DIAGNOSTIC AND SURGICAL

IMAGING ANATOMY
BRAIN • HEAD & EeK • SPINE
II
 DIAGNOSTIC AND SURGICAL

IMAGING NATOMY
AIN • HEAD & NECK • SPINE

H. Ric Harnsberger, MD Karen L. Salzman, MD

Professor of Radiology Associate Professor of Radiology
R.C. Willey Chair in Neuroradiology Division of Neuroradiology
University of Utah School of Medicine University of Utah School of Medicine

Anne G. Osborn, MD, FACR Charles R. Carrasco, MD

Distinguished Professor of Radiology Assistant Professor of Radiology
William H. and Patricia W. Child University of Utah School of Medicine
Presidential Endowed Chair in Radiology
University of Utah School of Medicine
Bronwyn E. Hamilton, MD
GE Healthcare Visiting Professor in Diagnostic Imaging
Assistant Professor of Radiology
Armed Forces Institute of Pathology
Oregon Health Sciences University

Jeffrey S. Ross, MD H. Christian Davidson, MD

Staff Neuroradiologist Assistant Professor of Radiology
Head, Radiology Research Vice Chairman, Department of Radiology
Cleveland Clinic Foundation University of Utah School of Medicine

Kevin R. Moore, MD Richard H. Wiggins, MD

Pediatric Neuroradiologist Associate Professor of Radiology
Primary Children's Medical Center Division of Neuroradiology
Adjunct Assistant Professor of Radiology Head and Neck Imaging
University of Utah School of Medicine University of Utah School of Medicine

Managing Editor
Andre J. Macdonald, MBChB
Attending Radiologist, VASalt Lake City Healthcare System
Adjunct Assistant Professor, Radiology
University of Utah School of Medicine

AMIRSYS·
Names you know, content you trust
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 ."
AMIRSYS'"
;.Jamesyou kno\\', cOlltl'nt you trus~

First Edition
Text - Copyright H. Ric Harnsberger MD, Anne G. Osborn MD, Jeff S. Roff MD 2006

Drawings - Copyright Amirsys Inc 2006

Compilation - Copyright Amirsys Inc 2006

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or media
or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from Amirsys lne.

Composition by Amirsys Inc, Salt Lake City, Utah

Printed by Friesens, Altona, Manitoba, Canada

ISBN: 1-9318-8429-3
ISBN: 1-9318-8430-7 (International English Edition)

Notice and Disclaimer

The inforTnation in this product ("Product") is provided as a reference for use by licellsl'o medical professionals and no others. II dOl'S not and should not be construed as any form
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Library of Congress Cataloging-in-Publication Data

Diagnostic and surgical imaging anatomy. Brain, head & neck, spine /
H. Ric Harnsbcrger. [et al.] ; managing editor, Andre Macdonald.
n 1st cd.
p. ; cm.
Includes index.
ISBN 1-931884-29-3 (alk. paper) n ISBN 1-931884-30-7 (Inter-
national cd. alk. paper)
1. Brain--Anatomy--Atlases. 2. Head--AnatomynAtlases. 3. Neck
nAnatomynAtlases. 4. Spine--AnatomynAtlases. 5. Brainnlmaging
nAtlases. 6. Hcad--Imaging--Atlases. 7. Neck--lmagingnAtiascs.
S. Spine--lmaginguAtlases. I. Harnsberger, H. Ric. II. Macdonald,
Andre. III. Title: Imaging anatomy. Brain. head & neck, spine.
IV. Title: Brain. head & neck, spine.
[DNLM: I. Brainnanatomy & histology--Atlases. 2. Head--anatomy
& histologyuAtlases. 3. Magnetic Resonance Spectroscopy--Atlases.
4. Neck--anatomy & histology--Atlases. 5. Spine--anatomy &
histology--Atlasl.:s. 6. Tomography, X-Ray Computed--Atlascs.
WL 17 D536 2006J
QM455.D486 2006
611'.9I dc22
n

2006040720
IV
 This book is dedicated to the busy physician who desires to he anatomically correct in their work but
often lacks ready access to key imaging anatomy reference material. To this intrepid physician group we
offer th~ Diagnostic and Surgical Imaging Anatomy series as all in depth critical imaging anatomy
reference book to assist in your daily work. We hope that easy access to anatomically precise reporting
will take some of the load off your increasingly challenging work days. Enjoy!

H. Ric Harnsberger, MIJ

v
 DIAGNOSTIC AND SURGICAL IMAGING ANATOMY: BRAIN, HEAD & NECK, SPINE

We at Amirsys, together with our distribution colleagues at LWW, are proud to present Dia~llostic alld Sllr~ical 'lIIa~ill~
AllatOl1ll/:Braill Head & Neck Soil/e, the first in a brand·new 3 volume series of anatomy reference titles. All books in the series are
designed specifically to serve clinicians in both medical imaging and the related subspecialty surgeons. We focus on anatomy that
is generally visible on imaging studies, crossing modalities and presenting bulleted single page anatomy descriptions along with a
rich offering of color normal anatomy graphics and in-depth multimodality, multi planar high-resolution imaging.

Each imaging anatomy textbook contains over 2,500 labeled color graphics and radiologic images, with heavy emphasis on
3 Tesla MR and state-of-the-art multi-detector CT. It is designed to give the medical professional rapid answers to imaging
anatomy questions with each normal anatomy sequence providing views of anatomic structures never before seen and discussed
in an anatomy reference textbook. I3raill, /-lead & Neck, Spille is organized into 3 major parts, then further subdivided to reflect
the normal anatomy topics inherent to each major part.

In summary, Dia~l1o.stic (Iud )lI(f?icalll1l(lli!ill~ Anatomv' Brain Head & Neck SO;lle is a product designed with you, the reader, in
mind. Today's typical radiologic or surgical practice settings demand both accuracy and efficiency in image interpretation for
clinical decision-making. We think you'll find this new approach to anatomy a highly efficient and wonderfully rich resource
that will be the core of your reference collection in Brain, Head & Neck and Spine anatomy. Future volumes arriving later in 2006
and 2007 will cover musculoskeletal, chest, abdomen, and pelvis imaging, among other relevant topics.

We hope that you will sit back, dig in, and enjoy seeing anatomy and imaging with a whole different eye.

Anne G. Osborn, MD
Executive Vice President and Editor-ill-Chief, Amirsys lne.

H. Ric Harnsberger, MD
CEO & Chairman, Amirsys Inc.

VII
VIII
 FOREWORD

As freshman medical students in the late 1950's we studied anatomy in the traditional manner with manuals of dissectioll,
cadavers, and no idea of the importance of what we were learning. As radiologists into the 1960's and early 70's, Ollf anatomic
universe was still lwo·dimcnsional, and texts of radiographic anatomy consisted of line drawings highlighting the larger
structures seen on film. Structures were separated into a few categories of density from air to bone with fat and water in between
and contrast material to provide silhouettes.

Sectional imaging changed all of that and has revealed anatomic structures that no one would have dreamed could be
visualized in vivo without a scalpel, let alone in three dimensions. Early on, a few anatomic-radiographic manuals appeared, but
labeling was gross, images were of varying quality, and anatomic comparisons were usually used "with permission" from a
variety of classical anatomic textbooks.

In this volume, which deals with the anatomy of the brain, head and neck, and spine, the Amirsys team, led again by H. Ric
Harnsberger, Anne G. Osborn and Jeff S. Ross, has built on its tradition of brevity of verbiage, uniformity of anatomic drawings
and high quality medical images. The reference anatomic images that accompany CT and MR scans are created to look at
human anatomy il/ tile projections radiologists lise, vistas that Gray, Cunningham, Willis, Galen, Hunter et al. could never have
imagined. What is most unique is the accompanying text organization, which includes the clinical and pathological entities to
consider in a given anatomic area.

As in their previous texts, radiological images are superb and discreetly labeled so as not to intrude on the anatomic lesson.
Images in different planes are often juxtaposed in the manner in which they might be viewed on a PACS station. Correlative
anatomic images are in color, and were created by a team of superb medical illustrators, and often include three dimensional
surface rendered CT images that are almost indistinguishable from a photograph of the anatomic specimen. In fact this book
raises the question of where the boundaries between classical anatomy and medical imaging lie.

With the bulk of diagnoses today being made in the radiology department, this is anatomy for 21 century medicine. This
\1

textbook not only teaches what the radiologist needs to know, but this should become a "bible" for the leaching of anatomy to
medical students. Its title appropriately eliminates reference to "radiological anatomy." It is anatomy for the entire universe of
medical and allied professionals and, as a bonus, will help them understand why they see what they see on those increasingly
important diagnostic images. The only thing missing is the formaldehyde.

Michael S. Huckman, MD
Professor of Radiology
Rush Medical College
Director of Neuroradiology
Rush University Medical Center

IX
x
 PREFACE

When I began my radiology career as a resident at Stanford University, CT was in its infancy and MR wasn't even in our
vocabulary. Neuroimaging was primarily plain film radiographs, cerebral angiography, and (ugh) pneumoencephalography. In
my attempt to [elearn neuroanatomy I discovered a real treasure: a small book, scarcely larger than one of today's paperbacks, by
McClure Wilson that was titled something like "Anatomic Foundations of Neuroradiology." It was prose, mostly text, with
relatively few images and line drawings but it did something no other book did, viz., it put the anatomic foundation firmly
under OUf crude neuroimaging procedures and taught me a principle that still holds true today: at least half of learning
neuroradiology is understanding neuroanatomy.

As CT and then MR became part of our standard ncuroimaging armamentarium, I longed for a new book that would do
for today's radiologists what Dr. Wilson's book did for me. While a number of atlases and other volumes have been published,
nothing has ever come close to the impact his book had on LIS. Until now. H. Ric Harnsberger came up with the idea of building
on our enormously successful Diag-nostic Ima~ing series, using succinct, bulleted text combined with our signature graphics, 31'
MR imaging and MDR CT to create a new series, Diagnostic and Surgical Imagin~ Anatomy. Jeff S. Ross and several of our
favorite co-authors have joined Ric and me in writing the first book in this innovative new series. Brain, llead & Neck, Spine are
combined into a single volume that we believe will help radiologists understand the detailed anatomy that underlies
neuroimaging. Each topic is lavishly illustrated, not only with gorgeous graphics but many series of high-resolution images that
portray the relevant anatomy in many planes.

We hope that this, the first in our series, will do for you what Dr. Wilson's book accomplished for an earlier generation of
radiologists. Sit down, put your feet up, and dig into what we hope will be a veritable imaging feast! You might even keep the
book on YOLir coffee table-the graphics/imaging correlates arc so clear that your family, friends and neighbors can tell at a glance
what it is that you do all day long. Enjoy!

Anne G. Osborn, MD, FACR

Distinguished Professor of Radiology
William H. and Patricia W. Child
Presidential Endowed Chair in Radiology
University of Utah School of Medicine

GE Healthcare Visiting Professor in Diagnostic Imaging

Armed Forces Institute of Pathology
Washington, D.C.

Xt
XII
ACKNOWLEDGMENTS

Illustrations
Lane R. Bennion, MS
Richard Coomb\, MS
James A. Cooper, MD

Image/Text Editing
Melissa A. Iloopes
Kacrli Main

Medical Text Editing

Andre J. Macdonald, MD
Richard II. vViggill\, MD
Karen 1.. Salzman, MD
R. Kenl Sanders, MD
H. Christian Davidson, MD

Case Management
Roth LaFleur
Christopher Odekirk

Project lead
Angie D. Mascarcnaz

XIII
XIV
 SECTIONS

PART I
Brain
Scalp, Skull, Meninges []]
Supratentorial Brain ~
Infratentorial Brain [1]
CSF Spaces [i]
Cranial Nerves [ID
Extracranial Arteries lliJ
Intracranial Arteries [2]
Veins and Venous Sinuses [ill

PART II
Head & Neck
Temporal Bone and Skull Base rn
Orbit, Nose and Sinuses ~
Suprahyoid and Infrahyoid Neck [1]
Oral Cavity [i]

PART III
Spine
Vertebral Column, Discs and Paraspinal Muscle []]
Cord, Meninges and Spaces ~
Vascular [1]
Plexus [i]
Peripheral Nerves [[]
xv
 TABLE OF CONTENTS
Midbrain 1-114
PART I Cha,les R. Carrasco, l\lllJ & KarCl/ L. SalzlI/aIl, MU

Pons 1-120
Brain Clwrles R. Carrasco, M/J & KarCl/ L. SalzlI/aIl, M/J

Medulla 1-128
Charles R. Carrasco, MD & Karell L. SalzlI/all, M/J
Section 1 Cerebellum 1-132
Scalp, Skull and Meninges Charles R. Carrasco, MD & Karell L. SaIZll/{lIl, M/J

Cerebellopontine Angie/lAC 1-140

Scalp and Calvarial Vault 1-2 J-/. IVc J-/afllsherger, M/J
Alllle G. OShOfll, MD

Cranial Meninges 1-8

Alllle G. OShOfll, MD
Section 4
Pia and Perivascular Spaces 1-16 CSF Spaces
Alllle G. OShOfll, M/J
Ventricles and Choroid Plexus 1-148
I3rollWYI1 E. Hamilton, MD
Section 2 Subarachnoid Spaces/Cisterns 1-160
Supratentorial Brain I3rollWYII E. Hmniltoll, MD

Cerebral Hemispheres Overview 1-28

Karen L. Salzl1/alJ, MD
Section 5
White Matter Tracts 1-42 Cranial Nerves
Karen L. 5alzl1Ial1, MD
Cranial Nerves Overview 1-174
Basal Ganglia and Thalamus 1-64 1-1.Ric I-Iafllsherger, MD
Karen L. Snlzf1/nll, MD
CN1 (Olfactory Nerve) 1-186
Limbic System 1-76 1-1.Ric I-Iafllsherger, MD
Karen L. 5alz11Ial1, MD
CN2 (Optic Nerve) 1-190
Sella, Pituitary and Cavernous Sinus 1-86 II. Ric J-/afllsherger, M/J
Broll\vYIl E. Hamilton, MD
CN3 (Oculomotor Nerve) 1-198
Pineal Region 1-98 Ulriel, Rassller, ,vlD & 1-1. Ric I-Iafllshelser, M/J
Hro/llvy" E. I-Iall/iltoll, MU
CN4 (Trochlear Nerve) 1-204
H. Ric Hamsberger, A1D
Section 3 CNS (Trigeminal Nerve) 1-208
Infratentorial Brain N. Ric J-/afllsherger, MD

CN6 (Abducens Nerve) 1-220

Brainstem and Cerebellum Overview 1-104 1-1.Ric l-IafllshergC/; ,vlD
Charles R. Carrasco, tWO & Karell L. Sa!zlII{/11, MD

XVI
CN7 (Facial Nerve) 1-224 Posterior Fossa Veins 1-372
H. Rie I-I"n/suerger, MIJ /11111C G. ChiJUrIl, Ivf/)

CN8 (Vestibulocochlear Nerve) 1-232 Extracranial Veins 1-378

H. Ric H"n/sberger, MIJ Alllle G. O.II}()rII, M/)

CN9 (Glossopharyngeal Nerve) 1-238

MIJ
H. Rie IInrllsberger,

CN10 (Vagus Nerve) 1-244 PART II

H. Rie IIIIn/sUergel; AfI)
Head & Neck
CN11 (Accessory Nerve) 1-250
H. Rie lIn/muerger, MIJ

CN12 (Hypoglossal Nerve) 1-254 Sedion 1

II. Ric 1I0n/suerger, MIJ
Temporal Bone and Skull Base
Sedion 6 Skull Base Overview 11-2
Extracranial Arteries Ilellry I. Illllkill, MIJ & II. Ric IllIr/lSVelger; MD

Anterior Skull Base 11-12

Aortic Arch and Great Vessels 1-262 II. We I-IIIImlJerger, ill/)
AfllIe G. Osuom, 1\.10
Central Skull Base 11-26
Cervical Carotid Arteries 1-266 II. Ric Han/\uerger, MD
Anile G. Os/Jom, MJ)
Posterior Skull Base 11-36
II. llie II"rll\uergel; MIJ

Sedion 7 Temporal Bone 11-46

Intracranial Arteries II. Rie H"n/slmgel; MIJ

Cochlea 11-62
Intracranial Arteries Overview 1-278 II. Rie lI"n/suerger, MI)
Anile G. OslJom, MD
Intratemporal Facial Nerve 11-66
Intracranial Internal Carotid Artery 1-282 II. Rie lI"rllsberger, All)
AI/fie G. Osbom, MU
Middle Ear and Ossicles 11-76
Circle of Willis 1-292 II. Rie IIIIImberger, A/IJ
A//lle G. Osborn, AI/)
Temporomandibular Joint 11-82
Anterior Cerebral Artery 1-298 liicllorr/ II. Wiggills, III MD
Anlle G. O~bomJ A(f)

Middle Cerebral Artery 1-304 Sedion 2

AI/Ile G. Osborn, MD
Orbit, Nose and Sinuses
Posterior Cerebral Artery 1-312
At/lie (;. OsborJ/, MlJ
Orbit Overview 11-90
Vertebrobasilar System 1-322 II. Cl1rht;nll lJOVi(/!}()fl, MO
Afllle G. OsbOnl, MIJ
Bony Orbit and Foramina 11-94
II. Cl1rhtillll Davidsofl, MD

Sedion 8 Optic Nerve/Sheath Complex 11-98

Veins and Venous Sinuses II. CIlri'itiwl Davidsofl, MD

Globe 11-102
Intracranial Venous System 1-334 II. CIlristiUI1/)(/\Iid\O/l, MD

Overview Sinonasal Overview 11-104

Alllle G. OSUOn/, AlflJ liicl/(/rr/ II. Wiggills, III MD

Dural Sinuses 1-342 Ostiomeatal Unit (OMU) 11-114

Alllle (;. Osborn, A41) Ilicl/(/r{111. Wig gills, III MIJ

Superficial Cerebral Veins 1-352 Pterygopalatine Fossa 11-118

AI/lie G. Osha,.", MV llicl/(/rr/ II. lI1iggilll, III MD

Deep Cerebral Veins 1-358

Anile G. Osborll, MlJ

XVII
 ~andible and ~axilla 11-292
Section 3 H. I?ic Hnnlsberger, MD
Suprahyoid and Infrahyoid Neck
Suprahyoid
Overview
and Infrahyoid Neck 11-126 PART III
H. Ric Hanlsberger, M/J Spine
ParapharyngealSpace 11-140
H. Ilic Harl/sberger, MV

Pharyngeal ~ucosal Space 11-148 Section 1

II. Ric Harl/sberger, MV Vertebral Column, Discs &
~asticator Space 11-160 Paraspinal Muscle
II. Ric Harl/slJerger, MD

Parotid Space 11-170 Vertebral Column Overview 111-2

51/(/1/1/01/ E. HOWI/ds, MD & H. llic Hal'llsberger, MD leffrey S. Ross, M 0

Carotid Space 11-180 Ossification 111-10

I-I. Ric HornS/Jerger, MlJ Kev;" R. Moore, 1\10

Retropharyngeal Space 11-186 Vertebral Body and Ligaments 111-26

II. Ric 1-lawsIJerger, MD leftrey S. Ross, M IJ

Perivertebral Space 11-194 Intervertebral Disc & Facet Joints 111-42

I-I. Ric Harl/sberger, MD leftrey S. Ross, M 0
Posterior Cervical Space 11-202 Paraspinal ~uscles III-50
II. Ric Harl/sberger, MD leffrey S. Ross, M IJ

Visceral Space 11-208 Craniocervical Junction III-56

Karel1 L. Sa/ZI//all, MV & H. Ric 1-/a/,//sbetgCl; MD leftrey S. Ross, M IJ

Hypopharynx-Larynx 11-214 Cervical Spine 111-74

Karell L. Sa/ZI//all, MV leftrey S. Ross, M IJ

Thyroid Gland 11-230 Thoracic Spine 111-92

H. Ric Harl/sberger, MV [eftrey s. Ross, MD
Parathyroid Glands 11-238 Lumbar Spine 111-104
H. Ric J-}arl/sberger, MIJ leffrey s. Ross, M IJ

Cervical Trachea and Esophagus 11-244 Sacrum and Coccyx 111-118

Karen L. SalZ1l1ml, MV Jeffrey s. 110.\5, MD

Cervical Lymph Nodes 11-252

Bellja11lill I-I. Gordon, MD & H. Ric Ilnnlsberger, MD
Section 2
Cord, Meninges and Spaces
Section 4
Oral Cavity Spinal Cord and Cauda Equina 111-130
Kevin K Moore, 1\1D

Oral Cavity Overview 11-260 ~eninges and Compartments 111-140

H. Ric Hanlsverger, M/J Kevi" /? Moore, MO

Oral ~ucosal Space 11-268

H. Ric J-}arllsberger, MD
Section 3
Sublingual Space 11-270 Vascular
II. Ilic I-Ia/'//sberger, MIJ

Submandibular Space 11-276 Spinal Arterial Supply 111-152

H. Ric Hanlsberger, MO leftrer S. Ross, M IJ
Tongue 11-282 Spinal Veins and Venous Plexus 111-162
H. Ric Harllsberge,; MD leffre)' S. Ross, M IJ
Retromolar Trigone 11-288
I I. Ric Harl/sberger, MIJ

XVIII
 Section 4
Plexus
Brachial Plexus 111-172
Kevin R. Moore, MD

Lumbar Plexus 111-180

Kevin R. Moore, MD

Sacral Plexus and Sciatic Nerve 111-186

Kevin R. Moore, MD

Section 5
Peripheral Nerves
Peripheral Nerve Overview 111-194
Kevin R. Moore, MD

Radial Nerve 111-200

Kevin R. Moore, MD

Ulnar Nerve 111-204

Kevin R. Moore, MD

Median Nerve 111-210

Kevin R. Moore, MD

Femoral Nerve 111-216

Kevin R. Moore, MD

Common Peroneal/Tibial Nerves 111-222

Kevin R. Moore, MD

XIX
xx
 ABBREVIATIONS

Brain CPA: Cerebellopontine angle

AA: Aortic arch CS: Cavernous sinus

ACA: Anterior cerebral artery CSF: Cerebrospinal fluid

AChoA: Anterior choroidal artery dAVF: Dural arteriovenous fistula

ACoA: Anterior communicating artery DMCV: Deep middle cerebral vein

AH: Adenohypophysis ECA: External carotid artery

alCA: Aberrant lCA EDS: Extradural space

AlCA: Anterior inferior cerebellar artery GP: Globus pallidus

APMV: Anterior pontomesencephalic vein/venous plexus lAC: Internal auditory canal

BA: Basilar artery ICA: Internal carotid artery

BCT: Brachiocephalic trunk ICV: Internal cerebral vein

BG: Basal ganglia IJV: Internal jugular vein

BVR: Basal vein of Rosenthal IPS: Inferior petrosal sinuses

CCA: Common carotid artery ISF: Interstitial fluid

CC: Corpus callosum ISS: Inferior sagittal sinus

CHD: Congenital heart disease IVN: Inferior vestibular nerve

CN: Cranial nerve IVV: Inferior vermian vein

CNl: Olfactory nerve LAO: Left anterior oblique

CN2: Optic nerve LCCA: Left common carotid artery

CN3: Oculomotor nerve LSCA: Left subclavian artery

CN4: Trochlear nerve MCA: Middle cerebral artery

CNS: Trigeminal nerve MHT: Meningohypophyseal trunk

CN6: Abducens nerve MLF: Medial longitudinal fasciculus

CN?: I:acial nerve MMA: Middle meningeal artery

CN8: Vestibulocochlear nerve NH: eurohypophysis

CN9: Glossopharyngeal nerve OA: Ophthalmic artery

CNIO: Vagus nerve PCA: Posterior cerebral artery

CN11: Accessory nerve PCoA: Posterior communicating artery

CN12: Hypoglossal nerve PCV: Precentral cerebellar vein

COW: Circle of Willis PICA: Posterior inferior cerebellar artery

XXI
 PVS: Perivascular space DS: Danger space
RCCA: Right common carotid artery EAC: External auditory canal

RAH: Recurrent artery of Heubner ECA: External carotid artery

RSCA: Right subclavian artery EOM: Extra-ocular muscles

SAS: Subarachnoid space FOM: Floor of mouth

SCA: Superior cerebellar artery FL: Frontal lobe

SDS: Subdural space FO: Foramen ovale

SHN: Suprahyoid neck FR: Foramen rotundum

SMCV: Superficial middle cerebral vein FS: Foramen spinosum

SNHL: Sensorineural hearing loss FVC: False vocal cord

SOF: Superior orbital fissure GWS: Greater wing of sphenoid

SPS: Superior petrosal sinuses lAC: Internal auditory canal

SS: Straight sinus ICA: Internal carotid artery

SSS: Superior sagittal sinus IE: Inner ear

SV: Septal vein IHN: Infrahyoid neck

SVN: Superior vestibular nerve IJC: Internal jugular (nodal) chain

SVV: Superior vermian vein IJV: Internal jugular vein

TS: Transverse sinus 101': Inferior orbital fissure

TSV: Thalamostriate vein 10V: Inferior ophthalmic vein

VA: Vertebral artery JF: Jugular foramen

VB: Vertebrobasilar LWS: Lesser wing of sphenoid

VofG: Vein of Galen Md: Mandible

VoIT: Vein of Trolard ME: Middle ear

VRS: Virchow-Robin spaces ME-M: Middle ear-mastoid

ML-DCF: Middle layer, deep cervical fascia

Head & Neck MS: Masticator space

ACS: Anterior cervical space MSG: Minor salivary glands

ASB: Anterior skull base Mx: Maxilla

BS: Buccal space OA: Ophthalmic artery
CCA: Common carotid artery OMC: Ostiomeatal complex

CG: Crista galli OMS: Oral mucosal space/surface

CN: Cranial nerve OMU: Ostiomeatal unit

CPo Cribriform plate ONSC: Optic nerve-sheath complex

CPA: Cerebellopontine angle OphA: Ophthalmic artery

CS: Carotid space OC: Oral cavity

CSB: Central skull base OpC: Optic canal

CSF: Cerebrospinal fluid PA: Petrous apex

DL-DCF: Deep layer, deep cervical fascia

XXII
PCA: Posterior cerebral artery Spine
PCS: Posterior cervical space AA: Atlanto-axial

PNT: Perineural tumor ADI: Atlanto-dental interval

PMR: Pterygomandibular raphe AIN: Anterior interosseous nerve

PMS: Pharyngeal mucosal space ALL: Anterior longitudinal ligament

PPF: Pterygopalatine fossa AM: Arachnoid matter

PPS: Para pharyngeal space AO: Atlanto-occipital

PS: Parotid space ASA: Anterior spinal artery

PSB: Posterior skull base ATP: Adenosine triphosphate

PTG: Parathyroid gland BA: Basilar artery

PTH: Parathormone BP: Brachial plexus

PVS: Perivertebral space CCJ: Craniocervical junction

REZ: Root entry zone CE: Cauda equina

RMT: Retromolar trigone CTS: Carpal tunnel syndrome

ROT: Root of tongue CSF: Cerebrospinal fluid

RPS: Retropharyngeal space CN: Cranial nerve

SAC: Spinal accessory (nodal) chain CPN: Common peroneal nerve

SAN: Spinal accessory nodes CV: Costovertebral

SAS: Subarachnoid space DL: Denticulate ligament

SB: Skull base OM: Dura matter

SCA: Superior cerebral artery DPR: Dorsal primary ramus
SCCa: Squamous cell carcinoma DRG: Dorsal root ganglion
SER: Sphenoethmoidal recess EDNAC: Extradural neural axis compartment

SHN: Suprahyoid neck EOI': External occipital protuberance

SL-DCF: Superficial layer, deep cervical fascia FCU: Flexor carpi ulnaris

SLS: Sublingual space FN: Femoral nerve

SMS: Submandibular space IJV: Internal jugular vein

SN: Sinonasal IVC: Inferior vena cava

SNHL: Sensorineural hearing loss LN: Ligamentum nuchae

SOF: Superior orbital fissure Lf>:Lumbar plexus
SOY: Superior ophthalmic vein LS: Lumbosacral
TEG: Tracheoesophageal groove LSP: Lumbosacral plexus

TG: Trigeminal ganglion LST: Lumbosacral trunk

TMJ: Temporomandibular joint mm: Muscles

TVC: True vocal cord MCf>: Metacarpal phalangeal joint

VC: Vidian canal MN: Median nerve

VS: Visceral space OC: Occipital condyle

PIN: Posterior interosseous nerve

XXlll
 PLL: Posterior longitudinal ligament
PM: Pia matter
PNS: Peripheral nervous system
PSP: Posterior spinal arteries
RN: Radial nerve

RTS: Radial tunnel syndrome

SAS: Subarachnoid spaces

SC: Spinal cord
SI: Sacroiliac
SN: Sciatic nerve

SP: Spinous process

SVC: Superior vena cava

TN: Tibial nerve

TP: Transverse process

UN: Ulnar nerve

VA: Vertebral artery

VPR: Ventral primary ramus
VVP: Vertebral venous plexus
VVS: Vertebral venous system

XXIV
xxv
XXVI
 DIAGNOSTIC AND SURGICAL
IMAGING NAlUMY
BRAIN • HEAD & NECK • SPINE

XXVII
 PART I
Brain

Scalp, Skull and Meninges

Supratentorial Brain

Infratentorial Brain

CSF Spaces

Cranial Nerves

Extracranial Arteries

Intracranial Arteries
Veins and Venous Sinuses
SECTION 1: Scalp, Skull and Meninges

Scalp and Calvarial Vault 1-2

Cranial Meninges 1-8
Pia and Perivascular Spaces 1-16
 -----------------------;-,----,--------~
SCALP AND CALVARIAL VAULT
ITerminology • Frontal bones often appear thickened,
hyperostotic (especially in older females)
Definitions o Parietal bones
• Bregma: Meeting of sagittal, coronal sutures (anterior • Areas of parietal thinning, granular foveolae (for
fontanelle in neonates) arachnoid granulations) common adjacent to
• Lambda: Meeting of sagittal, lambdoid sutures (site of sagittal su~re
posterior fontanelle in neonates) • Inner tables often slightly irregular (convolutional
• Pterion markings caused by gyri), grooved by paired
o "H-shaped" junction between frontal, parietal bones middle meningeal arteries + vein
plus greater sphenoid wing, squamous temporal o Occipital bone
bone • Deeply grooved by superior sagittal, transverse
o Site of anterolateral, i.e., sphenoidal, fontanelle sinuses
• Internal occipital protuberance marks sinus
confluence (torcular Herophili)
I Gross Anatomy o Temporal bones
• Thin, inner surface grooved by middle meningeal
Overview vessels
• Scalp • Outer surface grooved by superficial temporal
o Scalp has five layers artery
• Skin (epidermis, dermis, hair, sebaceous glands)
• Subcutaneous tissue (very vascular fibro-adipose
tissue) IAnatomy-Based Imaging Issues
• Epicranial tissue (scalp muscles, galea
aponeurotica) Imaging Recommendations
• Subaponeurotic tissue (loose areolar connective • Skull radiographs limited utility for evaluating
tissue) calvarium, skull base
• Pericranium (periosteum of skull) • Bone algorithm (not just soft tissue algorithm with
• Skull (28 separate bones, mostly connected by fibrous bone windows) recommended, should be routine on
sutures) all head CT scans
o Cranium has several parts • 3D volume-rendered NECT excellent for overall
• Calvarial vault calvarial anatomy, suspected craniosynostosis
• Cranial base • Contrast-enhanced fat suppressed MR excellent for
• Facial skeleton suspected calvarial, dural lesions
o Calvarial vault composed of several bones Imaging Pitfalls
• Frontal bone
• Most common cause of "thick skull" is normal variant
• Paired parietal bones
• Striking hyperostosis, especially of frontal bone,
• Squamous occipital bone
common in older females
• Paired squamous temporal bones .
• Areas of calvarial thinning, lucencies (foramina,
o Three major serrated fibrous joints (sutures) connect
vascular grooves, diploic venous lakes) are normal
bones of vault
(should not be mistaken for osteolytic metastases)
• Coronal suture
• Vascular grooves are corticated, usually less distinct
• Sagittal suture
than acute linear skull fracture
• Lambdoid suture
o Outer, inner tables
• Two thin plates of compact cortical bone
• Separated by diploic space (cancellous bone
I Embryology
containing marrow) Embryologic Events
o Endocranial surface • Skull base formed from endochondral ossification
• Lined by outer (periosteal) layer of dura • Calvarial vault forms via membranous ossification
• Grooved by vascular furrows o Curved mesenchymal plates appear at day 30
• May have areas of focal thinning (arachnoid o Extend towards each other, skull base
granulations), foramina (emissary veins) o As paired bones meet in midline, metopic and
sagittal sutures are induced (coronal suture is
present from onset of ossification)
I Imaging Anatomy o Unossified centers at edges of parietal bone form
Overview fontanelles
o Vault grows rapidly in first postnatal year
• Scalp largely high signal (fat) on Tl WI
• If separate ossification center develops, "sutural"
• Calvarium low signal outer/inner tables; diploic space
bone forms
filled with fatty marrow, usually high signal on Tl WI
o Frontal bones
• Frontal sinuses show wide variation in aeration

2
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ro
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ro
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I
3
 SCALP AND CALVARIAL VAULT
<Jl
<J) AXIAL NECT
be
c Ethmoid bone
Frontal bone
c
<J)
~
""0
Greater wing of sphenoid bone
c
C\l
Sphenoid sinus Sphenosquamosal suture

Clivus

Petrous temporal bone Petrooccipital suture

Mastoid process
Occipitomastoid suture
Occipital bone

Frontal bone
Crista galli

Greater wing sphenoid bone Anterior cranial fossa

Squamosal suture
Anterior clinoid process
Middle cranial fossa
Squamous temporal bone
Petrous apex

Posterior cranial fossa

Lambdoid suture

Occipital bone Internal occipital protuberance

Skin
Frontal bone
Subcutaneous fibroadipose tissue
Coronal suture

Temporalis muscle
Squamosal suture

Squamous temporal bone

Squamosal suture
Parietal bone Parietal bone

Occipital bone Lambdoid suture

(Top) Five sequential axial NECT images from presented inferior to superior through skull base, calvarium, are
depicted. Section through skull base shows major bones, sutures forming skull base. Sphenosquamosal,
petrooccipital, occipitomastoid sutures are normally well seen and should not be confused with fractures. (Middle)
Section through upper skull base shows anterior, middle and posterior cranial fossae as well as formation of lower
vault by frontal, greater wing sphenoid, squamous temporal and occipital bones. (Bottom) Section through lower
calvarial vault showing antero-posterior linear configuration of squamosal suture, not to be confused with a fracture.
Major bones forming vault are frontal, parietal, and occipital bones which are now all visible.

4
 SCALP AND CALVARIAL VAULT
AXIAL NECT & SAGITTAL T1 MR

Frontal bone Skin

Subcutaneous fibro-adipose
layer
Outer table
Coronal suture Diploic space
Temporalis muscle Inner table

Parietal bone

Lambdoid suture
Occipital bone

Bregma Coronal suture

Sagittal suture

Parietal bone

Lambda

Lambdoid suture

Skin (epidermis) Dermis

Subcutaneous fibro-adipose
Dura, superior sagittal sinus tissue

Outer table of calvarium

Diploic space

Inner table
Frontalis muscle

(Top) Section through vault shows the frontal, parietal and occipital bones separated by coronal and lambdoid
sutures. The calvarium consists of compact bone forming the external and inner tables with interposed diploic space.
(Middle) Section through upper vault shows coronal, sagittal and lambdoid sutures separating frontal, parietal and
occipital bones. The junction between the coronal and sagittal sutures is the bregma. Sagittal and lambdoid sutures
meet at the lambda. (Bottom) Sagittal Tl MR volume acquisition with 1 mm sections shows details of the scalp and
calvarial vault. The skin (epidermis, dermis) and subcutaneous fatty tissue can be distinguished. Marrow-bearing
diploic space is contained between the hypointense outer/inner tables. The image is of an eight year old child and
the hemopoietic marrow is hypointense. In adults it is hyperintense on Tl. I
5
6
7
 CRANIAL MENINGES
ITerminology
Abbreviations
• Extradural space (EDS)
• Subdural space (SDS)
• Subarachnoid space (SAS)
• Subpial space (SPS)
• Perivascular space (PVS)
• Interstitial fluid (ISF)
• Cerebrospinal fluid (CSF)
• Internal carotid artery (ICA)
• External carotid artery (ECA)
Definitions
• Pachymeninges: Dura
• Leptomeninges: Arachnoid, pia
• EDS: Potential space between dura, skull; seen only in
pathologic conditions (infection, hematoma, etc.)
• SDS: Potential space between inner dura, arachnoid;
seen only in pathologic conditions
• SAS: Normal CSF-filled space between arachnoid,
pial-covered brain
• SPS: Potential space between pia, glia limitans of
cortex
• PVS: Pial-lined, ISF-filled invagination along
penetrating arteries
I Gross Anatomy
Overview
• Brain encased by three meninges
o Dura
• Dense fibrocollagenous sheet
• Two layers (outer/periosteal, inner/meningeal)
• Closely adherent except where separate to enclose
venous sinus
• Outer layer forms periosteum of inner calvarium
• Inner layer folds inward (forming falx cerebri,
tentorium cerebelli, etc.), also continues
extracranially (into orbit, through foramen
magnum into spinal canal)
• At other foramina, meningeal dura fuses with
epineurium of cranial/peripheral nerves,
adventitia of carotid/vertebral arteries
• Blood supply from numerous dural vessels
(middle, accessory meningeal arteries;
cavernous/tentorial branches of ICA; posterior
meningeal branches of vertebral artery;
transosseous meningeal branches of ECA, etc.),
many with extensive extra/intracranial
anastomoses
• Dura tightly adherent to skull at sutural
attachments
o Arachnoid
• Thin, nearly transparent
• Outer surface loosely adherent to dura, easily
separated
• Arachnoid follows dura, does not invaginate into
sulci
• SAS lies between arachnoid, pia and is traversed by
sheet-like bridging trabeculae
8
• Arachnoid villi/granulations = endothelial-lined
extensions of arachnoid + SAS into dural sinus
o Pia
• Innermost layer of leptomeninges
• Covers brain, invaginates into sulci
• Follows penetrating cortical arteries into brain,
forming PVSs (Virchow-Robin spaces)
I Imaging Anatomy
Overview
• Dura
o Capillaries lack endothelial tight junctions so
macromolecules (e.g., contrast agents) easily leak
into dura
o Dura enhances normally on CECT, T1 c+ scans
• Should be smooth, 1-2 mm thick
• Most prominent near vertex, least prominent
under temporal lobes
• Enhancing segments appear discontinuous on
l.ST but typically well seen on 3T as continuous
curvilinear enhancement that hugs inner
calvarium
• Arachnoid
o Normally not seen
o Pathologic processes typically affect both dura,
arachnoid which become involved/thickened
together and are indistinguishable on imaging
o Arachnoid granulations seen as round/ovoid areas of
CSF density/signal intensity that project into dural
venous sinus (most typically in transverse/sigmoid
sinuses)
o Trabeculae/vessels that bridge SAS occasionally seen
on 3T T2WI or if they become pathologically
enlarged (e.g., in Sturge-Weber syndrome)
• Pia normally not seen on imaging but perivascular
spaces often normally seen as linear/ovoid CSF areas in
basal ganglia around anterior commissure, basal
ganglia, midbrain, deep cerebral white matter
IAnatomy-Based Imaging Issues
Imaging Recommendations
• T1 c+ scans in both axial, coronal planes
Imaging Pitfalls
• "Giant" arachnoid granulations (up to 1-2 cm) may
occur as normal variant in dural venous sinuses;
should not be mistaken for thrombus
• Veins in, around tentorium may appear quite
prominent on CECT, T1 C+ scans; should not be
mistaken for dAVF
I
9
 CRANIAL MENINGES
AXIAL T1 C+ MK 00
"""l
Pol
:::J
Superior ophthalmic vein

Meningeal dural layer passing into Dura (normal enhancement)

optic canal Diaphragma sellae
Intercavernous venous sinus Pontine venous plexus (NOT
Pol
pia) :::::l
0-
~
(t)
Tentorium cerebelli, tentorial veins :::::l
Transverse sinus
:::::l
OQ
(t)
(fl

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•
,
,
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•
, /'
,
I

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4 ,

Sinus confluence Arachnoid granulation

Dura (normal enhancement)

Falx cerebri

Superficial middle cerebral vein

Dura

Apex of tentorium cerebelli Superficial cortical vein

Straight sinus

Superior sagittal sinus

(Top) A series of six selected axial Tl C+ MR images through brain from inferior to superior shows normal meningeal
enhancement at l.ST. Unlike arachnoid microvessels, dural microvessels lack capillary endothelial tight junctions.
Dural enhancement is therefore normal following contrast administration. (Middle) The outer and inner dural layers
adhere to each other, except where encase dural venous sinuses. Venous flow in sinuses is relatively slow so strong
enhancement is normal. A small arachnoid granulation is present, seen here as a CSF-intensity filling defect within
the strongly enhancing sinus confluence. (Bottom) The falx cerebri encases the superior and inferior sagittal sinuses
at its upper and lower margins respectively. The V-shaped tentorial apex is seen very well on this image. Note
inhomogeneous signal within the superior sagittal sinus, a normal finding.
11
 CRANIAL MENINGES
tJ)
Q) AXIAL T1 C+ MR
be - Frontal cortical vein
c
c Dura (normal enhancement) -
Q)

~
""0

C
(\j

- Dura

Superior sagittal sinus -

Falx cerebri -

- Inferior sagittal sinus

Dura (normal enhancement) -

Falx cerebri -

- Superficial cortical veins

Vein of Trolard -

- Superior sagittal sinus

(Top) Normal dural enhancement is thin, smooth, discontinuous and symmetric (best appreciated on coronal
sections). Enhancing superficial cortical veins travel within subarachnoid space before traversing potential subdural
space to drain into dural sinuses. Superficial cortical veins are typically seen as thicker, more strongly enhancing
structures that branch and communicate with draining tributaries extending into sulci. (Middle) Section through the
centrum semiovale shows the falx cerebri with a prominent inferior sagittal sinus arcing above the corpus callosum.
(Bottom) Scan through the vertex shows the triangular-shaped superIor sagittal sinus, which is larger posteriorly
than anteriorly. The anastomotic vein of Trolard is seen here as it courses superiorly from the sylvian fissure towards
the superior sagittal sinus.
12
 CRANIAL MENINGES
CORONAL T1 C+ MR

Superior sagittal sinus & apex

of falx cerebri
Dural enhancement
Superficial cortical vein

l/1
A
C

Paired internal cerebral veins

Tentorium cerebelli

Superior sagittal sinus

Dura mater

Falx cerebri

Falx cerebri Dura

Superficial cortical vein

Cavernous sinus

(Top) First of three coronal Tl C+ MR images from posterior to anterior shows normal dural enhancement at l.ST
following contrast administration. At this field strength, dura is thickest near the superior sagittal sinus and typically
appears discontinuous as it sweeps inferiorly. Arachnoid microvessels have tight junctions and are part of
blood-brain barrier which normally does not enhance. (Middle) Normal dural enhancement is thin, smooth, and
discontinuous. Enhancement is less intense than adjacent dural venous sinuses. The falx cerebri and tentorium
cerebelli are dural reflections and therefore also normally enhance. (Bottom) Dural enhancement is most prominent
near vertex, least striking around and under the temporal lobes. Note that dural enhancement is less intense than the
cavernous sinus.
13
 CRANIAL MENINGES
CORONAL T2 MR

Superior sagittal sinus Superficial cortical vein

Sinus confluence

Superior sagittal sinus Vein of Trolard

Falx cerebri

Straight sinus
Tentorium cerebelli

Transverse sinus

Superior sagittal sinus

Scalp
Cortical vein in subarachnoid space
Falx cerebri

Tentorium cerebelli

(Top) First of six coronal T2 MR images from posterior to anterior obtained at 3T shows details of the dura and
cortical veins as they drain into the superior sagittal sinus. (Middle) Section through the straight sinus shows its
enclosure by leaves of the falx and tentorium cerebelli. The tentorium sweeps superiorly from the tops of the petrous
ridges and transverse sinuses to meet the falx cerebri in the midline and form the straight sinus. (Bottom) The
hypointense outer dura and inner table of the skull are indistinguishable but reflections of the inner (meningeal)
dural layer as it forms the falx cerebri and tentorium cerebelli are easily seen here.

14
 CRANIAL MENINGES
CORONAL T2 MR
Superior sagittal sinus
Trabeculae in subarachnoid
space
Falx cerebri

Sylvian (lateral cerebral) fissure

Tentorium cere belli

Falx cerebri

Perivascular spaces

Lateral wall, cavernous sinus

Dura

Superior sagittal sinus

Falx cerebri

Crista galli

(Top) The tentorial incisura is seen here between the two leaves of the tentorium and transmits the midbrain and
basilar artery. (Middle) Several perivascular spaces are seen here as linear areas of high signal intensity within the
centrum semiovale. Pia invaginates along penetrating vessels, forming the PVSswhich contain interstitial fluid.
(Bottom) Section through the frontal lobes demonstrates attachment of the falx cerebri to the crista galli. The
superior sagittal sinus is seen here and appears much smaller than on more posterior sections. The pia covering the
cortex is not distinguishable, even on these high-resolution 3T images.

