SKULL + Physiologic Intracranial Calcifications icv 1-94. Cakefcation in dhe deotare nucleus ofthe cerebellum. This form of eakifcation i not necessarily of linia Sigifcance and may be physiologic. FIGURE. 1-95. Iopathic exefication of rhe lal xanga nay be fia and unassisted with other disease., The Prontal Teneo FicUR 1-96. Closing setopic suture mistaken for a feature i 2 1V-yearold boy. Cl Fic 19K, Pes the outer.36 TH SKULL « The Frontal Bone Frontal bone, simulating a metopie suture Ficunt 1-101, Cranium bifidum occutum in 2 9-month-old gel‘The Frontal Rone « Tuk SKULL. 37 Ficus 1-102, Cranium bifidum eecultum ins Me-nonth-old boy. Fieame 1-103, Cranium bifidum coculorn in 28-year-old woanan38 THE SKULL « The Frontal Bone to ee Asymptomatic papal yeas of age the fo clopeental essai the fatal hone ina resent, essentially unchanged T-10S, Midline fetal accessory bone in an UT -mont-ld bey.Ficunr 1-107. Seleroas ofthe masofionial suture, which ‘gt be mistaken fr meningioms ofthe anterior few, ThGvRE 1-106. Prominent nawfrantal suture, not to be misiken fora fisctre. This surue nay persist ito dul fe FIGURE 1-108. The naoffontal suture in lateral projection Ficunt: 1-109. ‘The nasofcatal sur in a (3-year ie ™40 ‘Tue SKULL + The Frontal Bone GURL 1-111 Unis alles appearance ofthe Boor ofthe anterior Gn,‘The Frontal Bone + Tir SkuLL 1 ictxe 1-112. Tip and berm Tso examples of prominent fon ‘aketcaion uf he fale Fico 1-113. Vascular channel sunulaing asl fete. (Ref Schuak H, Maruyama Tivo vaseular grooves ofthe enteral table ofthe hl which simulate fractures. Acta Ral $4:186, 1960.)2 Tur SkutL. « The Frontal Bone icone 1-116, Viscolar channel shove the fot snes‘The Frontal Bone * Tue SKULL 43Yo THE SKULL « The Frontal Bone PIGURE 1-121, Nodular benign hyperostss frontal interna Ficnr (122, Nebulae hyperostosts fronais interna icLnt, 1-123. Diffuse benign hyperostos of the Fron baneSE | The Parietal Toe nf wo ncunates showing paral fissures caused by persistent strips of merbrarynsb These fsoures which isappear asthe child matures. are ofc mistaken for fserres. FiGune 1-131, Persistence of pari fssure in 2 year-old cil, simuloang a fractre. 47Hcy 1-152, Unilateral ineraparetal sure, which divides the parietal bone into upper and lawer seynents his sue, whit may abo eur blaerally extends frm the coronal suture tothe lid stare. (Ref: Shapiro R AAneralous pret stv ar the partite pail ewe, Aun J Roentgenol Radium Ther Nuel Med 115: 1972) Fuqua 1-133. Uniarerlierapareatsutare. When this suru i unvtera the skll may beast, withthe se harhoring the inuspurietl suture being larger thn te appa ie, as this cae mar 1-134, Biletcrl subsoil sures in a T-year-oll cil‘The Parietal Bone » ‘Vir SKULL 49 (UnuslIucencs in dhe parietal bones erssing the mi I lrg in an ade worn FIGURE 1-136, Normal parietal foranina, which transmit the emissary veins af Sanorini Ficume 1-137. Parietal emissary vascular channel, Note the depression inthe aur ble atits poi of ext‘The Parietal Bone » THE SKULL 51 Ficumr 1-142, Ayn52 “TH SKULL + ‘The Parietal Bone . @ Figue 1-143. Unusual pari foramina PicuR 1-144. Unusual venous vaseular markings in parietal bone. FPicuRt: 1-145. Localiaed aes of thinning ofthe external table at the ste ‘This area Frequently shows astrking vascular potter = ofthe anterior Toman, This should nt be mistaken for erosion of the outer table FicuKe 1-146, Parietal thining, a mania of rsrmennpausl oxeoporons The oer tbls st, with charac sera ofthe inner tle, Note lo slr lil ehnning fe atl bone nthe later pcan (Re Seine I. bats AWG: The signifeane of thinning of the parietal bones. Am Roentgenal Raden Ther Nud Med 7839, 1957) Pant hinning nay rately be oiler (Ref Wilson AK: Thinness of paral bones. Am J Roenyenol Rann They Nel Med 58724, 1947)‘The Parietal