Regional anatomy • Cranial cavity 8
Clinical app
Medical imaging of the head
Radiography
Until recently the standard method of imaging the head was
plain radiography. The radiographs are taken in three standard
projections—namely the posteroanterior view, the lateral view,
and the Towne’s view.
Computed tomography
Since the development of computed tomography (CT), cerebral
computed tomography has become the “workhorse” of
neuroradiological examination. It is ideally used for head injury
because the brain and its coverings can be easily and quickly
examined and blood is easily detected.
With intravenous contrast, CT angiography can be used
to demonstrate the position and the size of an intracerebral
aneurysm before endovascular treatment.
Magnetic resonance imaging
Magnetic resonance imaging (MRI) is unsurpassed by other
imaging techniques in its ability for contrast resolution. The
brain and its coverings, cerebrospinal fluid (CSF), and the
vertebral column can be easily and quickly examined.
Magnetic resonance angiography has been extremely useful
in determining the completeness of the intracranial vasculature
(circle of Willis), which is necessary in some surgical conditions.
Ultrasonography
Initial work using ultrasound to assess the brain appeared
fruitless, but with increasing probe technology it is now
possible to carry out intracranial Doppler studies, which enable
a surgeon to detect whether a patient is experiencing cerebral
embolization from a carotid plaque.
Clinical app
Fractures of the skull vault
The skull vault is a remarkably strong structure because
it protects our most vital organ, the brain. From a clinical
standpoint, skull fractures alert clinicians to the nature
and force of an injury and potential complications. Of key
importance is the need to minimize the extent of primary
brain injury and to treat potential secondary complications
rather than focusing on the skull fracture. Skull fractures that
have particular significance include depressed skull fractures,
compound fractures, and pterion fractures.
Depressed skull fractures
In a depressed skull fracture, a bony fragment is depressed
below the normal skull convexity. This may lead to secondary
arterial and venous damage with hematoma formation.
Furthermore, a primary brain injury can also result from this
type of fracture.
Clinical app—cont’d
Compound fractures
In a compound fracture there is a fracture of the bone together
with a breach of the skin, which may allow an infection to enter.
Typically these fractures are associated with scalp lacerations
and can usually be treated with antibiotics.
Pterion fractures
The pterion is an important circular area on the lateral aspect
of the skull where the frontal, parietal, sphenoid, and temporal
bones come together. Importantly, deep to the pterion is the
middle meningeal artery. An injury to this point of the skull is
extremely serious because damage to this vessel may produce
a significant extradural hematoma, which can be fatal.
Surface anatomy
Estimating the position of the middle
meningeal artery
The middle meningeal artery (Fig. 8.17) is a branch of the
maxillary artery in the infratemporal fossa. It enters the skull
through the foramen spinosum and is within the dura mater
lining the cranial cavity.
In lateral blows to the head, the middle meningeal artery
can be ruptured, leading to extradural hemorrhage and eventual
death if not treated.
The anterior branch of the middle meningeal artery is the
part of the vessel most often torn. This branch is in the temple
region of the head, approximately midway between the superior
margin of the orbit and the upper part of the external ear in
what is termed the pterion.
Lateral blows to the head can fracture the internal table
of bone of the skull and tear the middle meningeal artery in
the outer layer of dura mater that is fused to the cranium.
Blood under pulsatile arterial pressure leaks out of the vessel
and gradually separates the dura from the bone, forming a
progressively larger extradural hematoma.
Pterion
Superior
margin
External ear of orbit
Frankfort line
External
acoustic Inferior
meatus margin
of orbit
Fig. 8.17 Estimating the position of the middle meningeal
artery. Lateral head and neck of a man.
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