15
 PIA AND PERIVASCULAR SPACES
ITerminology
Abbreviations
• Perivascular spaces (PVSs)
• Subarachnoid space (SAS)
• Cerebrospinal fluid (CSF)
• Interstitial fluid (ISF)
Synonyms
• Virchow-Robin spaces (VRSs)
Definitions
• Pial-lined, ISF-filled structures that accompany vessels
entering (penetrating arteries) or leaving (draining
veins) cerebral cortex
I Gross Anatomy
Overview
• Leptomeninges: 'Thin" meninges (arachnoid, pia)
o Arachnoid: Translucent sheet of tissue loosely
adherent to inner surface of meningeal layer of dura
o Pia: Innermost layer of meninges consisting of thin
sheet (one or two cells thick) covering brain surface
• Pial cells form anatomic barrier between SAS,
brain
• Pia functions as regulatory interface between SAS,
brain (exhibit pinocytosis, enzymatic activity)
• SAS
o CSF-filled space contained between arachnoid (outer
wall), pia (inner wall)
o Contains traversing arteries, veins
o Numerous sheet-like filiform trabeculae extend
across SAS from arachnoid to pia, forming bridging
chordae coated by leptomeningeal cells that are
continuous with pia, inner arachnoid
• PVSs
o Accompany small, medium-sized arteries as they
penetrate brain parenchyma
o Flattened layer of pial cells invaginates along
penetrating arteries
• Basal ganglia, midbrain PVSs contain double layer
of pia so PVSs are "interpial" space
• Cortex, white matter PVSs lined by single pial
layer so PVS is between adventitia, pia
• PVSs inapparent as pass through cortex, become
larger in subcortical white matter
• Pia becomes fenestrated, then disappears at
capillary level
o PVSs are filled with ISI'; not CSF
• PVSs may drain ISF along periarterial
compartments, functionally bypassing SAS
o Most PVSs are) -2 mm but can become very large
o Immunocompetent lymphocytes, monocytes enter
brain through postcapillary venule walls into
perivenular spaces
• Perivenular spaces have discontinuous groups of
pial cells, not complete pial sheath
16
I Imaging Anatomy
Overview
• PVSs found in all parts of the brain
o Most common locations
• Around anterior commissure
• Inferior 1/3 of basal ganglia
• Anterior perforated substance
• Hemispheric white matter (centrum semiovale)
• Midbrain (around substantia nigra)
o Other locations
• Extreme capsule
• Subinsular white matter
• Dentate nuclei
• PVSs occur at all ages, although
prominence/prevalence t with age
• Seen commonly at 1.5'1', almost universally on 3'1' MR
o Usually 5 mm or less in size but can be up to 2-J cm
as normal variant
o Appear as round, ovoid or linear (depending on
orientation of PVSs to plane of section)
• Usually suppress completely on FLAIR (251M, have
small hyperintense rim)
• Do not enhance (sometimes linear enhancement
of central vessel can be seen)
• Typically not seen as pass through cortex, only
become visible as enter subcortical white matter
• Isointense with CSF on all sequences
Anatomy Relationships
• Pia invaginates along small/medium-sized arteries as
they penetrate brain and creates the PVSs
• Pia separates SAS from brain parenchyma
Internal Structures-Critical Contents
• PVSs are filled with interstitial fluid (not CSF)
Normal Variants, Anomalies
• Giant ("tumefactive") PVSs may cause mass effect,
obstructive hydrocephalus, mimic neoplasm
o Typically occur as clusters of variable-sized CSF-like
cysts
o Suppress on FLAIR, don't enhance
• Widespread enlarged PVSs in cerebral white matter
may appear bizarre but is extreme normal variant,
usually asymptomatic
IAnatomy-Based Imaging Issues
Imaging Recommendations
• FLAIR sequence helpful in distinguishing PVS from
lacunar infarct
Imaging Pitfalls
• Prominent PVSs in subinsular white matter, temporal
lobes common; should not be mistaken for
demyelinating/dysmyelinating disorders
• PVSs do not communicate with SAS (even when
extensive, subarachnoid hemorrhage does not enter
PVSs)
17
18
 PIA AND PERIVASCULAR SPACES
AXIAL T2 MR CO
~
~
::J
Vl
()
Perivascular spaces
Perivascular spaces OJ
-0
Vl
A
C

CSF in partially fused

hippocampal sulcus
PVSs in midbrain

PVSs in subcortical white

matter

PVSs in subinsular white matter

PVSs surrounding lateral
Anterior commissure
lenticulostriate arteries

PVSs in subcortical white matter

(Top) First of six 3T axial T2 MR images from inferior to superior demonstrate normal appearance of perivascular
spaces (PVS) in a middle-aged patient. This section shows prominent PVSs in the subcortical white matter of both
temporal lobes, a common location. Note that even at 3T, the PVSs are not seen as they pass through the cortex and
only become apparent once they reach the subcortical white matter. (Middle) PVSs are seen here in the midbrain
and white matter of the temporal lobes. The larger high signal collections just medial to the temporal lobes represent
CSF in a partially fused hippocampal sulcus, a normal congenital variant, and should not be mistaken for PVSs or
lacunar infarcts. (Bottom) PVSs are most common along the anterior commissure, clustered in the inferior third of
the basal ganglia. The subinsular region is another common normal site.
19
 PIA AND PERIVASCULAR SPACES
Qj AXIAL T2 MR
b.O
c
C
Q.)

~
-0 PVSsin extreme capsule
C PVSsin extreme capsule
ro PVSsin external capsule
PVSsin globus pallidus

Deep white matter PVSs

Perivascular spaces Enlarged (but normal) PVS

Perivascular spaces in centrum

semiovale

(Top) Section through the third ventricle and insular regions shows unusually prominent but normal PVSs in the
subinsular white matter (extreme capsule). A few "dot-like" PVSs are seen end-on here in the globi pallidi. PVSs in the
deep white matter of the posterior temporal and occipital lobes appear mostly linear at this level. (Middle) PVSs are
commonly seen in the corona radiata and centrum semiovale and may normally be quite prominent, as in this
patient. At the midventricular level, most are seen as linear streaks of CSF signal intensityl(although they are filled
with interstitial fluid, not CSF). On FLAIR (not shown), these would suppress completely. Some PVSs may appear
larger but are still normal. (Bottom) Close-up view shows PVSs in the deep white matter are seen as either linear or
dot-like or ovoid, depending on orientation within the plane of section.
20
 PIA AND PERIVASCULAR SPACES
CORONAL T2 MR

PVSs in centrum semiovale

(j)
7\
C

PVSs in subinsular white matter PVS in basal ganglia

Subcortical PVSs

PVSs in centrum semiovale

PVSs in subinsular white matter

PVSs in inferior basal ganglia

Anterior commissure
PVS along penetrating
lenticulostriate artery

PVSs surrounding lateral PVSs in subcortical white

lenticulostriate arteries matter

(Top) First of six 3T coronal T2 MR images from posterior to anterior demonstrate normal appearance of PVS in a
young patient. (Middle) Relatively few linear-appearing PVSs are seen in the subcortical and deep white matter here
but can be detected on careful examination. More prominent PVSsare seen in the inferior basal ganglia and
infralenticular internal capsule. (Bottom) PVSs often occur in clusters, especially in the inferior basal ganglia and
around the anterior commissure. Sometimes they can be seen following a penetrating artery along nearly its entire
course.

21
 PIA AND PERIVASCULAR SPACES
CORONAL T2 MR

PVSs in subcortical white

matter

PVS in centrum semi ova Ie

PVSs in extreme capsule

PVSs in subinsular region (subinsular white matter)

PVSs, lateral lenticulostriate arteries

in anterior perforated substance

PVSs in centrum semiovale

PVSs in subinsular white matter

Choroid fissure cyst

(Top) A double layer of pia accompanies penetrating arteries (here the lateral lenticulostriate arteries) as they pass
cephalad through the anterior perforated substance into the basal ganglia, seen especially well in this section. PVSsin
the basal ganglia and midbrain are contained within the two pial layers. (Middle) Relatively fewer PVSs are seen as
sections include basal ganglia in front of the anterior commissure. PVSs are still seen in the centrum semiovale in this
image. (Bottom) A single, somewhat prominent collection of CSF is seen above the temporal horn, possibly a small
choroid fissure cyst. Numerous smaller PVSsare seen as dots and linear streaks of high signal intensity in white
matter of the deep temporal lobe and in the subinsular regions.

22
 PIA AND PERIVASCULAR SPACES
SAGITTAL T1, AXIAL T2, AXIAL FLAIR MR

PVSs along penetrating arteries

Perivascular space

Anterior commissure

Enlarged (normal) PVS

Cluster of PVSs in inferior basal
ganglia

CSF in quadrigeminal cistern

PVSs

Enlarged (normal) PVS

(Top) These three images compare normal signal intensity of PVSs on MR. Sagittal TI MR image through an enlarged
perivascular space demonstrates hypointense fluid signal that is virtually identical to CSF even though it is interstitial
fluid. Also note linear penetrating arteries radiating from superior margin of perivascular space. (Middle) Axial T2 f
MR image shows the enlarged PVS has hyperintense signal similar to CSF in the quadrigeminal cistern and third
ventricle. Multiple other smaller perivascular spaces are seen in in the inferior basal ganglia around the anterior
commissure and in the subinsular white matter. (Bottom) Axial FLAIRimage shows suppression of fluid signal
within perivascular spaces with normal signal in surrounding brain parenchyma. A thin hyperintense rim can
sometimes be seen around the PVSs and is a normal finding. I
23
 PIA AND PERIVASCULAR SPACES
(f)
Q) CORONAL T2, AXIAL T2, AXIAL FLAIR MR
0.0
c
c
Q)

~
""0

c
<i:l

PVSs in deep white matter

PVSs in dentate nuclei

PVSs in centrum semiovale

Gliosis around PVSs

(Top) MR scans of variant perivascular spaces are illustrated in this and the following images. Coronal T2WI in an 8
year old male shows a cluster of CSF-like cysts in the left dentate nucleus. Originally called a low grade cystic
neoplasm, these are simply prominent PVSs. They suppressed completely on FLAIRand did not enhance. (Middle)
Axial T2 MR shows bilateral subcortical and deep white matter cysts with CSF-like signal intensity. Note focal
expansion of cortex over the more superficial cysts. Patient was middle-aged, asymptomatic. (Bottom) FLAIRMR
scan in same case shows fluid in cysts suppresses completely. A few areas of increased signal intensity surround some
of the enlarged PVSs, a finding seen in approximately 25% of cases that may represent mild adjacent spongiosis. This
is an example of unusually enlarged PVSs that are extreme variants of normal.
24
 PIA AND PERIVASCULAR SPACES
CORONAL T1, AXIAL T2, AXIAL T1 C+ MR

Obstructive hydrocephalus

(fl
A
C
Enlarged PVSs

Aqueduct stenosis

Enlarged PVSs expand left

Normal PVSs in right cerebral cerebral peduncle
peduncle
Obstructive hydrocephalus

Enlarged PVSs in expanded

peduncle

(Top) Coronal Tl MR of a middle-aged patient with headaches demonstrates numerous CSF-like cysts in the
midbrain and thalami causing local mass effect, aqueduct obstruction, and hydrocephalus. This image shows that the
cysts are variable in size. (Middle) Axial T2 MR shows the cysts, enlarged PVSs, expand the left cerebral peduncle.
Prominent midbrain PVSsoccur in many patients but this degree of enlargement and mass effect is atypical. The
PVSsin the right cerebral peduncle are more normal-sized. (Bottom) Axial Tl C+ MR shows the cystic midbrain
lesions do not enhance. Initially diagnosed as cystic neoplasm, these are enlarged PVSs.When they occur in the
midbrain, expanded PVSsmay cause obstructive hydrocephalus but should not be mistaken for tumor.

25
 2: Supratentorial Brain

Cerebral Hemispheres Overview 1-28

White Matter Tracts 1-42
Basal Ganglia and Thalamus 1-64
Limbic System 1-76
Sella, Pituitary and Cavernous Sinus 1-86
Pineal Region 1-98
 CEREBRAL HEMISPHERES
ITerminology
Definitions
• Gyri: Complex convolutions of brain cortex
• Sulci (fissure): CSF-filled grooves or clefts that separate
gyri
• Operculae: Parts of frontal, temporal, parietal lobes
that overhang/enclose insula
ICross Anatomy
Cerebral Hemispheres
• Two hemispheres, typically of nearly equal size, linked
by commissural fibers
o Separated by a deep median cleft, the great
longitudinal (interhemispheric) fissure
o Falx cerebri lies within interhemispheric fissure
• External highly convoluted mantle of cortical gray
matter overlies white matter
• Central sulcus separates frontal, parietal lobes
• Sylvian fissure separates frontal, parietal lobes above
from temporal lobe below
• Deep gray nuclei (basal ganglia, thalami), ventricles
centrally
Lobes
• Frontal lobe: Anterior region of hemisphere; anterior
to central sulcus, superior to sylvian fissure
• Parietal lobe: Posterior region of hemisphere; posterior
to central sulcus, anterior to parietooccipital sulcus
• Occipital lobe: Posterior to parietooccipital sulcus
• Temporal lobe: Inferior to sylvian fissure, anterior to
angular gyrus ..,
• Insula: Cortical region hidden within depths of lateral
(sylvian) fissure; covered by frontal, temporal, parietal
opercula
Ilmaging Anatomy
Overview
• Frontal lobe
o Central sulcus separates frontal, parietal lobes
o Precentral gyrus contains primary motor cortex
• Detailed topographically-organized map ("motor
homunculus") of contralateral body
• Head/face lateral, legs/feet along medial surface
o Premotor cortex: Within gyrus just anterior to
precentral gyrus (motor cortex)
o Three additional major gyri: Superior frontal gyrus,
middle frontal gyrus & inferior frontal gyrus
separated by superior & inferior frontal sulci
• Parietal lobe
o Posterior to central sulcus
o Separated from occipital lobe by parietooccipital
sulcus (medial surface)
o Postcentral gyrus: Primary somatosensory cortex
• Contains topographical map of contralateral body
• Face, tongue, lips are inferior; trunk, upper limb
superolateral; lower limb on medial aspect
o Superior & inferior parietal lobules lie posterior to
postcentral gyrus
OVERVIEW
o Supramarginal gyrus lies at end of sylvian fissure
o Angular gyrus lies ventral to supramarginal gyrus
o Medial surface of parietal lobe is precuneus
• Occipital lobe
o Posterior to parietooccipital sulcus
o Primary visual cortex on medial occipital lobe
o Cuneus on medial surface
• Temporal lobe
o Inferior to sylvian fissure
o Superior temporal gyrus: Contains primary auditory
cortex
o Middle temporal gyrus: Connects with auditory,
somatosensory, visual association pathways
o Inferior temporal gyrus: Higher visual association
area
o Includes major subdivisions of limbic system
• Parahippocampal gyrus on medial surface, merges
into uncus
• Insula
o Lies deep in floor of sylvian fissure, overlapped by
frontal, temporal, parietal operculae
o Somatosensory function
• Limbic system
o Subcallosal, cingulate, parahippocampal gyri
o Cingulate gyrus extends around corpus callosum;
tapers rostrally (anteriorly) into paraterminal gyrus,
subcallosal area
o Hippocampus including dentate gyrus, Ammon
horn (cornu ammonis)
• Base of brain
o Orbital gyri cover base of frontal lobe: Gyrus rectus
medially
o Olfactory bulb/tract lie within olfactory sulcus
• White matter tracts: Three major types of fibeIS
o Association fibers: Interconnect different cortical
regions in same hemisphere
• Cingulum is a long association fiber which lies
beneath cingulate gyrus
o Commissural fibers: Interconnect similar cortical
regions of opposite hemispheres
• Corpus callosum is largest commissural fiber, links
cerebral hemispheres
o Projection fibers: Connect cerebral cortex with deep
riuclei, brainstem, cerebellum, spinal cord
• Internal capsule is a major projection fiber
• Basal ganglia
o Paired deep bray nuclei
o Caudate nucleus, putamen, globus pallidus
• Thalamus: Paired nuclear complexes, serve as relay
station for most sensory pathways
IAnatomy-Based Imaging Issues
Imaging Recommendations
• Multiplanar MR best evaluates cerebral hemispheres
• White matter best evaluated by diffusion tensor
imaging (DTI) on 1.5 or 3 Tesla MR
• Limbic system best evaluated with high-resolution
coronal T2 MR, T1 volume images & FLAIR
• Multiplanar MR best evaluates basal ganglia, thalami
• Diffusion imaging often very helpful for evaluation of
supratentorial disease processes
29
30
 CEREBRAL HEMISPHERES OVERVIEW
AXIAL CECT Clj
~
$:lJ
:J
Falx cerebri
Vl
c
Frontal lobe ""0
.,
~
Sylvian fissure
.-+
ro
:J
.-+
Suprasellar cistern o
.,
Temporal lobe
Midbrain

Fourth ventricle

Frontal lobe
Corpus callosum genu

Caudate head
Lentiform nucleus
Sylvian fissure

Temporal lobe Midbrain

Quadrigeminal plate cistern Quadrigeminal plate

Tentorium cerebelli

Falx cerebri
Frontal lobe
Corpus callosum genu

Caudate head
Anterior limb, internal capsule
Lentiform nucleus
Sylvian fissure
Posterior limb, internal capsule
Temporal lobe Thalamus
Superior colliculus

Tentorium cerebelli, tentorial veins

(Top) First of six axial CECT images of cerebral hemispheres from inferior to superior shows interhemispheric fissure
containing falx cerebri. Sylvian (lateral) fissure is seen separating frontal & temporal lobes. (Middle) This image
shows frontal & temporal lobes & basal ganglia. Anterior limb of internal capsule separates caudate head from
lentiform nucleus (putamen & globus pallidus). Posterior limb contains corticospinal tract & separates thalamus from
lentiform nucleus. (Bottom) More superior image shows parts of basal ganglia including caudate, putamen & globus
pallidus. Anterior limb, genu & posterior limb of internal capsule are seen. Internal capsule is major projection fiber
to & from cerebral cortex & it fans out to form the corona radiata. Thalamus borders third ventricle & is separated
from basal ganglia by internal capsule.
31
 CEREBRAL HEMISPHERES OVERVIEW
C AXIAL CECT
rcl
"-
CO
Falx cerebr!
rcl Frontal lobe

Corpus callosum genu

Caudate head
Lentiform nucleus
Temporal lobe
Thalamus I
Internal cerebral veins

Cerebellar vermis

Occipital lobe

Frontal lobe

Corona radiata

Parietal lobe

Frontal lobe

Central sulcus

Falx cerebri
Parietal lobe

(Top) Image more superior shows thalamus & internal cerebral veins at level of lateral ventricles. Falx cerebri is
present within interhemispheric (great longitudinal) fissure. Occipital lobe is present posteriorly, just above
tentorium cerebelli & contains primary visual cortex. (Middle) The corona radiata (centrum semiovale) is comprised
of radial projection fibers from cortex to brainstem. Corona radiata is continuous with internal capsule inferiorly.
Occipital lobe is not seen on this and higher scans. (Bottom) Image at cerebral vertex shows central sulcus separating
frontal from parietal lobes. Primary motor cortex is within frontal lobe precentral gyrus while primary somatosensory
cortex is within parietal postcentral gyrus. Specific sulci & gyri are better resolved on MR imaging, although sylvian
fissure & central sulcus are reliably found on CT imaging.
32
 CEREBRAL HEMISPHERES OVERVIEW
AXIAL T1 MR .,
CO
~
-.
::J
Olfactory tracts (j')
c
""'0

.,
~
~
(t)
Uncus
:J
~
o
.,
Temporal lobe
Pons
Superior cerebellar peduncle
Fourth ventricle

Cerebellar hemisphere

Tentorium cerebelli
Occipital lobe

Olfactory sulcus Gyrus rectus

Lateral sulcus (sylvian fissure)
Amygdala

Interpeduncular fossa Hippocampal head"

Midbrain
Parahippocampal gyrus
Inferior collicuIus

Lingual gyrus

Occipital lobe

Interhemispheric fissure

Insula'
Lateral sulcus (sylvian fissure)

Amygdala'
Interpeduncular fossa
Midbrain
Cerebral aqueduct with Inferior colliculus
periaqueductal grey matter

Calcarine sulcus

(Top) First of nine axial Tl MR images through cerebral hemispheres from inferior to superior shows inferior aspect
of hemispheres. Occipital lobe is partially seen, superior to the sloping tentorium cerebelli. Uncus forms medial
border of temporal lobe, merges posteriorly with parahippocampal gyrus. (Middle) Basal aspect of frontal lobes is
formed by orbital gyri. Olfactory bulb/tract lies in/below olfactory sulcus. Hippocampus lies posterior & inferior to
amygdala. Parahippocampal gyrus is separated from medial occipitotemporal (lingual or fusiform) gyrus by collateral
sulcus. (Bottom) Axial image at level of midbrain shows sylvian fissure separating frontal & temporal lobes. Insula
lies deep to sylvian fissure covered by surrounding frontal, temporal & parietal operculae. Calcarine sulcus is
surrounded by primary motor cortex in posterior occipital lobe.
3
 CEREBRAL HEMISPHERES OVERVIEW
c AXIAL T1 MR
~
•....
en
~

Caudate head
Putamen
Anterior limb, internal capsule
Sylvian fissure Anterior commissure
Thalamus Third ventricle

Hippocampus tail

Parietooccipital sulcus

Calcarine sulcus

Frontal operculum Caudate head

Putamen
Claustrum
Globus pallidus
Insula
External capsule
Sylvian fissure
Extreme capsule
Thalamus
Hippocampus tail

Parietooccipital sulcus

Superior frontal gyrus

Frontal operculum
Genu, corpus callosum
Caudate head
Anterior limb, internal capsule
Pillars of fornix
Cortex of insula
Third ventricle
Posterior limb, internal capsule
Thalamus
Supramarginal gyrus
Splenium, corpus callosum
Angular gyrus

Parietooccipital sulcus
Occipital lobe

(Top) More superior image at level of inferior basal ganglia shows anterior limb of internal capsule separating
caudate head trom lentiform nucleus. Anterior commissure is a major commissural fiber which is seen anterior to
fornix in lamina terminales in anterior third ventricle. Anterior commissure connects anterior perforated substance &
olfactory tracts anteriorly & temporal lobe, amygdala & stria terminales posteriorly. (Middle) This image shows basal
ganglia & thalamus. Globus pallidus is hyperintense relative to putamen. Parietooccipital sulcus separates parietal &
occipital lobes. Hippocampal tail is seen wrapping around midbrain & thalamus. External capsule lies between
putamen & claustrum. Extreme capsule lies between claustrum & insula. (Bottom) Image through superior basal
ganglia shows supramarginal gyrus & angular gyrus of parietal lobe.
34
 CEREBRAL HEMISPHERES OVERVIEW
AXIAL T1 MR .,
O:l
~
Superior frontal gyrus ::J
Middle frontal gyrus

Genu, corpus callosum

Caudate nucleus

Supramarginal gyrus Splenium, corpus callosum

Angular gyrus
Parietooccipital sulcus
Occipital lobe

Interhemispheric fissure

Cingulate gyrus
Precentral gyrus
Central sulcus

Corona radiata
Cingulate gyrus

Parietooccipital sulcus

Interhemispheric fissure
Superior frontal gyrus

Precentral gyrus

Central sulcus, "hand knob"

Corona radiata
Postcentral gyrus

Superior parietal lobule

(Top) More superior image shows top of caudate nucleus body as it wraps around lateral ventricle. Parietooccipital
sulcus on medial aspect of hemispheres separates parietal & occipital lobes. (Middle) Cerebral hemispheres are
separated by interhemispheric (longitudinal) fissure which contains falx cerebri. Central sulcus separates frontal &
parietal lobes. Corona radiata (centrum semiovale) is formed by fibers from all cortical areas in internal capsule
fanning out into superior hemispheres. (Bottom) Image more superior shows falx cerebri within interhemispheric
fissure. Falx cerebri is a dural fold which contains superior sagittal sinus. Central sulcus separates frontal & parietal
lobes & is typically identified on MR imaging. Often, the "hand knob" representing hand motor area of precentral
gyrus can be identified.
35
 CEREBRAL HEMISPHERES OVERVIEW
c CORONAL T1 MR
ro
•....
CO
ro
Frontal lobe

Genu, corpus callosum

Sylvianfissure

Gyrus rectus Olfactory sulcus

o !factory tract
Temporal lobe

Superior frontal gyrus

Middle frontal gyrus

Caudate head Inferior frontal gyrus

Cingulate gyrus
Internal capsule
Putamen Insula
Globus pallidus Superiortemporal gyrus
Anterior commissure
Middle temporal gyrus
Amygdala
Inferior temporal gyrus
Occipitotemporal gyrus

Corona radiata
Body,corpus callosum
Fornix Insula

Third ventricle
Temporal horn
Hippocampal head
Collateral sulcus Parahippocampal gyrus

(Top) First of six coronal Tl MR images through cerebral hemispheres from anterior to posterior shows genu of
corpus callosum. Olfactory tract is embedded in olfactory sulcus. Olfactory sulcus defines lateral margin of gyrus
rectus at base of brain. (Middle) More posterior image shows anterior limb of internal capsule & anterior
commissure. Anteriorly, caudate head & putamen are connected. Central regions of frontal & temporal lobes are
seen. Insula is covered by frontal & temporal opercula. Superior, middle & inferior gyri of temporal lobe are well seen
on coronal imaging as are superior, middle & inferior frontal gyri. (Bottom) This image shows lobulated superior
surface of hippocampal head. Body of fornix runs below corpus callosum. Collateral sulcus separates
I parahippocampal & medial occipitotemporal (fusiform) gyri.
36
 CEREBRAL HEMISPHERES OVERVIEW
CORONAL T1 MR OJ
~
~
:J
(j)
C
-0
~
OJ
,...,.
Body, corpus callosum Caudate body ro
::J
,...,.
Insula
Thalamus o
~
Lateral geniculate nucleus
Parahippocampal gyrus
Hippocampal body

Corona radiata Parietal lobe

Cingulate gyrus
Sylvian fissure
Splenium, corpus callosum
Temporal lobe
Cingulate gyrus
Parahippocampal gyrus

Longitudinal fissure
Falx cerebri

Corona radiata

Vermis

Tentorium cerebelli

Cerebellum

(Top) More posterior image shows body of hippocampus & parahippocampal gyrus forming medial surface of
posterior temporal lobe. Lateral geniculate nucleus, a thalamic nucleus involved in visual pathway, is seen at this
level. Optic radiations course posteriorly from lateral geniculate nucleus to occipital lobe. (Middle) Image at corpus
callosum splenium. Cingulate gyrus encircles splenium in an arch to lie superior & inferior to it. Posterior
parahippocampal gyrus merges with cingulate gyrus. Posterior sylvian fissure is visible separating parietal lobe above
from temporal lobe below. (Bottom) Image more posterior shows interhemispheric fissure, falx cerebri & tentorium
cerebelli. Tentorium cerebelli is a dural fold in horizontal plane separating supratentorial & infratentorial
compartments & is continuous superiorly with falx cerebri.
37
 CEREBRAL HEMISPHERES OVERVIEW
c SAGITTAL T1 MR
("lj
•....
c::o
("lj Precentral gyrus

Postcentral gyrus
Central sulcus
Frontal lobe
Parietal lobe

Frontal operculum Occipital lobe

Sylvian fissure
Temporal operculum
Temporal lobe

Precentral gyrus
Postcentral gyrus
Central sulcus
Frontal lobe
Parietal lobe
Sylvian fissure

Hippocampus
Temporal lobe Occipital lobe

Central sulcus

Frontal lobe

Parietal lobe

Hippocampus
Parahippocampal gyrus
Occipital lobe
Temporal lobe

(Top) First of six sagittal Tl MR images from lateral to medial shows lateral aspect of sylvian fissure bounded
superiorly by frontal operculum & inferiorly by temporal operculum. Sylvian fissure contains insular (M2) and
opercular (M3) segments of middle cerebral artery. (Middle) This image shows central sulcus bordered by precentral
& postcentral gyri. Location of central sulcus & precentral gyrus (primary motor cortex) is extremely important in
pre-surgical planning. Hippocampus is seen along temporal horn. (Bottom) Image through medial temporal lobe
demonstrates hippocampus & parahippocampal gyrus. White matter along superior margin of hippocampus
represents fimbria which curves superiorly & anteriorly beneath corpus callosum as fornix, terminating in mamillary
I body. Lateral sulcus (sylvian fissure) separates temporal lobe from frontal & parietal lobes.
38
 CEREBRAL HEMISPHERES OVERVIEW
SAGITTAL T1 MR .,
OJ
~
::J
Precentral gyrus
(j)

Central sulcus c
Frontal lobe ""0

Postcentral sulcus
.,
OJ
r-T
Cingulate gyrus (D
::J
r-T
Parietooccipital sulcus o
.,
Subcallosal area Cuneus
Calcarine sulcus

Central sulcus

Frontal lobe Body, corpus callosum

Genu, corpus callosum Parietooccipital sulcus

Thalamus
Calcarine sulcus

Superior sagittal sinus

Cingulate gyrus
Genu, corpus callosum
Splenium, corpus callosum
Fornix Tentorium cerebelli
Mamillary body

(Top) More medial image shows central sulcus, bordered anteriorly by precentral gyrus (motor cortex) & posteriorly
by postcentral gyrus (sensory cortex). Calcarine sulcus & parietooccipital sulcus define cuneus of occipital lobe.
Cingulate gyrus extends around corpus callosum from para terminal gyrus & subcallosal area rostrally to
parahippocampal gyrus of temporal lobe. (Middle) Central sulcus separates frontal & parietal lobes. Parietooccipital
sulcus, located on medial side of hemispheres, separates parietal & occipital lobes. (Bottom) Midline sagittal image
shows fornix arching towards mamillary body. Cerebral hemispheres are above tentorium cerebelli, a dural fold
separating brain into supratentorial & infra tentorial compartments. Cerebral hemispheres are connected via corpus
callosum, largest commissural fiber.
39
 CEREBRAL HEMISPHERES OVERVIEW
c AXIAL T2 MR
~
•...
CO
~

Uncus Mamillary body

Amygdala
Uncal recess of temporal horn
Hippocampal head

Hippocampal fissural cysts Hippocampal body

Cerebral aqueduct

Cavum septi pellucidi

Genu, corpus callosum
Anterior limb, internal capsule Caudate head
Putamen
Genu, internal capsule
Globus pallidus
Posterior limb, internal capsule
Thalamus

Splenium, corpus callosum

Cingulate gyrus

Genu, corpus callosum

Caudate head
Anterior limb, internal capsule

Putamen

Thalamus

Splenium, corpus callosum

Centrum semiovale

(Top) First of three axial T2 MR images from inferior to superior shows hippocampus & amygdala. Hippocampal
fissural cysts (hippocampal sulcus remnants), a normal variant, are noted. Temporal horn separates amygdala
anteriorly & superiorly from hippocampus. (Middle) More superior image shows basal ganglia & thalamus. Putamen
is hypointense relative to other deep gray nuclei related to increased myelin content & iron deposition in older
patients. Globus pallidus is same signal intensity as internal capsule. Anterior limb, genu & posterior limbs of
internal capsule are seen. Anterior limb contains frontopontine fibers & thalamocortical projections. Genu contains
corticobulbar fibers & posterior limb contains corticospinal tracts. (Bottom) Image at level of superior thalamus.
Nerve fibers of corpus callosum radiate into centrum semiovale (white matter core) of hemispheres.
40
 CEREBRAL HEMISPHERES OVERVIEW
CORONAL T2 MR

Body, corpus callosum

Septum pellucidum
Column of fornix

Putamen
Globus pallidus

lnterdigitations of hippocampal
head
Temporal horn Hippocampal head
Parahippocampal gyrus
Collateral sulcus

Occipitotemporal gyrus

Body, corpus callosum

Body of fornix

Corticospinal tract Insula

Choroidal fissure Red nucleus

Hippocampal body Fimbria

Temporal horn Alveus

Parahippocampal gyrus
Substantia nigra
Collateral sulcus

Corona radiata

Posterior body, corpus callosum

Crus of fornix
Pulvinar of thalamus
Fimbria
Hippocampal tail

Collateral sulcus

(Top) First of three coronal T2 MR images through limbic system from anterior to posterior shows amygdala
separated from hippocampus by uncal recess of temporal horn. Hippocampal head is recognized by digitations on its
superior surface. Collateral sulcus separates parahippocampal gyrus from occipitotemporal (fusiform) gyrus. (Middle)
More posterior image shows body of hippocampus with normal architecture. Body of fornix arcs over thalamus to
split into two anterior columns which curve anteriorly to foramen of Monro & send fibers to mamillary body,
anterior thalamus & septal region. White matter tracts from internal capsule are seen coursing through cerebral
peduncles to pons. (Bottom) Image at posterior thalamus (pulvinar) shows hippocampal tail, smallest portion of
hippocampus. Fimbria arise from hippocampus & become crus of fornix which attaches to splenium.
41
 WHITE MATTER TRACTS
I Cross Anatomy
Overview
• Hemispheric white matter tracts divided by course,
connections into association, commissural,
projection fibers
• Association fibers (may be short or long)
o Short (arcuate or "u" fibers) link adjacent gyri,
course parallel to long axis of sulci
o Long fibers form fasciculi connecting widely spaced
gyri
• Cingulum, Long, curved fasciculus deep to
cingulate gyrus; interconnects parts of
frontal/parietal/temporal lobes
• Uncinate (asciculus: Connects motor speech area
& orbital gyri of frontal lobe with temporal lobe
cortex
• Superior longitudinal (arcuate) fasciculus:
Connects frontal to parietal, temporal and
occipital cortex
• Inferior longitudinal fasciculus: Connects
temporal and occipital cortex, contributes to
sagittal stratum
• Superior occipitofrontal fasciculus:'Connects
occipital & frontal lobes, lies beneath corpus
callosum (CC)
• Inferior occipitofrontal fasciculusj,Connects
occipital & frontal lobes, inferiorly; posteriorly
forms sagittal stratum which connects occipital
lobe to rest of brain
• Commissural fibers
o Corpus callosum
• Largest commissure; links hemispheres
• Four parts: Rostrum, genu, body, splenium
• Rostral fibers extend laterally connecting orbital
surfaces of frontal lobes
• Genu fibers curve forward as forceps minor,
connect lateral/medial frontal lobes
• Body fibers pass laterally, intersect with projection
fibers of corona radiata to connect wide areas of
hemispheres
• Tapetum: Formed by body, some splenium fibers;
course around posterior & inferior lateral
ventricles
• Most fibers from splenium curve into occipital
lobes as forceps major
o Anterior commissure
• Transversely oriented bundle of compact
myelinated fibers
• Crosses anterior to fornix, embedded in anterior
wall of third ventricle
• Splits into two bundles laterally
• Anterior bundle to anterior perforated substance,
olfactory tract
• Larger posterior fans out into temporal lobe
o Posterior commissure: Small; courses transversely
in posterior pineal lamina to connect midbrain,
thalamus/hypothalamus
• Projection fibers _ white matter
o Corona radiata: Fibers from internal capsule fan out
to form corona radiata, represent all cortical areas
o Internal capsule: Major conduit of fibers to/from
cerebral cortex
42
• Anterior limb: Frontopontine fibers,
thalamocortical projections
• Genu: Corticobulbar fibers
• Posterior limb: Corticospinal tracts, upper
limb-anterior, trunk & lower limbs-posterior
o Corticospinal tract: Major efferent projection fibers
connect motor cortex to brainstem, spinal cord
• Converge into corona radiata, continue through
posterior limb of internal capsule to cerebral
peduncle and lateral funiculus
o Corticobulbar tract: Major efferent projection fibers
connect motor cortex to brainstem and spinal cord
• Converge into corona radiata to genu of internal
capsule to cerebral peduncle, terminate in motor
cranial nerve nuclei
o Corticopontine tract: Motor information to pons
o Corticothalamic tract: Connects entire cerebral
cortex with isotopic location in thalamus
IImaging Anatomy
Overview
• Myelination generally proceeds inferior to superior;
central to peripheral; posterior to anterior
• MR signal depends on maturation
• Fully myelinated white matter hyperintense on Tl-,
hypointense on T2Wl
White Matter Maturation
• Occurs at different rates, times on Tl/T2 imaging
o Up to six months, Tl WI most useful
o After six months, T2 is most useful
• Newborn
o Tl WI: Newborn brain resembles T2 image in an
adult
• White matter has lower signal than gray matter
• With maturation, intensity of white matter
increases
o T2WI: Newborn brain resembles Tl image in an
adult
• White matter has higher signal than gray matter
• T2 superior for evaluating cerebellum and
brainstem maturation
• First six months
o TlWI
• Three months: High signal in anterior limb,
internal capsule ans cerebellar folia
• Four months: High signal in CC splenium
• Six months: High signal in CC genu
• Eight months: Near adult appearance, except most
peripheral fibers
• Six to eighteen months
o T2WI
• Six months: Low signal in CC splenium
• Eight months: Low signal in CC genu
• Eleven months: Low signal in anterior limb,
internal capsule
• Fourteen months: Low signal in deep frontal
• Eighteen months: Near adult appearance, except··
most peripheral fibers ,
43
44
46
 WHITE MATTER TRACTS
AXIAL T1 MR 32 WEEKS PREMATURE ~
""l
~
::3

Ventral (anterior) brainstem

Dorsal brainstem

Dentate nucleus
Inferior cerebellar hemisphere

Caudate head
Internal capsule, anterior limb
Lentiform nucleus
Internal capsule, posterior limb
Thalamus

Corona radiata

Central sulcus

Subcortical white matter

(Top) First of three axial Tl MR images from inferior to superior of a normal 32 week premature infant shows
posterior fossa structures. Superior & inferior cerebellar peduncles are bright on Tl images, but middle cerebellar
peduncles remain unmyelinated, isointense to cerebral white matter & dark on Tl images. Dorsal brain stem is
relatively hyperintense on Tl images compared with ventral pons. (Middle) Image at level of internal capsule shows
internal capsule is hypointense compared with lentiform nucleus. Sylvian fissures remain prominent. White matter is
hypointense related to lack of myelination. (Bottom) Image at level of corona radiata shows white matter as
completely unmyelinated, showing a Tl hypointense appearance. Sulci are prominent related to immaturity. Signal
intensity of entire cerebral cortex is uniform on Tl & T2 weighted images.
47
 WHITE MATTER TRACTS
c AXIAL T2 MR 32 WEEKS PREMATURE
C\l
•....
CO
C\l

Ventral brainstem
Dorsal brainstem

Dentate nucleus
Inferior cerebellar hemisphere

Caudate head
Internal capsule region
Lentiform nucleus
Lateral putamen
Thalamus Ventrolateral thalamus

Corona radiata
Central sulcus

(Top) First of three axial T2 MR images from inferior to superior of a normal 32 week premature infant shows
posterior fossa structures. Dorsal (posterior) brainstem is relatively hypointense (dark) on T2 images compared with
unmyelinated ventral (anterior) pons. Superior & inferior peduncles are hypointense on T2 images. Middle cerebellar
peduncle is hyperintense on T2 images, similar to cerebral white matter. (Middle) Image at level of internal capsule
shows the thalamus & basal ganglia are hypointense (dark). Internal capsule is typically hyperintense at this age,
although is difficult to differentiate in this case. T2 also shows hypointensity in far lateral putamen & ventrolateral
thalamus at this 32 week premature age. (Bottom) Image through corona radiata shows unmyelinated white matter,
hyperintense compared with gray matter.
48
 WHITE MATTER TRACTS
AXIAL T1 MR BIRTH OJ
"'"
~
:J
Vl
c
-0
...•
~
r-?
([)
:J
r-?
o
...•

Medulla
Inferior cerebellar peduncle
Dentate nucleus
Inferior cerebellar hemisphere

Genu, corpus callosum

Caudate head Anterior limb, internal capsule
Lentiform nucleus
Posterior limb, internal capsule
Thalamus

Splenium, corpus callosum

Corona radiata
Central sulcus
Myelinated white matter

(Top) First of three axial Tl MR images from inferior to superior of a normal full-term infant at birth shows posterior
fossa structures. Superior & inferior cerebellar peduncles are bright on Tl images, but middle cerebellar peduncles
remain unmyelinated, isointense to cerebral white matter & dark on Tl images. Dorsal brainstem is relatively
hyperintense on Tl images compared with ventral brainstem. (Middle) Image at level of internal capsule shows
hyperintensity of posterior limb compared with anterior limb. Lateral thalamus is also bright compared with
remainder of thalamus. (Bottom) Image through corona radiata shows increased signal intensity in rolandic
(precentral) & perirolandic gyri corresponding to known myelination within these gyri at or shortly after birth.
Reminder of cerebral white matter remains hypointense, related to lack of myelination.
49
 WHITE MATTER TRACTS
c AXIAL T2 MR BIRTH
r1j
•...
CO
r1j

Medulla
Inferior cerebellar peduncle
(restiform body)
Inferior cerebellar hemisphere Cerebellar vermis

Caudate head Genu, corpus callosum

Anterior limb, internal capsule
Lentiform nucleus

Thalamus Posterior limb, internal capsule

Splenium, corpus callosum

Corona radiata
Central sulcus

(Top) First of three axial T2 MR images from inferior to superior of a normal infant at birth shows posterior fossa
structures. At birth, low signal is present in inferior & superior cerebellar peduncles. Cerebellar vermis is also low
signal compared with rest of cerebellum. T2 imaging is more sensitive for evaluation of posterior fossa structure
maturation. (Middle) Image at level of internal capsule shows a small patch of hypo intensity within posterior limb
of internal capsule & within lateral putamen. Ventral lateral region of thalamus is also hypointense (dark) at birth.
Corpus callosum is unmyelinated at birth & matures in a posterior to anterior fashion. (Bottom) Image at corona
radiata shows predominantly unmyelinated white matter, hyperintense compared with gray matter. Subtle
hypo intensity in cortex of pre- & postcentral gyri can be seen and is normal.
50
 WHITE MATTER TRACTS
AXIAL T1 MR 3 MONTHS

Temporal white matter

Ventral (anterior) brainstem
Dorsal brainstem
Middle cerebellar peduncle

Inferior cerebellar hemisphere

Genu, corpus callosum

Caudate head
Anterior limb, internal capsule
Lentiform nucleus
Posterior limb, internal capsule
Thalamus
Splenium, corpus callosum

Deep occipital white matter

Corona radiata

Central sulcus

(Top) First of three axial Tl MR images from inferior to superior of a normal infant at three months shows posterior
fossa structures. Cerebellum has a nearly adult appearance by three months. Dorsal brain stem remains slightly
hyperintense compared with ventral brainstem. (Middle) Image at level of internal capsule shows high signal in
posterior limb & early, subtle high signal in anterior limb of internal capsule. Corpus callosum remains
unmyelinated, but splenium will show high signal by approximately four months. Deep white matter begins
myelinating around three months, appearing first in deep occipital white matter. (Bottom) Image through corona
radiata shows predominantly unmyelinated white matter, hypointense compared with gray matter. Deep white
matter matures in a posterior to anterior direction & early maturation in seen posteriorly.
51
 WHITE MATTER TRACTS
c AXIAL T2 MR 3 MONTHS
(ij
•....
eo
(ij

Temporal white matter

Ventral (anterior) brainstem
Dorsal brainstem Facial nerve CN? nucleus

Middle cerebellar peduncle

Inferior cerebellar hemisphere

Genu, corpus callosum

Caudate head Anterior limb, internal capsule
Lentiform nucleus

Thalamus Posterior limb, internal capsule

Splenium, corpus callosum

Corona radiata
Central sulcus

(Top) First of three axial T2 MR images from inferior to superior of a normal infant at three months shows posterior
fossa structures. Low signal intensity is noted in cranial nerve nuclei including: Abducens CN6, facial CN?, &
vestibulocochlear CN8 nerves. Dorsal brainstem is mildly hypointense compared with ventral brainstem & becomes
isointense at about five months. Middle cerebellar peduncles are low signal by three months. (Middle) Image at level
of internal capsule shows hypointense (dark) signal in posterior limb of internal capsule. Internal capsule matures in
a posterior to anterior fashion. Corpus callosum, deep & subcortical white matter remains unmyelinated. (Bottom)
Image through corona radiata shows predominantly unmyelinated white matter, hyperintense compared with gray
matter. Newborn white matter on T2 resembles adult on Tl images.
52
 WHITE MATTER TRACTS
AXIAL T1 MR 6 MONTHS

Temporal lobe white matter

Pons
Middle cerebellar peduncle

Cerebellum

Genu, corpus callosum

Caudate head
Anterior limb, internal capsule
Lentiform nucleus
Posterior limb, internal capsule
Thalamus
Splenium, corpus callosum

Corona radiata

Subcortical white matter

(Top) First of three axial TI MR images from inferior to superior of a normal six month old shows posterior fossa
structures. Cerebellum has an adult appearance by three months. Signal intensity in ventral (anterior) pons is bright
with an adult appearance at this age. (Middle) Image at level of internal capsule shows hyperintensity (bright) in
genu & splenium of corpus callosum. Internal capsule is hyperintense throughout. At birth, only posterior limb is
bright, but by three months, anterior limb is also bright. (Bottom) Image through corona radiata shows progressive
maturation of white matter with increasing hyperintensity of subcortical white matter, notably in occipital & parietal
regions. Deep white matter matures in a posterior to anterior direction with deep occipital white matter maturing
first, frontal & temporal white matter last.
53
 WHITE MATTER TRACTS
c AXIAL T2 MR 6 MONTHS
~
~
CO
~

Temporal white matter

Pons
Middle cerebellar peduncle

Cerebellum

Genu, corpus callosum

Caudate head
Anterior limb, internal capsule
Lentiform nucleus
Posterior limb, internal capsule
Thalamus

Splenium, corpus callosum

Corona radiata

Subcortical white matter

(Top) First of three axial T2 MR images from inferior to superior of a normal six month old shows posterior fossa
structures. Ventral brainstem becomes similar to dorsal brainstem at about five months, & is similar throughout pons
in this case. Cerebellar peduncles are hypointense, similar to adult patient, by about four months. (Middle) Image at
level of internal capsule shows dark posterior limb relative to anterior limb. Internal capsule matures in a posterior to
anterior fashion. Corpus callosum also matures in posterior to anterior fashion. Splenium is hypointense (dark)
compared with genu of corpus callosum. (Bottom) Image at level of corona radiata shows a relative decrease of signal
in deep white matter. Subcortical white matter matures last, beginning in posterior occipital lobes & extending
anteriorly to frontal & temporal lobes.
54
 WHITE MATTER TRACTS
AXIAL T1 MR 9 MONTHS C:::l
~
~
::J
V'l
"'0
c
""""

~
r-t-
('D

Temporal lobe white matter :J

r-t-

Ventral (anterior) pons

o
""""

Dorsal pons
Middle cerebellar peduncle

Inferior cerebellar hemisphere

Genu, corpus callosum

Caudate head
Anterior limb, internal capsule
Lentiform nucleus
Posterior limb, internal capsule
Thalamus