Bone » THe SKULL 53, Fieve 1-147, Connhined pail thinning and venous lakes and rowes in S6.year-old woman, icv 1-148, Parical thinning in an 82-year ok! man. This ey much less commen in males FIGURE 1-149, Hyperostoss cortical generalist and hypercstss paretalis= The Occipital Bone Ficus 1-150. Apparent maalignnent ofthe parietal nd occipital Ficus 1-151. Unusual ocopital configuration in the newborn i due to bones caused by molding of labor, not tobe mistake for faceure (9). the molding of lb. A cephalohemnatoma is present (1) FIGURE 1-153. Fhsures io an ifine around foramen magus sila thes in Figure 1-152 Ficune 1-152. Occipital ‘of merbranons bone, 2c fracture. The rital Fasures cause persistent tips Finng in infaestha may srt cadenl sures ae evident (1) sa‘The Occipital Bone + ‘Tur SKULL 55 ha FIGURE 1-154, Persistent membranous am aloescen gr fswores simulating » fae FIGURE. 1-155. ‘The synchondroses between the supe am ‘20ciptal porsons of the ecipital bene in a 6-weck al cl (3). ‘The mendocal sutures are also seen (+). FIGURE 1-156. ‘The mendosal suture (>) and synchondrusi betwen the Supranciptal and exoccpiul portions ofthe occipital han (2) in ena projection in a Lye od il HiGUeF L-AS7. Accessory ossice of the supraociptal hone (Kercksng’s asic) in 2 sommal infant. (Ref: Cafly J: Op acesory oxic of sapracccipal bane: Severely ecoicd roenigen features of normal inal skl. Am J Roemenal Raum I os Nek ‘Med 70:40, 1953)56 Tue SKULL + The Occipital Bone TFlctne 1-158, appearance of the accessory suprancipital osc in the ler precio. Picume 1-159. Unilateral ossice ofthe saprscceiptal bone FicuRE 1-160, Occipital esl in the lave proiesion‘The Occipital Bone « THE SKULL 57 FicuRe 1-162. Persistence ofan occipital osicle in 22 year-old man Ficunt 1-161. Iregulr midline occipital xsce in» 6-mooth-od gi58 THe SKULL + The Occipital Bone icone 1-167. Nomnal lage interpreta bone in ¢3-moath-ll child the frontal and lateral projection.‘The Occipital Bone « Tue SKULL 59 Ficum: 1-168, Three examples of bifid interpreta bones (Ines bone). this uding should note mistaken fore fracture (Ref Shapara R, Robinson F: The es ineae, AR Am J Roentgenol 127-469, 1976) 169. Two examples of how Ince bors may subacute in the Lateral projection,FictRe 1-170. teshap! Inca bone al aciptl olin (brcels eal}. This abnorinal head shape ts weatified asa peitive deformation sociated with breech intrauterine positon, Iereslves during infancy with no real npn in most eww. (Rel Habre CM, Snth DW Jones Kl: The "breech head!” and its relevance. Am J Dis Child 133:154, 1979.) te) Ficus 1-172, Recrangalariterpritl bone ian adult Fount 1 171. Cone shaped interpreta bane iene 1-173, Pate, teal placed interpartal betes a ee uu, 1-174. Soll ntesporictl bone thats persist in ada if ooice 1-175. Anceroefnanel bone seen inthe septal projection in 1 Myear ol, Ficune 1-176, Occipital flarening ome ly postural presure, nor to be confuse with changes ofcranicnyneiesis. Fictwe 1-177. ‘The superior men fissure ofthe occipital bune in a 2L-yeatold patient (-), hich shold nt be mistaken fora feature. Note alo et simulating a facrore (). ee ofa strip of membeancus ne FFicuRe 1-178. Examples uf ynmncric closure of the sichondrens Lxtueen the suprancepital and exrciptal portions of the weipital bane, {of \S-morth-old ian. Right, 12-noneh-old infu, The open sture may be misshen fora fracture 6SKULL + The Occipital Bone TFiGURE 1-179, Visualization uf the inner and ner aspss of te hon ‘suture, suguesting distare facture FicuRe 1-180, Persistent mendosal sutures in a 17-yeael by:cunt 1-181, Percent mendosal sures ina 25-yeareld man. A, Opensmeuth alent CCT san Ficum: 1-182, Mendonal sutre i a 29-month-old hil, istaken fora fracrve ‘The Occipital Bone + ‘THe SKULL view. B, Lateral projection, 8FFicume 1-183. Unicel prsitene mendonal suture in 2 46-year ol ‘naa. A, Front prejction. B, Occipital proection, C, Lana proton.