Splenium, corpus callosum

Corona radiata
Central sulcus

(Top) First of three axial Tl MR images from inferior to superior of a normal nine month old shows posterior fossa
structures. Brainstem & cerebellum have an adult appearance. Temporal lobe white matter remains unmyelinated.
(Middle) Image at level of internal capsule shows near adult appearance on Tl images. White matter of internal
capsule & corpus callosum is hyperintense compared with basal ganglia & thalamus, similar to an adult. Deep &
subcortical white matter of frontal lobes appears unmyelinated compared with occipital lobes. (Bottom) Image
through corona radiata shows further myelination of deep & subcortical white matter. Frontal & temporal lobe white
matter is last to completely myelin ate & appear slightly hypo intense compared with parietal lobe white matter. Only
minimal changes are seen in white matter after eight months on Tl images. I
55
 WHITE MATTER TRACTS
AXIAL T2 MR 9 MONTHS

Temporal white matter

Pons

Inferior cerebellar hemisphere

Genu, corpus callosum

Caudate head
Anterior limb, internal capsule
Lentiform nucleus
Posterior limb, internal capsule
Thalamus

Splenium, corpus callosum

Corona radiata
Central sulcus

Subcortical white matter

(Top) First of three axial T2 MR images from inferior to superior of a normal nine month old shows posterior fossa
structures. Cerebellum begins to develop low signal in white matter of cerebellar folia (arborization) by eight months,
but does not reach an adult appearance until approximately eighteen months. (Middle) Image at level of internal
capsule shows hypointensity in anterior & posterior limbs. Anterior limb continues to thicken until approximately
ten months. Corpus callosum is myelinated by approximately eight months. (Bottom) Image through corona radiata
shows partial myelination of deep & subcortical white matter, proceeding from occipital region anteriorly to frontal
& temporal lobes. Myelination of subcortical white matter begins at approximately nine to twelve months in
I occipital lobes. Temporal lobe white matter matures last.
56
 WHITE MATTER TRACTS
AXIAL T1 MR 12 MONTHS

Temporal lobe white matter

Pons
Middle cerebellar peduncle

Cerebellum

Genu, corpus callosum

Caudate head
Anterior limb, internal capsule
Lentiform nucleus

Thalamus Posterior limb, internal capsule

Splenium, corpus callosum

Corona radiata

Subcortical white matter

(Top) First of three axial T1 MR images from inferior to superior of a normal twelve month old shows posterior fossa
structures. Cerebellum has an adult appearance. Signal intensity in ventral (anterior) pons is bright as in an adult.
Only temporal lobe white matter remains immature. (Middle) Image at level of internal capsule shows adult
appearance on Tl images. White matter of internal capsule & corpus callosum is hyperintense compared with basal
ganglia & thalamus. Globus pallidus is distinguishable as slightly hyperintense compared with putamen located
laterally. (Bottom) Image at level of corona radiata shows an adult appearance of deep white matter & near adult
appearance of subcortical white matter. Subcortical white matter matures last, beginning in posterior occipital lobes
& extending anteriorly to frontal & temporal lobes.
57
 WHITE MATTER TRACTS
c AXIAL T2 MR 12 MONTHS
ro
•....
CO
ro

Temporal lobe white matter

Pons

Middle cerebellarpeduncle
Cerebellum

Genu, corpus callosum

Caudate head
Anterior limb, internal capsule
Lentiform nucleus
Posterior limb, internal capsule
Thalamus

Splenium, corpus callosum

Corona radiata

Subcorticalwhite matter

(Top) First of three axial T2 MR images from inferior to superior of a normal twelve month old shows posterior fossa
structures. Arborization of cerebellum, low signal in cerebellar folia subcortical white matter, begins at six to eight
months, but is not complete until eighteen months. Temporal white matter remains immature. (Middle) Image at
level of internal capsule shows dark anterior & posterior limbs by twelve months. Basal ganglia & thalamus appears
dark relative to white matter. Cortex & underlying white matter are essentially isointense throughout most of brain
at this age, making Tl images better for identifying structural abnormalities. (Bottom) Image at level of corona
radiata shows increased dark signal in white matter of paracentral & occipital regions. White matter maturation
I occurs in occipital regions first & moves anteriorly.
58
 WHITE MATTER TRACTS
AXIAL T1 MR 18 MONTHS

Temporal lobe white matter

Pons

Middle cerebellar peduncle

Cerebellum

Genu, corpus callosum

Caudate head
Anterior limb, internal capsule
Lentiform nucleus
Posterior limb, internal capsule
Thalamus

Splenium, corpus callosum

Corona radiata

Subcortical white matter

(Top) First of three axial Tl MR images from inferior to superior of a normal eighteen month old shows posterior
fossa structures. Posterior fossa structures have an adult appearance on Tl images. Temporal & frontal lobe white
matter is last to myelinate, but has an adult appearance on Tl images by eleven to twelve months. (Middle) Image at
level of internal capsule shows adult appearance of basal ganglia, thalamus & white matter. Corpus callosum has an
adult appearance on Tl images by six months while internal capsule has adult appearance by three months.
(Bottom) Image at level of corona radiata shows adult appearance with hyperintensity seen in deep white matter &
subcortical white matter. Myelination has adult appearance in white matter Tl images by eleven to twelve months &
an adult appearance on T2 images by eighteen months.
59
 WHITE MATTER TRACTS
c AXIAL T2 MR 18 MONTHS
(\j
•...
CO
(\j

Temporal lobe white matter

Pons
Middle cerebellar peduncle

Cerebellum

Genu, corpus callosum

Caudate head
Anterior limb, internal capsule
Lentiform nucleus
Posterior limb, internal capsule
Thalamus

Splenium, corpus callosum

Corona radiata

Subcortical white matter

(Top) First of three axial T2 MR images from inferior to superior of a normal eighteen month old shows posterior
fossa structures. Posterior fossa structures including brain stem & cerebellum have an adult appearance. Cerebellum
reaches adult appearance on T2 images by eighteen months. Temporal lobe subcortical white matter is last to mature
& reaches full maturity by 22-24 months. (Middle) Image at level of internal capsule shows adult appearance of
corpus callosum & internal capsule. White matter of frontal & temporal lobes is last to appear mature on T2 images
& remains relatively hyperintense, particularly in temporal lobes. (Bottom) Image at level of corona radiata shows
further hypo intensity in the deep & subcortical white matter. Although somewhat patchy, subcortical white matter is
I hypointense in majority of brain.
60
 WHITE MATTER TRACTS
AXIAL T1 MR 3 YEARS

Temporal lobe white matter

Pons
Middle cerebellar peduncle

Cerebellum
Cerebellar vermis

Genu, corpus callosum

Caudate head
Anterior limb, internal capsule
Putamen
Globus pallidus
Posterior limb, internal capsule
Thalamus
Splenium, corpus callosum

Corona radiata

Subcortical white matter

(Top) First of three axial Tl MR images from inferior to superior of a normal three year old shows adult appearance.
Cerebellar folia maturation, arborization, occurs much earlier on Tl than T2 images. Cerebellum appears mature on
Tl images by approximately three months. However, maturation of brainstem & cerebellum is more sensitively
assessed on T2 MR images. (Middle) Image at level of internal capsule shows adult appearance of internal capsule,
corpus callosum & deep gray nuclei including basal ganglia & thalamus. Temporal lobe subcortical white matter is
last to appear mature at approximately eleven to twelve months on Tl images. (Bottom) Image at corona radiata
shows adult appearance of deep & subcortical white matter. Although conventional MR imaging suggests an adult
appearance by two years, functional studies suggest complete myelination is not achieved until adolescence.
61
 WHITE MATTER TRACTS
c AXIAL T2 MR 3 YEARS
Ci:l
"-
CO
Ci:l

Temporallobe white matter

Pons
Middle cerebellarpeduncle

Cerebellum

Genu, corpus callosum

Caudate head Anterior limb, internal capsule
Putamen
Globus pallidus
Posteriorlimb, internal capsule
Thalamus
Splenium, corpus callosum

Corona radiata

Subcorticalwhite matter

(Top) First of three axial T2 MR images in a normal, mature three year old. Adult appearance of posterior fossa
structures is noted. Temporal lobe subcortical white matter is also mature. (Middle) Image at level of internal capsule
shows a near adult appearance in this three year old patient. Globus pallid us becomes more hypointense at around
ten years related to normal iron deposition. (Bottom) Image at level of corona radiata shows normal adult
appearance of deep & subcortical white matter. Corona radiata is formed by fibers from all cortical areas which fan
out from internal capsule. T2 MR imaging is superior for evaluating brain maturation after six months of age. Normal
adult appearance is usually obtained by eighteen months, except for most peripheral fibers.
I
62
 WHITE MATTER TRACTS
CORONAL STIR MR c;,
..,
~
:J
Corona radiata Vl
Body, corpus callosum ""0
c
~
~
~
(D
Anterior limb, internal capsule :J
Column of fornix ~
External capsule
o
~
Anterior commissure
Extreme capsule

Corona radiata
Body, corpus callosum
Body of fornix

External capsule
Extreme capsule
Optic tracts

Corona radiata

Splenium, corpus callosum

Crus of fornix

Fimbria of hippocampus

(Top) First of three coronal STIR MR images through white matter tracts from anterior to posterior. Anterior
commissure crosses through lamina terminalis. Anterior fibers of anterior commissure connect olfactory bulbs &
nuclei while posterior fibers connect middle & inferior temporal gyri. Anterior limb of internal capsule lies between
head of caudate & lentiform nucleus & passes projection fibers to & from thalamus (thalamocortical projections) &
frontopontine tracts. (Middle) Image more posterior shows body of fornix. Fornix is major white matter tract
associated with hippocampus & limbic system. (Bottom) Image posteriorly shows splenium of corpus callosum &
crus of fornix. Hippocampal fimbria continue along undersurface of splenium to form crus of fornix which extend
under body of corpus callosum to form commissure which becomes body anteriorly.
63
 BASAL GANGLIA AND THALAMUS
ITerminology
~ Definitions
o
.•.... • Basal ganglia (BG): Subcortical nuclear masses in
c: inferior hemispheres
Q)
.•.... o Involved in motivation, controlling movement
~
~ o Subthalamic, reticular nuclei included
o Lentiform nucleus: Putamen + globus pallidus (GP)
0.. o Corpus striatum: Caudate nucleus + putamen + GP;
::J
V) neostriatum = putamen, caudate
o Definition recently narrowed to exclude claustrum,
C
.~
... amygdala
• Thalamus: Paired ovoid nuclear complexes; relay
CQ stations for most sensory pathways.
• Subthalamus: Complex region of nuclear masses, fiber
tracts that plays major role in normal BG function
IGross Anatomy
Overview
• Basal ganglia: Caudate nucleus, putamen, GP
o Anterior limb of internal capsule separates caudate
head from putamen, GP
o Posterior limb separates thalamus from BG
• Caudate nucleus: "C-shaped" curved nucleus with
large head, tapered body, down-curving tail
o Head forms floor/lateral wall of anterior horn of
lateral ventricle
o Body borders, parallels lateral ventricle
o Tail follows curve of inferior horn, lies in ventricular
roof
o Deep groove (sulcus terminalis) separates caudate
from thalamus; its stria terminalis lies deep to
ependyma, helps form choroid fissure
o Caudate continuous anteriorly with inferior
putamen above anterior perforated substance; with
posteroinferior putamen at caudate tail
• Putamen: Located lateral to GP, separated by lateral
(external) medullary lamina
• GP: Two segments
o Lateral (external), medial (internal) segments
separated by internal medullary lamina
o Higher myelin content than putamen (darker on T2)
• Thalamus: Ovoid nucleus, extends from foramen of
Monro to quadrigeminal plate of midbrain
o Medially forms lateral walls of third ventricle
o Laterally bordered by internal capsule
o Subdivided into nuclear groups (anterior, medial,
lateral), geniculate nuclei (lateral, medial), pulvinar
• Nuclear groups further subdivided into 10
additional nuclei
• Internal medullary lamina separates medial,
lateral, anterior nuclear groups
• External medullary lamina separates lateral
nuclear group, reticular nucleus
o Geniculate nuclei
• Lateral geniculate nucleus: Ovoid ventral
projection from posterior thalamus (part of visual
system)
• Medial geniculate.nucleus: Medial to lateral
geniculate nucleus along posterior thalamus (part .
of auditory system)
I
64
o Pulvinar: Occupies caudal third of thalamus &
overhangs superior colliculus
o Massa intermedia (interthalamic adhesion):
Connects thalami across third ventricle
• Subthalamus
o Associated with Parkinson disease, ballism
o Subthalamic nucleus is lens-shaped, lies
superolateral to red nucleus
o Reticular nucleus: Lamella that wraps around lateral
thalamus, separated from it by external medullary
lamina
Vascular Supply
• BG: Mostly lenticulostriate arteries
• Thalamus: Mostly thalamoperforators from posterior
communicating, basilar, PI post;;>rior cerebral arteries
o Large thalamoperforator (artery of Percheron or
paramedian thalamic artery) may supply bilateral
medial thalami
I Imaging Anatomy
Overview
• CT: Deep gray nuclei hyperdense to white matter;
isodense with cortex
o Punctate or dense globular Ca++ common
o Usually symmetric, in medial GP
o Common in middle-aged, older patients
• MR
o Iron deposition in BG occurs with normal aging
• No Fe in brain at birth
• Progressive t with aging, ~ signal intensity on
TZWI
• GP hypointensity begins to t in 2nd decade,
plateaus after age 30
• Putamen = GP hypointensity at 80 years
IAnatomy-Based Imaging Issues
Imaging Recommendations
• MR (axial, coronal) best general imaging; NECT for
Ca++
• DWI, T2* helpful additions
I Clinical Implications
Clinical Importance
• Disorders of the BG are characterized by abnormalities
of movement, muscle tone & posture
• Putamen is most common location affected by
hypertensive hemorrhage
• GP is most sensitive area of brain to hypoxia (in
addition to hippocampus)
• BG is common location for strokes, particularly
lacunar infarcts & hypertensive hemorrhages
I
65
I
66
 BASAL GANGLIA AND THALAMUS
AXIAL CECT ~
~
~
:J
Vl
c
-0
..,
llJ
Head of caudate nucleus r-+
Anterior limb, internal capsule (l)

Genu, internal capsule Putamen ::l

r-+
Posterior limb, internal capsule
Globus pallidus o
..,

Head of caudate nucleus

Anterior limb, internal capsule
Putamen
Genu, internal capsule Globus pallidus
Posterior limb, internal capsule
Thalamus
Third ventricle

Anterior limb, internal capsule Head of caudate nucleus

Genu, internal capsule Putamen
Posterior limb, internal capsule Massa intermedia
Thalamus

(Top) First of three CECT images of basal ganglia & thalamus from inferior to superior. Note internal capsule appears
hypodense & helps separate caudate head from putamen & globus pallidus. External capsule, claustrum & extreme
capsule cannot be resolved on CT imaging. Un enhanced CT is an excellent choice for initial evaluation of possible
basal ganglia stroke as hypertensive hemorrhages & lacunar infarcts are common in basal ganglia & thalami & are
well seen by CT. (Middle) This image shows large anterior caudate head lying in floor & lateral wall of frontal horn
of lateral ventricle. Putamen, globus pallidus are separated on CT by location & subtle differences in density. GP is
often slightly less dense than putamen. (Bottom) Image more superior shows thalamus as it extends posteriorly.
Ma\sa intermedia (interthalamic adhesion) connects thalami across third ventricle.
67
 BASAL GANGLIA AND THALAMUS
c AXIAL T1 MR
ro
•....
CO
ro
Head of caudate nucleus
Anterior limb, internal capsule
External capsule Putamen
Genu, internal capsule
Globus pallidus
Anterior commissure
Column of fornix

Head of caudate nucleus

Anterior limb, internal capsule
External capsule Putamen

Genu, internal capsule Globus pallidus

Extreme capsule
Claustrum
Posterior limb, internal capsule
Massa intermedia
Thalamus
Habenula
Pulvinar, thalamus

Head of caudate nucleus

Anterior limb, internal capsule
Putamen
External capsule
Genu, internal capsule Globus pallidus
Extreme capsule Claustrum
Posterior limb, internal capsule Massa intermedia
Thalamus
Pulvinar, thalamus
Tail of caudate nucleus

(Top) First of six axial Tl MR images from inferior to superior shows inferior aspect of basal ganglia & thalamus. Note
caudate head lies inferior to frontal horns of lateral ventricles at this level. (Middle) Image thorough basal ganglia &
thalamus shows distinct nuclei of caudate, putamen & globus pallidus. Note massa intermedia (interthalamic
adhesion) across the third ventricle. The habenula (which connects olfactory impulses to brain stem nuclei) is seen at
this level. Lateral to putamen, external capsule, claustrum, extreme capsule & insular cortex are present. (Bottom)
This image shows internal capsule in its entirety with anterior limb, genu & posterior limb. Genu of internal capsule
contains corticobulbar fibers & thalamic fibers while posterior limb contains corticospinal tracts & thalamic fibers.
Lenticulostriate arteries supply internal capsule.
68
 BASAL GANGLIA AND THALAMUS
AXIAL T1 MR c::l
.,
~
:J
V"l
Genu, corpus callosum C
-0
Head of caudate nucleus """"'
Anterior limb, internal capsule OJ
r-+
ro
Putamen ::l
Genu, internal capsule r-+
o
""""'

Thalamus
Posterior limb, internal capsule

Tail of caudate nucleus

Splenium, corpus callosum

Genu of corpus callosum

Head of caudate nucleus

Septum pellucidum
Body of caudate nucleus

Splenium of corpus callosum

Body of caudate nucleus

(Top) Image more superior through basal ganglia at level of genu & splenium of corpus callosum. Head & tail of
caudate nucleus are seen as caudate curves around lateral ventricle. Tail of caudate lies in ventricular roof in temporal
lobe. Caudate is separated from thalamus by sulcus terminalis which contains stria terminalis & thalamostriate veins
anteriorly. Putamen is larger than globus pallidus & continues more superiorly. (Middle) Image at level of centrum
semiovale shows head & body of caudate as it wraps around lateral ventricle. Caudate nucleus lies in frontal lobe &
wraps around ventricle to end in temporal lobe at the amygdala. (Bottom) Image more superior shows body of
caudate head as it parallels the lateral ventricles.
I
69
 BASAL GANGLIA AND THALAMUS
c CORONAL T1 MR
~
•....
eel
~

Head of caudate nucleus

Internal capsule
Putamen
External capsule
Extreme capsule

Amygdala

Head of caudate nucleus

Internal capsule
Putamen
External capsule Globus pallidus
Extreme capsule
Anterior commissure Hypothalamus
Third ventricle
Amygdala

Head of caudate nucleus

Internal capsule
Putamen
External capsule Globus pallidus
Extreme capsule Claustrum
Hypothalamus

(Top) First of six coronal Tl MR images from anterior to posterior through basal ganglia & thalamus. Note inferior
part of caudate head becomes continuous with most inferior part of putamen just above anterior perforated
substance. (Middle) Image at level of anterior commissure shows anterior limb of internal capsule as it separates
caudate head from putamen & globus pallidus. Globus pallidus & putamen have different signal intensity related to
increased myelin in globus pallidus. Lateral & medial segments of globus pallidus cannot be distinguished on
conventional imaging. (Bottom) Image more posterior through third ventricle shows components of basal ganglia:
Caudate, putamen & globus pallidus. Typical pathologic conditions of basal ganglia include hypoxic-ischemic insults
& toxic-metabolic processes. Imaging with Tl & T2 as well as DWI sequences are useful.
70
 BASAL GANGLIA AND THALAMUS
CORONAL T1 MR ..,
OJ
~
::::l
(j)

""0
c
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Head of caudate nucleus OJ
r-+
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Sulcus terminalis Putamen ::J
r-+
External capsule Globus pallidus o
....•
Extreme capsule
Claustrum

Body of caudate nucleus

External capsule Thalamus

Putamen
Third ventricle

Body of caudate nucleus

Pulvinar, thalamus

(Top) Image more posterior shows basal ganglia & thalamus. The sulcus terminalis which separates caudate head
from thalamus contains thalamostriate vein & stria terminalis. Stria terminalis is most important efferent fiber
system of amygdala, runs below thalamostriate vein, but is not seen on conventional imaging. (Middle) Image more
posterior shows thalamus bordering third ventricle. Thalamus contains three major nuclear groups (anterior, medial,
lateral) which are not resolved on conventional imaging. Other thalamic nuclei include lateral & medial geniculate
nuclei which may be seen on high-resolution images. Subthalamic nuclei are located superolateral to red nucleus &
are important in movement disorders. (Bottom) Image more posterior shows caudate body as it parallels lateral
ventricle. Pulvinar occupies posterior third of thalamus;
71
 BASAL GANGLIA AND THALAMUS
c
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Putamen
Genu, internal capsule
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Posterior limb, internal capsule

Thalamus
Habenula
Pulvinar, thalamus

(Top) First of six axial T2 MR images from inferior to superior shows caudate head as it lies along floor of lateral
ventricle. Perivascular spaces, a normal variant, are seen in a typical location along lateral aspect of anterior
commissure. Perivascular spaces follow CSF on all pulse sequence & have no surrounding gliosis or edema & no
enhancement. Substantia nigra is within midbrain cerebral peduncles. (Middle) Image through basal ganglia shows
GP is hypointense compared with other deep gray nuclei because of normal age-related iron deposition. (Bottom)
Image more superior through basal ganglia & thalamus shows internal capsule components including anterior limb,
genu & posterior limb. Habenula, part of epithalamus, transmits olfactory impulses to brainstem. Habenula also
attaches to pineal gland.
72
 BASAL GANGLIA AND THALAMUS
AXIAL T2 MR CXl
~
~
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Vl
c
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...,
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r-+
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o
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Pulvinar, thalamus

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Anterior limb, internal capsule
Putamen

Thalamus

Head of caudate nucleus

Body of caudate nucleus

Thalamus

(Top) Image more superior shows basal ganglia & thalamus. Occasionally, a single large thalamoperforator artery,
called artery of Percheron or paramedian thalamic artery, supplies both medial thalami & can result in bilateral
medial thalamic infarcts. This condition may mimic neoplasm such as lymphoma or glioma on imaging. (Middle)
This image shows superior thalamus & superior aspects of caudate head & putamen. Anterior limb of internal capsule
separates caudate head from putamen, while posterior limb separates thalamus from globus pallidus & putamen.
(Bottom) Image at level of centrum semiovale shows caudate nucleus as it wraps around lateral ventricles.
Huntington disease is characterized by an inability to prevent unwanted movement. Caudate head becomes
atrophied in this disease making a "box-car" appearance of frontal horns of lateral ventricles.
7
 BASAL GANGLIA AND THALAMUS
C CORONAL STIR MR
('lj
I....
CO
('lj

Body, corpus callosum

Head of caudate nucleus

Internal capsule
Putamen
External capsule
Claustrum
Extreme capsule
Insula

Body, corpus callosum

Head of caudate nucleus
Internal capsule Putamen
External capsule Globus pallidus
Extreme capsule
External medullary lamina
Anterior commissure

Body, corpus callosum Head of caudate nucleus

Thalamus
Internal capsule
Putamen
Claustrum
External capsule
Insula
Extreme capsule Hypothalamus
External medullary lamina

(Top) First of six coronal STIR MR images from anterior to posterior shows caudate head continuous with inferior
putamen immediately above anterior perforated substance. Other connections between caudate & putamen can be
seen along course of anterior limb of internal capsule. (Middle) Image through anterior commissure shows decreased
signal of globus pallidus relative to putamen related to increased iron deposition in globus pallid us. Putamen is
separated from globus pallidus by external medullary lamina. Globus pallidus contains two segments, lateral &
medial, which are not resolved on conventional imaging. (Bottom) Image through anterior limb internal capsule.
The insula lies deep in floor of sylvian fissure & is overlapped by the operculum. Insula has many connections with
thalamus & amygdala, as well as with olfactory & limbic systems.
74
 BASAL GANGLIA AND THALAMUS
CORONAL STIR MR C::l
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Subthalamic nucleus

Body, corpus callosum Body of caudate nucleus

Thalamus

Cerebral peduncle Substantia nigra

Body, corpus callosum

Thalamus

(Top) Image more posterior through thalamus shows approximate location of subthalamic nucleus which is a
biconvex, lens-shaped nucleus medial to internal capsule & superolateral to red nucleus. Subthalamic nucleus plays
major role in normal function of basal ganglia. Pathologically, subthalamic nucleus is associated with Parkinson
disease & ballism. (Middle) Image through thalamus shows pigmented, dopaminergic neurons of substantia nigra.
Parkinson disease is most common pathologic condition of basal ganglia, related to degeneration of dopaminergic
neurons of substantia nigra & secondary depletion of dopamine in putamen & caudate. (Bottom) Image through
thalamus shows pulvinar which occupies posterior third of thalamus. Pulvinar function is poorly understood, but it
is thought to be an integration nucleus.
75
 LIMBIC SYSTEM
ITerminology
Definitions
• Limbic lobe
o Phylogenetically older cortex
o Fewer layers than neocortex
o Major role in memory, olfaction, emotion
o Composed of subcallosal, cingulate,
parahippocampal gyri + hippocampus, dentate
gyrus, subiculum, entorhinal cortex
• Limbic system
o Limbic lobe
o Plus some subcortical structures (e.g., amygdala,
mammillary bodies, septal nuclei, etc.)
I Gross Anatomy
Overview
• Limbic lobe formed by nested "C-shaped" arches of
tissues surrounding diencephalon, basal ganglia
• Outer arch
o Largest of the three arches
o Extends from temporal to frontal lobes, comprised
of
• Uncus (anterior end of parahippocampal gyrus)
• Parahippocampal gyrus (swings medially at
posterior temporal lobe, becomes isthmus of
cingulate gyrus)
• Cingulate gyrus (anterosuperior continuation of
parahippocampal gyrus)
• Subcallosal (paraolfactory area) is anteroinferior
continuation of cingulate gyrus
o Curves above callosal sulcus (continuous with
hippocampal sulcus of temporal lobe)
• Middle arch
o Extends from temporal to frontal lobes, comprised
of
• Hippocampus proper (Ammon horn)
• Dentate gyrus
• Supracallosal gyrus (indusium griseum, a thin strip
of gray matter that extends from
dentate/hippocampus all the way around corpus
callosum to paraterminal gyrus)
• Paraterminal gyrus (below corpus callosum
rostrum)
o Curves over corpus callosum, below callosal sulcus
• Inner arch
o Smallest arch
o Extends from temporal lobe to mamillary bodies
o Comprised of fornix, fimbria
I Imaging Anatomy
Overview
• Hippocampus
o Curved structure on medial aspect of temporal lobe
that bulges into floor of temporal horn
o Consists of two interlocking "U-shaped" gray matter
structures
• Hippocampus proper (Ammon horn) forms more
superolateral, upside-down U
• Dentate gyrus forms inferomedial U
o Has three anatomic subdivisions
• Head (pes hippocampus): Most anterior part,
oriented transversely; has 3-4 digitations on
superior surface
• Body: Cylindrical, oriented parasagittally
• Tail: Most posterior portion; narrows then curves
around splenium to form indusium griseum above
corpus callosum (CC)
• Ammon horn (hippocampus proper)
o Subdivided into four zones (based on histology of
main cell layers)
• CA 1 (Sommer sector): Small pyramidal cells (most
vulnerable; commonly affected by anoxia, mesial
temporal sclerosis)
• CA2: Narrow, dense band of large pyramidal cells
("resistant sector")
• CA3: Wide loose band of large pyramidal cells
• CA4 (end-folium): Loosely structured inner zone,
enveloped by dentate gyrus
o Blends laterally into subiculum
• Subiculum forms transition to neocortex of
parahippocampal gyrus (entorhinal cortex)
o Covered by layer of efferent fibers, the alveus
• Alveus borders temporal horn of lateral ventricle
ventricle
• Forms fimbria - crus of fornix
• Fornix
o Primary efferent system from hippocampus
o Four parts
• Crura (arch under CC splenium, form part of
medial wall of lateral ventricles)
• Commissure (connects crura)
• Body (formed by convergence of crura, attached to
inferior surface of septum pellucidum)
• Columns (curve inferiorly to mammillary bodies,
anterior thalamus, mamillary bodies, septal
nuclei)
• Amygdala
o Large complex of gray nuclei medial to uncus, just
in front of temporal horn of lateral ventricle
o Tail of caudate nucleus ends in amygdala
o Major efferent is stria terminalis
• Stria terminalis arches in sulcus between caudate
nucleus, thalamus
• Forms one margin of choroid fissure (other is
fornix)
IAnatomy-Based Imaging Issues
Imaging Recommendations
• MR is best performed in a slightly oblique plane,
perpendicular to long axis of hippocampus
o Coronal T1 volume images (SPGR): 1-3 mm
o Coronal T2 high-resolution: 2.5-3 mm
o Coronal FLAIR whole brain: 4-5 mm
Imaging Pitfalls
• Normal variant is incomplete fusion of hippocampal
sulcus - CSF-containing "cysts" along medial
hippocampus

76
77
78
 LIMBIC SYSTEM
CORONAL T1 MR l:l:'
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(j)

Septum pellucidum ""0

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r-+
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r-+
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o
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Third ventricle Hypothalamus
Amygdala
Uncus
Temporal horn
Hippocampal head

Cingulate gyrus

Septum pellucidum
Body of fornix

Mamillary bodies Amygdala

Uncinate gyrus
Uncal recess of temporal horn
Hippocampal head
Parahippocampal gyrus

Cingulate gyrus

Septum pellucidum
Body of fornix

Alveus

Temporal horn
Hippocampal body
Ambient cistern
Parahippocampal gyrus

Collateral sulcus

(Top) First of six coronal Tl MR images through limbic system from anterior to posterior. Note amygdala lies anterior
& superior to hippocampus, at medial aspect of temporal lobe, just lateral to the uncus. Tail of caudate nucleus ends
in amygdala. Pes hippocampus (hippocampal head) lies just posterior to amygdala. Anterior commissure contains
crossing fibers of temporal cortex, amygdala & stria terminales. (Middle) A more posterior image through third
ventricle shows digitations of the hippocampal head (pes hippocampus). The hippocampus is separated from
amygdala by uncal recess of temporal horn. The uncinate gyrus connects medial hippocampus with amygdala.
(Bottom) More posterior image shows hippocampal body with loss of hippocampal head digitations. Hippocampal I
body is bordered medially by ambient cistern & laterally by temporal horn of lateral ventricle.
79
 LIMBIC SYSTEM
CORONAL T1 MR

Cingulate gyrus

Crus of fornix

Tail of caudate
Body of hippocampus
Hippocampal fissural cyst

Ambient cistern

Cingulate gyrus
Indusium griseum

Crus of fornix

Tail of hippocampus
Hippocampal fissural cyst

Cingulate gyrus

Splenium of corpus callosum

Occipital horn
Hippocampal commissure
Crus of fornix
Fimbria
Hippocampal tail

(Top) A more posterior image through mid thalamus shows crura of fornices which join anteriorly to form body of
fornix. The body of hippocampus typically shows the normal internal architecture of hippocampus. In this case,
there are hippocampal fissural cysts bilaterally which mildly distort the typical architecture. These cysts are benign &
represent partially unfused hippocampal sulcus. (Middle) Image at posterior thalamus shows tail of hippocampus.
Tail is narrowest portion of hippocampus as it extends posteriorly. Indusium griseum may be the tiny area of gray
matter above corpus callosum. (Bottom) Image through splenium of corpus callosum shows fimbria as it becomes
crus of fornix. The crus attaches to anterior surface of splenium of corpus callosum. At inferior corpus callosum, the
two crus of fornix unite to form commissure of fornix (hippocampal commissure).
80
 LIMBIC SYSTEM
CORONAL T2 MR OJ
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Column of fornix C
""0

....•
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r-+
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Temporal horn
Parahippocampal gyrus

Collateral sulcus

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Red nucleus
Subthalamic nucleus

Hippocampal body Alveus

Collateral white matter Parahippocampal gyrus
Substantia nigra

Body of fornix

Fimbria
Choroidal fissure Alveus

Temporal horn Stratum radiata

Parahippocampal gyrus

Collateral sulcus

(Top) First of six coronal T2 MR images through limbic system from anterior to posterior. Hippocampal head (pes
hippocampus) is recognized by digitations on its superior surface. Amygdala is separated from hippocampus by uncal
recess of temporal horn or alveus of hippocampus. (Middle) Image more posterior shows body of hippocampus
which loses digitations seen in head. Body of fornix arcs over thalamus to split into two anterior columns which
curve anterior to foramen of Monro & send fibers to mamillary bodies, anterior thalamus & septal region. (Bottom)
More posteriorly, hippocampal body is seen with its normal architecture. The stratum radiata primarily makes up
white matter between Ammon horn & dentate gyrus. Loss of this normal architecture is one of major features of
mesial temporal sclerosis. Other major features are bright T2 signal & atrophy.
81
 LIMBIC SYSTEM
c CORONAL T2 MR
~
~
CO
~
Crus of fornix

Third ventricle

Alveus
Hippocampal body
Stratum radiatum
Ambient cistern

Cingulate gyrus

Corpus callosum

Thalamus

Hippocampus

Splenium of corpus callosum Lateral ventricle

Hippocampal commissure
Crus of fornix
Fimbria

Hippocampal tail

(Top) Image more posteriorly through thalamus shows crus of fornix. Hippocampal body is seen with its normal
architecture, bordered laterally by temporal horn of lateral ventricle & medially by ambient cistern. In mesial
temporal sclerosis, the hippocampal body is affected in approximately 90% of patients. Typically CAI & CA4 regions
are most affected by mesial temporal sclerosis, although the entire Ammon horn & dentate gyrus may be involved.
(Middle) Image at posterior thalamus (pulvinar) shows transition of hippocampal body to hippocampal tail, the
most narrow portion of hippocampus. (Bottom) Image through splenium of corpus callosum shows fimbria arising
from hippocampus & becoming crus of fornix. Crus attach to anterior splenium. At inferior corpus callosum, two
I crus of fornix unite to form hippocampal commissure (commissure of fornix).
82
 LIMBIC SYSTEM
CORONAL T2 MR t:l:l
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Amygdala :J
r-+
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Temporal horn
Ambient cistern

Collateral white matter

Collateral sulcus

Amygdala
Mamillary body
Alveus
Uncinate gyrus
Temporal horn
Hippocampal sulcus Hippocampal head
Parahippocampal gyrus Subiculum

Collateral white matter

Fimbria
Alveus
Hippocampal sulcus
Temporal horn
Ambient cistern Subiculum
Parahippocampal gyrus
Collateral white matter

Collateral sulcus

(Top) First of three high-resolution coronal T2 MR images through anterior aspect of limbic system. Amygdala is
anterior & superior to head of hippocampus. Amygdala is separated from hippocampus by alveus or uncal recess of
temporal horn. (Middle) Image at hippocampal head shows typical digitations at superior margin. Note uncinate
gyrus which connects medial hippocampus with amygdala. Mamillary body is well seen along the inferior third
ventricle. Mamillary body may be atrophied in severe cases of mesial temporal sclerosis as can the fornix. (Bottom)
Image at hippocampal body shows normal hippocampal architecture. Hippocampal sulcus is typically closed in adult
patients, as seen here. Parahippocampal gyrus (entorhinal cortex) continues as cingulate gyrus under splenium of
corpus callosum & above body of corpus callosum as part of the limbic lobe. I
83
 LIMBIC SYSTEM
c AXIAL T2 MR
~
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CO
~

Uncus
Amygdala
Temporal horn Hippocampal head
Hippocampal fissural cysts
Hippocampal body

Mamillary body
Uncus
Amygdala
Uncal recess of temporal horn Hippocampal head
Hippocampal body
Hippocampal fissural cysts

Olfactory tract

Hypothalamus
Column of fornix
Inferior third ventricle
Subthalamic nucleus
Red nuclei Hippocampal tail

(Top) First of three axial T2 MR images from inferior to superior at level of cerebral peduncles shows hippocampus &
amygdala. Note failure of normal involution of hippocampal sulcus resulting in hippocampal fissural cysts
(hippocampal sulcus remnants). These cysts are usually bilateral & occur between dentate gyrus & Ammon horn. This
normal variant occurs in 10-15% of patients. (Middle) More superior image shows hippocampal head, body. Uncal
recess of temporal horn separates amygdala from hippocampus. Mamillary bodies lie in interpeduncular cistern.
Uncus forms lateral border of suprasellar cistern. (Bottom) Image through superior aspect of midbrain/inferior third
ventricle shows hypothalamus, fornix, olfactory tract. Hippocampal tail is seen curving posteriorly around midbrain.
Subthalamic nucleus is almond-shaped, lies anterolateral to red nucleus.
84
 LIMBIC SYSTEM
SAGITTAL T1 MR ..,
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Temporal horn Hippocampal tail

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Parahippocampal gyrus

Cingulate gyrus

Commissure of fornix

Thalamus
Anterior commissure

Hypothalamus

Mamillary body

Cingulate gyrus
Body of fornix

Column of fornix Thalamus

Subcallosal area
Hypothalamus Mamillary body

(Top) First of three sagittal T1 MR images from lateral to medial shows hippocampus & amygdala. Note thin
temporal horn which separates amygdala anteriorly from hippocampal head posteriorly. (Middle) A more medial
image shows commissure of fornix as it extends under body of corpus callosum. Anterior commissure is seen in cross
section as it crosses anterior to columns of fornix within anterior third ventricle. Anterior commissure divides into
small anterior bundle which connects anterior perforated substance & olfactory tracts, while larger posterior bundle
connects medial temporal gyrus, amygdala & stria terminalis. (Bottom) Midline sagittal image shows body of fornix
which divides at anterior thalamus to become columns of fornix. Fornix ends in anterior thalamus, mamillary body
& septal region. Cingulate gyrus continues anteriorly to become subcallosal area. I
85
 SELLA, PITUITARY AND CAVERNOUS SINUS
I Terminology
Abbreviations
• Adenohypophysis (AH); neurohypophysis (NH)
Synonyms
• Pituitary gland = hypophysis
I Gross Anatomy
Overview
• Sella (concave midline depression in basisphenoid)
o Anterior borders: Tuberculum sellae, anterior clinoid
processes of lesser sphenoid wing
o Posterior borders: Dorsum sellae, posterior clinoid
processes
o Dural reflections
• Diaphragma sellae covers sella
• Variable-sized central opening transmits
infundibulum
• Dura lines floor of hypophyseal fossa
• Hypophysis (pituitary gland)
o Adenohypophysis
• 80% of gland; wraps anterolaterally around NH
• Includes pars anterior (pars distalis or glandularis),
pars intermedia, pars tuberalis
• Function: Cells secrete somato-, lactogenic, other
hormones
• Vascular supply: Venous (portal venous via
hypothalamus)
o Pars intermedia
• < S% of pituitary, located between AH/NH
• Contains axons from hypothalamus,
infundibulum
• Function: Carries releasing hormones to AH, NH
o Neurohypophysis
• 20% of pituitary
• Includes pars posterior (nervosa), infundibular
stem, median eminence of tuber cinereum
• Contains pituicytes, hypothalamohypophysial
tract
• Function: Stores vasopressin, oxytocin from
hypothalamus
• Vascular supply: Arterial (superior and inferior
hypophyseal arteries)
• Cavernous sinuses (CS)
o Paired septated, dural-lined venous sinuses that lack
valves
• Communicate with each other, clival plexus via
intercavernous, basal venous sinuses; posteriorly
to transverse sinuses via superior petrosal sinuses
• Drain inferiorly to pterygoid venous plexi via
emissary veins, to IJV via inferior petrosal sinuses
• Thicker lateral, thinner medial dural walls enclose
CS, separate it from pituitary
• Posteriorly dural walls enclose Meckel cave
(arachnoid-lined, CSF-filled extension of
prepontine cistern; contains fascicles of CNS,
trigeminal ganglion)
o Venous tributaries
• Superior, inferior ophthalmic veins
• Sphenoparietal sinus
86
o Contents (venous blood, cranial nerves, ICAs +
sympathetic plexus)
• CN3 lies within superior lateral dural wall
• CN4 just below CN3
• VI (ophthalmic division of CNS) in lateral wall
below CN4
• V2 (maxillary division of CNS) is most inferior CN
in lateral CS wall
• V3 (mandibular division of CNS) does NOT enter
CS proper (passes from Meckel cave inferiorly into
foramen ovale)
• CN6 lies within CS proper, next to ICA
I Imaging Anatomy
Overview
• Hypophysis
o NH usually has short Tl (posterior pituitary "bright
spot") caused by vasopressin/oxytocin (NOT fat!)
o Gland enhances strongly, uniformly, somewhat < CS
• 1S-20% of normal patients have incidental
finding of "filling defects" on Tl C+ MR (cyst,
nonfunctioning microadenoma)
• CS (inconstantly visualized at DSA)
o Strong, uniform enhancement on CT, Tl C+ MR
o Lateral dural walls should be flat or concave
o Medial dural walls difficult to image even at 3T
IAnatomy-Based Imaging Issues
Imaging Recommendations
• MR for pituitary, hypothalamic imaging
o Coronal/sagittal, 2 mm, small FOV
• Pre-contrast Tl-, T2WI
• Tl C+ with fat-saturated helpful in differentiating
post-operative fat packing from enhancing tissue
o "Dynamic" scan with rapid bolus of contrast,
sequential scans sorted by slice q 10-12 secs
Normal Variants
• Normal size, configuration of pituitary varies with age,
gender
o s 6 mm children; 8 mm males, post-menopausal
females; physiologic hypertrophy with 10 mm upper
limit in young females (can bulge upwards); 12 mm
pregnant/lactating females
• "Empty" sella
o Protrusion of arachnoid, CSF into sella
o Normal pituitary becomes flatted, displaced
posteroinferiorly against sellar floor
o Rarely symptomatic (may be associated with
pseudotumor cerebri)
Imaging Pitfalls
• Paramedian ICAs ("kissing carotids") can mimic
intrasellar aneurysm, compress pituitary
• Anterior clinoid pneumatization may mimic ICA
aneurysms
• Asymmetric skull base marrow (short Tl) can mimic
pathology: Fat-saturated MR or CT resolves
• Suprasellar "bright spot" usually ectopic NH, less often
lipoma, etc.
87
c
ro
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88
 SELLA, PITUITARY AND CAVERNOUS SINUS
AXIAL T1 C+ MR a:l
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t/'J
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Maxillary nerve (V2) :J
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Trigeminal ganglion in floor of o
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Meckel cave
Petrous segment, internal
Clival venous plexus carotid artery

Inferior ophthalmic vein

Internal carotid artery

Meckel cave

Basilar artery Abducens nerve

Sphenoid sinus

Cavernous sinus
Floor of sella
Clival venous plexus Meckel cave

Trigeminal nerve Abducens nerve

(Top) Series of six axial contrast-enhanced Tl MR images presented from inferior to superior through skull base and
cavernous sinus demonstrate right maxillary nerve (V2) passing anteriorly into foramen rotundum and the left
trigeminal ganglion. The mandibular nerve (V3) will exit inferiorly through foramen ovale (not shown). (Middle)
Meckel cave is located posterior, inferior and lateral relative to cavernous sinus. Dura forming posterior part of lateral
wall of cavernous sinus also forms upper medial third of Meckel cave, separating the two structures. Note the
abducens nerve (CN6), seen here as a filling defect within the diva 1venous plexus, just before entering Dorello canal.
(Bottom) Both abducens nerves are seen coursing through Dorello canal to enter the posterior cavernous sinus. The
right trigeminal nerve is seen entering Meckel cave. ".
89
 SELLA, PITUITARY AND CAVERNOUS SINUS
c AXIAL T1 C+ MR
(\j
•....
CO
(\j

Superior orbital fissure

Anterior intercavernous sinus
Oculomotor (CN3) nerve
Pituitary gland Posterior intercavernous sinus

Cavernous sinus
Basilar plexus
Dorsum sella Superior petrosal sinus

Optic nerves (CN2) in optic canals

Internal carotid artery

Ophthalmic artery Anterior clinoid process

Infundibulum
Dorsum sellae
Prepontine cistern
Basilar artery

Optic chiasm
Infundibulum Supraclinoid internal carotid
artery
Suprasellar cistern

Interpeduncular cistern

(Top) Cranial nerves exiting the cavernous sinus through the superior orbital fissure are: CN3, 4, 6, and the firsl
(ophthalmic or VI) division of CNS. (Middle) The optic nerve in the optic canal is located anteromedial to the
anterior clinoid and superomedial to the superior orbital fissure (SOF). It is separated from the SOF by a thin bony
strut, the "optic strut." The cavernous carotid is posteromedial to the anterior clinoid. Note origin of the ophthalmic
artery from the internal carotid artery, just above the transition from intracavernous carotid (below) to intradural
carotid (above) segments. (Bottom) Pituitary infundibulum is seen within the suprasellar cistern posterior to the
optic chiasm; avid enhancement seen here is typical. The supra clinoid internal carotid artery (or terminal segment) is
I seen laterally.
90
 SELLA, PITUITARY AND CAVERNOUS SINUS
CORONAL T2 MR OJ
~
~
::J
V'l

Right anterior cerebral artery (AI

c
'"'0
....,
segment)
\l)
Left optic tract r-+-
(D
::J
r-+-
Suprasellar cistern o
....,
Trigeminal fascicles within
Meckel cave
Lateral dural wall of Meckel cave

Optic chiasm

Right middle cerebral artery (MI

Left anterior cerebral artery (AI
segment)
segment)
Infundibulum Left supraclinoid carotid artery

Internal carotid artery Trigeminal fascicles within

Meckel cave

Trigeminal (gasserian) ganglion

Suprasellar cistern

Optic chiasm
Infundibulum Left supraclinoid internal
cerebral artery
Pituitary
Left cavernous internal carotid
artery

Meckel cave

(Top) First of six sequential coronal T2 MR images presented from posterior to anterior demonstrate the optic tracts
within the posterior aspect of the suprasellar cistern, and anterior cerebral and supraclinoid internal carotid arteries.
(Middle) The posterior optic chiasm and part of the pituitary infundibulum are seen here. Note the internal carotid,
middle cerebral, and anterior cerebral arteries. Individual trigeminal nerve rootlets are well demonstrated within
Meckel cave on thin-section imaging. (Bottom) Image at the level of the optic chiasm within the suprasellar cistern
demonstrates normal pituitary gland and regional vascular anatomy. Note the normal location and appearance of
Meckel cave, seen inferior and lateral. The pituitary gland and venous blood within the cavernous sinus are nearly
isointense with each other on T2WIs.
91
 SELLA, PITUITARY AND CAVERNOUS SINUS
c CORONAL T2 MR
CI:l
"-
CO
CI:l

Anterior communicating artery Middle cerebral artery genu

Optic chiasm

Pituitary stalk Left oculomotor nerve

Pituitary
Floor of sella turcica

Meckel cave

Right anterior cerebral artery (A2

segment)
Left optic nerve

Left supraclinoid internal

Suprasellar cistern cerebral artery
Left oculomotor nerve
Pituitary Left cavernous internal carotid
artery

Basisphenoid
Right petrous carotid artery

Left optic nerve

Left anterior clinoid process

Right supraclinoid internal carotid
artery Cavernous internal carotid
artery (anterior genu)
Right cavernous internal carotid
artery

(Top) Normal appearance of the anterior pituitary gland, cavernous sinus, Meckel cave, and suprasellar cistern are
seen here. The oculomotor nerves (CN3), and optic nerves (CN2) are well seen. The anterior communicating artery,
which connects the two anterior cerebral arteries, and the left middle cerebral artery genu, are visible here. (Middle)
The most anterior aspect of the suprasellar cistern demonstrates normal optic nerves (CN2), oculomotor nerves
(CN3), cavernous internal carotid arteries, and anterior cerebral artery within the anterior interhemispheric fissure.
(Bottom) The anterior clinoid processes seen here form the anterolateral boundaries of the sella turcica. Note normal
optic nerves, located medial to the anterior clinoids, and the anterior genu of the cavernous internal carotid artery
on the left.
92
 SELLA, PITUITARY AND CAVERNOUS SINUS
CORONAL T1 C+ MR 0:1
""'l
~
:J
V'l
Optic chiasm c
-0
Infundibulum (pituitary stalk) ....•
upper aspect tl)
r-t'
(t)
:::l
r-t'
Posterior cavernous internal carotid o
artery Gasserian ganglion ....•
Meckel cave
Mandibular nerve (V3)
Petrous internal carotid artery

Left anterior cerebral artery (A1

segment)
Left middle cerebral artery (Ml
Optic chiasm segment)
Infundibulum (pituitary stalk) Supraclinoid left internal
Cavernous internal carotid artery carotid artery

Basisphenoid Pituitary gland

Petrous internal carotid artery

Left foramen ovale

Mandibular nerve (V3) exiting
foramen ovale

Optic chiasm

Infundibulum (pituitary stalk) Oculomotor nerve (CN3)

Cavernous internal carotid artery
Abducens nerve within
cavernous sinus sinusoids

Mandibular nerve (V3)

Nasopharyngeal/ adenoidal
tissue

(Top) First of six sequential contrast-enhanced T1 MR images through the sella, presented from posterior to anterior,
demonstrates detail of Meckel cave. The mandibular (V3) division of the trigeminal nerve is seen inferior to the
normally enhancing gasserian ganglion. (Middle) The pituitary infundibulum insertion into the gland is well seen
here. Note the mandibular nerve (3rd division of trigeminal nerve, or V3), best seen on the right, as it exits through
foramen ovale, entering the high masticator space. It is easy to see how extracranial tumors may gain access to the
intracranial compartment without destroying the skull base, either through direct extension or via perineural spread.
(Bottom) The left foramen ovale is well seen here. Note the third and sixth cranial nerves within the cavernous
sinus. All of the cranial nerves are not well seen on this image.
93
 SELLA, PITUITARY AND CAVERNOUS SINUS
c CORONAL T1 C+ MR
ro
~
CO
ro
Optic chiasm

Oculomotor nerve (CN3)

Trochlear nerve (CN4)
Abducens nerve (CN6)
Ophthalmic (VI) division of CNS Maxillary nerve (V2)

Pituitary gland

Anterior clinoid process

Oculomotor nerve
Trochlear nerve (CN4)
Cavernous internal carotid artery
Abducens nerve (CN6)
Sphenoid bone Maxillary nerve (V2)

Anterior cerebral artery Optic nerves

Anterior clinoid process

Oculomotor nerve
Ophthalmic nerve (VI)

Vidian canal
Sphenoid bone

Nasopharynx

(Top) This image demonstrates the oculomotor, abducens, and maxillary nerves. The pituitary gland enhances less
strongly than venous blood in the cavernous sinus. (Middle) Normal cranial nerves traversing the cavernous sinus
from superior to inferior include: Oculomotor nerve, trochlear nerve, abducens nerve, ophthalmic nerve (VI), and
maxillary nerve (V2). The fourth cranial nerve (trochlear) is small and difficult to visualize, but is normally located in
the lateral cavernous sinus, between the oculomotor and trigeminal nerves, lateral to the abducens. (Bottom) The
oculomotor nerve is again well seen in the anterior cavernous sinus, before it traverses the superior orbital fissure.
The vidian canal, which contains the vidian artery and nerve, is seen in the sphenoid bone. Note the optic nerves
medial to the anterior clinoids before entering the optic canals.
94
 SELLA, PITUITARY AND CAVERNOUS SINUS
SAGITTAL T2 MR l:O
"'"
~
::J
Vl
c
~....,
\:U
~
([)
::J
~
o
....,

Median eminence
Mammillary body(ies)

Optic chiasm

Interpeduncular cistern
Infundibulum
(pituitary stalk)

Pituitary gland

Clivus

Tuber cinereum

Mammillary body
Optic nerve

Pituitary gland

Clivus Basilar artery

(Top) First of four sequential fat-saturated sagittal T2 MR images, presented midline to lateral, depicts normal sellar
osseous boundaries: Sphenoid and clivus (floor), anterior clinoids anterolaterally, tuberculum sella anteriorly, dorsum
sella and posterior clinoids posteriorly. The pituitary sits in the sella, connected superiorly to the hypothalamus via
the pituitary infundibulum. Note the median eminence of hypothalamus, which forms part of the neurohypophysis.
(Bottom) The tuber cinereum of hypothalamus is located between the optic chiasm anteriorly and mammillary
bodies posteriorly. Its ventral aspect has small grooves and eminences but on imaging it should be smooth, flat, and
slightly convex inferiorly. Thickening or nodularity should raise suspicion for pathology. The infundibulum courses I
inferiorly from the tuber cinereum to the hypophysis.
95
 . SELLA, PITUITARY AND CAVERNOUS SINUS
c SAGITTAL T2 MR
ro
•...
CO
ro

Optic nerve (CN2)

Suprasellar cistern

Pituitary gland

Clivus

Anterior commissure
Posterior cerebral artery

Optic nerve entering Oculomotor nerve

optic canal (CN3)

Cavernous internal
carotid artery

(Top) The optic nerve traverses the suprasellar cistern. Note lack of sphenoid sinus pneumatization in this case, a
normal anatomical variant that may make transsphenoidal surgery more difficult. (Bottom) The optic nerve is seen
here entering the posterior aspect of the optic canal. The suprasellar and interpeduncular cisterns are normally in
communication, are appreciated here. Volume averaging of the cavernous internal carotid artery together with part
of the pituitary gland on off-midline images, as seen here, is common and should not be mistaken for abnormality.
The oculomotor nerve courses anteriorly between the posterior cerebral artery above and the superior cerebellar
artery below.

96
 SELLA, PITUITARY AND CAVERNOUS SINUS
SAGITTAL FAT-SATURATED T1 MR O:::l
-r
~
:J
(j)
C
"D
~
~
.....•.
([)
::l
.....•.
o
~

Optic chiasm
Midbrain

Infundibulum
(pituitary stalk)
Pons
Adenohypophysis
(anterior lobe, pituitary
gland)
Neurohypophyseal
"bright spot" Clivus

Tuber cinereum
Optic chiasm

Infundibulum
(pituitary stalk) Sphenoid sinus

Pituitary gland
Clival venous plexus

Nasopharyngeal
adenoidal tissue

(Top) Unenhanced sagittal Tl fat-saturated MR image through the midline sella turcica demonstrates Tl shortening
in the neurohypophysis (posterior pituitary "bright spot" or PPBS).The PPBSis caused by vasopressin and oxytocin,
not fat, and therefore does not suppress. Note prominent developmental sphenoid pneumatization in this case.
(Bottom) Enhanced sagittal Tl fat-saturated MR image through the midline in the same case shows normal pituitary
gland and stalk enhancement. The tuber cinereum and hypothalamus between the infundibulum and mammillary
bodies lacks a blood-brain barrier and also enhances. Note normal enhancement of the nasopharyngeal tissue and its
proximity to the central skull base.

97
 PINEAL REGION
o Inferior: Superior colliculi of midbrain tectum
ITerminology o Anterior: Pineal and suprapineal recesses, third
•... Synonyms ventricle
o
•... • Pineal gland, pineal body, epiphysis cerebri o Posterior and superior: Vein of Galen
c • Posterior commissure: Epithalamic commissure o Posterior and inferior: Superior cerebellar cistern
•...
Q)
(ij
•... Definitions
Q..
:J
• Epithalamus: Dorsal nuclei of diencephalon jlmaging Anatomy
(jJ
Overview
C
.-
tOO
I Gross Anatomy • Pineal gland lacks blood-brain barrier, enhances after
10..
contrast administration
CIQ Overview • CT
• Major components of pineal region o Pineal gland calcifications common, increase with
o Pineal gland age
o Posterior recesses of third ventricle • Globular or concentric lamellar patterns common
o Internal cerebral veins, vein of Galen; medial • Incidence increases with age « 3% at 1 year, 7%
posterior choroidal artery by 10 years, 33% by 18 years, > 50% of older
o Epithalamus, quadrigeminal plate (tectum), corpus patients)
callosum • Central calcifications normal, generally s 10 mm
o Dura, arachnoid • Larger, peripheral or "exploded" calcifications
• Pineal gland abnormal, may signify underlying neoplasm
o Unpaired midline endocrine organ located within o Habenular commissure sometimes calcifies
quadrigeminal cistern ("C-shaped" on lateral projections)
o Structure • MR
• Attached to diencephalon & posterior wall of o Homogeneous enhancement is typical
third ventricle by pineal stalk o Incidental, nonneoplastic intrapineal cysts common
• Pineal stalk consists of superior/inferior lamina • Usually proteinaceous (FLAIR bright)
(form superior & inferior borders of pineal recess • Enhancement can be nodular, crescentic or
of third ventricle) ring-like
• Superior/inferior lamina connect
habenular/posterior commissures, respectively, to
pineal gland IAnatomy-Based Imaging Issues
o Vascular supply: Primarily medial posterior
choroidal artery (lacks blood-brain barrier) Imaging Recommendations
o Contents: Pineal parenchymal cells, germ cells, some • MR: Thin-section enhanced sagittal images (l mm)
neuroglial cells (predominately astrocytes) and smaller field of view (16 cm) best
o Functions: Incompletely understood but include
Imaging Pitfalls
• Secretion of melatonin, thought to regulate
• Benign, nonneoplastic pineal cysts are common
sleep/wake cycle in humans
o Most appropriate management and follow-up
• Regulation of reproductive function, such as onset
recommendations are controversial
of puberty in humans
o Unilocular small simple cysts most common (on
• Pineal gland connections
routine imaging), usually do not require follow-up
o Habenular commissure: Connects habenular,
o Suggested follow-up if> 1 cm or atypical
amygdaloid nuclei and hippocampi
enhancement pattern; some authors suggest
o Posterior commissure: Connections with dorsal
follow-up based on clinical indications
thalamus, superior colliculi, pretectal nuclei and
o Large cysts can become symptomatic (cause
others; medial longitudinal fasciculus fibers also
cross here hydrocephalus or Parinaud syndrome)
• Pineal cysts may mimic tumors (pineocytoma) and
o Stria medullaris thalami: Fibers connecting both
vice versa
habenular nuclei
• Exophytic midbrain tecta I masses may mimic primary
o Habenular nuclei: Relay station for olfactory centers,
pineal region tumors (pineal tumors usually compress
brain stem, and pineal
tectum and displace it inferiorly)
o Paraventricular nuclei: Connections with
hypothalamus, hippocampus, amygdala, brain stem, Clinical Implications
septal nuclei and stria terminalis • Parinaud syndrome
o Superior cervical ganglia sympathetic fibers o Dorsal midbrain or collicular syndrome caused by
o Dorsal tegmentum nonadrenergic tract mass in pineal region compressing tectal plate
Anatomy Relationships o Loss of vertical gaze; nystagmus on attempted
convergence; pseudo-Argyll-Robertson pupil
• Pineal gland boundaries
o Superior: Cistern of velum interpositum and internal • "Pineal apoplexy"
o Sudden onset severe headache, visual problems
cerebral veins
o Hemorrhage into pineal cyst or neoplasm

98
99
 PINEAL REGION
c CORONAL T2 MR
Cij
"-
CO
Cij

Fornices

Internal cerebral veins

Basal vein of Rosenthal

Pineal gland
Left superior colliculus
Left inferior colliculus

Right internal cerebral vein

Pineal gland
Right superior colliculus

Crus of right fornix Internal cerebral veins

Supra pineal recess of third

Pineal gland ventricle
Left superior colliculus

(Top) First of three coronal T2 MR images, presented sequentially from posterior to anterior, is seen at the level of
the superior and inferior colliculi and posterior pineal gland. (Middle) Image through body of pineal gland
demonstrating multiple small cysts within the gland, a common finding on high-resolution scans. The pineal is
located just above the superior colliculi of the midbrain tectum. Exophytic tectal masses can be difficult to
distinguish from pineal origin masses because of this proximity; thin slice sagittal and/or coronal imaging best
evaluates this area in this situation. (Bottom) The suprapineal recess of third ventricle is seen here as a small
fluid-filled space located between the pineal gland inferiorly and internal cerebral veins superiorly. The internal
cerebral veins traverse the cistern of the velum interpositum.
100
 PINEAL REGION
SAGITTAL T2 MR o::l
-,:
~
:J
Cistern of the velum
Cfl
interpositum C
Internal cerebral vein
Suprapineal recess of third U
.....•
ventricle ~
r-+
Habenular commissure ('D
Vein of Galen
:J
r-+
Pineal recess Pineal gland o
.....•
Posterior commissure
Tectum (quadrigeminal plate)

Internal cerebral vein within

cistern of velum interpositum
Habenular commissure
Vein of Galen
Inferior lamina of pineal stalk Pineal gland

Quadrigeminal cistern
Superior cerebellar cistern

Confluence of basal vein &

vein of Galen
Pineal gland (margin)
Superior colliculus
Inferior colliculus

(Top) Series of three sagittal T2 MR images presented from medial to lateral. Midline section through the pineal
gland demonstrates multiple small cysts, commonly seen with high-resolution imaging. Note the habenular and
posterior commissures, which are connected to the pineal by the superior and inferior lamina, respectively. The
posterior recesses of the third ventricle are well seen here: The supra pineal recess just above the pineal gland, and the
pineal recess immediately anterior to the gland. (Middle) Note the normal pineal location just superior to the
tectum. The inferior lamina is seen here, connecting the pineal gland and posterior commissure. Internal cerebral
veins drain into the posteriorly located vein of Galen. (Bottom) The lateral aspect of the pineal gland is
demonstrated here. Note the superior and inferior colliculi of the midbrain tectum.
101
SECTION 3: Infratentorial Brain

Brainstem and Cerebellum Overview 1-104

Midbrain 1-114
Pons 1-120
Medulla 1-128
Cerebellum 1-132
Cerebellopontine Angle/lAC 1-140
 BRAINSTEM AND CEREBELLUM OVERVIEW
ITerminology
Abbreviations
• Cerebrospinal fluid (CSF)
• Cranial nerves (CN): Oculomotor nerve (CN3),
trochlear nerve (CN4), trigeminal nerve (CNS),
abducens nerve (CN6), facial nerve (CN?),
vestibulocochlear nerve (CN8), glossopharyngeal nerve
(CN9), vagus nerve (CNIO), accessory nerve (CNll),
hypoglossal nerve (CNI2)
Synonyms
• Classical nomenclature (simplified nomenclature)
o Superior (tentorial), inferior (suboccipita!), anterior
(petrosal) cerebellar surfaces
o Primary (tentorial), horizontal (petrosal),
prebiventral/prepyramidal (suboccipital) cerebellar
fissures
Definitions
• Posterior fossa: Houses brainstem and cerebellum,
below tentorium cerebelli (infratentorial)
• Brainstem: Composed of midbrain (mesencephalon),
pons and medulla oblongata
• Cerebellum: Largest part of hindbrain, integrates
coordinations & fine-tuning of movement &
regulation of muscle tone
I Gross Anatomy
Overview
• Posterior fossa: Infratentorial contents
o Protected space surrounded by calvarium, contains:
• Brainstem anteriorly, cerebellum posteriorly
• Cerebral aqueduct and fourth ventricle
• CSF cisterns containing CNs, vertebrobasilar
arterial system and veins
o CSF cisterns suspend & cushion brainstem and
cerebellum
• Brainstem
o Anatomic divisions
• Midbrain (mesencephalon): Upper brainstem,
connects pons and cerebellum with forebrain
• Pons: Mid portion of brainstem, relays
information from brain to cerebellum
• Medulla: Caudal (inferior) brainstem, relays
information from spinal cord to brain
o Functional divisions
• Ventral part: Contains large descending white
matter tracts: Midbrain cerebral peduncles,
pontine bulb, medullary pyramids
• Dorsal part: Tegmentum, common to midbrain,
pons and medulla; contains CN nuclei and
reticular formation
• Cerebellum
o Two hemispheres & midline vermis, three surfaces
o Connected to brainstem by three paired peduncles
o Cortical gray matter, central white matter & four
paired deep gray nuclei
Anatomy Relationships
• Posterior fossa boundaries
o Tentorium cerebelli superiorly
104
o Bony clivus anteriorly
o Temporal bones and calvarium laterally
o Foramen magnum and calvarium inferiorly
• Mtdbraid
o Ventral: Cerebral peduncles (crus cerebri)
containing corticospinal, corticobulbar and
corticopontine tracts
o Dorsal tegmentum: Ventral to cerebral aqueduct
• White matter tracts: Medial longitudinal
fasciculus, medial lemniscus, lateral lemniscus,
spinothalamic tract, central tegmental tract
• Gray matter: Substantia nigra and red nucleus
• Upper midbrain: Contains CN3 nucleus, at
superior colliculus level
• Lower midbrain: Contains CN4 nucleus, at
inferior colliculus level
o Tectum (quadrigeminal plate): Dorsal to cerebral
aqueduct
• Superior & inferior colliculi
• Periaqueductal gray matter
• Pons
o Ventral: Longitudinal fibers primarily from
corticospinal, corticobulbar & corticopontine tracts
I o Dorsal tegmentum: White matter tracts & CN nuclei
• White matter tracts: Medial longitudinal fasiculus,
medial lemniscus, lateral lemniscus, trapezoid
body, spinothalamic tract, central tegmental tract
• Upper pons: Contains main nuclei of CNS
• Lower pons: Contains nuclei of CN6, ? & 8
• Medulfa
o Ventral: Olives & pyramids
o Dorsal tegmentum: White matter tracts & CN
nuclei
• White matter tracts: Medial longitudinal fasiculus,
medial lemniscus, spinothalamic tract, central
tegmental tract, spinocerebellar tract
• CN nuclei: CN9, 10 & 11 (bulbar portion) in upper
& mid medulla; CN12 nuclei in mid medulla
• Cerebellum
o Three surfaces: Superior (tentorial), inferior
(suboccipital), anterior (petrosal)
o Two hemispheres and a midline vermis
• Divided into lobes & lobules by transverse fissures
• Major fissures: Primary (tentoria!), horizontal
(petrosal), prebiventral/prepyramidal
(suboccipital) cerebellar fissures
o Three paired peduncles
• Superior cerebellar peduncle (brachium
conjunctivum) connects to cerebrum via midbrain
• Middle cerebellar peduncle (brachium pontis)
connects to pons
• Inferior cerebellar peduncle (restiform body)
connects to medulla
• Vertebrobasilar system
o Midbrain: Perforating branches from basilar,
superior cerebellar & posterior cerebral arteries
o Pons: Superior cerebellar artery, perforating branches
of basilar artery
o Medulla: Anterior spinal artery, vertebral artery
penetrating branches, posterior inferior cerebellar
artery
o Cerebellum: Superior cerebellar, posterior inferior
cerebellar & anterior inferior cerebellar arteries
105
 BRAINSTEM AND CEREBELLUM OVERVIEW
c AXIAL T2 MR
(\j
"-
CO
(\j

o
"-
.•....•
c Clivus
Q)
.•....•
(\j
"-
'-+-
C Vertebral artery /
'Junction of cervical spina.l cord &/
-medulli
Cerebellar tonsil

Inferior cerebellar hemisphere

Clivus

MeduiIary pyramid
Vertebral artery
Medullary olive'

Dorsal median sulcus I'

Cerebellar tonsil i
Inferior cerebellar hemisphere

Medullary cistern
Medullary pyramid J
Pre-olivary sulcus /
Medullary olive ' Postolivary sulcus;

Hypoglossal eminence
Inferior fourth ventricle
Cerebellar tonsil i

Inferior cerebellar hemisphere

(Top) First of nine axialT2 MR images from inferior to superior shows inferior posterior fossa at junction of cervical
spinal cord & medulla. Cerebellar tonsils are seen at foramen magnum. (Middle) Image at level of inferior "closed"
medulla shows ventral (anterior) medullary pyramids & olives which include white matter fibers from corticospinal
& corticobulbar tracts which continue through ventral pons & ventral midbrain. Dorsal median sulcus continues
superiorly to divide floor of fourth ventricle. (Bottom) Image of mid medulla shows hypoglossal eminence, formed
by hypoglossal nerve CN12 nucleus as a bulge in fourth ventricular floor. CN12 exits anterolateral medulla in
pre-olivary sulcus while glossopharyngeal CN9, vagus CNlO, & cranial roots of accessory CNll nerves exit lateral
medulla in postolivary sulcus, posterior to medullary olive.
106
 BRAINSTEM AND CEREBELLUM OVERVIEW
AXIAL T2 MR C:::l
"""I
~
:J

Basilar artery Abducens nerve (CN6)

Flocculus Anterior inferior cerebellar

artery

Inferior cerebellar peduncl~

Cerebellar tonsil
Inferior fourth ventricle
Cerebellar vermis
Inferior cerebellar hemisphere

Meckel cave Pons

Trigeminal nerve (CNS)

Cerebellopontine angle cistern
Cerebellar flocculus
Middle cerebellar peduncle
Facial colliculus
Nodulus
Dentate nucleus

Cerebellar vermis

Prepontine cistern Basilar artery

Corticospinal tracts
Pons

\ledialiongitudinal fasciculus
Superior cerebellar peduncle Fourth ventricle

Sigmoid sinlls

Cerebellar vermis

(Top) Image more superiorly at pontomedullary junction shows inferior cerebellar peduncles (restiform body) where
cochlear nuclei of vestibulocochlear nerve CNH are found. Abducens nerve (CN6) exits anteriorly at pontomedullary
junction. Anterior inferior cerebellar artery, which arises from basilar artery, is seen looping in region of internal
auditory canal. (Middle) Image at mid pons shows middle cerebellar peduncles (brachium pontis), major cerebellar
peduncle. Facial colliculus, formed by axons of facial nerve CN? looping around abducens nucleus CN6, creating
bulge in floor of fourth ventricle. Trigeminal nerve CNS is seen as it courses toward Meckel cave. Dentate nucleus is
only cerebellar nucleus that is seen on imaging. (Bottom) Image at superior pons shows superior cerebellar peduncles
(brachium conjunctivum). Corticospinal tracts are present in ventral pons.
107
 BRAINSTEM AND CEREBELLUM OVERVIEW
c AXIAL T2 MR
(Ij
•....
CO
(Ij
•....
..--oc Basilar artery
Q)
..--
(Ij
Corticospinal tracts
•....
'+- Ambient cistern
C
Medial longitudinal fasciculus
Superior fourth ventricle

Cerebellar vermis

Superior cerebellar hemisphere

Transverse sinus

Interpeduncular cistern
Cerebral peduncle

Trochlear nucleus CN4 Trochlear nerve (CN4)

Inferior colliculus Superior medullary velum

Cerebellar vermis

Cerebral peduncle Substantia nigra

Oculomotor nucleus CN3 Red nucleus

Cerebral aqueduct Periaqueductal grey

Superior colliculus

Cerebellar vermis

(Top) Image more superiorly shows junction of pons & midbrain. Major white matter tracts including corticospinal
tracts & medial longitudinal fasciculus are known by typical location, but are not directly seen. (Middle) Image at
inferior midbrain shows interpeduncular fossa where oculomotor nerve CN3 exits. Trochlear nucleus CN4 is present
in paramedian gray matter, just dorsal to medial longitudinal fasciculus, approximate location shown. CN4
decussates in superior medullary velum & is seen exiting dorsally & wrapping around midbrain in ambient cistern.
(Bottom) Image of superior midbrain shows cerebral peduncles where major white matter tracts including
corticospinal tracts travel. Major pigmented gray nuclei, substantia nigra & red nucleus are seen. Oculomotor nerve
CN3 nucleus is present at level of superior colliculus, approximate location shown.
108
 BRAINSTEM AND CEREBELLUM OVERVIEW
AXIAL T1 MR o::l
~
~
~

Vertebral artery
Medullary pyramid
Jugular foramen
Medullary olive

Cerebellar tonsil

Cerebellar vermis

Basilar artery

Cerebellar flocculus
Inferior cerebellar peduncle
Cerebellar tonsil

Cerebellar vermis

Basilar artery
Cochlea
Vestibule
Facial (CN?) &
vestibulocochlear (CN8) nerves
Middle Cerebellar Peduncle
Nodulus of vermis
Cerebellar tonsil
Cerebellar white matter
Cerebellar vermis

(Top) First of six axial Tl MR images from inferior to superior through posterior fossa at level of medulla. Dorsal
medulla (tegmentum) contains cranial nerve nuclei & white matter tracts which can be identified by typical location,
but are not directly visualized. (Middle) Image at level of superior medulla/pontomedullary junction shows inferior
cerebellar peduncles (restiform body) where cochlear nuclei arise. Cerebellar flocculus is a common pseudolesion.
(Bottom) Image at level of lower pons shows facial nerve CN? & vestibulocochlear nerve CN8 coursing towards
interior auditory canal. Nodulus of vermis may protrude into fourth ventricle & cause a pseudolesion. Middle
cerebellar peduncle (brachium pontis) is major cerebellar peduncle & contains fibers from pontine nuclei.

109
 BRAINSTEM AND CEREBELLUM OVERVIEW
c AXIAL T1 MR
C"Cl
•....
ro
C"Cl
•....
o
+-'
C Basilarartery Prepontine cistern
(J)
+-'
C"Cl Trigeminal nerve (CNS)
•....
'+-
C
Middle cerebellar peduncle
Fourth ventricle Facialcolliculus
Nodulus of vermis

Cerebellarvermis

Basilarartery Prepontine cistern

Corticospinal tracts

Medial longitudinal fasciculus

Fourth ventricle Superior cerebellarpeduncle
Cerebellarvermis

Superior cerebellarhemisphere

Interpeduncular cistern

Cerebral peduncle Substantial nigra

Oculomotor nucleus CN3
Cerebral aqueduct Periaqueductal grey
Superior colliculus

Superior cerebellarvermis

(Top) Image more superiorly through mid pons shows middle cerebellar peduncles & trigeminal nerve CNS. Facial
colliculus represents axons of facial nerve CN? wrapping around nucleus of abducens nerve CN6. (Middle) Image at
superior pons shows superior cerebellar peduncle (brachium conjunctivum). Approximate location of medial
longitudinal fasciculus is shown, just lateral to midline, which is important in extraocular muscle movement & head
location. (Bottom) Image through midbrain at superior colliculus shows approximate location of oculomotor nerve
CN3 nucleus. Cerebral peduncles (crus cerebri) contain descending white matter tracts from cerebral hemispheres
including corticospinal, corticobulbar & corticopontine tracts. Periaqueductal grey surrounds cerebral aqueduct.

110
 BRAINSTEM AND CEREBELLUM OVERVIEW
CORONAL T2 MR O:l
-:
~
::J

Cerebral peduncle

Tentorium
Superior cerebellar hemisphere
~
Horizontal/petrosal fissure Middle cerebellar peduncle
CO
.....•
Inferior cerebellar hemisphere ~
:J
Cerebellar tonsil

Cisterna magna

Cerebral peduncle

Tentorium
Superior cerebellar hemisphere

Horizontal/petrosal fissure Middle cerebellar peduncle

Cerebellar flocculus
Inferior cerebellar hemisphere
Medulla
Cerebellar tonsil

Interpeduncular cistern
Cerebral peduncle
Trigeminal nerve (CNS)
Pons
Facial nerve (CN?) Anterior inferior cerebellar
Vestibulocochlear nerve (CN8) artery

Cerebellar flocculus
Medulla
Vertebral artery
Posterior inferior cerebellar
artery

(Top) First of six coronal T2 MR images through posterior fossa from posterior to anterior shows prominent
horizontal (petrosal) fissure of cerebellum which extends from middle cerebellar peduncle onto inferior (suboccipital)
surface of cerebellum. (Middle) This image shows continuation of midbrain, pons & medulla. Cerebral peduncles
contain corticospinal & other white matter tracts which are continuous with anterior (ventral) pons white matter
tracts & continue to extend to medullary pyramids in ventral medulla. (Bottom) Image through brain stem at level of
internal auditory canals. Trigeminal nerve is seen arising from lateral pons. Facial CN? & vestibulocochlear CN8
nerves are seen coursing in cerebellopontine angle to internal auditory canal. Vertebrobasilar system is seen which
supplies vast majority of brainstem & cerebellum.
111
 BRAINSTEM AND CEREBELLUM OVERVIEW
c CORONAL T2 MR
<\l
l-
ce
<\l
I- Oculomotor nerve (CN3)
o
+-' Cerebral peduncle
C
Q)
+-' Trigeminal nerve (CNS)
<\l Pons
l-
'-+-
C
Internal auditory canal Anterior inferior cerebellar
Cerebellopontine angle cistern artery

Medulla
Vertebral artery
Posterior inferior cerebellar
artery

Posterior cerebral artery

Oculomotor nerve (CN3)

Superior cerebellar artery
Pons
Trigeminal nerve (CNS)
Cochlea
Cerebellopontine angle cistern

Vertebral artery

Posterior cerebral artery

Oculomotor nerve (CN3)
Superior cerebellar artery
Pons Trigeminal nerve (CNS)

Cerebellopontine angle cistern Basilar artery

Vertebral artery

(Top) Image more anteriorly shows anterior aspect of pons, pons belly or bulb, which contains multiple transverse
pontine fibers & descending tracts. Vertebral arteries form basilar artery in region of pontomedullary junction.
Posterior inferior cerebellar artery arises from vertebral artery & has a reciprocal relationship with anterior inferior
cerebellar artery which arises from basilar artery. (Middle) This image shows oculomotor nerve CN3 coursing
between posterior cerebral artery above & superior cerebellar artery below. (Bottom) Image through anterior pons
shows trigeminal nerve CNS entering porus trigeminus of Meckel cave. Basilar artery is seen coursing along anterior
surface of pons giving rise to superior cerebellar & posterior cerebral arteries. Pons is supplied by perforating branches
from basilar artery & superior cerebellar artery branches.
112
 BRAINSTEM AND CEREBELLUM OVERVIEW
SAGITTAL T2 MR CO
'""'l
~
:::::l

Tentorium
Tectum
Primary/tentorial fissure
Flow void within cerebral aqueduct
Midbrain Horizontal/petrosal fissure

Prepyra ill idal/ subocci pi tal

Pons fissure
Fourth ventricle

Medulla Tonsil

Cisterna magna

Superior colliculus

Primary/tentorial fissure
Inferior colliculus

Superior medullary velum

Horizontal/petrosal fissure
Inferior medullary velum

Pontomedullary junction
Cerebellar tonsil

Cisterna magna

Superior cerebellar hemisphere

Cerebellar white matter
Pons
Middle cerebellar peduncle Dentate nucleus

Inferior cerebellar hemisphere

(Top) First of three sagittal T2 MR images from medial to lateral shows midline posterior fossa structures situated
below tentorium cerebelli. Brainstem is anterior & separated from cerebellum by cerebral aqueduct & fourth
ventricle. Brainstem consists of midbrain (mesencephalon), pons & medulla. Major fissures of cerebellum separate
cerebellum & vermis into lobules. (Middle) Image just lateral of midline shows continuation of primary (tentorial) &
horizontal (petrosal) fissures dividing cerebellar hemisphere into lobules. Superior & inferior medullary velum makes
up roof of fourth ventricle. Superior & inferior colliculi of tectum are seen. (Bottom) Image more lateral shows white
matter core of cerebellum, arbor vitae (tree of life). Largest gray nucleus of cerebellum, dentate nucleus is visible.

113
 C MIDBRAIN
n:l
•....
co ITerminology o Central tegmental tract: Motor
n:l • Gray matter formations
•.... Abbreviations a Substantia nigra: Pigmented nucleus, extends
o
+-J • Cerebrospinal fluid (CSF) through midbrain from pons to subthalamic region,
C • Cranial nerves (CN): Oculomotor nerve (CN3), important in movement
Q)
+-J trochlear nerve (CN4) • Pars compacta: Contains dopaminergic cells
n:l (atrophied in Parkinson disease)
•....
...•...
c Synonyms • Pars reticularis: Contains GABAergic cells
• Midbrain, mesencephalon o Red nucleus: Relay and control station for
cerebellar, globus pallidus and corticomotor
Definitions impulses
• Midbrain: Portion of brainstem which connects pons • Important for muscle tone, posture, locomotion
and cerebellum with forebrain o Periaqueductal grey: Surrounds cerebral aqueduct
• Important in modulation of pain and defensive
behavior
I Gross Anatomy • Cranial nerve nuclei
o CN3 nuclei at superior colliculus level
Overview
• Paramedian, anterior to cerebral aqueduct
• "Butterfly-shaped" upper brainstem which passes • Motor nuclei consists of five individual motor
through hiatus in tentorium cerebelli
subnuclei that supply individual extraocular
• Composed of gray matter formations, CN nuclei muscles
(CN3-4) and white matter tracts
• Edinger-Westphal parasympathetic nuclei: Dorsal
• Three main parts to CN3 nucleus in periaquaductal grey
o Cerebral peduncles: White matter tracts
• CN3 fibers course anteriorly through midbrain to
• Continuous with pontine bulb and medullary exit at interpeduncular fossa
pyramids
a CN4 nuclei at inferior colliculus level
o Tegmentum: CN nuclei, gray matter nuclei, white
• Paramedian, anterior to cerebral aqueduct
matter tracts
• Dorsal to medial longitudinal fasciculus
• Continuous with pontine tegmentum • CN4 fibers course posteriorly around cerebral
• Ventral to cerebral aquedu<;t aqueduct, decussate in superior medullary velum
o Tectum (quadrigeminal plate): Superior and
• CN4 exits dorsal midbrain just inferior to inferior
inferior colliculi colliculus
• Dorsal to cerebral aqueduct • Reticular formation: Expands from medulla to rostral
• Midbrain connections midbrain
o Rostral (superior): Cerebral hemispheres, basal o Occupies central tegmentum
ganglia and thalami o Afferent and efferent connections
o Dorsal (posterior): Cerebellum
o Important in consciousness, motor function,
o Caudal (inferior): Pons respiration and cardiovascular control
• Cerebral aqueduct passes through dorsal midbrain
between tectum posteriorly and tegmentum Tectum (Quadrigeminal Plate)
anteriorly, connecting third and fourth ventricles • Superior coIIicuIi: Visual pathway
• Adjacent CSF cisterns • Inferior coIIiculi: Auditory pathway
o Interpeduncular: Anterior, contains CN3
o Ambient (perimesencephalic): Lateral, contains CN4
o Quadrigeminal plate: Posterior, contains CN4' I Imaging Anatomy
• Blood supply by vertebrobasilar circulation
a Small perforating branches from basilar, superior Overview
cerebellar and posterior cerebral arteries • CN3 & 4 seen as they exit midbrain
o CN3 at level of superior colliculus, seen in
Cerebral Peduncles (Crus Cerebri) interpeduncular fossa
• Corticospinal, corticobulbar & corticopontine fibers o CN4 at level of inferior colliculus, seen dorsally and
• Cerebral peduncles separated in midline by in ambient cistern as wraps around midbrain
interpeduncular fossa • Cerebral aqueduct: Signal varies due to flow artifact
Mesencephalic Tegmentum • CN nuclei and white matter tracts can be identified by
typical location, but are not resolved on imaging
• Directly continuous with pontine tegmentum,
contains same tracts • Substantia nigra and red nucleus well seen
• Multiple white matter tracts (not resolved on
conventional imaging)
a Medial longitudinal fasciculus: IAnatomy-Based Imaging Issues
Ocu 10motor -ves t ibu lar Imaging Recommendations
o Medial lemniscus: Somatosensory
• MR for cranial neuropathy or acute ischemia
o Lateral lemniscus: Auditory
• CT may be helpful in acute setting
a Spinothalamic tract: Somatosensory
• CTA and MRA for vertebrobasilar circulation

114
115
 MIDBRAIN
c AXIAL T1 MR
(Ij
~
CO
(Ij

Basilarartery
Corticospinal tracts
Decussation of superior
Medial longitudinal fasciculus cerebellar peduncle
Superiorfourth ventricle Superior cerebellarpeduncle

Suprasellarcistern

Interpeduncular cistern Cerebral peduncle

Ambient cistern
Trochlear nucleus (CN4)
Quadrigeminal plate cistern
Superior medullary velum

Suprasellarcistern

Interpeduncular cistern Cerebral peduncle

Ambient cistern
Trochlear nucleus (CN4)
Quadrigeminal plate cistern Inferior colliculus
Superior medullary velum

(Top) First of six axial Tl MR images of midbrain from inferior to superior shows junction of pons with inferior
midbrain. The brains tern tegmentum is dorsal & is common to all three parts of the brainstem: Medulla, pons &
midbrain. At pons level, tegmentum is covered by cerebellum, while at midbrain level, tectal plate (superior &
inferior colliculi) covers tegmentum. (Middle) Image through inferior midbrain shows location of trochlear nucleus
CN4, in paramedian midbrain anterior to cerebral peduncle at level of inferior colliculus. Although not seen, medial
longitudinal fasciculus is just ventral (anterior) to CN4 nucleus. (Bottom) Image through inferior midbrain & inferior
colliculus shows superior medullary velum which contains decussation of CN4. CN4 exits dorsally & wraps around
midbrain in ambient cistern.
116
 MIDBRAIN
AXIAL T1 MR c:::l
""'l
~
:::s

Cerebral peduncle
Interpeduncular cistern
Substantia nigra
Region of red nucleus
CN3 nucleus area
Periaqueductal grey
Cerebral aqueduct
Superior collicuIus

Cerebral peduncles
Substantia nigra
Red nucleus
Periaqueductal grey Cerebral aqueduct

Superior colliculus

Head of caudate nucleus

Putamen
Anterior commissure
Globus pallidus
Third ventricle
Thalamus

Superior colliculus

(Top) Image through superior midbrain at level of superior colliculus shows approximate location of oculomotor
nerve CN3 nucleus along anterolateral periaqueductal grey. CN3 exits midbrain in interpeduncular fossa. Pigmented
nuclei, substantia nigra & red nucleus are seen at this level, although are better seen on T2 images. (Middle) Image
through superior midbrain shows cerebral peduncles as they descend from cerebral hemispheres. Cerebral peduncles
(crus cerebri) contain descending white matter tracts from cerebral hemispheres including corticospinal,
corticobulbar & corticopontine tracts. Periaqueductal grey surrounds cerebral aqueduct & is important in modulation
of pain & defensive behavior. (Bottom) Image through junction of midbrain with inferior basal ganglia. White
matter tracts extend from midbrain to basal ganglia & thalamus.
117
 MIDBRAIN
c AXIAL T2 MR
<i:l
"-
CO

"-
o
+-'
C
Q) Posterior cerebral artery
+-'
<i:l Oculomotor nerve (CN3)
"-
'+-
C Corticospinal tracts

Medial longitudinal fasciculus

Fourth ventricle Superior cerebellar peduncle

Posterior cerebral artery

Oculomotor nerve (CN3)
Corticospinal tracts

Medial longitudinal fasciculus

Fourth ventricle Superior cerebellar peduncle

Interpeduncular cistern Oculomotor nerve (CN3)

Trochlear nerve (CN4)

Ambient cistern
Medial longitudinal fasciculus
Fourth ventricle Superior cerebellar peduncle

(Top) First of six axial T2 MR images (balanced steady state free precession technique) from inferior to superior
through midbrain shows junction of pons & midbrain. White matter tracts including corticospinal tracts & medial
longitudinal fasciculus continue into midbrain in approximately same location as they are seen in pons. (Middle)
This image shows oculomotor nerves CN3 bilaterally, anterior to midbrain. Posterior cerebral artery is noted just
anterior to CN3. CN3 passes between posterior cerebral artery & superior cerebellar artery. A posterior
communicating artery aneurysm may result in a CN3 palsy. (Bottom) Image at inferior midbrain shows trochlear
nerve CN4 as it wraps around midbrain in ambient cistern. It is only cranial nerve to exit dorsally from brainstem.
Oculomotor nerves CN3 exit midbrain at interpeduncular fossa.
118
 MIDBRAIN
AXIAL T2 MR CO
~
~
:J

Interpeduncular cistern
Oculomotor nerve (CN3)
Cerebral peduncle

Ambient cistern
Medial longitudinal fasciculus
Superior fourth ventricle Superior cerebellar peduncle

Interpeduncular cistern
Oculomotor nerve (CN3)
Cerebral peduncle

Ambient cistern
Trochlear nucleus (CN4)
Superior recess fourth ventricle

Superior medullary velum

Optic tract
Cerebral peduncle Substantia nigra
Red nucleus
Periaqueductal grey Oculomotor nucleus (CN3)

Quadrigeminal plate cistern Superior colliculus

(Top) A more superior image shows midbrain at level of superior fourth ventricle. Oculomotor nerve is seen in
interpeduncular fossa as it heads towards cavernous sinus. (Middle) Image more superiorly shows midbrain at level
of superior recess of fourth ventricle. Trochlear nucleus CN4 is located in paramedial gray matter, just dorsal to
medial longitudinal fasciculus, approximate location shown. CN4 decussates in superior medullary velum. (Bottom)
Image more superiorly in a different patient shows superior midbrain at level of superior colliculi. The pigmented
nuclei, substantia nigra & red nucleus are well seen. Substantia nigra contains two parts, pars compacta & pars
reticularis. Pars compacta becomes atrophied in Parkinson's disease where there is a loss of dopaminergic cells.
Oculomotor nucleus CN3 is present at this level, approximate location shown.
119
 PONS
• Axons of facial nerve (CN?) loop around abducens
ITerminology nucleus creating a bulge in floor of fourth
•... Abbreviations ventricle, the facial colliculus
o
.•.... • Cerebellopontine angle (CPA)
o CN? nucleus
c • CN? has three main nuclei within pons: Motor,
Q)
• Cranial nerves (CN): Trigeminal nerve (CNS),
.•.... superior salivatory, solitary tract
abducens nerve (CN6), facial nerve (CN?),

-- • Located in ventrolateral aspect of tegmentum of

(\l
•... vestibulocochlear nerve (CN8)
lower pons
c
Definitions o CN8 nuclei
• Pons: Portion of brain stem which relays information • CN8 has cochlear and vestibular nuclei
from brain to cerebellum • Vestibular nuclei beneath lateral recess along floor
of fourth ventricle (rhomboid fossa)
• Dorsal and ventral cochlear nuclei on lateral
IGross Anatomy surface of inferior cerebellar peduncle (restiform
body)
Overview
• Bulbous mid portion of brainstem located between
midbrain (superiorly) & medulla oblongata (inferiorly) I Imaging Anatomy
• Composed of gray matter formations, CN nuclei
(CNS-8) and white matter tracts Overview
• Two main parts • CN root entry & exit zones visualized
o Ventral (anterior) pons: White matter tracts o CNS root entry zone at mid lateral pons
• Continuous with cerebral peduncles superiorly o CN6 exit brainstem anteriorly at pontomedullary
and medullary pyramids inferiorly junction
o Dorsal tegmentum: CN nuclei, gray matter nuclei, o CN? exit lateral brainstem at root exit zone in
white matter tracts pontomedullary junction
• Continuation of midbrain tegmentum superiorly o CN8 enters brainstem, posterior to CN? at
and medullary tegmentum inferiorly pontomedullary junction
• Dorsal surface of pons forms rostral half of rhomboid • CN nuclei not resolved on conventional imaging
fossa of fourth ventricle • Specific white matter tracts can be identified by typical
• Adjacent CSF cisterns location, but are not resolved on imaging
o Prepontine cistern: Anterior to pons; contains CNS • CPA: Junction between pons and cerebellum
&6
o CPA cistern: Lateral to pons; contains CN? & 8
• Blood supply by vertebrobasilar circulation IAnatomy-Based Imaging Issues
o Medial branches of superior cerebellar arteries
o Perforating branches of basilar artery,
Imaging Recommendations
thalamoperforator arteries • CT may be useful for acute setting
o Pontine hemorrhage, ischemia
Ventral (Anterior) Pons • MR for cranial neuropathy
• Contains longitudinal fibers primarily from • Diffusion imaging for acute ischemia
corticospinal, corticobulbar & corticopontine tracts • CTA and MRA for vertebrobasilar circulation
• Multiple transverse pontine fibers make up bulk
• May be referred to as pontine bulb or belly Clinical Issues
• White matter lesions affecting middle cerebellar
Dorsal Tegmentum peduncle (brachium pontis) or location of medial
• Continuation of medulla except medullary pyramids longitudinal fasciculus, think multiple sclerosis
• Multiple white matter tracts of tegmentum (not • Hypertensive hemorrhages and lacunar infarcts are
resolved on conventional imaging) common pontine lesions
o Medial lemniscus: Somatosensory • Acute pontine ischemia often not seen on routine CT
o Medial longitudinal fasciculus: orMR
Oculomotor -ves ti bu la r o Use diffusion weighted imaging (OWl) sequence
o Lateral lemniscus: Auditory when acute ischemia suspected
o Trapezoid body: Auditory • Osmotic demyelination (central pontine myelinolysis)
o Spinothalamic tract: Somatosensory is characterized by central T1 hypointensity and T2
o Central tegmental tract: Motor hyperintensity in ventral pons
• Cranial nerve nuclei • Cerebellopontine angle lesions are common
o CNS nuclei located throughout brainstem and upper o Enhancing mass: Vestibulocochlear schwannoma
cord (most common) or meningioma
• Bulk of motor, main sensory and mesencephalic o Nonenhancing: Epidermoid or arachnoid cyst
nuclei located in pons o Don't forget posterior circulation aneurysm for
o CN6 nucleus fusiform or unusual masses
• Nucleus located in pontine tegmentum near
midline, anterior to fourth ventricle

120
121
 PONS
c AXIAL T1 MR
ro
•....
CO

Basilar artery
Anterior inferior cerebellar artery

Inferior cerebellar peduncle

Inferior fourth ventricle Origins, CN? & 8

Abducens nerve (CN6) Basilar artery

Facial nerve (CN?)
Corticospinal tracts
CPA cistern Vestibulocochlear nerve (CN8)
Medial longitudinal fasciculus Middle cerebellar peduncle
Inferior fourth ventricle

Basilar artery
Corticospinal tracts
CPA cistern

Middle cerebellar peduncle

Facial coIIiculus
Fourth ventricle

(Top) First of six axial Tl MR images of pons from inferior to superior shows pontomedullary junction & inferior
aspect of inferior cerebellar peduncle (restiform body). Cochlear nerve nuclei are found on lateral surface of inferior
cerebellar peduncle. (Middle) Image through inferior pons shows cisternal segment of CN6 as it ascends
anterosuperiorly in prepontine cistern. Basilar artery is seen anteriorly along belly of pons as it sits in shallow median
sulcus. CN7 & 8 exit laterally in pontomedullary junction to enter cerebellopontine angle (CPA) cistern. (Bottom)
Image through pons at level of facial colliculu1 which is formed by axons of CN7 as they wrap around nucleus of
CN6 just anterior to fourth ventricle. A lesion in this location would result in both CN6 & 7 palsies.