‘The Occipital Bone « THE SKULL 65 FIGURE 1-185. Anonlin midline occipital siture (cerebellar synchondnii) This is abo 2 common ste of fractures in soa children. sw te digoss of an tomato suture should be rae with cation. Lef, Adult with sturl serous vient ight. Child with no history of rama, (Ref Franken EA Jr: The line ceeptal isan Dignan of Factore versus anatomic vara. Radiogy 93-1083, 1909)66 THe Sxe + The Occipital Bone Ficuet_ 1-187. Staking example of esymunetic prominence of ane ‘cipitomastond sore siggesting fret, which accentuated by Ficus 1-188. A,B, Oec Y ira FicuRe 1-190, Defects in the lari suture, presumably representing ersten mastoid fontanels "The patene dl at have neuribromatost FGuRE 1-189, Sutra bone in the wcipitonnstend sure‘The Occipital Bone » THe Sku HicuRe 1-191. A ponton ofthe ata suture seen through the occipital bone, simula a facrre FrGURE 1-192. The metopic suture amy le seen in Town projeson and cunfined with facta: Note ts contncaton acess the cotine ofthe foramen magn. Ficuay 1-193. Metopic sour simulating occipital facture in 2 22-onth-eld child [None the lek of sural erations Ficune 1-194, Examples uf occipital emsty channels or68 THF SKULL « ‘The Occipital Bone Fic 1-195, Ts exsanples uf the foramen forthe acipital emissary ven, the nioentinea cana. This 3 mune stracture, in contrast tothe ‘enous lakes, ich ae seen on hath sides ofthe mln. (Ref O RakillyR ‘Anomilus ociptl spertres, AMA Arch Pathol 53509, 1952) Freie 1-196, An unusual occipital emisary vin immediately ave the forainen magn FPicunr 1-197, Midhine vascular channel (¢-)- Ociptal venous ake ae aha present (6),‘The Occipital Bone « THF SKULL. 69 Ficus 1-199. Lf Oxcipalpocchionian impresion €-). Nete the draining vein (6). Right, Confirmation on CT sean, (Ref: Shlly RD, Mark EJ. MeNealy BV: Case 42-1984; Phechionian grasolaton. N Fag} Mel 22-1036, 1984)70 ‘Tur SkULL + The Occipital Bone FIGURE 1-200. Occipital veo ks. These strates iy wily in ber and appearance They ae uml seen nar the tudine ofthe occipital bone, nest cormonly in older indvivals. "These ake ein thee space and ae of no cna Significance. (From Kest TE: Four nol nitomicvanations of importance to radiclogis. Arm J Rantgerl Ram Ther Noel Mi 78H, 1957) Theres evidene that identical octal rdilucenis maybe the praduct of ectopic neural tise. These are witha elie sigiicnce. (Re Guiding S, etal: Fete new ase of th octal hone J Newtosrg 21:47, 1968)72 ‘Tue SKULL + The Occipital Bone iL 1-204, Other variations of eciptal wrens lakes. FiceRE 1-205. Devclopinent of ocipital venous lake. The ln on the right was exposed 16 yeas after he film um the let Fico 1-206, Occipital enon lake with «prominent draining venus channel,‘The Occipital Bone + Tuk SKULL. 73 Recut 1-207. Nocinal unilateral prominence of the pron: forthe tranwerse venos snus, FIGURE 1-208. The transverse sinuses sen on env evidenced 35 teenies inthe mastoid, Ficune, 1-209. Prominent taraverce venous sinises, producing rikingradioluceny in the letcal projection.74 ‘THe SKULL » The Occipital Bone Frvne 1-210, Occipital midime radicluceney, probably representing a losure defect. There were no seca linia findings. Ficune, 1-212, Striking appesrance oftae eit region produced by cans 1-211, Localized thickening of the octal bone, aural variant. fc sinanes snl reveal rooney af the exci hanes Fravat 1-213. Preumatization ofthe occipital bane as an extension from the mastoid‘The Occipital Bone « THE SKULL. 