122
 PONS
AXIAL T1 MR 0::1
~
~
:J

Meckel cave
Basilar artery
Prepontine cistern
Trigeminal nerve (CNS)
CPA cistern Cerebellopontine angle

Middle cerebellar peduncle

Fourth ventricle

Basilar artery
Corticospinal tracts

Medial longitudinal fasciculus

Superior cerebellar peduncle
Fourth ventricle

Basilar artery
Corticospinal tracts

Medial longitudinal fasciculus

Superior cerebellar peduncle
Fourth ventricle

(Top) A more superior image through pons at level of CNS root entry zone, where CNS exits lateral pons. From here,
CNS courses anteriorly through prepontine cistern, passes over petrous ridge & enters middle cranial fossa passing
through porus trigeminus to enter Meckel cave. Meckel cave is an arachnoid lined, dural diverticulum filled with CSF
& houses trigeminal ganglion. (Middle) Image through superior pons shows approximate location of corticospinal
tracts which continue as pyramidal tracts into medulla. The anterior aspect of pons which contains corticospinal/
tracts/will become atrophied in cortical strokes that affect motor cortex, related to Wallerian degeneration: (Bottom)
Image through superior pons shows approximate location of medial longitudinal fasciculus, just lateral to midline.
MLF is important in extraocular muscle movement.
123
 PONS
c AXIAL T2 MR
~
~
CQ

Abducens nerve (CN6)

Basilar artery
Anterior inferior cerebellar artery

Inferior cerebellar peduncle Flocculus

Inferior fourth ventricle Origins, CN? & 8

Abducens nerve (CN6)

Cochlear nerve (CN8)
Basilar artery
Inferior vestibular nerve (CN8)
Facial nerve (CN?)
Anterior inferior cerebellar artery
Vestibulocochlear nerve (CN8)

Inferior fourth ventricle

Meckel cave

Abducens nerve (CN6) Basilar artery

Anterior pontine membrane
Cerebellopontine angle cistern

Middle cerebellar peduncle

Facial colliculus Fourth ventricle

(Top) First of six axial T2 MR images of pons from inferior to superior shows pontomedullary junction & inferior
aspect of inferior cerebellar peduncle (restiform body). CN6 exits brainstem anteriorly at pontomedullary junction
just above medullary pyramid. Inferior cerebellar peduncle (restiform body) lateral surface is where dorsal & ventral
cochlear nuclei are found. (Middle) Image through inferior pons shows cisternal segment of CN6 as it ascends in
prepontine cistern. Basilar artery/is seen anteriorly. It gives rise to thalamoperforator arteri~s which supply majority
of pons & anterior inferior cerebellar arteri~s which loop in region of internal auditory canals. CN? and 8 exit
laterally at pontomedullary junction. (Bottom) Image through mid pons shows middle cerebellar peduncle
(brachium pontis), a common location for multiple sclerosis plaques.
124
 PONS
AXIAL T2 MR ..,
CQ
~
:J

Meckel cave

Prepontine cistern Basilar artery

Trigeminal nerve (CNS)
CPA cistern

Middle cerebellar peduncle

Fourth ventricle

Basilar artery

Corticospinal tracts

Medial longitudinal fasciculus

Superior cerebellar peduncle
Fourth ventricle

Posterior cerebral artery

Corticospinal tracts

Superior cerebellar peduncle

Medial longitudinal fasciculus
Fourth ventricle

Cerebellar vermis

(Top) A more superior image through pons at level of CNS root entry zone, where CNS exits lateral pons. From here,
CNS courses through prepontine cistern, enters middle cranial fossa & passes through opening in dura to enter
Meckel cave which houses trigeminal ganglion. (Middle) Image through superior pons shows approximate location
of corticospinal tracts & medial longitudinal fasciculus. These specific fibers cannot be resolved on conventional
imaging, but knowledge of their location is useful when evaluating patients with weakness or cranial neuropathies.
(Bottom) Image through superior pons shows superior cerebellar peduncles. The superior medullary velum, a thin
sheet of tissue that covers dorsal fourth ventricle attaches laterally to superior cerebellar peduncles. The lingula of
cerebellar vermis overlies superior medullary velum. I.
125
 PONS
c CORONAL T2 MR
(\j
"--
C!) Third ventricle

Midbrain

Tentorium cerebelli

Middle cerebellar peduncle

Cisterna magna

Third ventricle

Cerebral peduncle

Tentorium cerebelli

Middle cerebellar peduncle

Pontomedullary junction
Flocculus of cerebellum

Medulla

Cerebellar tonsil

Third ventricle

Interpeduncular cistern
Cerebral peduncle

Pons Trigeminal nerve (CNS)

Cerebellopontine angle cistern Internal auditory canal

Pontomedullary junction Flocculus of cerebellum

Medulla

Vertebral artery

(Top) First of six coronal T2 MR images of pons from posterior to anterior shows dorsal pons & middle cerebellar
peduncles, largest of cerebellar peduncles. Superior & inferior cerebellar peduncles are small. Dorsal surface of pons is
hidden by cerebellum which covers posterior aspect of fourth ventricle (rhomboid fossa). (Middle) This image shows
ponto medullary junction at inferior border of pons where pons & medulla meet. Cerebral peduncles which contain
corticospinal tracts are continuous with anterior pons where corticospinal tracts continue inferiorly to medullary
pyramids. (Bottom) A more anterior image shows preganglionic segment of CNS arising from lateral pons. CN? and
8 exit brainstem laterally at pontomedullary junction & traverse the cerebellopontine angle cistern before entering
internal auditory canal.
126
 PONS
CORONAL T2 MR

Third ventricle
Interpeduncular cistern

Cerebral peduncle Oculomotor nerve (CN3)

Trigeminal nerve (CNS)

Pons
Cerebellopontine angle cistern Internal auditory canal

Pontomedullary junction
Medulla

Vertebral artery

Third ventricle

Interpeduncular cistern
Posterior cerebral artery

Superior cerebellar artery Trigeminal nerve (CNS)

Pons

Vertebral artery

Third ventricle

Basilar tip
Superior cerebellar artery
Oculomotor nerve (CN3)
Basilar artery
Trigeminal nerve (CNS)
Pons entering Meckel cave

(Top) A more anterior image shows anterior aspect of pons which contains multiple transverse pontine fibers &
descending corticospinal, corticobulbar & corticopontine tracts. Vertebral arteries unite to form basilar artery in
region of pontomedullary junction. Ectasia & tortuosity of the vertebrobasilar system (dolichoectasia) is often seen in
elderly adults, particularly those with atherosclerotic disease. (Middle) A more anterior image shows preganglionic
segment of eNS, largest of cranial nerves. Pons is a common location for lacunar infarcts related to small
thalamoperforator arteries that supply it. (Bottom) This image shows most anterior aspect of pons with basilar artery
coursing along surface. The basilar tip is the most cephalad aspect of basilar artery & a location for posterior
circulation aneurysms.
127
 MEDULLA
I Terminology Ventral (Anterior) Medulla
• Medullary pyramids
Abbreviations
o Corticospinal tracts (pyramidal tracts) make up bulk
• Cranial nerves (CN): Trigeminal nerve (CNS),
• Medullary olives
vestibulocochlear nerve (CN8), glossopharyngeal nerve o Consists of inferior olivary nucleus, dorsal & medial
(CN9), vagus nerve (CNlO), accessory nerve (CNII), accessory olivary nuclei & superior olivary nucleus
hypoglossal nerve (CNI2) o Inferior olivary nucleus is largest and forms bulge on
Definitions surface of medulla, "medullary olive"
• Medulla: Caudal brainstem, transition from spinal Dorsal Tegmentum
cord to brain
• Multiple white matter tracts of tegmentum (not
resolved on conventional imaging)
o Medial longitudinal fasciculus:
I Gross Anatomy Oculomotor-vestibular
Overview o Medial lemniscus: Auditory
o Spinothalamic tract: Somatosensory
• Caudal part of brainstem composed of gray matter
o Central tegmental tract: Motor
formations, CN nuclei (CN9-I2) & white matter tracts
o Spinocerebellar tract: Somatosensory
o Located between pons (superiorly) and spinal cord
• Cranial nerve nuclei
o Fourth ventricle and cerebellum dorsal to medulla
o CN9 nuclei in upper and mid medulla: Nucleus
o Caudal border: First cervical nerves
ambiguus, solitary tract nucleus, inferior salivatory
• Medulla subdivided into two main parts
nucleus
o Ventral (anterior) medulla: Olive & pyramidal tract
• Sensory fibers terminate in spinal nucleus CNS
o Tegmentum (dorsal): CN nuclei and white matter
• CN9 exits medulla in postolivary sulcus above
tracts
CNlO
• Medulla may also be divided into rostral (superior)
o CNIO nuclei in upper and mid medulla: Nucleus
defined by fourth ventricle (open) and caudal
ambiguus, solitary tract nucleus, dorsal vagal
(inferior) defined by central canal (closed portion)
nucleus
• Medulla external features
o Pyramid • Sensory fibers terminate in spinal nucleus CNS
• CNlO exits medulla in postolivary sulcus between
• Paired structure on anterior surface, separated in
CN9 and 11
midline by ventral median fissure
o CNll bulbar nuclei in lower nucleus ambiguus in
• Contains ipsilateral corticospinal tracts prior to
upper and mid medulla
decussation more inferiorly
o Olive • CNII exits medulla in postolivary sulcus below
CNlO
• Medullary olives are lateral to pyramids, separated
o CN12 nuclei in mid medulla, dorsally results in
by ventrolateral sulcus (pre-olivary sulcus)
hypoglossal eminence or trigone (bulge in fourth
• Formed by underlying inferior olivary complex of
ventricle)
nuclei
• CNI2 exits anterior medulla in pre-olivary sulcus
• Posterolateral sulcus (postolivary sulcus) is lateral
to olives • Reticular formation
o Occupies central tegmentum, afferent and efferent
o Inferior cerebellar peduncle (restiform body)
connections
• Arise from superior aspect of dorsal medulla;
o Important in consciousness, motor function,
peduncles diverge and incline to enter cerebellar
respiration and cardiovascular control
hemispheres
• Nuclei of CN8 located along dorsal surface
o Gracile and cuneate tubercles
• Form lower aspect of dorsal medulla
jlmaging Anatomy
• Produced by paired nuclei gracilis (medial) and Overview
cuneatus (lateral)
• Medullary olives and pyramids well seen on imaging
• Dorsal median sulcus separates gracile tubercles • CN9-I2 seen as they exit medulla
• Fourth ventricle o CN9-11 exit medulla in postolivary sulcus
o Dorsal median sulcus divides ventricular floor o CN12 exits anterior medulla in pre-olivary sulcus
longitudinally
• CN nuclei and white matter tracts can be identified by
o Terminates in caudal medulla
typical location, but are not resolved on imaging
o Roof formed by superior and inferior medullary
velum
• Blood supply from vertebrobasilar circulation IAnatomy-Based Imaging Issues
o Distal vertebral arteries
o Posterior inferior cerebellar arteries Imaging Recommendations
o Anterior spinal artery • MR for cranial neuropathy or acute ischemia
• CTA and MRA for vertebrobasilar circulation

128
129
 MEDULLA
c AXIAL T2 MR
(ij
"-
CO
(ij

"-
o
......,
c
Q)
......,
(ij
"-
'+- Hypoglossal nerve (CNl2)
C Vertebral artery
Hypoglossal canal
Pre-olivary sulcus

Postolivary sulcus Spinal root of accessory nerve

(CNll)

Dorsal median sulcus

Jugular foramen Anterior inferior cerebellar

artery
Medullary pyramid
Medullary olive

Inferior fourth ventricle

Medullary pyramid
Medullary olive
Vagus nerve (CNlO)

Foramen of Luschka
Glossopharyngeal nerve (CN9)
Hypoglossal eminence

(Top) First of six axial T2 MR images through medulla from inferior to superior shows hypoglossal nerve CN12
exiting medulla at pre-olivary sulcus. Spinal root of accessory nerve CN11 is seen laterally as it ascends through
foramen magnum to unite with cranial roots of CN11 before exiting via jugular foramen. Dorsal median sulcus
continues superiorly to divide floor of fourth ventricle longitudinally. (Middle) Image at level of jugular foramen
shows medullary olives &: pyramids. (Bottom) This image shows hypoglossal eminence (trigone), formed by CN12
nucleus as bulge in fourth ventricular floor. Glossopharyngeal CN9, vagus CNlO, &: cranial roots of accessory CNll
nerves exit lateral medulla in postolivary sulcus, posterior to olive. These nerves exit skull base via jugular foramen.
Thin-section, high-resolution imaging allows identification of CN9-11.
130
 MEDULLA
AXIAL T2 MR

Basilarartery

Vagus nerve (CNIO)

Foramen of Luschka
Glossopharyngeal nerve (CN9)
Hypoglossal eminence

Abducens nerve (CN6) Anterior inferior cerebellar

artery
Pontomedullary junction
Flocculus
Inferior cerebellar peduncle
Origins, CN7 & 8

Basilarartery Abducens nerve (CN6)

Anterior inferior cerebellar artery

Facial nerve (CN7)
VestibuIocochlear nerve (CN8)
Inferior fourth ventricle
Choroid plexus along inferior
roof of fourth ventricle

(Top) Image more superiorly shows medullary olives bilaterally. Olives become atrophied in the degenerative disease,
olivopontocerebellar atrophy. Wallenberg syndrome is a neurological condition caused by ischemia of lateral
medulla related to vertebral or posterior inferior cerebellar artery disease. (Middle) Image more superiorly at level of
pontomedullary junction. Inferior cerebellar peduncle (restiform body) is where cochlear nuclei of vestibulocochlear
nerve CN8 are found. Abducens nerve 'CN6 exits anteriorly at pontomedullary junction, just above medullary
pyramid. Important to remember that anterior inferior cerebellar artery is seen about brainstem in order to not
mistake it for a cranial nerve. (Bottom) Image at inferior pons junction with upper medulla. Facial nerve CN? &
vestibulocochlear nerve CN8 exit laterally at pontomedullary junction.
131
 CEREBELLUM
I Terminology
Abbreviations
• Cerebrospinal fluid (CSF)
Synonyms
• Classical nomenclature (simplified nomenclature):
Superior (tentorial), inferior (suboccipital), anterior
(petrosal) cerebellar surfaces
• Primary (tentorial), horizontal (petrosal),
prebiventral/prepyramidal (suboccipital) cerebellar
fissures
Definitions
• Cerebellum: Integrative organ for coordination & /
fine-tuning of movement & regulation of muscle tone /
I Gross Anatomy
Overview
• Bilobed posterior fossa structure located posterior to
brainstem and fourth ventricle
o Two hemispheres & midline vermis
o Three surfaces
o Divided into lobes & lobules by transverse fissures
o Connected to brainstem by three paired peduncles
o Cortical gray matter, central white matter & four
paired deep gray nuclei
Anatomy Relationships
• Surfaces
o Superior (tentorial) surface
• Faces & conforms to inferior surface of tentorium
• Transition between vermis & hemispheres is
smooth
• Primary (tentorial) fissure divides superior
(tentorial) surface into anterior & posterior parts
o Inferior (suboccipital) surface
• Located below, between lateral & sigmoid sinuses
• Vermis is contained within a deep vertical
depression, the posterior cerebellar incisura which
separates the cerebellar hemispheres
• Prebiventral/prepyramidal (suboccipital) fissure
divides inferior (suboccipital) surface into superior
& inferior parts
• Tonsil is part of hemisphere, located on
inferomedial part of inferior (suboccipital) surface
o Anterior (petrosal) surface
• Faces the posterior surface of petrous bone,
brainstem & fourth ventricle
• Vermis lies dorsal to fourth ventricle
• Horizontal (petrosal) fissure divides anterior
(petrosal) surface into superior & inferior parts
• Horizontal (petrosal) fissure continues
posterolaterally onto inferior (suboccipital) surface
• Peduncles: 3 paired peduncles attach cerebellum to
brainstem
o Superior cerebellar peduncle (brachium
conjunctivum)
• Connects to cerebrum via midbrain
• Contains efferent fiber systems extending to red
nucleus & thalamus
o Middle cerebellar peduncle (brachium pontis)
132
• Connects to pons
• Contains fiber mass originating from pontine
nuclei & represent continuation of corticopontine
tracts
o Inferior cerebellar peduncle (restiform body)
• Connects to medulla
• Contains spinocerebellar tracts & connections to
vestibular nuclei
• Adjacent CSF cisterns
o Cerebellopontine angle cistern: Lateral to pons
o Cisterna magna: Inferior to cerebellum
o Quadrigeminal plate cistern: Posterior to midbrain,
above cerebellum
o Superior cerebellar cistern: Above cerebellum, below
tentorium
• Blood supply from vertebrobasilar circulation
o Superior cerebellar artery, anterior inferior cerebellar
artery & posterior inferior cerebellar artery
Cerebellar lobes and lobules
• Vermis: Superior & inferior, separated by horizontal
(petrosal) fissure '
o Superior vermis: Lingula (anterior), central lobule,
culmen, declive, folium (posterior) lobules
o Inferior vermis: Tuber (posterior), pyramid, uvula,
nodule (anterior) lobules
• Lobules of vermis are associated with pair of
hemispheric lobules
o Lingula: Wing of lingula
o Central lobule: Wing of central lobule
o Culmen: Quadrangular lobule
• Primary (tentorial) fissure
o Declive: Simple lobule
o Folium: Superior semilunar lobule
• Horizontal (petrosal) fissure
o Tuber: Inferior semilunar lobule
• Prebiventral/prepyramidal (suboccipital) fissure
o Pyramid: Biventral lobule
o Uvula: Tonsils
o Nodule: Flocculus
Cerebellar Nuclei
• Located deep in cerebellar white matter
• Nuclei project fibers to coordinate goal directed
movement
• Fastigial nucleus: Medial group (vermis)
o Fibers from vermis cortex, vestibular nuclei and
other medulla nuclei
• Globose (posterior) nucleus: Intermediate group
o Fibers from vermis cortex, sends fibers to medulla
nuclei
• Emboliform (anterior) nucleus: Intermediate group
o Fibers from cerebellar cortex between vermis and
hemispheres, sends fibers to thalamus
• Dentate nucleus: Lateral group
o Fibers from hemispheric cortex, sends fibers to red
nucleus and thalamus
o Largest nucleus, shaped as a heavily folded band
with medial opening (hilum)
133
 CEREBELLUM
c AXIAL T1 MR
('\l
I-
CO
('\l
I-
o
+-'
C
Q.)
+-'

--
('\l
I-

C
Inferior medulla

Cerebellar tonsil
Inferior cerebellar hemispherd

Medulla
Inferior fourth ventricle
Cerebellar tonsil
Inferior cerebellar hemisphere'

Basilar artery

Flocculus
Inferior cerebellar peduncle

Nodule of inferior vermis Cerebellar tonsil

Inferior cerebellar hemisphere I

Cerebellar vermis

(Top) First of six axial T1 MR images through cerebellum from inferior to superior shows junction of medulla with
cervical spinal cord. Cerebellar tonsils are most inferior extension of cerebellum & may herniate inferiorly in patients
with cerebellar edema or mass resulting in descending tonsillar herniation. (Middle) Image shows inferior cerebellar
hemispheres which are supplied primarily by posterior inferior cerebellar artery (PICA). Anterior inferior cerebellar
artery (AICA) supplies anterolateral aspect of cerebellar hemispheres; Ischemia in a PICA distribution is most
common cerebellar stroke. (Bottom) Image more superiorly shows inferior cerebellar peduncle (restiform body)
which ascends from lower medulla to cerebellum & contains spinocerebellar tracts & connections to vestibular
I nuclei. It is also location of cochlear nerve CN8 nuclei.
134
 CEREBELLUM
AXIAL T1 MR

Pons

Middle cerebellar peduncle

Nodulus
Cerebellar white matter
Vermis
Cerebellar hemisphere

Pons

Superior cerebellar peduncle

Fourth ventricle

Superior cerebellar hemisphere I

Vermis

Superior pons

Superior fourth ventricle

Vermis
Superior cerebellar hemisphere

(Top) Image more superiorly at level of middle cerebellar peduncles shows midline vermis & nodulus. Nodulus, just
posterior to fourth ventricle, is occasionally mistaken for a lesion in fourth ventricle. Middle cerebellar peduncle
(brachium pontis) connect pons with cerebellum & contains corticopontine tracts. It is a common location for
multiple sclerosis plaques. (Middle) This image shows superior cerebellar peduncles (brachium conjunctivum) which
connects cerebellum with red nucleus & thalamus. Superior cerebellar hemisphere is sup'plied primarily by superior
cerebellar arteri~which arise from basilar artery'just before posterior cerebral arteries, which are terminal branches.
Superior cerebellar arteries also supply superior cerebellar peduncle, dentate nucleus, & part of middle cerebellar
peduncle. (Bottom) Image more superiorly shows midline vermis.
135
 CEREBELLUM
c CORONAL T2 MR
~
I.....
CO
~

Quadrigeminal plate cistern

Primary (tentorial) fissure

Cerebellar hemisphere Horizontal (petrosal) fissure

Midline vermis

Quadrigeminal plate

Primary (tentorial) fissure

Cerebellar hemisphere
Dentate nucleus
Vermis

Central lobule Fourth ventricle

Nodulus
Dentate nucleus
Tonsil
Uvula

Vallecula

(Top) First of six coronal T2 MR images from posterior to anterior shows primary (tentorial) fissure which is deepest
fissure on superior (tentorial) surface of cerebellum. Other main fissure is horizontal (petrosal) fissure which extends
from middle cerebellar peduncle on anterior (petrosal) surface posterolaterally onto inferior (suboccipital) surface of
cerebellum. (Middle) Image more anteriorly shows dentate nucleus which receives cortical fibers of cerebellar
hemispheres & sends fibers through superior cerebellar peduncles to red nucleus & thalamus. Other cerebellar nuclei
are midline & paramedian & are not resolved on conventional imaging. (Bottom) This image shows some of vermian
lobules including central lobule, uvula & nodulus. Typically, vermis is discussed as single entity on imaging, with
exception of nodulus.
1 6
 CEREBELLUM
CORONAL T2 MR

:J
-+,
....•
OJ
,......
(t)
:J
,......
o
....•
Superior cerebellar peduncle
OJ
Tentorium cerebelli
Choroid plexus in fourth OJ
....•
Horizontal (petrosal) fissure ventricle OJ

Cerebellar white matter :J

Nodule of vermis

Tonsil

Red nucleus

Superior cerebellar peduncle

Horizontal (petrosal) fissure
Middle cerebellar peduncle
Nodulus

Foramen of Magendie
Tonsil

Middle cerebellar peduncle

Flocculus
Horizontal (petrosal) fissure

Tonsil
Vallecula

(Top) Image more anteriorly shows nodulus projecting into fourth ventricle. Superior cerebellar peduncle is seen
along superior fourth ventricle as it extends to superior pons & midbrain to send fibers to red nucleus & thalamus.
(Middle) This image shows horizontal (petrosal) fissure curving anteriorly onto anterior (petrosal) surface of
cerebellum. Surface of cerebellum exhibits numerous narrow, almost parallel convolutions called folia. Cerebellar
hemispheres contain lobules or wings that are paired with vermis lobules. (Bottom) Image more anteriorly shows
middle cerebellar peduncles & cerebellar tonsils. Flocculus & nodulus make up flocculonodular lobe of cerebellum.
Flocculus is a common pseudolesion in CPA cistern. Inferiorly, cerebellar hemispheres are separated by a deep
vallecula which contains falx cerebelli. Vallecula is bounded by tonsils bilaterally.
137
 CEREBELLUM
c SAGITTAL 12 MR
ro
~
CO
ro

Tentorium cerebelli

Superior cerebellar hemisphere

Horizontal (petrosal) fissure
Cerebellar white matter

Inferior cerebellar hemisphere

Superior (tentorial) surface

Dentate nucleus

Anterior (petrosal) surface

Inferior (suboccipital) surface

Horizontal (petrosal) fissure

Pons
Middle cerebellar peduncle Dentate nucleus

Tonsil

(Top) First of six sagittal T2 MR images form lateral to medial show white matter core of cerebellum which branches
into medullary laminae, which occupy central lobules & are covered by cerebellar cortex. In sagittal section, the
highly branched pattern of medullary laminae is known as arbor vitae (tree of life). Cerebellar nuclei are located deep
in white matter, but only dentate nucleus is resolved on imaging. (Middle) Image through lateral cerebellar
hemisphere showing superior (tentorial), inferior (suboccipital) & anterior (petrosal) surfaces. Dentate nucleus has a
folded band appearance with medial part remaining open (hilum of dentate nucleus). (Bottom) Image more medially
shows relationship of cerebellum to brainstem. Note middle cerebellar peduncle connects cerebellum to pons.

138
 CEREBELLUM
SAGITTAL T2 MR ...,
CI:l
PJ
:;,

Quadrigeminal plate cistern

Quadrigeminal plate Primary (tentorial) fissure

Horizontal (petrosal) fissure

Pons

Pontomedullary junction
Tonsil
Medulla
Cisterna magna

Superior cerebellar cistern

Quadrigeminal plate cistern

Primary (tentorial) fissure

Midbrain
Horizontal (petrosal) fissure

Pons Prebiven tral/prepyramidal

(suboccipital) fissure

Cisterna magna

Central lobule
Culmen
Lingula
Declive
Midbrain
Folium
Superior medullary velum Tuber
Inferior medullary velum
Pyramid
Uvula
Medulla Nodulus
Tonsil

(Top) This image shows quadrigeminal plate cistern, anterior & superior to cerebellum. (Middle) Slightly off-midline
image shows major fissures. Primary (tentorial) fissure separates anterior culmen from posterior declive. Horizontal
(petrosal) fissure separates folium above from tuber below. Prebiventral/prepyramidal (suboccipital) fissure separates
posterior tuber from anterior pyramid. Superior cerebellar cistern is above cerebellum, below tentorium. (Bottom)
Midline image shows components of vermis. Superior vermis includes lingula, central lobule, culmen, declive &
folium from anterior to posterior. Horizontal (petrosal) fissure separates superior from inferior vermis. Inferior vermis
includes tuber, pyramid, uvula & nodulus from superior to inferior. Cerebellum forms roof of fourth ventricle with
superior & inferior medullary velum.
139
 CEREBELLOPONTINE
I Terminology
Abbreviations
• Cerebellopontine angle (CPA) & internal auditory
canal (lAC)
• Superior vestibular nerve (SVN) & inferior vestibular
nerve (lVN)
• Anterior inferior cerebellar artery (AICA)
Definitions
• CPA-lAC cistern: Cerebrospinal fluid (CSF) space in
CPA & lAC containing CN? & CN8 and AICA loop
• lAC fundus: Lateral CSF-filled cap of lAC cistern
containing distal CN?, SVN, IVN & cochlear nerve
• Cochlear aperture: Bony opening connecting lAC
fundus to cochlea
I Imaging Anatomy
Internal Structures-Critical Contents
• Vestibulocochlear nerve (CN8): CPA-lAC cistern
o Components
• Vestibular (balance) & cochlear portions (hearing)
o Cochlear nerve portion, CN8 course
• Leaves spiral ganglion as auditory axons
• Travels as cochlear nerve in anterior-inferior
quadrant of lAC
• Joins SVN & IVN at porus acusticus to become
CN8 bundle in CPA cistern
• Crosses CPA cistern as posterior nerve bundle to
enter brainstem at pontomedullary junction
• Enters brainstem, bifurcates to synapse with both
dorsal & ventral cochlear nuclei
o CN? & CNS orientation in lAC cistern
• "Seven-up, coke down" useful pneumonic
• CN? anterosuperior; cochlear nerve anteroinferior
• SVN posterosuperior; IVN posteroinferior in lAC
• Facial nerve (CN?): CPA-lAC cistern
o Root exit zone in pontomedullary junction
o Travels anterior to CN8 in CPA cistern
o Anterosuperior in lAC cistern
• Anterior inferior cerebellar artery (AICA loop)
o Arises from basilar artery then rises into lAC
o Continues in lAC as internal auditory artery (lAA)
o May mimic cranial nerve on high-resolution T2
o IAA supplies 3 branches to inner ear
• Other structures in CPA cistern
o Flocculus of cerebellum in posteromedial CPA
o Choroid plexus may pass from fourth ventricle
though foramen of Luschka into CPA cistern
• Other structures in lAC cistern
o Crista falciformis (horizontal crest): Horizontal
bony projection from lAC fundus
o Vertical crest (Bill bar): Vertical bony ridge in
superior portion lAC fundus (not visible on CT or
MR)
o Cochlear aperture: lAC outlet for cochlear nerve to
cochlea
o Macula cribrosa: Perforated bone between lAC &
vestibule of inner ear
140
ANGLE/lAC
IAnatomy-Based Imaging Issues
Imaging Approaches
• Cochlear portion of CN8
o Principal impetus for imaging CN8
o Bone CT used in trauma, otosclerosis & Paget disease
o MR used for all other indications
• MR imaging approach to uncomplicated unilateral
sensorineural hearing loss (SNHL)
o Screening MR involves high-resolution thin-section
T2 MR imaging through CPA-lAC
• MR imaging approach to complex SNHL (unilateral
SNHL + other symptoms)
o Whole brain & posterior fossa sequences
o Begin with whole brain axial T2 & FLAIR sequences
o Conclude with axial & coronal T1 thin-section C+
MR of posterior fossa & CPA-lAC
Imaging Pitfalls
• Normal variants in CPA-lAC
o Normal structures, when unusually prominent,
trouble radiologist evaluating CPA-lAC
o AICA loop flow void on high-resolution T2 MR
• Will not prominently enhance on T1 C+ MR
• Subtle enhancement in lAC on T1 C+ MR may be
mistaken for small acoustic schwannoma
o Marrow space foci in walls of lAC can mimic lAC
tumor on T1 C+ MR images
• Correlate location of foci with lAC cistern
• Bone CT of T-bone may be necessary to identify
this normal variant
I Clinical Implications
Function-Dysfunction
• CPA-lAC lesions most commonly present with SNHL
o Uncomplicated unilateral SNHL: Patient otherwise
healthy & presents with unilateral SNHL
o Complicated SNHL: Patient has other symptoms in
addition to unilateral SNHL
• Symptoms include other cranial neuropathy, long
tract signs & headache
• Cochlear nerve injury
o SNHL & tinnitus primary symptoms
• Facial nerve injury, CPA-lAC portion
o Peripheral facial neuropathy
• Lacrimation, stapedial reflex, anterior 2/3 tongue
taste loss & complete loss of muscles of facial
expression on side of lesion
• CN? rarely injured by lesion in CPA-lAC
• If lesion in CPA-lAC and CN? is out, consider
non-acoustic schwan noma causes such as facial
nerve schwannoma or metastatic disease
I Embryology
Embryologic Events
• lAC forms separately from inner ear & external ear
• Forms in response to migration of CN? & CN8
through this area
141
 CEREBELLOPONTINE ANGLE/lAC
C AXIAL BONE CT
n:l
•...
CO
n:l

Labyrinthine segment CN?

Labyrinthine segment CN? exit

from lAC
Porus acusticus Epitympanum

Mastoid antrum
lAC fundus
Vestibule
Sigmoid sinus

Cochlear aperture
Petrous apex

Porus acusticus Macula cribrosa

Singular canal Mastoid antrum

Superior margin high jugular bulb

Sigmoid sinus

Mesotympanum
Cochlear modiolus

Cochlear aperture
External auditory canal
lAC fundus
Mastoid antrum
High jugular bulb

Sigmoid sinus

(Top) First of three axial bone CT images of the left ear through the internal auditory canal presented from superior
to inferior. In this CT image the labyrinthine segment of the facial nerve is seen exiting the anterosuperior fundus of
the lAC. (Middle) In this image the cochlear aperture is seen connecting the anteroinferior fundus of the lAC to the
cochlea. The cochlear nerve accesses the modiolus of the cochlea through this aperture. Note the posterolateral
fundal bony wall abutting the medial vestibule. Multiple branches of the vestibular nerves pass to the vestibule and
semicircular canals through this wall called the macula cribrosa. (Bottom) The cochlear modiolus is visible as a high
density structure at the cochlear base directly inside the cochlea from the cochlear aperture. The high jugular bulb
projects cephalad behind the internal auditory canal.
142
 CEREBELLOPONTINE ANGLE/lAC
SAGITTAL T2 MR C:l
~
~
:J

Facial nerve

Superior vestibular nerve

Crista falciformis (horizontal crest)
Inferior vestibular nerve

Cochlear nerve

Temporal horn lateral ventricle

Temporal lobe

Facial nerve Superior vestibular nerve

Cochlear nerve Inferior vestibular nerve

Cerebellar hemisphere

Facial nerve
Vestibulocochlear nerve

Cochlear aqueduct

(Top) First of 3 oblique sagittal high-resolution T2 MR images presented from lateral to medial shows the fundus of
the internal auditory canal (lAC) filled with high signal cerebrospinal fluid. The horizontal low signal line in the
fundus is the crista falciformis. The facial nerve is anterosuperior while the cochlear nerve is anteroinferior. (Middle)
In this image through the mid-lAC the 4 discrete nerves are well seen. Notice that the anteroinferior cochlear nerve is
normally slightly larger than the other three nerves in the lAC. (Bottom) At the level of the porus acusticus the facial
nerve is visible just anterior to the vestibulocochlear nerve. The overall appearance of these two nerves is that of a
"ball" (facial nerve) in a "catcher's mitt" (vestibulocochlear nerve). The vestibulocochlear nerve contains the cochlear,
inferior & superior vestibular nerves.
143
 CEREBELLOPONTINE ANGLE/lAC
c AXIAL T2 MR
C\l
"-
CD

C\l Meckel cave

"-
o
+-' Porus acusticus Anterior inferior cerebellar
C
Q) artery loop
+-'
C\l
Mid-internal auditory canal Facial nerve
"-
'+- Fundus of internal auditory canal Cochlea
C

Superior vestibular nerve

Middle cerebellar peduncle

Pons
Fourth ventricle

Cerebellopontine angle cistern

Meckel cave
Cochlear nerve
Facial nerve
Modiolus

Superior vestibular nerve Inferior vestibular nerve

Anterior inferior cerebellar
artery

Cochlear nerve
Facial nerve
Modiolus of cochlea

Inferior vestibular nerve Vestibulocochlear nerve

Cerebellopontine angle

(Top) First of three axial T2 MR images presented from superior to inferior reveals the porus acusticus, mid-portion
and fundus of the internal auditory canal (lAC) on the right. On the left the anterior inferior cerebellar artery is seen
looping through the cerebellopontine angle cistern. Also note the facial nerve and superior vestibular nerve on the
left within the lAC. (Middle) In this image the facial nerve and superior vestibular nerve are seen in the right
internal auditory canal while the cochlear nerve and inferior vestibular are visible on the left. (Bottom) In this image
the cochlear nerve is seen in the right internal auditory canal exiting through the cochlear aperture to reach the
modiolus of the cochlea. On the left the cerebellopontine angle is seen with the vestibulocochlear nerve emerging
from the brain stem at this point.
144
 CEREBELLOPONTINE ANGLE/lAC
CORONAL T2 MR CO
~
~
:J
:J
-+,
....•
0)
•....•.
(t)
Preganglionic segment CNS
Anterior inferior cerebellar :J
•....•.
artery o
....•
Fundus of lAC
Porus acusticus Facial nerve
Vestibulocochlear nerve
Flocculus of cerebellum
Vertebral artery

Facial nerve
Preganglionic segment CNS
Crista falciformis
Crista falciformis
Cochlear nerve
Jugular foramen
Anterior inferior cerebellar
Vertebral artery artery

Preganglionic segment CNS

Anterior belly of pons

Middle turn of cochlea Internal auditory canal

Basal turn of cochlea

Basal turn of cochlea
Jugular tubercle Vertebral artery

(Top) First of three coronal T2 MR images presented from posterior to anterior through the cerebellopontine angle
and internal auditory canal cisterns shows important regional structures including the preganglionic segment of
eNS, anterior inferior cerebellar artery loop, flocculus of cerebellum and vertebral artery. (Middle) In this image the
crista falciform is in the fundus of the internal auditory canal is seen. The facial nerve & superior vestibular nerve are
above and the cochlear nerve & inferior vestibular nerve are below the crista falciformis. (Bottom) At the level of the
cochlea the anterior belly of the pons is visible. The preganglionic segment of the trigeminal nerve is in the
anterosuperior portion of the cerebellopontine angle cistern while the jugular tubercle is in the anteroinferior
portion.
145
 S CTION 4: eSF Spaces

Ventricles and Choroid Plexus 1-148

Subarachnoid Spaces/Cisterns 1-160
 V1
Cl)
VENTRICLES AND CHOROID PLEXUS
U
~ o Borders
0..
rJ')
I Terminology • Anterior: Lamina terminalis, anterior commissure
u.. Definitions • Lateral: Thalami
rJ')
• Tela choroidea: Double layer of pia, formed during • Roof: Tela choroidea, choroid plexus
U • Floor: Optic chiasm, infundibulum lit tuber
folding of brain where hemispheres overgrow
c: cinereum, mammillary bodies, posterior
.~
~
diencephalon lit cerebellum apposes
• Choroidal fissure: Narrow, pial-lined
dorsal brainstem
channel between perforated substance, tegmentum of midbrain
co SAS lit ventricles; Site of attachment of choroid plexus • Posterior: Pineal gland, habenular lit posterior
in lateral ventricles commissures
o Recesses
• Inferior: Optic, infundibular
I Gross Anatomy • Posterior: Suprapineal, pineal
o Communicates with fourth ventricle via cerebral
Overview aqueduct
• Cerebral ventricles • Fourth ventricle
o Four cerebrospinal fluid-filled, ependymal lined o Diamond-shaped cavity (rhomboid fossa) along
cavities deep within brain dorsal pons lit upper medulla
o Paired lateral, midline third and fourth ventricles o Borders
o Communicate with each other as well as central • Roof: Tent-shaped, covered by anterior (superior)
canal of spinal cord, subarachnoid space (SAS) medullary velum above lit inferior medullary
• Choroid plexus velum below
o Secretory epithelium that produces cerebrospinal • Walls: Dorsal surface of pons lit medulla, cerebral
fluid (CSF) peduncles (superior/middle/inferior)
o Choroid plexus forms where tela choroidea contacts o Five recesses
ependymal lining of ventricles: Roof of third • Paired posterior superior: Thin, flat pouch capping
ventricle, body lit temporal horn of lateral ventricle tonsils
via choroidal fissure, inferior roof of fourth ventricle • Paired lateral: Curve anteriorly under brachium
o CSF flows from lateral ventricles through foramen of pontis, contain choroid plexus, communicate
Monro into third ventricle, through cerebral with SAS via foramina of Luschka
aqueduct into fourthventricle; exits through • Fastigium: Blind-ending, dorsally pointed midline
foramina of Luschka lit Magendie to SAS outpouching from body of fourth ventricle
o Bulk of CSF resorption through arachnoid o Communicates with SAS via foramina of Magendie
granulations in region of superior sagittal sinus and Luschka, with central canal of cord via obex

Anatomy Relationships
• Lateral ventricles
o Each has body, atrium, three horns
o Frontal horn formed by
• Roof: Corpus callosum
• Lateral wall, floor: Caudate nucleus
• Medial wall: Septum pellucidum (thin midline
structure that separates right, left frontal horns)
o Body formed by
• Roof: Corpus callosum
• Floor: Dorsal surface of thalamus
• Medial wall, floor: Fornix
• Lateral wall, floor: Body, tail of caudate nucleus
o Temporal horn formed by
• Roof: Tail of caudate nucleus
• Medial wall, floor: Hippocampus
• Lateral wall: Geniculocalcarine tract, arcuate
fasciculus
o Occipital horn: Surrounded by white matter
(forceps major of corpus callosum, geniculocalcarine
tract)
o Atrium: Confluence of horns; contains glomi of
choroid plexus
o Lateral ventricles communicate with each other
third ventricle via nY-shaped" foramen of Mon~o
• Third ventricle
o Midline, slit-like vertical cavity between right, left
diencephalon that contains interthalamic adhesion
(not a true commissure)
I Imaging Anatomy
Overview
• Lateral ventricles: Paired, "C-shaped", curve posteriorly
from temporal horns, arch around/above thalami
• Third ventricle: Thin, usually slit-like; 80% have
central adhesion between thalami (massa intermedia)
o Recesses: Optic is rounded, superior to optic chiasm;
infundibular is pointed, extends inferiorly into
infundibular stalk; suprapineal is thin, extends over
pineal; pineal is pointed projectinK into pineal stalk
• Fourth ventricle: Diamond-shaped midline
infratentorial ventricle
o Terminates inferiorly at obex, which communicates
with central canal of spinal cord (dorsal "bump"
covering obex is nucleus gracilis)
Normal Variants
• Ventricles: Cavum septi pellucidi, cavum vergae,
cavum veli interpositi
• Choroid plexus: Calcification, xanthogranulomas
(glomi appear lobulated, cystic)
IAnatomy-Based Imaging Issues
Imaging Pitfalls
• Spin dephasing with pulsatile CSf flow can mimic
intraventricular mass (e.g., colloid cyst)!

148
149
 VENTRICLES AND CHOROID PLEXUS
IJl
Q) AXIAL T2 MR
u
('j
Q..
rJ)
L.l....
rJ)
U
c:
•..
('j

Q:::l
Vertebral artery in medullary
Medulla
cistern
Obex
Foramen of Magendie

Cisterna magna

Vertebral artery in medullary

cistern
Medulla

Foramen of Magendie
Cerebellar tonsil

Cisterna magna

Medullary cistern
Choroid plexus (in foramen of
Luschka)
Flocculus of cerebellum
Foramen of Luschka

Inferior fourth ventricle

(Top) First of 12 sequential axial T2 MR images from inferior to superior demonstrates the obex, which is the inferior
termination of the fourth ventricle in the upper cord. The obex separates the central canal of the spinal cord from
the intracranial ventricular system. (Middle) Scan at lower medulla demonstrates foramen of Magendie (median
aperture), which allows communication between the fourth ventricle and cisterna magn~ In contrast to the
foramina of Luschka, the foramen of Magendie contains no choroid plexus. (Bottom) Image at the level of the
medulla. The fourth ventricle communicates laterally with the medullary cisterns via the foramina of Luschka as
demonstrated here. Choroid plexus in the foramina of Luschka normally protrudes through the lateral recess into the
medullary cisterns and should not be mistaken for an enhancing mass.
150
 VENTRICLES AND CHOROID PLEXUS
AXIAL T2 MR o::l
""'t
~
::J
n
Vl
"'Tl
Vl
Cerebellopontine angle cistern ""0

7th & 8th cranial nerve

~
()
complex entering internal ro
tJl
auditory canal
Internal auditory canal

Cerebellar tonsils

Basilar artery in prepontine

cistern

Facial colliculi

Fourth ventricle
Vermis

Posterior superior recesses

Temporal horns

Prepontine cistern

Superior cerebellar peduncle Upper fourth ventricle

Vermis

(Top) Image at the level of lower pons demonstrates the seventh & eighth cranial nerves as they traverse the
cerebellopontine angle cistern towards the internal auditory canals. The anterior inferior cerebellar artery loop
usually extends into the proximal internal auditory canal. (Middle) Image through the body of the fourth ventricle
shows the thin, CSF-filled blind-ending posterior superior recesses capping the tonsils. (Bottom) Image at the level of
the superior cerebellar peduncles shows the normal appearing upper fourth ventricle, which begins at the inferior
aspect of the cerebral aqueduct (of Sylvius). Note the normally crescentic appearance of the temporal horn also seen
here, which are bounded medially by the hippocampi. Rounding of the temporal horns should raise suspicion for
obstruction.
151
 VENTRICLES AND CHOROID PLEXUS
<Jl
Q.) AXIAL T2 MR
u
ro
Q..
(/)

L..L..
(/)
Infundibular recess of third
U ventricle
Suprasellar cistern

Temporal horn of lateral ventricle Midbrain

Apex of fourth ventricle

Quadrigeminal cistern

Anterior (superior) medullary

velum

Lamina terminalis
Third ventricle

Posterior cerebral artery within

Temporal horn, lateral ventricle ambient cistern
Quadrigeminal cistern
Cerebral aqueduct with
periaqueductal gray matter

Frontal (anterior) horn of lateral

ventricle

Anterior commissure

Posterior commissure
Retropulvinar cistern
Choroid plexus in atrium of lateral
ventricle

Occipital horn of lateral

ventricle

(Top) The suprasellar cistern and infundibular recess of the third ventricle are seen at this level. Note the normal thin
crescentic appearance to the temporal horns. The hippocampi line the inner margins of the temporal horns.
(Middle) Image at the midbrain level shows the lamina terminalis as a thin tract of white matter crossing midline at
the anterior margin of the third ventricle. The cerebral aqueduct, barely visible in this case, may have increased T2
signal (due to CSF) or decreased signal (from high flow). (Bottom) Image at the level of the anterior commissure,
which forms part of the anterior boundary of the third ventricle. Choroid plexus is normally present within the
trigone (atrium) of the lateral ventricle. Choroid plexus in roof of the third ventricle is often hypoplastic or
inapparent, even on contrast-enhanced Tl weighted MR scans.
152
 VENTRICLES AND CHOROID PLEXUS
AXIAL T2 MR

Frontal horn
Genu of corpus callosum
Cavum septi pellucidi
Septum pellucidum
Columns of fornix

Foramina of Monro

Internal cerebral veins in cistern of Choroid plexus glomus in

velum interpositum atrium of lateral ventricle

Occipital horns of lateral

ventricles

Frontal horn of lateral ventricle

Caudate head
Septum pellucidum

Internal cerebral vein

Thalamus

Atrium of lateral ventricle

Choroid plexus within lateral
ventricular atria

Frontal horn of lateral ventricle

Caudate head

Body of lateral ventricle

Choroidal arteries, veins

Choroid plexus in lateral

ventricles

(Top) Image at the foramina of Monro level shows connection between the lateral and third ventricles. Choroid
plexus is seen in the lateral ventricular atria. The occipital horns contain no choroid plexus, and are a common place
for subtle intraventricular blood to collect dependently (Middle) Image at the level of the lateral ventricular atria.
Note the septum pellucidum which separates the lateral ventricles. Choroid plexus is normally seen in the
anteromedial body and atria of the lateral ventricles. The caudate head impresses upon the floor and lateral wall of
the frontal horn, and the thalamus forms the lateral boundary of the lateral ventricle body. (Bottom) This image
demonstrates normal choroid plexus in the anteromedial body of the lateral ventricles. Note the normal concavity
along the lateral margins of the lateral ventricles from the caudate nuclei.
153
 VENTRICLES AND CHOROID PLEXUS
V'l
Cl) CORONAL T2 MR
U
n:l
Q..
t/)
u.. Atrium of lateral ventricl~
t/)
U
Choroid plexus
Internal cerebral veins

Posterior superior recess of~

fourth ventricle j

Atrium of lateral ventricle

Splenium of corpus callosum
Choroid plexus in lateral
ventricle

Internal cerebral veins

Cerebellar vermis Fourth ventricle fastigium;

Choroid plexus in body of

lateral ventricle

Posterior crura of fornix

Choroid plexus in temporal
horn

Fourth ventricle'

Lateral recess with choroid plexus

Foramen of Magendiel

(Top) First of 12 sequential coronal T2 MR images from posterior to anterior, through the ventricles. Here normal
choroid plexus is seen in the trigone (atria) of the lateral ventricles. The posterior superior recesses of the fourth
ventricle are partly imaged here. (Middle) Normal choroid plexus is seen in the lateral ventricular atria. (Bottom)
The fornices, seen here, are thin white matter tracts with complex communications with the hippocampus,
thalamus, hypothalamus, septal nuclei and entorhinal cortex. Anatomically, the fornix separates posteriorly into two
posterior crura along the inferior surface of the corpus callosum as seen here, then unites in the mid portion (body)
and separates again anteriorly into the anterior columns (pillars) that descend towards the mammillary bodies and
form the anterior border of the foramen of Monro.
154
 VENTRICLES AND CHOROID PLEXUS
CORONAL T2 MR

Body of lateral ventricl

Choroid plexus in lateral
Body of fornix ventricle

Internal cerebral veins

Cavum veli interpositi

Medulla

Septum pellucidum

Choroid plexus in lateral

ventricle
Third ventricle

Flocculus

Body of lateral ventricle

Septum pellucidum

Choroid plexus in lateral

ventricle
Third ventricle
Choroid plexus of the temporal
Interpeduncular cistern horn

7th & 8th cranial nerves in internal

Tri~eminal nerves in
auditory canal
cerebellopontine angle

(Top) Choroid plexus is seen here within the lateral ventricles. The internal cerebral veins traverse normally within
the cistern of the velum interpositum located superior to the pineal gland. (Middle) The lateral ventricles are
separated in the midline by a thin membrane(s), the septum pellucidum. Choroid plexus is normally present in the
lateral ventricle body, as again is appreciated here. The caudate nuclei are located along the lateral margins of the
lateral ventricles, and form an outwardly concave appearance. (Bottom) Choroid plexus is normally seen within the
temporal horn and body of the lateral ventricle as appreciated here. Note also the interpeduncular cistern, which
should not be confused with the third ventricle on coronal scans. The cisternal portions of the trigeminal nerves are
well demonstrated within the prepontine cisterns.
155
 VENTRICLES AND CHOROID PLEXUS
CORONAL T2 MR

Septum pellucidum
Choroid plexus in body of ,
lateral ventricle ,
Choroid plexus in roof of third
ventricle

Third ventricle
Temporal horn of lateral
ventricle

Hippocampal head

Lateral ventricle
Septum pellucidum

Foramen of Monro I

Third ventricle Anterior columns of fornix

Temporal horn of lateral

ventricle

Frontal horn of lateral ventricl

Septum pellucidum

Anterior commissure
Third ventricle Optic tract
Suprasellar cistern
Median eminence of
hypothalamus

(Top) This image demonstrates normal choroid plexus in the roof of the third ventricle and body of the lateral
ventricle. Note the normal undulations along the superior aspect of the hippocampal head which are in contact with
the temporal horn (Middle) The anterior temporal horns are well seen here. Note the normally narrow transverse
dimension of the third ventricle; when this configuration widens, or is outwardly convex, concern for obstruction
should be considered. Note also the fornix again divides into two anterior columns at this level, anterior to the
foramina of Monro. (Bottom) Image through the anterior third ventricle through the level of the anterior
commissure, which forms part of the anterior boundary of the third ventricle. The median eminence of the
hypothalamus forms part of the anterior floor of third ventricle. The optic tracts are also well demonstrated.
156
 VENTRICLES AND CHOROID PLEXUS
CORONAL T2 MR C:l
~
~
Frontal horn of lateral ventricle ::J
Septum pellucidum

Anterior column of fornix

Right optic tract Suprasellar cistern

Temporal horn of lateral

Infundibular recess, third ventricle ventricle
Fascicles of CNS in Meckel cave

Frontal horn of lateral ventricle

Septum pellucidum
Left anterior column of fornix

Interhemispheric fissure
Anterior cerebral artery
Optic chiasm
Suprasellar cistern

Cavernous sinus

Right frontal horn Genu of corpus callosum

Anterior cerebral artery within

interhemispheric fissure

(Top) Image through the frontal horns of the lateral ventricles. The suprasellar cistern has the appearalli:f of a five
pointed star at this level. (Middle) Image through the optic chiasm and frontal horns of lateral ventricles is shown
here. The thin linear fluid collection inferior to the frontal horns is the interhemispheric fissure, not the third
ventricle. Note the presence of the anterior cerebral arteries inferiorly within the interhemispheric fissure. This part
of the interhemispheric fissure is sometimes called the "cistern of the lamina terminalis." (Bottom) The frontal horns
of the lateral ventricles normally show concave lateral margins. Note slice is anterior to the septum pellucidum; the
midline white matter tract is the genu of the corpus callosum. Choroid plexus is not present in the frontal horns.

157
 VENTRICLES AND CHOROID PLEXUS
lJl
Q) SAGITTAL T2 MR
u
C\l
Q..
V)
u..
V)
U
c:
C\l Choroid plexus
lo..
i:Q
Temporal horn of lateral ventricle
Hippocampus

Atrium of lateral ventricle

Temporal horn of lateral ventricle
Choroid plexus
Occipital horn of lateral
ventricle

Atrium of lateral ventricle

Choroid plexus

Occipital horn of lateral

ventricle

Trigeminal nerve entering Meckel

cave

Cerebellar hemisphere

(Top) First of 6 sagittal T2 MR images from lateral to medial, through the temporal horn and atrium of the lateral
ventricle demonstrating normal choroid plexus within the atrium. Note also normal appearing hippocampus along
the inferior margin of the temporal horn. (Middle) Image showing normal choroid plexus within the atrium
(collateral trigone) of the lateral ventricle. Choroid plexus is not normally located within the occipital horns of the
lateral ventricle. (Bottom) This image demonstrates normal choroid plexus within the atrium (collateral trigone) of
the lateral ventricle. Note the normal cisternal portion the trigeminal nerve as it passes anteriorly over the petrous
ridge to enter Meckel cave.

158
 VENTRICLES AND CHOROID PLEXUS
SAGITTAL T2 MR .,
~
~
::J
Choroid plexus in body of lateral n
ventricle V'l
-n
V'l
""0

t:lJ
(')
(D
Cerebral peduncle IJl

Pons
Prepontine cistern
Cerebellum

Lateral recess, choroid plexus of

fourth ventricle

Body of lateral ventricle

Choroid plexus in lateral
ventricle body

Optic tract
.9culomotor nerve travl"rsini the.
intelJ?eduncular cistern •
Prepontine cistern Fourth ventricle

Choroid plexus
Medullary cistern

Cisterna magna

Choroid plexus in body of lateral Massa intermedia

ventricle
Choroid plexus in roof of third
ventricle Pineal gland
Anterior commissure Cerebral aqueduct (of Sylvius)

Optic (chiasmatic) recess of third Superior medullary velum

ventricle
Infundibular recess of third Fastigium of fourth ventricle
ventricle Choroid plexus in fourth
ventricle
Foramen of Magendie

(Top) Image at the level of the cerebral peduncle demonstrates choroid plexus within the body of the lateral
ventricle. The lateral wing of the fourth ventricle is seen here. (Middle) Choroid plexus is seen within the body of
the lateral ventricle and inferior roof of fourth ventricle. Note also the oculomotor nerve traversing the
interpeduncular cistern. (Bottom) This image demonstrates normal choroid plexus in the roof of third ventricle,
body of lateral ventricle, and posterior roof of fourth ventricle. The posterior choroidal artery is seen passing forward
into the third ventricle. The superior medullary velum and pons, which form part of the fourth ventricle boundaries,
are well seen here. The anteriorly located optic and infundibular recesses of the third ventricle are also well
demonstrated. The lamina terminalis forms the anterior border of third ventricle.
159
 SUBARACHNOID SPACES/CISTERNS
• Infratentorial (posterior fossa) cisterns
ITerminology o Midline (unpaired)
Abbreviations • Prepontine cistern: Between upper clivus,
• SASs: Subarachnoid spaces anterior pons
• Premedullary cistern: From pontomedullary
Definitions junction above to foramen magnum below;
• SASs: Cerebrospinal fluid-filled spaces between pia, between lower clivus and medulla
arachnoid; expand at base of brain, around brainstem, • Superior cerebellar cistern: Between upper
tentorial incisura vermis, straight sinus
• Liliequist membrane: Thin arachnoid membrane • Cisterna magna: Between medulla (anterior) and
separates suprasellar, interpeduncular & prepontine occiput (posterior), below/behind inferior vermis
cisterns o Lateral (paired),
• Velum interpositum: Double layer of pia (tela • Cerebellopontine cistern: Between anterolateral
choroidea), the result of folding of brain where pons/cerebellum, petrous temporal bone
hemispheres overgrow diencephalon, forms velum • Cerebellomedullary cistern (sometimes included
interpositum which may remain open & communicate as lower cerebellopontine cistern): From dorsal
posteriorly with quadrigeminal cistern (cavum veli margin of inferior olive laterally around medulla
interpositi) • Fissures
• Choroidal fissure: Narrow, pial-lined channel between o Interhemispheric fissure: Longitudinal cerebral
SAS & ventricles; site of attachment of choroid plexus fissure separates hemispheres
in lateral ventricles • Inferior part contains cistern of the lamina
terminalis; upper part contains pericallosal cistern
o Sylvian (lateral) fissure: Separates frontal, temporal
ICross Anatomy lobes anteriorly, courses laterally to cover insula

Overview Internal Structures-Critical Contents

• Numerous trabeculae, septae, membranes cross SAS - • Supratentorial/peri tentorial cisterns ,
create smaller compartments termed cisterns o Suprasellar cistern: Infundibulum, optic chiasm,
o Liliequist membrane separates suprasellar, circle of Willis
interpeduncular & prepontine cisterns o Interpeduncular cistern: Oculomotor nerves (CN3),
o Anterior/lateral pontine, medial/lateral basilar artery (BA) bifurcation, posterior
pontomedullary membranes separate posterior fossa thalamoperforating arteries
cisterns o Ambient cisterns: Trochlear nerves (CN4), P2
• All cranial nerves, major arteries/veins traverse cisterns posterior cerebral artery (PCA) segments and
• All structures within cisterns invested with thin branches, superior cerebellar arteries (SCAs), basal
pial-like layer of cells veins of Rosenthal
• All SAS cisterns communicate with each other and o Quadrigeminal cistern: Pineal gland, trochlear
with ventricular system (through foramina of nerves (CN4), P3 PCA segments, medial & lateral
Magendie and Luschka) posterior choroidal arteries, vein of Galen (VofG) +
• Cisterns provide natural pathways for disease spread as tributaries
well as surgical approaches o Cistern of velum interpositum: Internal cerebral
• SAS cisterns divided into supra- and peritentorial, veins (lCVs), MPChAs
infratentorial groups • Infratentorial cisterns ,
• Sulci separate gyri, fissures separate hemispheres/lobes o Prepontine cistern: BA, anterior inferior cerebellar
artery (AICA), CNS and 6
o Premedullary cistern: Vertebral arteries (VAs),
I Imaging Anatomy anterior spinal artery, posterior inferior cerebellar
artery (PICAs), CN12
Overview o Superior cerebellar cistern: SCA branches, superior
• Supratentoriallperitentorial cisterns , vermian and precentral cerebellar veins
o Suprasellar cistern: Superior to pituitary gland o Cisterna magna: Cerebellar tonsils (often have
o Interpeduncular cistern: Between cerebral dense trabecular attachments), tonsillohemispheric
peduncles, Liliequist membrane PICA branches
o Ambient (perimesencephalic) cisterns: Wrap o Cerebellopontine cistern: CNS, 7 & 8; AlCA;
around midbrain, connect suprasellar, petrosal vein
quadrigeminal cisterns o Cerebellomedullary cistern: CN9, 10 & 11
o Quadrigeminal cistern: Under corpus callosum • Fissures
splenium, behind pineal gland, tectum; continuous o Interhemispheric fissure: Falx cerebri with inferior
anteriorly with velum interpositum sagittal sinus, anterior cerebral artery (ACA) and
o Cistern of velum interpositum: Formed by double branches
layers of tela choroidea (pia), lies above third o Lateral fissure: Middle cerebral artery (MI-3
ventricle; communicates posteriorly with segments) & vein
quadrigeminal cistern

160
161
162
 SUBARACHNOID SPACES/CISTERNS
AXIAL T2 MR

Premedullary cistern

Verteb.ral artery Upper cervical cord

Posterior inferior cerebellar artery
Cisterna magna

Vertebral arteries in
cerebellomedullary cisterns ~

Medulla

Cisterna magna

Cerebellomedullary cisterns
Vertebrobasilar confluence in,
premedullary cistern i
CNs 9-11
Fourth ventricle

Cisterna magna

(Top) First of nine sequential axial T2 MR images presented from inferior to superior demonstrates the subarachnoid
spaces and cisterns. The cisterna magna is located behind the upper cervical cord and lower medulla, and below the
cerebellar hemispheres. It is continuous with the subarachnoid space of the spinal cord. The vertebral arteries and
posterior inferior cerebellar arteries normally traverse the cisterna magna, as seen here. (Middle) The cisterna magna
is seen here as a small eSF-filled space posterior to the cerebellum in the midline. The vertebral arteries travel within
the medullary cisterns. (Bottom) The vertebral arteries are seen in the medullary cistern at their confluence with the
basilar artery.

163
 SUBARACHNOID SPACES/CISTERNS
trl
Q) AXIAL T2 MR
u
C'1:l
Cl.
CJ)
u....
CJ)
U Meckel cave with CNS fascicles
Basilar artery in prepontine cistern

eN? & 8 in cerebellopontine

cisterns
Superior petrosal vein

Basilar artery

CNS in superior aspect of

cerebellopontine cistern

Fourth ventricle

Cerebellar folia

Anterior cerebral artery Middle cerebral artery in lateral

(sylvian) fissure

Suprasellar cistern
Infundibular recess of third
ventricle
Interpeduncular cistern
Posterior cerebral artery in
ambient cistern

Quadrigeminal cistern

(Top) Cranial nerves 7 & 8 are demonstrated traversing the cerebellopontine cisterns. The anterior inferior cerebellar
arteries and posterior inferior cerebellar arteries also course through this cistern. CSF in Meckel cave communicates
freely with the prepontine and cerebellopontine angle cisterns. (Middle) The basilar artery is seen in the prepontine
cistern. Cerebellar folia are seen here as the numerous curvilinear fluid-filled subarachnoid spaces over the
cerebellum. (Bottom) The pituitary infundibulum lies in the center of the suprasellar cistern; the small fluid-filled
structure centrally is the variably hollow portion of the infundibulum which is contiguous with the infundibular
recess. The ambient cisterns surround the midbrain and connect the suprasellar and quadrigeminal cisterns.

164
 SUBARACHNOID SPACES/CISTERNS
AXIAL T2 MR .,
~
~
:J
Anterior cerebral artery in
interhemispheric fissure n
V'l
Cistern of the lamina terminalis Middle cerebral artery branches "'Tl
within sylvian fissure ""0
V'l

Third ventricle Anterior commissure ~

(")
(D
Vl

Ambient
..• --cistern with --,
-- basal vein of
R9~al
.• Quadrigeminal cistern

~n teJiQ!s:erejJI.eLa.l~ll.ewithin .•
interhemis heri<:.fiss.!]re
Sylvian fissure

Anterior third ventricle

Massa inter media
(interthalamic adhesion)
Posterior third ventricle
Pulvinar of thalamus

Internal cerebral veins in

Superior cerebellar cistern quadr-i;min~l ~is!ein•.•

Anterior cerebral artery within

interhemispheric fissure

Cistern of the velum

interpositum, ICVs

Parietooccipital sulcus

(Top) The quadrigeminal plate cistern is located between the cerebellar vermis and the colliculi. Middle cerebral
artery branches are well demonstrated within the sylvian fissure. The anterior commissure is only partly visualized
on this image, but demarcates the anterior aspect of the third ventricle. The interhemispheric fissure is visualized
anteriorly. (Middle) The sylvian and interhemispheric fissures are demonstrated here. The retropulvinar cisterns are
the lateral extensions of the ambient cisterns, located posterior to the thalami. The internal cerebral veins are located
within the cistern of the velum interpositum. (Bottom) The parietooccipital sulci and interhemispheric sulci are
demonstrated here. The superior aspect of the cistern of the velum interpositum is also visible.
I
165
 SUBARACHNOID SPACES/CISTERNS
lJl
Q) CORONAL T2 MR
u
ro
0...
(j)

l.J....
(j)

U Third ventricle
Posterior perforated substance
Oculomotor nerve (CN3)

Interpeduncular cistern Ambient cistern

Posterior cerebral artery (in

ambient cistern)
Cerebellopontine angle cistern

Vertebral artery within

premedullary cistern

Third ventricle

Oculomotor nerves traversing

interpeduncular cistern

Cerebellopontine angle cistern

Vertebrobasilar junction at
prepontine & medullary cistern
junction

Interpeduncular cistern
Right posterior cerebral artery
Ambient cistern

Oculomotor nerve (CN3)

Right superior cerebellar arteries

Basilar artery within prepontine
cistern

(Top) First of 12 coronal T2 MR images through the central cisterns presented from posterior to anterior
demonstrates the posterior third ventricle, interpeduncular and cerebellopontine cisterns. The vertebral arteries run
within the premedullary cisterns. (Middle) The oculomotor nerves traverse in the interpeduncular cistern. Note the
vertebrobasilar junction, at the junction of the prepontine and medullary cisterns. (Bottom) The anterior vasculature
within the prepontine cistern is well seen here: Top of basilar artery, which divides into the posterior cerebral
arteries, and the superior cerebellar arteries. Duplication of the superior cerebellar artery, as seen here, is a common
anatomical variant. Note the position of the oculomotor nerves which travel between the posterior cerebral and
superior cerebellar arteries in the interpeduncular cistern.
166
 SUBARACHNOID SPACES/CISTERNS
CORONAL T2 MR

Interpeduncular cistern at junction

with suprasellar cistern

AICA in prepontine cistern

Basilar artery within prepontine
cistern

Diencephalic membrane

Liliequist membrane attachment at Oculomotor nerve

oculomotor nerve

Prepontine cistern Meckel cave

Anterior commissure
Optic tract
Third ventricle
Hypothalamus
Suprasellar cistern
Oculomotor nerve
Liliequist membrane

(Top) Scan just anterior to basilar bifurcation shows confluence of suprasellar, interpeduncular, mesencephalic,
prepontine cisterns. (Middle) The Liliequist membrane is seen at its lateral attachments to/around the oculomotor
nerves. Suprasellar cistern is anterosuperior; interpeduncular is posterosuperior; prepontine is posteroinferior.
(Bottom) The normal transverse appearance of the Liliequist membrane is appreciated here; it is normally about half
the width of the third ventricular floor. Laterally, the Liliequist membrane attaches to the oculomotor nerves or the
arachnoid membranes around them. The interpeduncular and suprasellar cisterns are thus separated anatomically
when this membrane is completely intact. Note also how the hypothalamus forms part of the anterior floor of the
third ventricle. Note also the midline crossing fibers of the anterior commissure.
167
 SU BARACH NOI D SPACES/CISTERNS
CORONAL T2 MR

Hypothalamus

Infundibular recess of third Optic tract

ventricle
Liliequist membrane
Suprasellar cistern

Lamina terminalis
Suprasellar cistern
Optic recess of third ventricle

Right optic tract

Oculomotor nerve
Infundibular recess of third
ventricle
Meckel cave with CNS fascicles

Sylvian fissure
Cistern of the lamina terminalis

Pituitary infundibulum Suprasellar cistern

Meckel cave

(Top) The anterior attachment of the Liliequist membrane to the dorsum sellae is appreciated here. The suprasellar
cistern is seen above and surrounding the pituitary infundibulum. (Middle) The anterior recesses of the third
ventricle are seen here in the midline: Optic and infundibular recesses. The lamina terminalis, which forms part of
the third ventricle, is seen here. A small CSF-filled extension of the suprasellar and interpeduncular cisterns
surrounds the third cranial (oculomotor) nerve. CSF in Meckel cave contains fascicles of the trigeminal nerve (CNS)
and communicates freely with the prepontine cistern. (Bottom) The suprasellar cistern is visualized here, above the
pituitary gland, surrounding the pituitary infundibulum and optic chiasm.
I
168
 SUBARACHNOID SPACES/CISTERNS
CORONAL T2 MR ..,
O:l
~
::J
Al segments of anterior
Cistern of lamina terminalis cerebral arteries
Suprasellar cistern
MI segment entering sylvian
Optic chiasm
fissure
Supraclinoid internal carotid
Oculomotor nerve entering
artery
posterior cavernous sinus
Dural wall of Meckel cave
Pituitary Infundibulum

Anterior cerebral artery within

interhemispheric fissure

Middle cerebral artery within

Optic chiasm sylvian fissure
Supraclinoid internal carotid
Pituitary infundibulum artery
Suprasellar cistern

Anterior cerebral artery within

interhemispheric fissure

Optic nerves
Middle cerebral artery within
sylvian fissure
Supraclinoid internal carotid
Suprasellar cistern
artery
Pituitary gland

(Top) The anterior circle of Willis vasculature is well seen in the suprasellar cistern at this level with Al and MI
segments arising from the supraclinoid internal carotid arteries. The proximal MI segments are seen entering the
sylvian fissures. (Middle) The pituitary infundibulum is seen at the anterior inferior insertion into the pituitary
gland. The optic chiasm is seen in the suprasellar cistern. The anterior cerebral arteries are identified within the
anterior interhemispheric fissure, and the proximal middle cerebral arteries within the sylvian fissures. (Bottom) The
optic nerves are seen separately in the anterior aspect of the suprasellar cistern. The anterior curvature of the anterior
cerebral arteries is visualized in the interhemispheric fissure, and middle cerebral artery within the sylvian fissure.

169
 SUBARACHNOID SPACES/CISTERNS
SAGITTAL T2 MR

Internal cerebral vein within

Choroid plexus in foramen of cistern of velum interpositum
Monro Quadrigeminal cistern!

A2 ACA segment in Quadrigeminal plate cistern

interhemispheric fissure

Anterior commissure
Lamina terminalis
Cistern of the lamina terminalis Superior cerebellar cisternf
Membrane of Liliequist

Suprasellar cistern Interpeduncular cistern

Basilar artery in prepontine

cistern
Vertebral artery in premedullary
cistern

Cisterna magna

Choroid plexus in roof of third

ventricle
Superior cerebellar cistern
Interpeduncular cistern

Prepontine cistern

Medullary cistern

Cisterna magna

(Top) First of 6 sequential sagittal T2 MR images shown from left to right demonstrates the internal cerebral veins
traversing the cistern of the velum interpositum. The quadrigeminal cistern is posterior to the pineal gland and the
collicular plate. (Middle) This image demonstrates the membrane of Liliequist, a delicate arachnoid membrane
between the dorsum sella and mamillary bodies, separating the prepontine, interpeduncular & suprasellar cisterns.
Note how the thin lamina terminalis and the anterior commissure form part of the anterior third ventricular margin
The cistern of the lamina terminalis is seen anterior to the lamina terminalis. (Bottom) Cisterns anterior to the
brainstem, and the superior cerebellar cistern are well demonstrated here. Note course of the basilar artery, which
travels in the prepontine cistern.
170
 SUBARACHNOID SPACES/CISTERNS
SAGITTAL T2 MR

n
Vl
"'T1
Vl
Liliequist membrane "'0
OJ
n
Suprasellar cistern ro
Vl

Interpeduncular cistern

Prepontine cistern

Pericallosal artery in peri callosal

cistern

Suprasellar cistern

CN3 traversing interpeduncular

cistern

Foramen of Monro

Superior cerebellar cistern

Cisterna magna

(Top) The Liliequist membrane is again seen attaching posterosuperiorly to the mammillary bodies and
anteroinferiorly to the dorsum sella. This small arachnoid membrane may also require perforation when third
ventriculostomies are performed to relieve obstruction when anatomically complete. (Middle) The peri callosal artery,
an A2 branch of the anterior cerebral artery, is seen in the peri callosal cistern above the corpus callosum. The
oculomotor nerve is seen as it emerges from the midbrain in the interpeduncular cistern. (Bottom) The superior
cerebellar cistern lies above the vermis and cerebellar hemispheres and connects to the ambient and quadrigeminal
cisterns. The right stem of the foramen of Monro is seen here. The cisterna magna is dorsal to the cervicomedullary
junction.
171
SECTION 5: Cranial Nerves

Cranial Nerves Overview 1-174

C 1 (Olfactory Nerve) 1-186
CN2 (Optic Nerve) 1-190
CN3 (Oculomotor Nerve) 1-198
CN4 (Trochlear Nerve) 1-204
CN5 (Trigeminal Nerve) 1-208
C 6 (Abducens Nerve) 1-220
C 7 (Facial Nerve) 1-224
C 8 (Vestibulocochlear Nerve) 1-232
C 9 (Glossopharyngeal erve) 1-238
C 10 (Vagus Nerve) 1-244
CN 11 (Accessory Nerve) 1-250
CN 12 (Hypoglossal Nerve) 1-254
 r.n
e;
CRANIAL NERVES OVERVIEW
>
l-
e; I Terminology
Z Imaging Pitfalls
• Radiologist forgets to image the extracranial structures
Abbreviations associated with cranial nerve affected
• Olfactory nerve: CNI
• Optic nerve: CN2
•
•
Oculomotor nerve: CN3
Trochlear nerve: CN4
I Clinical Implications
• Trigeminal nerve: CNS Clinical Importance
• Abducens nerve: CN6 • Cranial nerves and their functions
• Facial nerve: CN? o Olfactory nerve
• Vestibulocochlear nerve: CN8 • Sense of smell
• Glossopharyngeal nerve: CN9 o Optic nerve
• Vagus nerve: CNlO • Sense of vision
• Accessory nerve: CNll o Oculomotor nerve
• Hypoglossal nerve: CN12 • Motor to all extraocular muscles except lateral
rectus and superior oblique
• Parasympathetic supply to ciliary and pupillary
I Imaging Anatomy constrictor muscles
o Trochlear nerve
Overview • Motor to superior oblique
• Cranial nerve groupings based on area of brainstem o Trigeminal nerve
origin • Motor (V3) to muscles of mastication, anterior
o Diencephalon: CN2 belly digastric, mylohyoid, tensor tympani and
o Mesencephalon (midbrain): CN3 and CN4 palatini
o Pons: CNS, CN6, CN?, and CN8 • Sensory to surface of forehead and nose (VI),
o Medulla: CN9, CNlO, CNll and CN12 cheek (V2) and jaw (V3)
• Sensory to surfaces of nose, sinuses, meninges and
external surface of tympanic membrane
IAnatomy-Based Imaging Issues (auriculotemporal nerve)
Imaging Recommendations o Abducens nerve
• Motor to lateral rectus muscle
• Best imaging modality for any simple or complex
o Facial nerve
cranial neuropathy is MR
• Motor to muscles of facial expression
o Single exception to this directive is distal vagal
• Motor to stapedius muscle
neuropathy where it is necessary to image to
• Parasympathetic to lacrimal, submandibular and
aortopulmonic window on left
sublingual glands
• Contrast-enhanced CT better here as less affected
• Anterior 2/3 tongue taste (chorda tympanic nerve)
by breathing, swallowing and coughing
• General sensation for periauricular skin, external
movements
surface of tympanic membrane
• If a lesion is located in bony area such as skull base,
o Vestibulocochlear nerve
sinuses or mandible, bone CT is highly recommended
• Senses of hearing and balance
to provide complimentary bone anatomy and
o Glossopharyngeal nerve
lesion-related information
• Motor to stylopharyngeus muscle
o Contrast-enhancement of CT is not necessary if full
• Parasympathetic to parotid gland
TI, T2 and TI C+ MR is available
• Visceral sensory to carotid body
Imaging Approaches • Posterior 1/3 tongue taste
• Remember cranial nerves do not stop at skull base! • General sensation to posterior 1/3 of tongue and
• Radiologist must image to "functional endplate" of internal surface of tympanic membrane
affected cranial nerve o Vagus nerve
o CNl, 2, 3, 4 and 6: Include focused orbital • Motor to pharynx-larynx
sequences • Parasympathetic to pharynx, larynx, thoracic and
o CNS: Include entire face to inferior mandible if V3 abdominal viscera
affected • Visceral sensory from pharynx, larynx and viscera
o CN?: Include CPA, temporal bone and parotid • General sensation from small area around external
space ear
o CN8: Include CPA-lAC and inner ear o Accessory nerve
o CN9-12: Include basal cistern, skull base, • Motor to sternocleidomastoid and trapezius
nasopharyngeal carotid space muscles
• CNI0: Follow carotid space to aortopulmonic o Hypoglossal nerve
window on left, cervicothoracic junction on right • Motor to intrinsic and extrinsic tongue muscles
• CN12: Remember to reach hyoid bone to include except palatoglossus
distal loop as it rises into sublingual space

I
174
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177
 CRANIAL NERVES OVERVIEW
Vl
Q) AXIAL BONE CT
>
'-
Q)
Z
Cephalad nasal cavity
ru
c
ru
'-
U Inferior orbital fissure
Foramen rotundum (V2)

Vidian (pterygoid) canal Foramen ovale (V3)

Clivus Foramen spinosum (middle

meningeal artery)
Inferior jugular foramen
Hypoglossal canal (CN12) (CN9-11)

Stylomastoid foramen (CN?)

Crista galli

Roof of nasal cavity

Inferior orbital fissure

Foramen rotundum (V2)

Foramen ovale (V3)

Foramen lacerum (floor of carotid

Foramen spinosum (middle
canal)
meningeal artery)

jugular foramen (CN9-11) Carotid canal, vertical segment

(sympathetic plexus)

Crista galli

Cribriform plate (CNl)

Inferior orbital fissure

jugular foramen, pars nervosa

(CN9) Carotid canal, horizontal
jugular spine segment
Carotid canal, vertical segment
jugular foramen, pars vascularis
(CNIO & 11)

(Top) First of six sequential axial bone CT images through skull base presented from inferior to superior shows
foramina of sphenoid bone including foramen rotundum (CNV2) & foramen ovale (CNV3). More posteriorly oblique
hypoglossal canal is visible bilaterally in the occipital bone. (Middle) At the level of the inferior jugular foramen the
entry to the vertical segment of the carotid canal is also seen just anterior to jugular foramen. Notice the ovoid shape
of the jugular foramen at this level. The floor of the anteromedial aspect of the horizontal segment of !petrous ICA is
called the foramen lacerum. (Bottom) At the level of the cribriform plate the jugular foramen is now divided by the
jugular spine into more anterior pars nervosa (CN9, Jacobsen nerve and inferior petrosal sinus) and more
posterolateral pars vascularis (CNlO, 11, Arnold nerve and jugular bulb).
178
 CRANIAL NERVES OVERVIEW
AXIAL BONE CT

Crista galli
Subfrontal cistern (olfactory
bulb here)

Superior orbital fissure (CN3, 4, 6 &

VI)
z
([)
Internal carotid artery, ....•
cavernous segment <
([)
Carotid canal, horizontal r.r>

segment
jugular foramen, pars nervosa Jugular spine
(CN9)
jugular foramen, pars vascularis
(CNIO & 11) Facial nerve canal, mastoid
segment (CN7)
jugular tubercle

Superior orbital fissure (CN3, 4, 6 & Superior orbital fissure

VI)
Cavernous sinus area (CN3, 4,
6, VI & V2)
Petrooccipital fissure, cephalad Inferior bony margin of porus
aspect (CN6) trigeminus (CNS)

Cochlea
Facial nerve canal, cephalad
mastoid segment Roof of jugular bulb

Roof of jugular bulb

Greater wing of sphenoid bone

Optic canal (CN2)

Anterior clinoid process

Dorsum sellae
Petrous apex
Internal auditory canal (CN7 & 8)
Facial nerve canal, labyrinthine
segment (CN7)
Mastoid air cells

(Top) At the level of the mid-horizontal portion of the petrous ICA the superior orbital fissure is seen. Remember
that CN3, 4 and 6 as well as the ophthalmic division of CNS and the superior ophthalmic vein all enter the orbit
through this structure. (Middle) At the level of the cochlea and upper petrous apex, the petrooccipital fissure is seen.
This is approximately the location of CN6 after it pierces the dura to leave the prepontine cistern on its way to the
cavernous sinus. On bone CT the area of the cavernous sinus can only be approximated. Notice also the inferior
margin of the porus trigeminus. (Bottom) The internal auditory canal is visible on this most cephalad CT image. The
facial (CN?) and vestibulocochlear (CN8) nerves pass through the lAC. The optic nerve (CN2) enters orbit via the
optic canal which lies medial to the anterior clinoid process.
179
 CRANIAL NERVES OVERVIEW
CD AXIAL T2 MR
>
~
Q)
Z
ro
c
ro
~ Vertebral artery
U
Nasopharyngeal internal carotid
Hypoglossal nerve (CN12)
artery
Preolivary sulcus Hypoglossal canal

Postolivary sulcus
Spinal root of accessory nerve
(CNll)

Medulla
Dorsal median sulcus

Basilar artery

Pyramid
Anterior inferior cerebellar
Jugular foramen artery

Posterior inferior cerebellar

Olive artery
CN9-11
Postolivary sulcus
Inferior fourth ventricle

Basilar artery
Anterior inferior cerebellar artery

Glossopharyngeal nerve (CN9) Glossopharyngeal nerve (CN9)

Vagus nerve (CNIO) Vagus nerve (CNIO)

Inferior cerebellar peduncle
Foramen of Luschka
Fourth ventricle
Hypoglossal trigone

(Top) First of twelve axial T2 MR image sequence presented from inferior to superior shows the left hypoglossal nerve
leaving the preolivary sulcus of the medulla. Spinal root of accessory nerve (CNll) ascends through foramen
magnum, lateral to brainstem to unite with cranial roots of accessory nerve before exiting via jugular foramen.
(Middle) Glossopharyngeal (CN9), vagus (CNIO) and cranial (bulbar) roots of spinal accessory (CNll) nerves emerge
from lateral brainstem posterior to olive in the postolivary sulcus and exit the skull base via jugular foramen. Do not
confuse the posterior or anterior inferior cerebellar arteries for cranial nerves. (Bottom) Nucleus of hypoglossal nerve
(CN12) forms a characteristic bulge on floor of fourth ventricle called the hypoglossal trigone. It is often difficult to
separate CN9 from CNlO in the basal cistern.
180
 CRANIAL NERVES OVERVIEW
AXIAL T2 MR

Abducens nerve (CN6)

Z
Abducens nerve (CN6) Anterior inferior cerebellar ro
....•
artery <
ro
Cochlear nerve CJl

Inferior cerebellar peduncle Flocculus of cerebellum

Origins, CN? & 8

Fourth ventricle

Maxillary division, CNS (V2)

Meckel cave
Abducens nerve (CN6)
Cochlear nerve Abducens nerve (CN6) piercing
dura

Inferior vestibular nerve Facial nerve (CN?)

Vestibulocochlear nerve (CN8)

Anterior inferior cerebellar artery
loop

Clivus Meckel cave

Abducens nerve (CN6) Basilar artery

Porus acusticus
Pons

Fourth ventricle Middle cerebellar peduncle

(Top) Abducens (CN6) nerves exit brainstem anteriorly at pontomedullary junction just above pyramid, ascending
from there through prepontine cistern towards clivus. Cochlear nerve nuclei are found on lateral surface of inferior
cerebellar peduncle (restiform body). (Middle) CN? and CN8 exit brainstem laterally at pontomedullary junction to
enter cerebellopontine angle cistern. CN? lies anterior to CN8 in cerebellopontine angle cistern. Notice CN6 piecing
dura on patient's left to enter Dorello canal an interdural channel passing along dorsal surface of clivus within basilar
venous plexus towards cavernous sinus. (Bottom) Meckel cave is formed by a dural reflection, lined with arachnoid
and containing cerebrospinal fluid. The Gasserian ganglion (trigeminal ganglion) is semi-lunar in shape and lies
antero-inferiorly in Meckel cave.
181
 CRANIAL NERVES OVERVIEW
lJl
Q) AXIAL T2 MR
>
•....
Q)
z
rtl CN6 piercing dura
C
rtl CNS enters Meckel cave
•....
U Prepontine cistern

Preganglionic segment, CNS

Pons
Root entry zone, CNS
Middle cerebellar peduncle

Pituitary gland
CN3 in oculomotor cistern
CN3 in oculomotor cistern

Pons

Superior cerebellar peduncle

Fourth ventricle

Infundibulum

Posterior communicating artery Posterior cerebral artery

Oculomotor nerve (CN3) Oculomotor nerve (CN3)

Pons
Superior cerebellar artery

Superior cerebellar peduncle

Cephalad fourth ventricle

(Top) CNS exits lateral pons at point referred to as the root entry zone. Preganglionic segment courses anteriorly
through prepontine cistern and passes over petrous apex to enter Meckel cave via porus trigeminus (entrance to
Meckel cave). (Middle) In this image the oculomotor nerve (CN3) can be seen surrounded by high signal
cerebrospinal fluid as it enters the roof of the cavernous sinus. This area is referred to as the oculomotor cistern
(Bottom) At level of upper pons important vascular relationships of CN3 passing between posterior cerebral and
superior cerebellar arteries visible. Notice CN3 coursing anteriorly within suprasellar cistern adjacent to posterior
communicating artery. An aneurysm of posterior communicating artery will result in compression of CN3.