75 Figur 1-214, The ocipital hone may have e variety ofsynmetic ad aynmmeric areas of thinning nea the midi (@), which may simulate srosion of the inner table, Some uf chem relate to the configura of the transverse venous sruse. Important thatthe innacence ofthese ‘arias be recognize. The cased arms (6) indiate the vere ines. FiGURE 1-215. Developmental thinning ofthe occipital bone (A) proved by CT sean, The defect contains normal brain tise (B) (Fro tlacen MA, Keats TE: The anatomic hss for localized ociptl thinning A vorial anatomic variant. Skeletal Radiol 8:21, 1982)16 Tur Skvt4. « The Occipital Bone FicuRE 1-216, Aional ramps of wcipal thinning. Nove sini to changes of ‘toson of nner table Ficus 1-217. Asymmetric ocpital thinning below the rorcular Herophil in a 2-year-old woman. Ficuae 1-218, Occipital thinning near the dine‘The Occipital Bone « Tue SKULL 77 Faun 1-219. Seal discrete are of vaxiptal thinning ‘Ficewe 1-220. Symmetric ocipitalthining above the torclar in «26-year-old woman, [thas been suggested tha the Incerces inthis location may cainide withthe eit pole, best observed inpatients wih thin caval vals. (Ref: Newton TH, Ports DG: Radiology of the Skll and Bran, vol 1. St. Lous, Mosby, 1971.)= = ARF 1-221. Synineti ress of expt hing simulating a Prcamvencephalograr Ficure 1-222. Occipital thinning seen in ber projection above the transverse sinuses. Note the apparent los the inner table of the cari Fic 1-223. Large aynmetric occipital thinning in 43-year old woman We * eas 1-20 Noa pen of di eal wr Amal ac pect inert Nac eer rganny PARE 1-22, forme con foce ith ae oe fhe roerce nung ofthe Soumen rnagyem (send sacked tiem eft (The cong ena! seen within de fas). teat Canny age Cees cna emer eat sil view. Arm J Roeonpenol Radin Ther Noel Med 107:515, 1969)‘The Occipital Bone « THE SKULL. 79 FicuRs, 1-226. Prominent external eccpital protaberance prshuing a midline density in the hal-axal projection. iGUme 1-227. ‘The external ocipital protuberance predcng a vague density superimposed on the front snus. Ficuar 1-228. Hoge extemal occipital protuberance,80 THe Sku + The Occipital Bone Ficurt 1-230, Ragilucency produced by the hase ofthe external ‘ossptal protuberance PicuRt 1-229. Prominent external ecipital promuberance with aljcent ‘alefeation inthe ligamentum nuchae. Fictrr 1-231, Uno appearance produced by superimpostion of external occipital prorberance and onfhonce ofthe vencs sinuses‘The Occipital Bone » Tue Skuts. 81 32. Samulated abnormality of foramen magnum, prxdoed by superimposed projection of eng hyperostosis of the internal surface ofthe Frontal bane & A ‘ ° = * FIGURE 1-233. Two examples of normal regularities ofthe margins ofthe framien magn,2 Tue SKULL + The Occipital Bone FIGURE 1-234, Paracondylar process. "Ths cone-shaped, any stractore projects down from the lateral aspect of the acta conle toward the transverse process of CI It may be unite cor bioteral. A Lateral projection. Band CTeanograns. (Ref: Shopro R, Raburn Anomalies of the cranerechral borer. ATR Am) Roentgenol 127.241, 1976,& The Temporal Bone Ficus 1-237, Skull ufa 3 month-old infant, showing woraiza bees in the anterior end ofthe squamosa sure (¢-). Note also the vacul rove inthe parietal nae at simulates a facture (6+). The skll seated ‘nits erie xi. andthe gro pojeted actos he coronal sutures, - FIGURE 1-238, To examples of grooves for the middle temporal aerysimolating fractures. (Ref Schunk I, Maruyama V: Tio vascular rows ‘ofthe externa ble ofthe sll hat simulate atures. Ata Redol 4186, 1960) Fit 1-236. Vascular grocvesin the temporal lan seen through the sphnvi sinus, simulating rarures. te84 Tur SkULA « The Temporal Bone FIGURE 1-239. ‘Teo example f seul grooses inthe temporal bone simulaing Factores (Re: Alley WE, Se, ta: Pills in the evasion of hl trauma, A review, Radiol Clin North Am 113478, 1973) Ficune 1-240, Additions examples of vasula grooves hat may be mistaken for factureFicurt 1-241. Convolutional impressions The