182
 CRANIAL NERVES OVERVIEW
AXIAL T2 MR O::l
~
~
::J
Optic nerve

Pituitary infundibulum
Optic chiasm

Oculomotor nerve (CN3)

Oculomotor nerve (CN3)
z
Trochlear nerve (CN4)
-.<
(t)

(t)
Ambient cistern Vl

Superior cerebellar peduncle

Pituitary infundibulum Anterior cerebral artery

Optic tract
Oculomotor nerve (CN3)
Interpeduncular cistern

Cerebral peduncle
Ambient cistern

Superior recess fourth ventricle Midbrain

Superior medullary velum

Optic tract

Optic tract
Mamillary body

Cerebral peduncle

Ambient cistern
Cerebral aqueduct

Inferior colliculi

(Top) Anteriorly note the optic nerves (CN2) form optic chiasm in suprasellar cistern. Fibers originating from nasal
halves of retina cross within optic chiasm. CN3 course anteriorly within suprasellar cistern towards cavernous sinus.
(Middle) Note CN3 is seen on the patient's left exiting the brainstem along medial aspect of cerebral peduncle where
it enters the interpeduncular cistern. The trochlear nerve decussates in the superior medullary velum, then exits
dorsal surface of the midbrain below the inferior colliculus to enter quadrigeminal plate cistern. From there CN4
courses around brainstem below tentorium cerebelli in ambient cistern passing between posterior cerebral and
superior cerebellar arteries. (Bottom) Optic tracts connect the lateral geniculate body to the optic chiasm. Only a
portion of the optic tracts are visible here.
183
 CRANIAL NERVES OVERVIEW
lJl
Cl) CORONAL T2 MR
>
~ Third ventricle
Cl)
z Interpeduncular cistern

Tentorium cerebelli Cerebral peduncle

Superior cerebellar artery

Proximal preganglionic segment,
CNS Anterior inferior cerebellar
artery
Vestibulocochlear nerve (CN8)
Flocculus of cerebellum
Facial nerve (CN?)
Medulla
Cerebellopontine angle cistern

Vertebral artery

Interpeduncular cistern

Oculomotor nerve (CN3) Oculomotor nerve (CN3)

Pons
Prepontine segment, CNS
Crista falciformis
Porus acusticus
Pontomedullary junction

Vertebral artery

Posterior cerebral artery Posterior cerebral artery

Oculomotor nerve (CN3)

Oculomotor nerve (CN3)
Superior cerebellar artery
Tentorium cerebelli
Cochlea
Preganglionic segment, CNS
Ventral belly of pons

Vertebral artery

(Top) First of six coronal T2 MR images of brainstem, cisterns and cranial nerves presented from posterior to anterior.
Preganglionic segment of trigeminal nerve is seen arising from lateral pons. Also seen are facial and vestibulocochlear
nerves traversing cerebellopontine angle cistern into internal auditory canal. (Middle) Oculomotor nerves are seen
emerging from medial aspect of cerebral peduncle into interpeduncular cistern. Basal cistern cranial nerves are not
visible. The abrupt transition between the pons and the medulla is termed the pontomedullary junction. (Bottom) In
this image notice the oculomotor nerves passing between posterior cerebral artery above and superior cerebellar
artery below. The distal preganglionic segment of eNS is poised to enter the porus trigeminus on its way into Meckel
cave.
184
 CRANIAL NERVES OVERVIEW
CORONAL T2 MR O::l
~
~
:J
Posterior communicating artery
Optic tract (CN2)

Oculomotor nerve (CN3)

Oculomotor nerve (CN3)

Superior cerebellar artery

Trigeminal nerve
z
(!)
.,
<
(!)
Trigeminal nerve entering porus tr>
trigeminus
Pontine belly
Vertebral artery

Third ventricle
Optic tract (CN2)

Anterior choroidal artery

Oculomotor nerve (CN3)
Posterior communicating artery

Trigeminal nerve rootlets in

Meckel cave
Meckel cave

Ml segment of middle cerebral

Optic chiasm artery

Oculomotor nerve in oculomotor Oculomotor nerve (CN3)

cistern

Pituitary gland
Meckel cave

(Top) This image shows the oculomotor nerve between the posterior communicating artery above and the superior
cerebellar artery below. The trigeminal nerve is visible entering the porus trigeminus of Meckel cave. (Middle) Here
the optic tracts are seen converging toward optic chiasm. Note a large left anterior choroidal artery coursing
posterolaterally within suprasellar cistern. Preganglionic fibers of trigeminal nerve are seen within Meckel cave.
Meckel cave is formed by a reflection of dura which is lined with arachnoid and contains cerebrospinal fluid which
communicates freely with prepontine cistern. (Bottom) In this most anterior coronal T2 image the pituitary is seen
below optic chiasm. Notice the oculomotor nerve is entering the cavernous sinus in the oculomotor cistern. The high
signal ring around CN3 is cerebrospinal fluid.
185
 rJl
(])
CN1 (OLFACTORY NERVE)
>
~
(])
z ITerminology
Abbreviations
• Olfactory nerve: CNl, CN I
Synonyms
• First cranial nerve
Definitions
• CNl: Special visceral afferent cranial nerve for
olfaction (sense of smell)
I Imaging Anatomy
Overview
• Visceral afferent system providing sense of smell
• Olfactory nerve segments
o End receptor in olfactory epithelium in nasal vault
o Transethmoidal segment through cribriform plate
o Intracranial olfactory bulb, tract and cortex
Nasal Epithelium
• Approximately 2 cm2 nasal epithelium in roof of each
nasal cavity
o Extends onto nasal septum and lateral wall of nasal
cavity including superior turbinates
• Bipolar olfactory receptor cells (neurosensory cells)
located in nasal pseudostratified columnar epithelium
o Peripheral processes of receptor cells in olfactory
epithelium act as sensory receptors for smell
• Olfactory glands (of Bowman) secrete mucous which
solubilizes inhaled scents (aromatic molecules)
Transethmoidal Segment
• Central processes of bipolar receptor cells traverse
cribriform plate to synapse with olfactory bulb
• Hundreds of central processes traverse cribriform plate
as unmyelinated fascicles (fila olfactoria)
o Fila olfactoria are actual olfactory nerves
o Each side of nasal cavity has - 20 fila olfactoria
Intracranial, Olfactory Bulb and Tract
• Olfactory bulb and tracts are extensions of the brain,
not nerves
o Historically bulb and tract are called "olfactory
nerve"
• Olfactory bulb closely apposed to cribriform plate at
ventral surface of medial frontal lobe
o Rostral enlargement of olfactory tract
o Bipolar cells synapse in olfactory bulb with
secondary neuronal cells (mitral and tufted cells)
o Mitral cell axons project posteriorly in olfactory
tract
o Granule cells modulate mitral cells
• Olfactory tract divides into medial, intermediate and
lateral stria at anterior perforated substance
o This trifurcation creates olfactory trigone
o Anterior perforated substance is perforated by
multiple small vascular structures
o Olfactory tract is made up of secondary sensory
axons, not primary sensory axons
o Majority of fibers project through lateral olfactory
stria and intermediate stria
186
Intracranial, Central Pathways
• Complex pattern of central connections
• Lateral olfactory striae
o Formed by majority of fibers of olfactory tracts
o Course over insula to prepiriform area (anterior to
uncus) and amygdala
o On way to prepiriform area collaterals are given to
subfrontal or frontal olfactory cortex
o Fibers to subthalamic nuclei with
collaterals/terminal fibers to thalamus and stria
medullaris
• Medial olfactory striae
o Majority terminate in parol factory area of Broca
(medial surface in front of the subcallosal gyrus)
o Some fibers end in subcallosal gyrus and in anterior
perforated substance
o Few fibers cross in anterior commissure to opposite
olfactory tract
• Intermediate olfactory striae
o Intermediate olfactory stria terminate in anterior
perforated substance
o Intermediate olfactory area contains anterior
olfactory nucleus and nucleus of diagonal band
• Medial forebrain bundle
o Formed by fibers from basal olfactory region,
periamygdaloid area and septal nuclei
o Some fibers terminate in hypothalamic nuclei
o Majority of fibers extend to brainstem to autonomic
areas in reticular formation, saliva tory nuclei and
dorsal vagus nucleus
IAnatomy-Based Imaging Issues
Imaging Recommendations
• Coronal sinus CT is best study for isolated anosmia
o Identifies nasal vault and cribriform plate lesions
• MR of brain, anterior cranial fossa and sinonasal
region used in complex anosmia cases
o Identifies intracranial dural and parenchymal lesions
Imaging "Sweet Spots"
• Intracranial: Include anterior cranial fossa floor and
medial temporal lobes
• Extracranial: Include nasal vault and cribriform plate
Imaging Pitfalls
• Coronal sinus CT insensitive to intracranial pathology
I Clinical Implications
Clinical Importance
• CNl dysfunction produces unilateral anosmia
o Each side of nose must be tested individually
• Esthesioneuroblastoma arises from olfactory
epithelium in nasal vault
• Head trauma may cause anosmia: Cribriform plate
fracture or shear forces; anterior temporal lobe injury
• Seizure activity in lateral olfactory area may produce
"uncinate fits", imaginary odor, oroglossal
automat isms and impaired awareness
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Cribriform plate

Lateral lamella Olfactory bulb area

Anterior ethmoid sinus

Superior nasal turbinate

Nasal septum

Crista galli
Orbital plate of frontal bone
Cribriform plate
Fovea ethmoidalis
Lateral lamella

Olfactory mucosa

Nasal septum

Crista galli

Fovea ethmoidalis

Lateral lamella
Cribriform plate
Olfactory mucosa

Nasal septum

(Top) First of three coronal bone CTs through anterior cranial fossa presented from posterior to anterior. Olfactory
epithelium is found on roof of nasal cavity, extending inferolaterally on superior turbinate and inferomedially on
nasal septum. Olfactory nerves pass through perforations in cribriform plate. The olfactory bulbs sit just above the
cribriform plates. (Middle) In this CT image ethmoid bone forms medial floor of anterior cranial fossa and consists of
cribriform plate and crista galli. Fenestrated cribriform plate is depressed relative to orbital plate of frontal bone.
Fovea ethmoidalis is most medial portion of orbital plate of frontal bone and separates ethmoid labyrinth from
anterior cranial fossa. (Bottom) Anterior cribriform plate is seen at the base of the larger anterior crista galli.
I
188
 CNl (OLFACTORY NERVE)
CORONAL T2 MR OJ
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Gyrus rectus

Orbital gyrus Olfactory sulcus

Olfactory tract Olfactory tract

Falx cerebri Gyrus rectus

Olfactory sulcus
Orbital gyrus
Crista galli

Olfactory bulbs

(Top) First of three sequential coronal T2 MR images presented from posterior to anterior shows triangular olfactory
tracts which are comprised of centrally projecting axons, embedded within olfactory sulcus. (Middle) Olfactory
sulcus is easily identified separating gyrus rectus medially from orbital gyrus laterally. Again note the olfactory tracts
at the base of the olfactory sulcus. (Bottom) In this image through the anterior cribriform plate note the olfactory
bulbs. The olfactory bulbs are rostral enlargement of olfactory tracts which lie on either side of midline on
intracranial surface of cribriform plate. Olfactory nerves arise from olfactory epithelium located in roof nasal cavity
and pass through fenestrated cribriform plate to end in olfactory bulbs.

189
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CN2 (OPTIC NERVE)
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z ITerminology
Abbreviations
• Optic nerve: CN2, CN II
Synonyms
• Second cranial nerve
Definitions
• CN2: Nerve of sight
• Visual pathway consists of optic nerve, optic chiasm
and retrochiasmal structures
I Imaging Anatomy
Overview
• Optic nerve not true cranial nerve but rather
extension of the brain
o Represents collection of retinal ganglion cell axons
o Myelinated by oligodendrocytes not by Schwann
cells as with true cranial nerves
o Enclosed by meninges
o Throughout its course to visual cortex nerve fibers
are arranged in retinotopic order
• Optic nerve has four segments
o Intraocular, intraorbital, intracanalicular and
intracranial
• Partial decussation CN2 fibers within optic chiasm
o Axons from medial portion of each retina cross to
join those from lateral portion of opposite retina
• Retrochiasmal structures: Optic tract, lateral geniculate
body, optic radiation and visual cortex
Optic Pathway
• Optic nerve: Intraocular segment
o 1 mm length
o Region of sclera termed lamina cribrosa where
ganglion cell axons exit globe
• Optic nerve: Intraorbital segment
o 20-30 mm in length
o Extends posteromedially from back of globe to
orbital apex within intraconal space of orbit
o CN2 longer than actual distance from optic chiasm
to globe allowing for movements of eye
o Covered by same 3 meningeal layers as brain
• Outer dura, middle arachnoid and inner pia
• Subarachnoid space (SAS) between arachnoid and
pia contains cerebrospinal fluid (CSF); continuous
with SAS of suprasellar cistern
• Fluctuations in intracranial pressure transmitted
via SAS of optic nerve-sheath complex
o Central retinal artery
• 1st branch of ophthalmic artery
• Enters optic nerve about 1 em posterior to globe
with accompanying vein to run to retina
• Optic nerve: Intracanalicular segment
o 4-9 mm segment within bony optic canal
o Ophthalmic artery lies inferior to CN2
o Dura of CN2 fuses with orbit periosteum (periorbita)
• Optic nerve: Intracranial segment
o About 10 mm length from optic canal to chiasm
o Covered by pia and surrounded by CSF within
suprasellar cistern
I
190
o Ophthalmic artery runs inferolateral to nerve
• Optic chiasm
o Horizontally oriented; "X-shaped" structure within
suprasellar cistern
o Forms part of floor of 3rd ventricle between optic
recess anteriorly and infundibular recess posteriorly
o Immediately anterior to infundibulum (pituitary
stalk), superior to diaphragma sellae
o Anteriorly chiasm divides into optic nerves
o In chiasm nerve fibers from the medial half of retina
cross to opposite side
o Posteriorly chiasm divides into optic tracts
o Medial fibers of optic tracts cross in chiasm to
connect lateral geniculate bodies of both sides
(commissure of Gudden)
• Optic tracts
o Posterior extension of optic chiasm
o Fibers pass posterolaterally curving around cerebral
peduncle and divide into medial and lateral bands
• Lateral band (majority of fibers) ends in lateral
geniculate body of the thalamus
• Medial band goes by medial geniculate body to
pretectal nuclei deep to superior colliculi
• Optic radiation and visual cortex
o Efferent axons from lateral geniculate body form
optic radiations (geniculocalcarine tracts)
o Fan out from lateral geniculate body and run as
broad fiber tract to calcarine fissure
• Initially pass laterally behind posterior limb
internal capsule and basal ganglia
• Extend posteriorly around lateral ventricle passing
through posterior temporal and parietal lobes
• Terminate in calcarine cortex (primary visual
cortex) on medial surface of occipital lobes
IAnatomy-Based Imaging Issues
Imaging Recommendations
• CT best for skull base and optic canal bony anatomy
• MR for CN2, optic chiasm and retrochiasmal structures
o Axial and coronal thin-section T2, Tl and Tl c+
Imaging Pitfalls
• Orbital CT may see subtle calcified optic sheath
meningioma when MR may not
I Clinical Implications
Clinical Importance
• Lesion location
o Optic nerve pathology: Monocular visual loss
o Optic chiasm pathology: Bitemporal
heteronymous hemianopsia (loss of bilateral
temporal visual fields)
o Retrochiasmal pathology: Homonymous
hemianopsia (vision loss in contralateral eye)
• Increased intracranial pressure transmitted along SAS
of optic nerve-sheath complex
o Manifests clinically as papilledema
o Imaging shows flattening of posterior sclera,
tortuosity and elongation of intraorbital optic
nerves and dilatation of perioptic SAS
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Optic nerve, intracranial
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Areaof pretectaI nucleus

Superiorcolliculi

Medial rectus muscle

Lateralrectus muscle
Subarachnoid space Optic nerve

Optic chiasm
Optic tract
Cerebralpeduncle

Optic disc

Optic nerve

Optic tract

Anterior commissure
Optic tract

Thalamus Lateralgeniculate body

(Top) First of three axial STIRMR images from inferior to superior demonstrate intraorbital, intracanalicular and
intracranial segments of optic nerve. Intraorbital segment extends from back of globe posteromedially to orbital apex
within intraconal space. Intracanalicular segment passes through bony optic canal. Intracranial segment is about 10
mm long from optic canal to chiasm. (Middle) Subarachnoid space with cerebrospinal fluid surrounds optic nerve
and is continuous with subarachnoid space of suprasellar cistern. Optic chiasm lies within suprasellar cistern. Optic
tracts extend posteriorly around cerebral peduncles to lateral geniculate body. (Bottom) Majority of fibers from optic
tracts terminate in lateral geniculate body located at posteroinferior aspect of thalamus. Efferent axons from lateral
geniculate body form optic radiation extending to calcarine cortex.
193
 CN2 (OPTIC NERVE)
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Optic nerve

Annulus tendineus (common

annular tendon & annulus of
Lateral rectus muscle linn)
Inferior rectus muscle

Superior rectus muscle/levator

palpebrae superioris
Ophthalmic artery
Superior ophthalmic vein
Superior oblique muscle
Subarachnoid space Optic nerve
Medial rectus muscle
Lateral rectus muscle
Inferior rectus muscle

Maxillary sinus

Levator palpebrae superioris

Superior rectus muscle

Superior ophthalmic vein
Superior oblique muscle
Optic nerve

Lateral rectus muscle Medial rectus muscle

Ethmoid sinus
Inferior rectus muscle

Infraorbital nerve

(Top) First of three coronal Tl MR images through orbit from posterior to anterior. Section through orbital apex
shows optic nerve passing through common annular tendon which serves as site of origin of rectus muscles.
(Middle) In this image both the superolateral ophthalmic vein and the superomedial ophthalmic artery are visible.
Note that the subarachnoid space is visible as a thin black line surrounding the optic nerve, a finding often not seen
on routine T1 imaging of the orbit. (Bottom) In this image just behind the globe all the extraocular muscles are
clearly visible. Notice the levator palpebrae superioris muscle may be difficult to distinguish from the superior rectus
muscle even with high resolution MR imaging.

194
 CN2 (OPTIC NERVE)
CORONAL T2 MR O::l
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Optic tract
Optic tract
z
Basal vein .,
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Mamillary body <
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Posterior cerebral artery Vl
Oculomotor nerve (CN3)
Superior cerebellar artery

Trigeminal nerve, preganglionic Trigeminal nerve

segment
Pontine belly

Basal vein
Third ventricle

Optic tract Optic tract

Uncus
Oculomotor nerve (CN3)

Basilar artery
Trigeminal nerve entering
Meckel cave

Third ventricle
Optic tract

Tuber cinereum

Meckel cave

(Top) First of six coronal T2 MR images showing the optic tracts and chiasm from posterior to anterior. Optic tracts
course posterolaterally curving around cerebral peduncle to eventually terminate in lateral geniculate body (lateral
root) and pretectal nuclei at superior colliculi (medial band). (Middle) Optic tracts course through posterior
suprasellar cistern towards ambient cistern closely related to basal vein (of Rosenthal). (Bottom) In this image
through the back of the optic chiasm the optic tracts are shown as the posterior extension of optic chiasm carrying
fibers from the ipsilateral half of both retinae. The tuber cinereum leads to infundibulum (pituitary stalk). Notice the
third ventricle just above the posterior optic chiasm.

195
 CN2 (OPTIC NERVE)
lJl
Q) CORONAL T2 MR
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z
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c Anterior cerebral artery Third ventricle
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u Ml segment, middle cerebral
artery
Optic chiasm
Supraclinoid internal carotid
Suprasellar cistern artery
Infundibulum
Cavernous internal carotid artery
Meckel cave

Anterior cerebral arteries

Suprasellar cistern Optic chiasm

Internal carotid artery
Oculomotor nerve (CN3)
Pituitary gland
Infundibulum

Optic nerve, intracranial segment Optic nerve, intracranial

segment

Anterior clinoid process

Internal carotid artery

Cavernous internal carotid artery

(Top) In this image the optic chiasm is seen forming part of the floor of the third ventricle between optic recess
anteriorly and infundibular recess posteriorly. It is immediately anterior to infundibulum (pituitary stalk). (Middle)
Optic chiasm is horizontally oriented, "X-shaped" structure within suprasellar cistern. Nerve fibers from the medial
halves of both retinae cross to continue to lateral geniculate bodies. Interruption of crossing chiasmatic fibers leads to
bitemporal hemianopia. (Bottom) The intracranial segment of optic nerves are visible in this image. This segment is
approximately 10 mm in length from optic canal anteriorly to optic chiasm posteriorly. Although not seen, they are
covered by pia. The bright CSF within suprasellar cistern surrounds the nerves.
I
196
 CN2 (OPTIC NERVE)
AXIAL & SAGITTAL T1 MR CO
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Lacrimal gland
Medial rectus muscle z
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Lateral rectus muscle
Optic nerve, intraorbital
segment
Retrobulbar Fat
Ophthalmic artery

Optic nerve, intracanalicular

segment

Globe
Lacrimal gland

Superior oblique muscle

Optic nerve
Retrobulbar fat

Superior ophthalmic vein

Levator palpebrae superioris

Superior rectus muscle

Optic nerve

Globe Retrobulbar fat

Choroid
Sclera

Inferior rectus muscle

(Top) Axial TI MR demonstrates intraorbital segment of optic nerve extending posteromedially from back of globe to
orbital apex surrounded by fat within intraconal space. Note intra canalicular segment passing through bony optic
canal. (Middle) Axial TI MR image shows origin of optic nerve from globe. Nerve fibers of retina unite forming optic
nerve before exiting eyeball through lamina cribrosa, a thin, perforated portion of sclera. In the superior orbit the
lacrimal gland is seen in its superolateral fossa. (Bottom) Sagittal TI MR image through optic nerve demonstrating
intraorbital segment of optic nerve. Sclera of globe is hypointense while pigmented choroid of uvea is hyperintense
due to TI shortening effects of melanin.

197
 rJl CN3 (OCULOMOTOR NERVE)
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z ITerminology
Extracranial Segment
(\l Abbreviations • CN3 enters orbit through superior orbital fissure and
c • Oculomotor nerve: CN3; CN III passes through annulus tendineus (annulus of Zinn)
(\l
•.... Synonyms • Divides into superior and inferior branches
u • Third cranial nerve
o Superior branch supplies levator palpebrae superioris
c and superior rectus muscles
0(tj Definitions o Inferior branch supplies inferior rectus, medial
L-
• CN3: Motor nerve to extraocular muscles exce t lateral rectus and inferior oblique muscles
eo rectus (CN6) & superior oblique muscles (CN4); • Preganglionic parasympathetic fibers follow inferior
parasympathetic to pupillary sphincter & ciliary branch to ciliary ganglion of orbit
muscle o Postganglionic parasympathetic fibers continue as
short ciliary nerves to enter globe with optic nerve
o In globe short ciliary nerves to ciliary body and iris
IImaging Anatomy o Control papillary sphincter function and
accommodation via ciliary muscle
Overview
• Mixed cranial nerve (motor and parasympathetic)
• Four anatomic segments: Intra-axial, cisternal, IAnatomy-Based Imaging Issues
cavernous and extracranial
Imaging Recommendations
Intra-Axial Segment • Bone CT best for skull base, bony foramina
• Oculomotor nuclear complex • MR for intra-axial, cisternal, cavernous segments
o Paired paramedian nuclear complex o Thin-section high-resolution T2 MR sequences in
• Located in midbrain anterior (ventral) to cerebral axial and coronal planes
aqueduct at level of superior colliculus • Depicts cisternal CN3 surrounded by CSF with
• Partially embedded in periaqueductal gray matter high contrast and high spatial resolution
• Bounded laterally and inferiorly by medial
longitudinal fasciculus Imaging "Sweet Spots"
o Consists of five individual motor subnuclei that • CN3 nuclear complex and intra-axial segment not
supply individual extraocular muscles directly visualized
• Edinger-Westphal parasympathetic nuclei o Find periaqueductal gray matter to localize
o Located dorsal to oculomotor nuclear complex in
poorly myelinated periaqueductal gray matter
Imaging Pitfalls
o Preganglionic parasympathetic fibers exit nucleus, • Negative MR and MRA does not completely exclude
course ventrally with motor CN3 fibers posterior communicating artery aneurysm
o Innervation of internal eye muscles (sphincter o Cerebral angiography still represents gold standard
pupillae and ciliary muscles) to exclude this diagnosis
• Oculomotor fascicles course anteriorly through medial
longitudinal fasciculus, red nucleus, substantia nigra
and medial cerebral peduncle I Clinical Implications
o Exit midbrain into interpeduncular cistern Clinical Importance
• Parasympathetic Perlia nuclei
• Uncal herniation pushes CN3 on petroclinoid
o Located between the Edinger-Westphal nuclei
ligament
o Thought to be involved in ocular convergence
• During trauma downward shift of brainstem upon
Cisternal Segment impact can stretch CN3 over petroclinoid ligament
• Courses anterolaterally through interpeduncular and • CN3 susceptible to compression by PCA aneurysms
prepontine cisterns • CN3 neuropathy divided into simple if isolated and
• Passes between posterior cerebral (PCA) and superior complex if with other CN involvement (CN4 & CN6)
cerebellar arteries (SCA) o Simple CN3 with pupillary involvement
• Courses inferior to posterior communicating artery • Must exclude PCA aneurysm as cause
and medial to free edge of tentorium cerebelli • Explanation: Parasympathetic fibers are
• Crosses the petroclinoid ligament and penetrates dura peripherally distributed
to enter roof of cavernous sinus o Simple CN3 with pupillary sparing
• Presumed microvascular infarction involves
Cavernous Segment vessels supplying core of nerve with relative
• Enters roof of cavernous sinus surrounded by narrow sparing of peripheral pupillary fibers
oculomotor CSF cistern
• Courses anteriorly through lateral dural wall of Clinical Findings
cavernous sinus • Oculomotor ophthalmoplegia
• CN3 remains most cephalad of all cranial nerves o Strabismus, ptosis, pupillary dilatation, downward
within cavernous sinus abducted globe and paralysis of accommodation

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199
 CN3 (OCULOMOTOR NERVE)
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Cavernous sinus
Oculomotor nerve
Oculomotor cistern Oculomotor nerve

Basilar artery

Pons

Internal carotid artery

Internal carotid artery
Posterior communicating artery Uncus

Oculomotor nerve Posterior cerebral artery

Oculomotor nerve

Internal carotid artery

Posterior cerebral artery

Superior cerebellar artery

Oculomotor nerve
Oculomotor nerve
Prepontine cistern
Pons

(Top) First of five axial T2 MR images presented from inferior to superior demonstrates the oculomotor nerves
entering the oculomotor cisterns in the posterior roof of cavernous sinus. Notice the nerves are surrounded by high
signal cerebrospinal fluid. From here the oculomotor nerves course anteriorly in the wall of the cavernous sinus
above trochlear nerve and enters orbit via superior orbital fissure. (Middle) Oculomotor nerves course anteriorly
through prepontine cistern inferolateral to posterior communicating artery and medial to uncus of temporal lobe.
Left oculomotor nerve is seen passing below posterior cerebral artery. (Bottom) After exiting brainstem, oculomotor
nerves course anteriorly through interpeduncular and prepontine cisterns towards cavernous sinus, passing between
I posterior cerebral and superior cerebellar arteries.
200
 CN3 (OCULOMOTOR NERVE)
AXIAL T2 & T1 MR ~-,:
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Oculomotor nerve
Oculomotor nerve
Interpeduncular fossa
Z
Posterior cerebral artery ro
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Posterior cerebral artery Midbrain <
ro
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Pituitary infundibulum

Oculomotor nerve Oculomotor nerve

Interpeduncular cistern Cerebral peduncle

Midbrain

Cerebral aqueduct

Mammillary bodies
Optic tract

Cerebral peduncle

CN3 nucleus area

Periaqueductal gray matter

Cerebral aqueduct
Superior colliculus

(Top) This image shows both oculomotor nerves coursing through the interpeduncular cistern. (Middle)
Oculomotor nerves exit midbrain from medial surface of cerebral peduncle to enter interpeduncular cistern and
continue anteriorly underneath the posterior cerebral arteries. (Bottom) Axial inversion recovery prepared Tl
weighted MR image through brainstem at level of superior colliculus. Paired oculomotor nuclear complex is not
directly visualized. However, since it is partially embedded in periaqueductal gray matter anterior to cerebral
aqueduct at level of superior colliculus, its position can be inferred by these landmarks. Approximate location of
oculomotor nucleus in marked on left.

201
 CN3 (OCULOMOTOR NERVE)
IJl
(l) CORONAL T2 MR
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(l)
Z
Third ventricle
C\3
C
C\3
I.... Oculomotor nerves
U Interpeduncular cistern
Posterior cerebral artery
Posterior cerebral artery Cerebral peduncle

Pons
Trigeminal nerve

Oculomotor nerve

Oculomotor nerve rootlets Posterior cerebral artery

Posterior cerebral artery Superior cerebellar artery

Pons

Third ventricle

Uncus
Posterior cerebral artery
Oculomotor nerve Oculomotor nerve

Superior cerebellar artery

Anterior inferior cerebellar artery Basilar artery

(Top) First of six coronal T2 MR images presented from posterior to anterior reveals the most proximal aspects of
both oculomotor nerves exiting the midbrain from the medial surface of cerebral peduncle to enter interpeduncular
cistern. (Middle) Oculomotor nerves often emerge from midbrain by several rootlets as seen in this T2 coronal image
(circle), which subsequently fuse to form a single trunk. (Bottom) Oculomotor nerves pass between posterior cerebral
artery above and superior cerebellar artery below. Proximity of the oculomotor nerve to the uncus makes the nerve
vulnerable to injury through uncal herniation. Its nearness to the posterior communicating, posterior cerebral and
superior cerebellar arteries makes it easily injured by aneurysm.

202
 CN3 (OCULOMOTOR NERVE)
CORONAL T2 MR CO
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Third ventricle n
.,
OJ
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Liliequistmembrane Posterior communicating artery z

(t)
Oculomotor nerve .,
Oculomotor nerve <
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Prepontine cistern (fl

Meckelcave

Optic recess Optic tract

Infundibular recess

Oculomotor nerve Oculomotor nerve

Meckelcave

Optic recess
Optic chiasm
Internal carotid artery
Pituitary infundibulum
Oculomotor cistern Oculomotor nerve & cistern
Cavernous sinus

(Top) Oculomotor nerves are seen coursing through interpeduncular cistern towards cavernous sinus closely related
to posterior communicating artery. An aneurysm of posterior communicating artery can result in compression of
oculomotor nerve. Lateral margin of Liliequist membrane attaches to arachnoidal sheath surrounding oculomotor
nerves. (Middle) The oculomotor nerve crosses petroclinoid ligament and is situated medial to and slightly beneath
level of free edge of tentorium at point of entry into roof of cavernous sinus. (Bottom) A short length of oculomotor
nerve is surrounded by a dural and arachnoid cuff to create the oculomotor cistern within roof and lateral wall of
cavernous sinus. Oculomotor nerve courses anteriorly above trochlear nerve within lateral wall of cavernous sinus
and enters orbit via superior orbital fissure.
203
 (Jj
Q)
CN4 (TROCHLEAR NERVE)
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•...
Q) • Supplies motor innervation to superior oblique muscle
z ITerminology
Abbreviations
• Trochlear nerve: CN4, CN IV IAnatomy-Based Imaging Issues
Synonyms Imaging Recommendations
• Fourth cranial nerve • CT best for skull base, bony foramina
• MR best for brainstem, cisternal, cavernous and
Definitions intra-orbital imaging
• CN4: Motor nerve to su erior oblique muscle. • Intra-orbital segment not visualized by any imaging
modality or sequence

I Imaging Anatomy Imaging "Sweet Spots"

• CN4 nucleus and intra-axial segment not directly
Overview visualized
• CN4 is a pure motor nerve o Nuclei position inferred by identifying
• Four segments: Intra-axial, cisternal, cavernous and periaqueductal gray matter and cerebral aqueduct at
extracranial level of inferior colliculi on high-resolution MR
• MR for intra-axial, cisternal and cavernous segments
Intra-Axial Segment o Thin-section high-resolution T2 and T1 C+ MR in
• Trochlear nuclei axial and coronal planes
o Paired nuclei located in paramedian midbrain • Coronal imaging margins: Fourth ventricle to
• Anterior to cerebral aqueduct anterior globe
• Dorsal to medial longitudinal fasciculus • Axial imaging margins: Orbital roof-diencephalon
• Caudal to oculomotor nuclear complex at level of to maxillary sinus roof-medulla
inferior colliculus
• Trochlear nerve fascicles course posteriorly & inferiorly Imaging Pitfalls
around cerebral aqueduct • Difficult to visualize CN4 despite best MR imaging
o Fibers then decussate within superior medullary efforts
velum • During image interrogation by radiologist, view
o Key concept: Each superior oblique muscle is known landmarks along its course
innervated by contralateral trochlear nucleus o Midbrain --+ tentorial margin --+ cavernous sinus --+

• CN4 exists dorsal midbrain just inferior to inferior
colliculus
o Key concept: CN4 is the only cranial nerve to exit
dorsal brainstem
Cisternal Segment
• CN4 courses anterolaterally in ambient cistern
o Runs underneath the margin of the tentorium
o Passes between free edge of tentorium cerebelli and
midbrain just superolateral to pons
• Passes between posterior cerebral artery above and
superior cerebellar artery below
o Oculomotor nerve travels this gap as well
o CN4 is just inferolateral to oculomotor nerve
• Penetrates dura to enter lateral wall of cavernous sinus
just inferior to oculomotor nerve
Cavernous Segment
• Courses anteriorly through lateral dural wall of
cavernous sinus
• Intracavernous relationships of CN4
o Remains inferior to CN3
o Superior to ophthalmic division of trigeminal nerve
(CNVl)
o Lateral to cavernous internal carotid artery
Extracranial Segment
• CN4 enters orbit through superior orbital fissure
together with CN3 and CN6
• Crosses over CN3 and courses medially
• Passes above annulus of Zinn (CN3 and CN6 go
through annulus)
superior orbital fissure --+ extraconal orbit
Normal Measurements
• CN4 is smallest cranial nerve
• CN4 has longest intracranial course (- 7.S cm)
I Clinical Implications
Clinical Importance
• CN4 neuropathy divided into simple and complex
o Simple CN4 neuropathy (isolated)
• Most common form; usually secondary to trauma
• Cisternal segment injury by free edge of tentorium
cerebelli or from posterior cerebral or superior
cerebellar artery aneurysm
• Contusion of superior medullary velum
o Complex CN4 neuropathy (associated with other
CN injury, CN3 ± CN6)
• Brainstem stoke or tumor
• Cavernous sinus thrombosis, tumor
• Orbital tumor
Clinical Findings
• Paralysis of superior oblique muscle results in
extorsion (outward rotation) of affected eye
• Extorsion is secondary to unopposed action of inferior
oblique muscle
• Patient complaints: Diplopia, weakness of downward
gaze, neck pain from head tilting
• Physical exam: Compensatory head tilt usually away
from affected side

204
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Interpeduncular cistern

Midbrain
Posterior cerebral artery

Fourth ventricle
Trochlear nerve

Superior medullary velum

Optic tract

Uncus

Cerebral peduncle

Ambient cistern
Trochlear nerve

Superior medullary velum

Optic tract

MamiIlary body

Inferior colliculus Fourth ventricle

Trochlear nerve
Quadrigeminal plate cistern

Superior medullary velum

(Top) First of three axial T2 MR images presented from inferior to superior through midbrain. The left trochlear
nerve passes around the brainstem within ambient cistern where it courses anteriorly below tentorium cerebelli. The
trochlear nerves decussate in the superior medullary velum with fibers from the nucleus passing to the contralateral
CN4. (Middle) Trochlear nerve (CN4) is smallest cranial nerve (0.75-1.00 mm diameter) and is not routinely
visualized. In addition trochlear nerve may easily be confused with numerous small arteries and veins in the ambient
cistern. (Bottom) After decussating in superior medullary velum, trochlear nerve exits dorsal surface of brainstem
below the inferior colliculus to enter quadrigeminal plate cistern. Trochlear nerve is only cranial nerve to exit dorsal
I brainstem.
206
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Posterior cerebral artery
Superior cerebellar artery

Trochlear nerve (CN4) Trochlear nerve (CN4)

Middle cerebellar peduncle

Medulla oblongata

Posterior cerebral artery

Oculomotor nerve (CN3)

Trochlear nerve (CN4)
Superior cerebellar artery

Trigeminal nerve
Anterior inferior cerebellar artery

Basilar artery

(Top) First of three coronal T2 MR images from posterior to anterior through brainstem demonstrates right the
trochlear nerve exiting from dorsal brainstem below inferior colliculus as multiple discrete rootlets to enter
quadrigeminal plate cistern. Left trochlear nerve is obscured by lateral mesencephalic vein. (Middle) Trochlear nerves
can be visualized bilaterally coursing anteriorly within the ambient cistern below free margin of tentorium cerebelli.
Only very focused thin-section high-resolution T2 MR imaging has any chance of seeing CN4 in this location.
(Bottom) At the level of the basilar artery the trochlear nerve is hidden on the left but visible on the right
inferolateral to the oculomotor nerve. Both nerves pass between the posterior cerebral artery and the superior
cerebellar artery.
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Abbreviations
• Trigeminal nerve: CNS, CNV
• Ophthalmic division, trigeminal nerve: CNVI
• Maxillary division, trigeminal nerve: CNV2
• Mandibular division, trigeminal nerve: CNV3
Synonyms
• Fifth cranial nerve, nervus trigeminus
Definitions
• CNS: Great sensory cranial nerve of head and face;
motor nerve for muscles of mastication
I Imaging Anatomy
Overview
• Mixed nerve (both sensory, motor components)
• Four segments: Intra-axial, cisternal, interdural and
extracranial
Intra-Axial Segment
• Four nuclei (3 sensory, 1 motor)
• Located in brainstem, upper cervical cord
o Mesencephalic nucleus CNS
• Slender column of cells projecting cephalad from
pons to level of inferior colliculus
• Found anterior to upper fourth ventricle/aqueduct
near lateral margin of central gray
• Afferent fibers for facial proprioception (teeth,
hard palate and temporomandibular joint)
• Sickle-shaped mesencephalic tract descends to
motor nucleus, conveys impulses that control
mastication and bite force
o Main sensory nucleus CNS
• Nucleus lies lateral to entering trigeminal root
• Provides facial tactile sensation
o Motor nucleus CNS
• Ovoid column of cells anteromedial to principal
sensory nucleus
• Supplies muscles of mastication (mediaillateral
pterygoids, masseter, temporalis), tensor
palatine/tensor tympani, mylohyoid and anterior
belly of digastric
a Spinal nucleus CNS
• Extends from principal sensory root in pons into
upper cervical cord (between C2 to C4 level)
• Conveys facial pain, temperature
Cisternal (Preganglionic) Segment
•
•
Two roots: Smaller motor, larger sensory
Emerges from lateral pons at root entry zone (REZ)
• Courses anterosuperiorly through prepontine cistern
• Enters middle cranial fossa by passing beneath
tentorium at apex of petrous temporal bone
• Passes through an opening in dura matter called porus
trigeminus to enter Meckel cave
Interdural Segment
• Meckel cave formed by meningeal layer of dura lined
by arachnoid
208
o Cave is filled with cerebrospinal fluid (CSF) (90%)
and continuous with prepontine subarachnoid space
• Pia covers CNS in trigeminal cave
• Preganglionic CNS ends at trigeminal ganglion (TG)
o TG located in inferior aspect of Meckel cave
o TG synonyms: Gasserian or semilunar ganglion
Divisions (Post-Ganglionic) of CNS
• Ophthalmic nerve
o Courses in lateral cavernous sinus wall below CN4
o Exits skull through superior orbital fissure
o Enters orbit, divides into lacrimal, frontal and
nasociliary nerves
• Sensory innervation scalp, forehead, nose, globe
• Maxillary nerve
o Courses in cavernous sinus lateral wall below CNV I
o Exits skull through foramen rotundum
o Traverses roof of pterygopalatine fossa
o Continues as infraorbital nerve in floor of orbit
o Exits orbit through infraorbital foramen
• Sensory to cheek and upper teeth
• Mandibular nerve
o Does not pass through cavernous sinus
o Exits directly from Meckel cave, passing inferiorly
through foramen ova Ie into masticator space
o Carries both motor and sensory fibers
• Motor root bypasses TG, joins V3 as it exits
through foramen ovale
• Divides into masticator (muscles of mastication)
and mylohyoid nerves (mylohyoid and anterior
belly of digastric muscles)
• Masticator nerve takeoff just below skull base
• Mylohyoid nerve takeoff at mandibular foramen
o Main sensory branches include inferior alveolar,
lingual and auriculotemporal nerves
IAnatomy-Based Imaging Issues
Imaging Recommendations
• CT best for skull base and bony foramina
• MR for intra-axial, cisternal and intradural segments
o Thin-section T2 in axial and coronal planes
• TI C+ fat-saturated MR of entire extracranial course
Imaging Pitfalls
• Trigeminal ganglion is small crescent of tissue found
in the anteroinferior Meckel cave
o Trigeminal ganglion lacks blood-nerve barrier
therefore normally enhances with contrast
I Clinical Implications
Clinical Importance
• Sensory complaints: Pain, burning, numbness in face
• Motor (V3 only): Weakness in chewing
o Proximal V3 injury causes motor atrophy of
masticator muscles within 6 weeks to 3 months
o Distal V3 injury (above mylohyoid nerve takeoff)
affects only anterior belly of digastric & mylohyoid
• Tic douloureux (trigeminal neuralgia)
o Sharp, excruciating pain in V2-3 distributions
o Look for vascular compression at REZ (on MR)
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Inferior orbital fissure

Pterygopalatine fossa
Pterygopalatine fossa
Foramen rotundum (CNV2)

Vidian canal (pterygoid nerve &

artery) Foramen ovale (CNV3)

Foramen spino sum (middle

Clivus
meningeal artery, vein &
meningeal branch of CNV3)

Ethmoid sinus

Pterygopalatine fossa
Sphenoid sinus
Foramen rotundum (CNV2)

Sphenooccipital fissure Foramen ovale (CNV3)

Foramen spinosum

Vertical segment, petrous ICA

Jugular foramen

Superior orbital fissure Superior orbital fissure (CNVl,

CN3, 4 & 6)

Sphenoid sinus

Cephalad clivus
CN6 sulcus

(Top) First of three axial bone CT images presented from inferior to superior through central skull base. CNV2 exits
skull base through foramen rotundum to enter superior margin of pterygopalatine fossa. CNV3 exits via foramen
ovale to enter masticator space where it supplies motor innervation to muscles of mastication and sensory branches
inferior alveolar, lingual and auriculotemporal nerves. (Middle) In this image the foramen ovale (CNV3) and
foramen rotundum (CNV2) are now best seen on the patient's left. Notice left foramen rotundum is seen opening
into then superior pterygopalatine fossa. (Bottom) The superior orbital fissure transmits ophthalmic division of
trigeminal nerve from cranium to orbit. Other structures which pass through superior orbital fissure include
oculomotor nerve (CN3), trochlear nerve (CN4) and abducens nerve (CN6) and the superior ophthalmic vein.
212
 eNS (TRIGEMINAL NERVE)
AXIAL T2 MR CO
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Abducens nerve (CN6)
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Trigeminal nerve fascicles in

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Preganglionic segment CNS

Root entry zone CNS
Pons
Area of main sensory nucleus
Area of motor nucleus CNS
Fourth ventricle

Basilar artery
Meckel cave

Prepontine cistern
Porus trigeminus
Preganglionic segment CNS
Pons Root entry zone

(Top) First of three axial T2 MR images through the trigeminal nerve and Meckel cave presented from inferior to
superior demonstrates a layer of hypointense dura mater forming lateral wall and roof of Meckel cave. Right
abducens nerve is seen penetrating dura to enter Dorello canal. Trigeminal nerve fascicles can be seen with the
cerebrospinal fluid of Meckel cave. (Middle) Preganglionic fascicles of CNS are seen within Meckel cave. Meckel cave
is an arachnoid lined, dural diverticulum protruding from the lateral aspect of the prepontine cistern. It contains
cerebrospinal fluid, trigeminal fascicles and trigeminal ganglion. Note approximate location of the main sensory and
motor nuclei of CNS. (Bottom) In this image the preganglionic segment of CNS is seen spanning the distance
between the root entry zone on the lateral pons and the porus trigeminus of Meckel cave. I
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Sphenoid sinus
Foramen rotundum
Maxillary nerve (CNV2)
Mandibular nerve (CNV3)
Petrous ICAturning cephalad into
cavernous sinus Middle meningeal artery in
foramen spinosum

Clivus

Sphenoid sinus

Cavernous ICA
Trigeminal ganglion
Clivus Meckel cave

Abducens nerve in Dorello canal Abducens nerve in Dorello

canal

Superior orbital fissure

Cavernous sinus

Cavernous ICA
CNS in porus trigeminus

Pons Preganglionic segment CNS

Root entry zone CNS

(Top) First of three axial Tl C+ fat-saturated MR images presented from inferior to superior through central skull base
demonstrates right maxillary nerve (CNV2) passing anteriorly into foramen rotundum and left mandibular nerve
(CNV3) passing inferiorly through foramen ovale. Both nerves are surrounded by enhancing veins communicating
with extracranial venous system. (Middle) This more superior image demonstrates the ovoid shape of the
cerebrospinal fluid-filled Meckel cave. The trigeminal ganglion is the linear anteroinferior structure in Meckel cave. It
lacks a blood-nerve barrier and therefore normally enhances with contrast. (Bottom) Preganglionic segment of
trigeminal nerve arises from lateral pons at root entry zone. Right internal carotid artery is tortuous within cavernous
sinus.
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Optic chiasm
Cavernous lCA

Trigeminal fascicles
Dural margin to Meckel cave

Trigeminal ganglion Trigeminal ganglion

Anterior clinoid process

Cavernous sinus Cavernous internal carotid

artery
Maxillary nerve (V2)

Mandibular nerve (V3)

(Top) First of three coronal T2 MR images presented from posterior to anterior demonstrates the ovoid preganglionic
segment of the trigeminal nerve surrounded by high signal cerebrospinal fluid. The preganglionic segment has just
exited the lateral pons root entry zone area. (Middle) This more anterior image through Meckel cave delineates the
trigeminal fascicles of preganglionic trigeminal nerve. The trigeminal ganglion is visible as a semilunar structure in
the floor of Meckel cave bilaterally. (Bottom) This image through the anterior cavernous sinus shows the maxillary
nerve (CNV2) passing anteriorly within lateral wall of cavernous sinus and the mandibular nerve (CNV3) passing
inferiorly to its exit point in the skull base (foramen ovale).

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Infundibulum
Oculomotor nerve (CN3)
Pituitary gland

Foramen ovale
Foramen ovale

Mandibular nerve (CNV3) Mandibular nerve (CNV3)

Nasopharyngeal airway

Trochlear nerve (CN4)

Abducens nerve (CN6) Oculomotor nerve (CN3)

Maxillary nerve (CNV2)

Foramen ovale

Mandibular nerve (CNV3)

Mandibular nerve (CNV3)
Lateral pterygoid muscle

Medial pterygoid muscle

(Top) First of six coronal T1 C+ MR images through cavernous sinus presented from posterior to anterior. The
trigeminal ganglion is seen as a crescentic area of enhancement in floor of Meckel cave. Trigeminal ganglion
enhances because it lacks a blood-nerve barrier. (Middle) In this image through foramen ovale mandibular nerve
(CNV3) is visible exiting inferiorly into masticator space. The 1st branch of CNV3, masticator nerve, supplies motor
innervation to all 4 muscles of mastication (masseter, medial and lateral pterygoid and temporalis muscles).
(Bottom) In this image the patient's left foramen ovale and mandibular nerve are seen. Mandibular nerve plunges
directly into masticator space where it gives of its main motor branch (masticator nerve) to innervate muscles of
mastication. It also give off sensory branches including inferior alveolar, lingual and auriculotemporal branches.
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Anterior clinoid process

Oculomotor nerve (CN3)
Abducens nerve (CN6)

Maxillary nerve (CNV2) Maxillary nerve (CNV2)

Vidian canal Vidian canal

Torus tubarius

Maxillary nerve in foramen Maxillary nerve in foramen

rotundum rotundum

Vidian nerve Vidian nerve

Venous plexus in vidian canal

Nasal cavity

(Top) In this image through the anterior margin of the pituitary gland, the maxillary nerve (CNV2) is well seen
bilaterally in the inferoIateraI wall of the cavernous sinus. (Middle) In this more anterior image the maxillary nerves
are seen in the inferolateral wall of the cavernous sinus just prior to its entry into the foramen rotundum.
Inferomedially note the vidian canals. (Bottom) In this image the maxillary nerve can be seen in the foramen
rotundum. Notice also the vidian canal widening on its extracranial side with the vidian nerve visible surrounded by
a venous plexus. The vidian nerve carries secretomotor fibers originally in the facial nerve which are responsible for
lacrimation.