scalloping of the inner tale ofthe mide eranial Foss adults (Ref Lame Be Frasions of the shul, Radiol Clin Nosth Ars 122257, 1974) a Ticuwe 1-242. ‘Tow examples of temporal tur slerose simulating supra alison. Ficune 1-243. Focal ara of sclerosis inthe squamol sure in T6-yearald wamin RS86 Tie SkULL + The Temporal Bone Ficuet 12H. Fssgqersbon ofthe normal lucency ofthe squarnosal parton of the emperlhons Ficunr 1-245, Tempors shinning in Snes’ proection simulating destruction of the abt Ficus 1-246. Iealated hyperostusis interna ofthe temporal bones‘The Mastoid + The Temporal Bone » THE SKULL. 87 The Mastoid cae 1-247, Large anim simulating a devrusive lesion, Feuer 1-248, Aicin dhe external auieary ena, seen a deste lucene ice 1-249. Masod emsary vein scen unilaterally Towne’ peojrtion (¢-). Note the prominent conoid fosa on the opposite side (+)x8 THe SKULL Phe ‘Temporal Bone + The Mastoid cere 1-251, A, An cumple of unusually masked pnevmarivaton of the mascots. B, A detailed view ofthe mastoid air cells‘The Mastoid + The Temporal Bone « THe SKULL 89 wont 1-252. Extremely marked poeumatization uf che misid Asymmetric development af the mastoid in tent’ rght side, (¢-) Note the Iucene inthe mid variant (C) Right A detailed view ofthe right masini na S-year-old child win warked overdevelopment € of the ocepital bone, which represents 4 normal9 Tite SKULL + The ‘Temporal Bone « The Mastoid Ficuee 1-255. Large mastoid ai ell below che emisary Fiovur 1-256. Large mescid emissary vein ‘ein simulating an area uf bon destruction, ucune 1-257, Large mastol emsary vein icuer 1-258, Sigmoid sinus (@) and mas emissary win (OH)‘The Pewous Pyramid « The Temporal Bone «THE SKULL 91 The Petrous Pyramid Fieve 1-259, Normal ayumetey in fcight of de ptrous ridges ‘This entity nay occasionally be avucited with geminal ners, (Ref Obeador S, eal. Trigeminal neuralgia secondary to asymmetry ofthe pert bone, Case report. J Newsonang 33596, 1970) FicURE 1-260, Toe example of normal aymmety in height and ‘configurtion ofthe peters. FicuRe 1-261. Large maswid sit cll at the pero ops lating Ue changes of acti (Ref Dalat PJ, Reals Giant air el of petrouyape: Taregraphie Radiology 129-103, 1978)92 ‘Tie SKULL + The Temporal Bone * The Petrous Pyramid Fie RE. 1-262. Stenver’ projection ofthe patrons ips ofthe ease illustrated in Figure 1-261 Fike 1-263. Preunatiaton of une ptrous tip simulating enlargement ofthe internal auditory meats FiGURF 1-264. Ayparci destruction of the petrous tips cased by pneuratzation.‘The Petrous Pyramid + The ‘Temporal Bone « THE SKULL. 93 icumt 1-266, Unusual cochlea densities in a paient without sjmproms referable to the inner ear, lou 1-267, Dense nodular form of caefcation ofthe petoctizui lgarent simulating ssyemetrc development af me petrous bone, with the dense portion seen in the ler projection.94 Tue SkULL + The Temporal Bone + The Petrous Pyramid Pict 1-26K, The om spre petronn uf Meckel Gee Fig 74) Ficune 1-269. Left, Sal, rounded bony knab onthe superior margin of the petrous lunes. This fring i usually unlaerl but may be biel, this case, (Ref: Shapiro R: An interesting normal vain ofthe teyporal bane, Radulogy 128354, 1978) Right, Bone inglke conigurauon of a. the pets tp, FIGURE 1-270. Variation i development ofthe petro idges producing an anomalous “foramen” com ome ide. A, Phin ln. B, Torngrar‘The Petrous Pyramid * The Temporal Bone « THE SkULL 95 ‘Ficus 1-271, ‘The same phenomenon as in Figure 1-270, seen hen Lisa Ficune 1-272. “Fish-mouth" intemal auditory meats on tomogram, ‘one ofthe normal variations in configuration, Pict 1-273. Io examples uf nonnal symmetry of the configuration ofthe internal autory canals. (Ref: Fuser RA, Carter BL: Unilateral dhltation ofthe sternal auditory canal. Neuroradiology 92227, 1975)