217
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Porus trigeminus

Meckel cave with trigeminal Middle cerebellar peduncle

fascicles
Trigeminal ganglion Preganglionic segment CNS

Petrous apex marrow

Clivus

Maxillary sinus

Cephalad aspect of pterygopalatine Infraorbital nerve (CNV2

fossa branch)

Maxillary nerve in superior

pterygopalatine fossa Maxillary nerve in foramen
rotundum
Sphenoid sinus
Meckel cave Maxillary nerve in inferolateral
wall of cavernous sinus

Temporalis muscle Maxillary sinus

Internal maxillary artery in

pterygopalatine fossa
Vidian nerve in vidian canal

Mandibular nerve in foramen ovale Mandibular nerve in foramen

ovale
Middle meningeal artery in Horizontal petrous ICA
foramen spino sum

(Top) Sagittal T2 MR along line of proximal trigeminal nerve shows the preganglionic segment between the root
entry zone in the lateral pons and the trigeminal ganglion in the anteroinferior Meckel cave. The cerebrospinal fluid
within Meckel cave communicates with prepontine cistern through the porus trigeminus. (Middle) First of five axial
Tl unenhanced MR images extending from the skull base to the mandibular body presented from superior to
inferior. Notice the left maxillary nerve in the foramen rotundum. Distally it give rise to the infraorbital nerve.
(Bottom) Image through foramen ovale of skull base. Notice the mandibular nerves exiting skull base. The vidian
canal and nerve are also visible connecting the foramen lacerum to pterygopalatine fossa. The many black dots
within pterygopalatine fossa are from the normal terminal internal maxillary artery.
218
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Vertical segment petrous lCA Mandibular condyle

Masseter muscle

Marrow space of mandibular ramus Medial pterygoid mu~c1e

Inferior alveolar nerve in Inferior alveolar nerve in

mandibular foramen mandibular foramen

Parotid gland

Mental foramen
Mental foramen

Inferior alveolar nerve

Inferior alveolar nerve

Mylohyoid muscle Mylohyoid muscle

Submandibular gland

(Top) Image just under skull base shows both mandibular nerves are entering medial portion of upper masticator
space. At this level that mandibular nerve gives off masticator nerve, motor branch to muscles of mastication.
Auriculotemporal nerve branches posterolaterally at this level. (Middle) Image at level of mandibular foramina.
Inferior alveolar nerve is seen bilaterally in the mandibular foramina. Mylohyoid nerve branches off inferior alveolar
nerve just prior to mandibular foramen. It is the motor nerve to the mylohyoid and anterior belly of digastric
muscles. Lingual nerve also branches anteromedially off inferior alveolar nerve at this level. (Bottom) In this image
at level of the body of mandible the inferior alveolar nerve is seen within the high intensity marrow fat. The inferior
alveolar nerve exits mandible via the mental foramen.
219
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z ITerminology within lateral wall of cavernous sinus
Abbreviations • Within cavernous sinus CN6 runs along inferolateral
• Abducens nerve: CN6, CN VI aspect of cavernous internal carotid artery

Synonyms Extracranial (Intra-Orbital) Segment

• Abducens nerve: Sixth cranial nerve • CN6 enters orbit through superior orbital fissure
together with CN3 and CN4
Definitions • Passes through annulus of Zinn
• CN6: Motor nerve to lateral rectus muscle only • Supplies motor innervation to lateral rectus muscle

I Imaging Anatomy IAnatomy-Based Imaging Issues

Overview
• CN6 is a pure motor nerve
• Five segments can be defined: Intra-axial, cisternal,
interdural, cavernous and extracranial (intra-orbital)
Intra-Axial Segment
• Abducens nucleus
o Paired CN6 nuclei located in pontine tegmentum
near midline
• Found just anterior to fourth ventricle
o Facial colliculus: Axons of facial nerve (CN7) loop
around abducens nucleus creating this bulge in floor
of fourth ventricle
• Abducens nerve axons course anteroinferiorly through
pontine tegmentum
• Emerges from anterior brainstem near midline
through groove between pons and pyramid of medulla
oblongata (bulbopontine sulcus)
Cisternal Segment
• CN6 ascends anterosuperiorly in prepontine cistern
toward site where it penetrates dura
• May be posterior or anterior to anterior inferior
cerebellar artery
• Penetrates dura of basisphenoid to enter Dorello canal
Interdural Segment
• Dorello canal represents channel within basilar
venous plexus (petroclival venous confluence)
o Channel is located between two layers of dura
o Basilar venous plexus is continuous with cavernous
sinus anteriorly
o Basilar venous plexus drains into inferior petrosal
sinus
• Extends from point where CN6 pierces inner (cerebral)
layer dura mater to its entrance into cavernous sinus
• Within Dorello canal, abducens nerve is surrounded
by layer of arachnoid mater & occasionally dura mater
• After penetrating dura, CN6 passes superiorly through
basilar venous plexus
o It then arches over petrous apex below
petrosphenoidalligament into upper posterior
region of cavernous sinus
o Bony sulcus of CN6 as it passes over top of petrous
apex usually present
Cavernous Segment
• CN6 courses anteriorly within cavernous sinus
o Abducens nerve is only cranial nerve to lie within
cavernous sinu~
Imaging Recommendations
• MR for intra-axial, cisternal, interdural & cavernous
segments
o Thin-section high-resolution T2 and
contrast-enhanced Tl in axial and coronal planes
• Depicts small structures including cranial nerves
surrounded by CSF with high contrast & high
spatial resolution
• Bone CT best for skull base and its bony foramina
• Dorello canal, cavernous sinus and orbital CN6 not
visualized on routine MR imaging
Imaging "Sweet Spots"
• Axial and coronal MR sequences should include
brainstem, fourth ventricle, cavernous sinus and orbit
• CN6 nucleus and intra-axial segment not directly
visualized
o Position of CN6 inferred by identifying facial
colliculus in floor of fourth ventricle on
high-resolution thin-section T2 MR
• Cisternal segment routinely visualized on
high-resolution T2
• CN6 entrance into Dorello canal may be visualized
due to invagination of cerebrospinal fluid into
proximal canal
Imaging Pitfalls
• Use of fat-saturation on post-contrast T1 MR
sequences can amplify blooming (susceptibility)
artifact around a well aerated sphenoid sinus
o Cavernous sinus & orbital apex subtle lesions may
be obscured by this artifact
o Remove fat-saturation and repeat Tl post-contrast
MR if this artifact obscures key areas of interest
I Clinical Implications
Clinical Importance
• In abducens neuropathy, affected eye will not abduct
(rotate laterally)
• CN6 neuropathy divided into simple if isolated &
complex if associated with other CN involvement
(CN3, 4 and 7)
o Simple CN6 neuropathy most common ocular
motor nerve palsy
o Usually presents as complex cranial neuropathy
• Pontine lesions affect CN6 with CN7
• Cavernous sinus, superior orbital fissure lesions
affect CN6 with CN3, 4 and CNVI

220
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Left abducens nerve
Right abducens nerve
Anterior inferior cerebellar
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Fourth ventricle

Upper clivus

Cavernous internal carotid artery

Basilar venous plexus

Meckel cave
Abducens nerve within basilar
Abducens nerve (CN6) venous plexus

Internal auditory canal

Cavernous internal carotid

artery

Meckel cave

Proximal cavernous CN6 Cavernous CN6

Preganglionic segment CNS Pons

(Top) Axial T2 MR image near level of lAC presented to show the appearance of the abducens nerve in the
prepontine cistern. On the person's right CN6 is just exiting the bulbopontine sulcus while on the left it is poised to
penetrate the dura. Both nerves are rising in the prepontine cistern. (Middle) Axial Tl enhanced MR image
demonstrates the interdural segment of abducens nerve within Dorello canal surrounded by brightly enhancing
basilar venous plexus. (Bottom) Axial Tl enhanced MR image just above the internal auditory canal shows the
abducens nerves passing through the superior basilar venous plexus to enter the posterior margin of the cavernous
sinus. At this point CN6 is arching over the petrous apex below the petrosphenoidalligament into upper posterior
region of cavernous sinus.
222
 CN6 (ABDUCENS NERVE)
SAGITTAL T2 MR

Oculomotor nerve (CN3)

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CN6 piercing dura
Medulla
CN6 in prepontine cistern

Oculomotor nerve (CN3)

Areaof CN6 nucleus

Clivus
Bulbopontine sulcus

CN6 in prepontine cistern

Vertebralartery

Optic tract
Posterior cerebral artery
Superiorcerebellarartery
Oculomotor nerve (CN3)

Pons
Clivus

Abducensnerve (CN6)

Vertebralartery

(Top) First of three sagittal T2 MR images presented from lateral to medial reveals the abducens nerve traversing
prepontine cistern towards clivus. In this image the abducens nerve is visible penetrating the dura to enter Dorello
canal which lies between cranial dura and periosteum surrounded by basilar venous plexus. (Middle) Image of
brainstem area shows abducens nerve coursing anterosuperiorly from its exit point from the brainstem
(bulbopontine sulcus) towards its point of dural penetration into Dorello canal. Notice the approximate location of
CN6 nucleus and the steep course the intra-axial fibers take to reach the bulbopontine sulcus. (Bottom) Image of
brainstem and prepontine cisterns shows proximal cisternal CN6 closely associated with the belly of the pons. CN3 is
seen passing between posterior cerebral and superior cerebellar arteries.
223
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CN7 (FACIAL NERVE)
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Abbreviations
• Facial nerve: CN?, CN VII
Synonyms
• Seventh cranial nerve
Definitions
• CN?: Cranial nerve that carries motor nerves to
muscles of facial expression, parasympathetics to
lacrimal, submandibular and sublingual glands and
taste from anterior 2/3 of tongue
I Imaging Anatomy
Overview
• Mixed nerve: Motor, parasympathetic and special
sensory (taste)
• Two roots: Motor & sensory (nervus intermedius) roots
o Nervus intermedius exits lateral brainstem between
motor root of facial and vestibulocochlear nerves,
hence its name
• Four segments: Intra-axial, cisternal, intratemporal
and extracranial (parotid)
Intra-Axial Segment
• Three nuclei (one motor, two sensory)
• Motor nucleus of facial nerve
o Located in ventrolateral pontine tegmentum'
o Efferent fibers loop dorsally around CN6 nucleus in
floor of fourth ventricle forming facial colliculus
o Fibers then course anterolaterally to exit lateral
brainstem at pontomedullary junction
• Superior salivatory nucleus
o Located lateral to CN? motor nucleus in pons
o Efferent parasympathetic fibers exit brainstem
posterior to CN? as nervus intermedius
• To submandibular, sublingual and lacrimal glands
• Solitarius tract nucleus
o Termination of taste sensation fibers from anterior
2/3 of tongue
o Cell bodies of these fibers in geniculate ganglion
o Fibers travel within nervus intermedius
Cisternal Segment
• Two roots in cisternal CN?
o Larger motor root anteriorly
o Smaller sensory nervus intermedius posteriorly
• Emerge from lateral brainstem at root exit zone in
pontomedullary junction to enter cerebellopontine
angle (CPA) cistern
o CN8 exits brainstem posterior to CN?
• 2 roots j?in together & pass anterolaterally through
CPA cistern with CN8 to internal auditory canal (lAC)
Intratemporal Segment
• CN? further divided in T-bone into 4 segments: lAC,
labyrinthine, tympanic and mastoid
• lAC segment: Porus acusticus to lAC fundus;
anterosuperior position above crista falciformis
• Labyrinthine segment: Connects fundal CN? to
geniculate ganglion (anterior genu)
• Tympanic segment: Connects anterior to posterior
genu, passing under lateral semicircular canal
• Mastoid segment: Inferiorly directed from posterior
genu to stylomastoid foramen
Extracranial Segment
• CN? exits skull base through stylomastoid foramen
to enter parotid space
• Parotid CN? passes lateral to retromandibular vein
• Ramifies within parotid, passes anteriorly to innervate
muscles of facial expression
CN7 Branches
• Greater superficial petrosal nerve
o Arises at geniculate ganglion, passes anteromedially,
exits temporal bone via facial hiatus
o Carries parasympathetic fibers to lacrimal gland
• Stapedius nerve
o Arises from high mastoid segment of CN?
o Provides motor innervation to stapedius muscle
• Chorda tympani nerve
o Arises from lower mastoid segment
o Courses across middle ear to exit anterior T-bone
o Carries taste fibers from anterior 2/3 tongue
• These fibers travel with lingual branch of
mandibular division of trigeminal nerve
• Terminal motor branches
IAnatomy-Based Imaging Issues
Imaging Recommendations
• Bone CT best for intratemporal segment of CN?
• MR for intra-axial, cisternal, lAC and extracranial
segments
• Do not image routine Bell palsy!
Imaging "Sweet Spots"
• Include brainstem, CPA cistern, lAC, T-bone and
parotid when MR completed for CN? palsy
Imaging Pitfalls
• Mild enhancement of labyrinthine segment,
geniculate ganglion and proximal tympanic segments
of CN? can be normal on post-contrast T1 MR
o Secondary to circum neural arteriovenous plexus
• Always check parotid in peripheral CN? paralysis
Clinical Issues
• Facial nerve paralysis can be central or peripheral
o Central: Supranuclear injury resulting in paralysis of
contralateral muscles of facial expression with
forehead sparing
o Peripheral: Injury to CN? from brainstem nucleus
peripherally, resulting in paralysis of all ipsilateral
muscles of facial expression
• If lesion proximal to geniculate ganglion,
lacrimation, sound dampening and taste affected
• If CN6 involved, check pons for lesion
• If CN8 involved, check CPA-lAC for lesion
• If lacrimation, sound dampening and taste are
variably affected, T-bone lesion possible
• If lacrimation, sound dampening and taste are
spared, extracranial CN? implicated
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225
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Internal auditory canal Mastoid antrum

Vestibule

Geniculate fossa

Tympanic segment facial nerve

Cochlea canal

Posterior genu of facial nerve

canal
Vestibule

Facial hiatus for greater

superficial petrosal nerve

Anterior tympanic segment

CN?
Cochlea
Facial nerve recess
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Pyramidal eminence
Sinus tympani

(Top) First of six axial bone CT images of the left temporal bone presented from superior to inferior shows the
labyrinthine segment of the facial nerve canal as a C-shaped structure arching anterolateraHy over the top of thp
cochlea. (Middle) In this image the labyrinthine segment CN? canal terminates in geniculate fossa. The facial nerve
canal turns abruptly at the geniculate fossa (anterior genu). The tympanic segment arises from geniculate fossa,
coursing posterolaterally in axial plane, running under the lateral semicircular canal before turning 90 degrees
inferiorly at posterior genu to become mastoid segment. (Bottom) At the level of the oval window, the mastoid
segment is visible deep to the facial nerve recess. Notice the more medial pyramidal eminence and sinus tympani.

226
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AXIAL BONE CT ..,
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Sinus tympani
Stapedius muscle

Belly of tensor tympani muscle

Basal turn of cochlea External auditory canal

Cochlear aqueduct
Mastoid segment CN?

Foramen ovale

Foramen spinosum
Mandibular condyle

Vertical segment, petrous ICA

Hypoglossal canal
Stylomastoid foramen

Mastoid tip

(Top) Mastoid segment extends approximately 13 mm from posterior genu to stylomastoid foramen coursing
inferiQrly within posterior wall of middle ear cavity. Mastoid segment is related anteriorly to facial nerve recess and
medially to stapedius muscle within pyramidal eminence on posterior wall of middle ear cavity. (Middle) At the level
of the basal turn of the cochlea the mastoid segment of facial nerve is still visible. Both the nerve to stapedius muscle
proximally and chorda tympani distally branch off the mastoid segment eN? (Bottom) Image at the level of the
stylomastoid foramen. Notice the "bell" of the stylomastoid foramen is just anteromedial to the mastoid tip. The
mastoid tip protects the facial nerve from traumatic injury as it exits the skull base.

227
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Mastoid antrum

Jugular foramen Mastoid segment CN?

Hypoglossal canal Stylomastoid foramen

Mastoid tip

Lateral semicircular canal

Sinus tympani

Posterior genu CN?

Round window niche

Pyramidal eminence

Arcuate eminence

Tegmen tympani
Internal auditory canal

Lateral semicircular canal

Oval window
Basal turn of cochlea Tympanic segment of CN?

Tympanic annulus

(Top) First of six cor()nal bon~ CT images of left temporal bone presented from pQSt~J;'iQrtQ.anteriQr .shows lower
mastoid segment of the facial. nerve (CN?) and stylomastoid foramen. (Middle) At the level of the round window the
posterior genu of the facial nerve can be seen just lateral to the pyramidal eminence. Notice the sinus tympani is
medial to the pyramidal eminence. (Bottom) At the level of the oval window the tympanic segment of the facial
nerve can be seen coursing under the lateral semicircular canal. Notice the fine bony covering (thin white line)
surrounding the facial nerve. Also note the location relative to the upper margin of the oval window. In patients
with oval window atresia, the facial nerve is found near or within the oval window niche.

228
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Tympanic annulus

Labyrinthine segment CN? Anterior tympanic segment

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Internal auditory canal Tensor tympani tendon

Cochlea Scutum
Cochleariform process
Vertical segment petrous internal
carotid artery

Tegmen tympani
Geniculate ganglion in geniculate
fossa

Cochlea Malleus

Horizontal segment petrous

internal auditory canal
Tensor tympani muscle

(Top) At the level of the anterior margin of the oval window the tympanic segment of the facial nerve can be seen
under the lateral semicircular canal. Notice the fine bony covering (thin white line) surrounding the facial nerve is
now not seen. The facial nerve canal bony covering in this area is normally incomplete. (Middle) In the anterior
middle ear cavity the labyrinthine segment of the facial nerve can be seen exiting the internal auditory canal over
the top of the cochlea. The anterior tympanic segment of the facial nerve is also visible. Do not confuse the
muscle-tendon of the tensor tympani in the cochleariform process with the facial nerve. (Bottom) In the most
anterior portion of middle ear cavity (where both the carotid and the cochlea are visible), the geniculate ganglion is
seen within the geniculate fossa as an ovoid structure just above the cochlea.
229
 CN7 (FACIAL NERVE)
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Pontomedu!lary junction
Cochlear nerve
Facial nerve (CN?)
Inferior vestibular nerve
Superior vestibular nerve
Vestibulocochlear nerve (CNS)
Vestibulocochlear nerve (CNS)

Flocculus of cerebellum

Facial nerve (CN?)

Cochlear nerve
Facial nerve (CN?)
Inferior vestibular nerve
Superior vestibular nerve
Vestibulocochlear nerve (CNS)
Vestibulocochlear nerve (CNS)

Fourth ventricle

Parotid gland

Facial nerve in stylomastoid

Facial nerve in stylomastoid foramen
foramen
Mastoid sinuses Mastoid sinuses

(Top) First of two axial high-resolution T2 MR images through the cerebellopontine angle cistern and internal
auditory canal. The facial nerve root exit zone is seen anterior to the vestibulocochlear nerve in the pontomedullary
junction bilaterally. Notice the facial nerve maintains an anterior relationship with the vestibulocochlear nerve as it
crosses through the cerebellopontine angle cistern. (Middle) Image through cephalad internal auditory canal (lAC)
on person's left shows the facial nerve anterior to the superior vestibular nerve throughout its lAC course. (Bottom)
Axial Tl MR image at the level of the stylomastoid foramen shows the exiting low signal facial nerve surrounded by
high signal fat in the "bell" of the stylomastoid foramen. If perineural parotid malignancy is present, the fat in this
I area is obscured.
230
 CN7 (FACIAL NERVE)
OBLIQUE SAGITTAL T2 MR

Facial nerve-in. lAC fundus

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Crista falciformis
Inferior vestibular nerve
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Basal turp of cochlea

Mid-lAC facial nerve

Superior vestibular nerve

Anterior margin of lAC
Inferior vestibular nerve

Cochlear nerve

Temporal lobe

Facial nerve in porus acusticus

Vestibulocochlear nerve (CNS)

Cerebellar hemisphere

(Top) First of three oblique sagittal T2 MR images presented from lateral to medial shows normal fundal anatomy.
The horizontal crista falciformis separates the fundus into upper and lower portions. Facial nerve is anterosuperior,
separated from superior vestibular nerve by a vertical bony septum called "Bill bar" which is not resolved. Below
falciform crest are larger anterior cochlear nerve and posterior inferior vestibular nerve. (Middle) In the mid-internal
auditory canal (lAC) 4 nerves are clearly identified. The facial nerve is anterosuperior. (Bottom) This image through
the porus acusticus reveals the characteristic "ball in catcher's mitt" appearance of the facial and vestibulocochlear
nerves. The facial nerve is the "ball" and the vestibulocochlear nerve is the "catcher's mitt".
I
231
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Abbreviations
• Vestibulocochlear nerve: CN8; CN VIII
Synonyms
• Eighth cranial nerve
Definitions
• CN8: Afferent sensory nerve of hearing & balance
I Imaging Anatomy
Overview
• Sensory nerve consisting of two parts
o Vestibular part: Balance
o Cochlear part: Hearing
• CN8 bes~ described from peripheral to central
Cochlear Nerve
• Arises from bipolar neurons located in spiral ganglion
within modiolus of cochlea
o Peripheral fibers pass to organ of Corti in cochlear
duct (scala media) within cochlea
o Central fibers coalesce &; pass as auditory
component of CN8 (cochlear nerve) to brainstem
• Central fibers pass from modiolus through cochlear
aperture into internal auditory canal (lAC)
o Cochlear aperture defined as bony opening into
anteroinferior quadrant of fundus of lAC.
o Maximum diameter of cochlear aperture - 2 mm
• Cochlear nerve passes from lAC fundus to porus
acusticus within anteroinferior quadrant of lAC
• Near porus acusticus cochlear nerve joins together
with superior & inferior vestibular nerves to form
vestibulocochlear nerve (CN8) .
• CN8 crosses cerebellopontine angle (CPA) cistern
posterior to facial nerve -
• CN8 enters lateral brainstem at pontomedullary
junction posterior to facial nerve
• Cochlear nerve fibers bifurcate, ending in dorsal &
ventral cochlear nuclei
• Dorsal & ventral cochlear nuclei
o Cochlear nuclei found on lateral surface of inferior
cerebellar peduncle (restiform body)
Vestibular Nerve
• Arises from bipolar neurons located in vestibular
(Scarpa) ganglion located within vestibular nerve in
fundal portion of lAC
o Vestibular ganglion not visible on imaging
o Peripheral fibers pass to sensory epithelium of
utricle, saccule & semicircular canals
• Traverse multiple foramina in cribriform plate in
lateral wall of lAC fundus
o Central fibers coalesce to form superior & inferior
vestibular nerves that pass medially to brainstem .
• Fundus of lAC
o Superior & inferior vestibular nerves are separated by
falciform crest (transverse crest)
o Superior vestibular nerve separated from facial nerve
anteriorly by vertical bony structure called Bill bar
• Bill bar not visible on imaging (CT or MR)
232
NERVE)
• Superior & inferior vestibular nerves pass medially
from lAC fundus to porus acusticus within
posterosuperior & posteroinferior quadrants of lAC
• Near porus acusticus superior & inferior vestibular
nerves join together with cochlear nerve to form
vestibulocochlear nerve (CN8)
• Vestibulocochlear nerve crosses CPA cistern posterior
to facial nerve
• Enters lateral brainstem at junctiuH.pons & medulla
posterior to facial nerve
• Vestibular nerve fibers divide into ascending &;
descending branches which mainly terminate in
vestibular nuclear complex
• Vestibular nuclear complex
o Four nuclei (lateral, superior, medial & inferior)
o Located beneath lateral recess along floor of fourth
ventricle (rhomboid fossa) in lower pons
o Complex connections exist between vestibular
nuclei, cerebellum, spinal cord (vestibulospinal
tract) & nuclei controlling eye movement
IAnatomy-Based Imaging Issues
Imaging Recommendations
• Sensorineural hearing loss (SNHL)
o Intracochlear lesion suspected
• CT & MR both useful for imaging
• Congenital lesions of membranous labyrinth seen
as abnormalities of fluid spaces on MR or in bony
labyrinth shape on T-bone CT
• T-bone CT better for otosclerosis, Paget disease,
labyrinthine ossificans or if trauma suspected
• Only MR will demonstrate labyrinthitis or
intralabyrinthine tumor
o CN8 lesion suspected (CPA-lAC)
• MR imaging method of choice
• Thin-section, high-resolution T2 sequence in axial
& coronal planes may be used to screen patients
with unilateral sensorineural hearing loss
• Tl C+ MR remains gold standard
Imaging "Sweet Spots"
• Unilateral sensorineural hearing loss
o Focus on brainstem (inferior cerebellar
peduncle )-CPA-lAC-cochlea
o Central acoustic pathway (intra-axial pathways
above cochlear nuclei) rarely site of offending lesion
• Cisternal & lAC segments of CNS routinely visualized
on high-resolution T2 MR
Imaging Pitfalls
• Beware small lesions of lAC (;5 2 mm)!
o Follow-up imaging recommended as may be
transient finding where surgery not needed
I Clinical Implications
Clinical Importance
• Vestibular nerve dysfunction (dizziness, vertigo,
imbalance) alone usually has negative MR
• 95% of lesions causing unilateral SNHL found by MR,
are vestibulocochlear schwannoma
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233
 CN8 (VESTIBULOCOCHLEAR NERVE)
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U Labyrinthine segment, CN?

Epitympanic cavity of middle

Internal auditory canal ear

Mastoid antrum
Cribriform plate foramen

Vestibule

Anterior tympanic segment

CN?
Cochlear aperture

Macula cribrosa foramen

Mastoid segment of CN?
Singular canal

Posterior semicircular canal

Superior semicircular canal

Crista falciformis

Porus acusticus Lateral semicircular canal

Basal turn of cochlea

Internal auditory canal

(Top) Axial bone CT through the upper portion of the internal auditory canal shows the C-shaped labyrinthine
segment of the facial nerve & a main canal of the superior vestibular nerve crossing the cribriform plate toward the
vestibule. (Middle) Axial bone CT through the lower lAC shows anterolateral cochlear aperture through which the
cochlear nerve passes on its way from the cochlear modiolus into the lAC. Also notice the cribriform plate foramen
through which the inferior vestibular nerve reaches the vestibule & the smaller singular canal. (Bottom) Coronal
bone CT image through lAC demonstrates horizontal falciform crest which divides fundus of lAC into upper & lower
portions. Facial & superior vestibular nerves pass above & cochlear & inferior vestibular nerves pass below falciform
crest. Porus acusticus is bony aperture of internal auditory canal.
234
 CN8 (VESTIBULOCOCHLEAR NERVE)
AXIAL T2 MR O::l
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Cochlea
Facial nerve z
Facial nerve (CN?) .,
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Anteroinferior cerebellar artery

Superior vestibular nerve <
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Vestibulocochlear nerve (CN8)

Vestibulocochlear nerve (CN8)
Flocculus of cerebellum

Cochlear nerve Abducens nerve (CN6)

Facial nerve (CN?)

Cochlea

Inferior vestibular nerve

Superior vestibular nerve

Vestibulocochlear nerve (CN8) Vestibulocochlear nerve (CN8)

Facial nerve (CN?)

Abducens nerve (CN6)

Facial nerve (CN?) Abducens nerve (CN6)

Anterior inferior cerebellar
artery
Superior vestibular nerve

Middle cerebellar peduncle

Fourth ventricle

(Top) First of three axial T2 MR images presented from inferior to superior through cerebeJlopontine angle cistern &
internal auditory canal. Section through superior left lAC demonstrates cochlear nerve anteriorly & inferior
vestibular nerve posteriorly at fundus. (Middle) Vestibulocochlear nerve arises posterior to facial nerve from
brainstem at pontomeduJlary junction & maintains a posterior position throughout its course through CPA/lAC. On
patient's right the cochlear nerve is anterior to inferior vestibular nerve within fundus of lAC. On left the superior
fundus of lAC is seen with the anterior facial nerve & posterior superior vestibular nerve. (Bottom) This MR slice
through superior lAC area demonstrates the superior vestibular nerve posterior to facial nerve on the patient's right.

235
 CN8 (VESTIBULOCOCHLEAR NERVE)
CORONAL T2 MR

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Pons
Brachium pontis
Pontomedullary junction

Medulla oblongata

Cerebellar tonsil

Trigeminal nerve

Superior semicircular canal

Facial nerve (CN?)

Vestibule

Vestibulocochlear nerve (CN8) Anteroinferior cerebellar artery

Cerebellar flocculus
Vertebral artery

Facial nerve (CN?)

Falciform crest

Porus acusticus
Cochlear nerve

Anteroinferior cerebellar artery

Cerebellopontine angle cistern

(Top) First of three coronal T2 MR images presented from posterior to anterior. Vestibulocochlear nerve emerges
from brainstem posterior to facial nerve at pontomedullary junction. (Middle) Facial & vestibulocochlear nerves
course through CPA into lAC. Facial nerve is anterior & superior to vestibulocochlear nerve within CPA & lAC.
Notice the somewhat cephalad course of CN8 as it rises into the lAC from its origin at the pontomedullary junction.
(Bottom) Section through fundus of internal auditory canal demonstrates horizontal falciform crest separating
fundus into upper & lower portions. At this level, facial nerve is above & cochlear nerve is below falciform crest. The
anteroinferior cerebellar artery loop is a constant fixture in the normal anatomy of the CPA & lAC area.

236
 CN8 (VESTIBULOCOCHLEAR NERVE)
OBLIQUE SAGITTAL T2 MR

Superior semicircular canal

Facial nerve, anterosuperior in lAC
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Inferior vestibular nerve
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Cochlear nerve

Basal turn of cochlea

Temporal lobe

Facial nerve, anterosuperior lAC Superior vestibular nerve

Cochlear nerve Inferior vestibular nerve

Cerebellum

Cerebellopontine angle cistern

Porus acusticus
Vestibulocochlear nerve (CN8)

Facial nerve, anterior CPA cistern

Cerebellum

(Top) First of three sequential oblique sagittal T2 MR images through lAC presented from lateral to medial. Slice is
through fundus of lAC showing horizontal falciform crest separating fundus into upper & lower portions. Facial
nerve is anterosuperior, separated from superior vestibular nerve by a vertical bony septum called "Bill bar" which is
not resolved with even focused imaging. Below falciform crest are cochlear nerve anteriorly & inferior vestiqular
nerve posteriorly. (Middle).In the mid-lAC this image shows 4 discrete nerves. (Bottom) At the level of porus
acustiqis both superior & inferior vestibular nerves join together with cochlear nerve to form a C-shaped
vestibulocochlear nerve. The facial nerve remains discrete as it travels across the cerebellopontine angle cistern.

237
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I Terminology parotid gland
Abbreviations o Arises from inferior sensory ganglion within jugular
• Glossopharyngeal nerve: CN9, CN IX foramen
o Passes through inferior tympanic canaliculus into
Synonyms middle ear
• Ninth cranial nerve • Aberrant internal carotid artery enters middle ear
via this canal
Definitions o Forms tympanic plexus on cochlear promontory
• Complex cranial nerve functions • Glomus bodies associated with this nerve form
o Taste & sensation to posterior 1/3 tongue glomus tympanicum paraganglioma
o Sensory nerve to middle ear & pharynx • Stylopharyngeus branch
o Parasympathetic to parotid gland o Motor to stylopharyngeus muscle
o Motor to stylopharyngeus muscle • Sinus nerve
o Viscerosensory to carotid body & sinus o Supplies viscerosensory fibers to carotid sinus &
carotid body
o Conducts impulses from mechanoreceptors of sinus
I Imaging Anatomy & chemoreceptors of carotid body to medulla
• Pharyngeal branches
Overview o Sensory to posterior oropharynx & soft palate
• Mixed nerve (sensory, taste, motor, parasympathetic) • Lingual branch
• Four segments: Intra-axial, cisternal, skull base & o Sensory & taste to posterior 1/3 of tongue
extracranial
Intra-Axial Segment
• Glossopharyngeal nuclei are in upper & middle IAnatomy-Based Imaging Issues
medulla Imaging Recommendations
o Motor fibers to stylopharyngeus muscle originate in
• MR imaging method of choice
nucleus ambiguus
o Superior sensitivity to skull base, meningeal,
o Sensory fibers from tympanic membrane, soft
cisternal & brainstem pathology
palate, tongue base & pharynx terminate in spinal
o Sequences should include a combination of T2, Tl
nucleus CNS
without fat-saturation & contrast-enhanced Tl with
o Taste fibers from posterior 1/3 tongue terminate in
fat-saturation in axial & coronal planes
solitary tract nucleus
• Bone CT used to supplement MR when complex skull
o Parasympathetic fibers to parotid gland originate
base pathology discovered
in inferior salivatory nucleus
Cisternal Segment Imaging "Sweet Spots"
• Focused enhanced MR imaging extends from
• Exits lateral medulla in postolivary sulcus just above
pontomedullary junction above to hyoid bone below
vagus nerve
• CN9 nuclei & intra-axial segment not directly
• Travel anterolaterally through basal cistern together
visualized
with vagus nerve & bulbar portion of accessory nerve
o Position inferred by identifying upper medulla,
• Passes through glossopharyngeal meatus into pars
posterior to postolivary sulcus
nervosa portion of jugular foramen
o Cisternal segment is not always visualized on
Skull Base Segment routine MR imaging
• Passes through anterior pars nervosa portion of • High-resolution thin-section T2 sequences usually
jugular foramen demonstrate CN9, 10, 11 nerve complex passing
o Accompanied by inferior petrosal sinus through basal cisterns
o Vagus (CNlO) & spinal accessory (CNll) nerves are • Bone CT with bone algorithm clearly
posterior within pars vascularis portion of jugular demonstrates bony anatomy of pars nervosa
foramen • Extracranial segment not visualized
o Superior & inferior sensory ganglia of CN9 are found Imaging Pitfalls
within jugular foramen
• Remember to image entire extracranial course of CN9;
Extracranial Segment do not just stop at skull base!
• Exits jugular foramen into anterior nasopharyngeal
carotid space
• Passes lateral to internal carotid artery & I Clinical Implications
stylopharyngeus muscle
• Terminates in posterior sublingual space in floor of
Clinical Importance
mouth (posterior 1/3 taste function) • Glossopharyngeal nerve dysfunction usually associated
with CNlO & 11 neuropathy
Extracranial Branches o Isolated glossopharyngeal neuropathy exceedingly
• Tympanic branch Oacobsen nerve) rare

238
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Petrooccipital fissure
Vertical segment, petrous rCA
Pars nervosa, jugular foramen

Pars vascularis, jugular foramen

Sigmoid sinus

Petrooccipital fissure
Horizontal petrous rCA canal

Pars nervosa, jugular foramen

Pars vascularis, jugular foramen

Jugular spine
Jugular tubercle

Upper clivus
Petrous apex

Pars nervosa, jugular foramen

Sigmoid plate
Pars vascularis, jugular foramen
Jugular spine

(Top) First of three axial bone CT images presented from inferior to superior through posterior skull base
emphasizing the bony anatomy of the jugular foramen. The jugular foramen is located on floor of posterior cranial
fossa between petrous temporal bone anterolaterally & occipital bone posteromedially. It is therefore a venous
channel between these bones. (Middle) The jugular foramen is seen here as two discrete pieces, the smaller
anteromedial pars nervosa & larger posterolateral pars vascularis, separated by jugular spine of petrous bone.
(Bottom) The two parts of the jugular foramen are visibile. The pars nervosa transmits the glossopharyngeal nerve
(CN9), Jacobsen nerve & inferior petrosal sinus. The pars vascularis transmits the vagus (CNlO) & accessory (CNll)
cranial nerves, Arnold nerve & sigmoid sinus which becomes the internal jugular vein.
242
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artery

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Glossopharyngeal nerve (CN9)
Vagus nerve (CNIO)
Vagus nerve (CNlO)

Fourth ventricle
Postolivary sulcus

Glossopharyngeal nerve (CN9)

Vagus nerve (CNlO) Glossopharyngeal nerve (CN9)
Vagus nerve (CNlO)
Fourth ventricle
Inferior cerebellar peduncle

(Top) First of three axial high-resolution T2 MR images through the brainstem medulla presented from inferior to
superior. Glossopharyngeal nerve is seen passing laterally into the pars nervosa of the jugular foramen. (Middle) The
glossopharyngeal nerve (CN9), vagus nerve (CNlO) and bulbar accessory nerve (CNll) all exit the medulla laterally
in the postolivary sulcus. CN9 is the most cephalad of these. With routine MR imaging it is not possible to see these
three cranial nerves individually. (Bottom) In the upper medulla the vagus nerve is well seen leaving the brainstem
via the postolivary sulcus. The glossopharyngeal nerve is seen more laterally as it has already exited the brainstem
above the vagus nerve.

243
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CN10 (VAGUS NERVE)
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I Terminology
Abbreviations
• Vagus nerve: CNlO, CN X
Synonyms
• Tenth cranial nerve
Definitions
• CNlO: Parasympathetic nerve supplying regions of
head and neck and thoracic and abdominal viscera
• Additional vagus nerve components
o Motor to soft palate (except tensor veli palatini
muscle), pharyngeal constrictor muscles, larynx and
palatoglossus muscle of tongue
o Visceral sensation from larynx, esophagus, trachea,
thoracic and abdominal viscera
o Sensory nerve to external tympanic membrane,
external auditory canal (EAC) and external ear
o Taste from epiglottis
I Imaging Anatomy
Overview
• Mixed nerve (sensory, taste, motor, parasympathetic)
• Segments: Intra-axial, cisternal, skull base and
extracranial
Intra-Axial Segment
• Vagal nuclei are in upper and middle medulla
o Motor fibers originate in nucleus ambiguus
o Taste from epiglottis goes to solitary tract nucleus
o Sensory fibers from viscera terminate in dorsal
vagal nucleus (afferent component)
o Parasympathetic fibers project from dorsal vagal
nucleus (efferent component)
o Sensory from regional meninges and ear project to
spinal nucleus CNS
• Fibers to and from these nuclei exit lateral medulla in
postolivary sulcus inferior to CN9 and superior to
bulbar portion of CN 11
Cisternal Segment
• Exits lateral medulla in postolivary sulcus between
CN9 and bulbar portion of CN!!
• Travel anterolaterally through basal cistern together
with CN9 and bulbar portion of CN!!
Skull BaseSegment
• Passes through posterior pars vascularis portion of
jugular foramen OF)
o Accompanied by CN!! and jugular bulb
o Superior vagal ganglion is found within )F
Extracranial Segment
• Exits)F into nasopharyngeal carotid space
• Inferior vagal ganglion lies just below skull base
• Descends along posterolateral aspect of internal
carotid artery into thorax
o Passes anterior to aortic arch on left and subclavian
artery on right
• Forms plexus around esophagus and major blood
vessels to heart and lungs
244
• Gastric nerves emerge from esophageal plexus and
provide parasympathetic innervation to stomach
• Innervation to intestines and visceral organs follows
arterial blood supply to that organ
Extracranial Branches in Head & Neck
• Auricular branch (Arnold nerve)
o Sensation from external surface of tympanic
membrane, EAC and external ear
o Arises from superior vagal ganglion within)F
o Passes through mastoid canaliculus extending from
posterolateral)F to mastoid segment CN? canal
o Enters EAC via tympanomastoid fissure
• Pharyngeal branches
o Pharyngeal plexus exits just below skull base
o Sensory to epiglottis, trachea and esophagus
o Motor to soft palate [except tensor veli palatini
muscle (CNV3)] and pharyngeal constrictor muscles
• Superior laryngeal nerve
o Motor to cricothyroid muscle
o Sensory to mucosa of supraglottis
• Recurrent laryngeal nerve
o On right recurs at cervicothoracic junction, passe>
posteriorly around subclavian artery
o On left recurs in mediastinum by passing posteriorly
under aorta at aortopulmonary window
o Nerves recur in tracheoesophageal grooves (TEG)
o Motor to all laryngeal muscles except cricothyroids
o Sensory to mucosa of infraglottis
IAnatomy-Based Imaging Issues
Imaging Recommendations
• Proximal vagal neuropathy
o Image from medulla to hyoid bone
o MR imaging method of choice
• Superior sensitivity to skull base, meningeal,
cisternal and brainstem pathology
• Sequences should include a combination of T2, T1
without fat-saturation and contrast-enhanced T1
with fat-saturation in axial and coronal planes
• Bone CT used to supplement MR when complex
skull base pathology is present
• Distal vagal neuropathy
o Image from hyoid bone to mediastinum
o Must reach carina if left vagal neuropathy
o Key areas to evaluate are carotid space and TEG
o CECT imaging method of choice
I Clinical Implications
Clinical Importance
• Vagal nerve dysfunction separated into proximal and
distal symptom complexes
• Proximal symptom complex
o Injury site: Between medulla and hyoid bone
o Multiple cranial nerves involved (CN9-!2) with
oropharyngeal and laryngeal dysfunction
• Distal symptom complex
o Injury site: Below hyoid bone
o Isolated CNlO involvement with laryngeal
dysfunction only
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Petrous apex
Pars nervosa

Jugular foramen CNlO, approximate location in

pars vascularis
Jugular spine

Sphenooccipital synchondrosis

Horizontal petrous internal

carotid canal
Channel for inferior petrosal sinus Pars nervosa

Pars vascularis
Jugular spine

Jugular tubercle

Sphenooccipital synchondrosis
Clivus

Vertical segment petrous internal Petrooccipital fissure

carotid artery
CNlO, approximate location in
Pars vascularis pars vascularis

Jugular tubercle
Sigmoid sinus

(Top) First of three axial bone CT images of the skull base presented from superior to inferior. The jugular foramen is
divided by the jugular spine into the anteromedial pars nervosa and posterolateral pars vascularis. The pars vascularis
transmits the vagus and accessory cranial nerves, Arnold nerve and jugular bulb which becomes internal jugular vein.
(Middle) In this image the pars nervosa is seen to connect anteromedially to the inferior petrosal sinus. CN9,
Jacobsen nerve and the inferior petrosal sinus are all found within the pars nervosa. (Bottom) Image through lower
jugular foramen shows the sigmoid sinuses emptying into the pars vascularis of the jugular foramen. Notice the
jugular foramen is located on floor of posterior cranial fossa in the seam between petrous temporal bone
anterolaterally and occipital bone posteromedially.
248
 CN10 (VAGUS NERVE)
AXIAL T2 MR CO
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Preolivary sulcus
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Postolivary sulcus

Vagus nerve (CNlO)

Vagus nerve (CNlO)

Preolivary sulcus
Medullary pyramid
Inferior olivary nucleus area

Post olivary sulcus Vagus nerve entering jugular

foramen
Bulbar portion, CNll
Bulbar portion, CNll

Fourth ventricle

(Top) First of three axial T2 MR images of low brainstem presented from superior to inferior. The vagus nerve is seen
exiting the lateral medulla in postolivary sulcus inferior to glossopharyngeal nerve. (Middle) In this image the vagus
nerve is clearly seen exiting the postolivary sulcus into the lateral basal cistern bilaterally. CN9 exits this sulcus just
above the vagus nerve while the bulbar CN11 exits it just inferiorly. (Bottom) At the level of the cephalad margin of
the jugular foramen the bulbar root of the accessory nerve is seen exiting the postolivary sulcus. The vagus nerve is
entering the jugular foramen laterally. Unless thin-section focused T2 imaging is completed it is often difficulty to
separate the glossopharyngeal nerve, vagus nerve and bulbar root of the accessory nerve in the basal cisterns.

249
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CN11 (ACCESSORY NERVE)
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z ITerminology muscle
Abbreviations o Innervates sternomastoid muscle
• Accessory nerve: CN 11, CN XI o Continues across floor of posterior cervical space in
cervical neck
Synonyms o Terminate in & innervate trapezius muscle
• Eleventh cranial nerve
Definitions IAnatomy-Based Imaging Issues
• CNll: Pure motor cranial nerve supplying
sternocleidomastoid & trapezius muscles Imaging Recommendations
• MR imaging method of choice
o Superior sensitivity to skull base, meningeal,
I Imaging Anatomy cisternal & brainstem pathology
o Sequences should include a combination of T2, T1
Overview without fat-saturation & contrast-enhanced TI with
• Motor cranial nerve only fat-saturation in axial & coronal planes
• Four CNll segments are defined • Bone CT used to supplement MR when complex skull
o Intra-axial, cisternal, skull base & extracranial base pathology is present
Intra-Axial Segment Imaging "Sweet Spots"
• Two distinct nuclear origins • CNll nuclei & intra-axial segment not directly
o Bulbar (cranial) motor fibers originate in lower visualized
nucleus ambiguus • Cisternal segment is often not visualized on routine
• Fibers course anterolaterally to exit lateral medulla MR imaging
in postolivary sulcus inferior to CN9 & 10 o High-resolution thin-section T2 MR sequence
o Spinal motor fibers originate from spinal nucleus usually demonstrates CN9, 10, 11 nerve complex
of accessory nerve passing through basal cisterns from post-olivary
• Narrow column of cells along lateral aspect of sulcus to pars vascularis of jugular foramen
anterior horn from Cl to CS • Bone CT clearly demonstrates bony anatomy of pars
• Nerve fibers emerge from lateral aspect of cervical vascularis of jugular foramen
spinal cord between anterior & posterior roots • Extracranial CNll segment not directly visualized
• Fibers combine forming a bundle that ascends o Location inferred from its constant position deep to
entering skull base via foramen magnum sternocleidomastoid muscle in floor of posterior
cervical space
Cisternal Segment
• Bulbar portion travels anterolaterally through basal Imaging Pitfalls
cistern together with CN9 & 10 • Hypertrophic levator scapulae muscle following
• Bulbar & spinal portions join together within lateral serious CNll injury may mimic tumor
basal cistern • Don't mistake this enlarged muscle for mass!
Skull Base Segment
• Passes through posterior pars vascularis portion of
jugular foramen
I Clinical Implications
o Vagus nerve (CN1O) & jugular bulb are also in pars Clinical Importance
vascularis • CNll innervates sternocleidomastoid & trapezius
• Bulbar & spinal portions remain together in jugular muscles
foramen
Function-Dysfunction
Extracranial Segment • CNll dysfunction: Isolated CNll injury
• Combined CNll exits jugular foramen into o Most common cause is radical neck dissection
nasopharyngeal carotid space because spinal accessory nodal chain intimately
• Fibers from bulbar portion which arose within nucleus associated CNll
ambiguus transfer to vagus nerve o Initial symptoms of spinal accessory neuropathy
o Travels via CN10 to supply muscles of pharynx & • Downward & lateral rotation of scapula
larynx • Shoulder droop resulting from loss of trapezius
• Larynx: Except cricothyroid muscle via recurrent tone
laryngeal nerve o Long term findings in spinal accessory neuropathy
• Pharynx: Superior constrictor & soft palate via • Within 6 months results in atrophy of ipsilateral
pharyngeal plexus sternocleidomastoid & trapezius muscles
• Fibers from spinal portion remain in extracranial • Compensatory hypertrophy of ipsilateral levator
CNll scapulae muscle occurs over months
o Diverges posterolaterally from carotid space • CNll dysfunction: Complex CNll dysfunction
associated with CN9 & 10 neuropathy

250
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Pre-olivary sulcus Medullary pyramid

Posterior inferior cerebellar
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Pars vascularis, jugular foramen

Bulbar portion CNll

Bulbar portion CNll

Posterior inferior cerebellar artery Vertebral artery

Spinal portion CNll Spinal portion CNll

Posterior inferior cerebellar artery Posterior inferior cerebellar

artery

(Top) Axial bone CT through the jugular foramen shows the anteromedial pars nervosa, the jugular spine & the
posterolateral pars vascularis. The pars nervosa transmits CN9, Jacobsen nerve & inferior petrosal sinus. The pars
vascularis transmits CNlO, CNll, Arnold nerve & sigmoid sinus which becomes internal jugular vein. (Middle) Axial
T2 MR image at level of medulla shows the bulbar portion of CNll emerging from the post olivary sulcus just inferior
to CNlO. The bulbar portion travels anterolaterally through basal cistern together with CNlO & CN9. (Bottom) Axial
T2 MR image through lower medulla reveals the spinal root of CNll climbing cephalad through foramen magnum
to join bulbar root of CNll before they enter the pars nervosa of jugular foramen. It is spinal root that eventually
becomes the extracranial CNll with motor fibers to sternocleidomastoid & trapezius muscles. I
253
 rJ'J
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CN12 (HYPOGLOSSAL NERVE)
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z ITerminology branches after exiting hypoglossal canal
Abbreviations o Hypoglossal nerve descends in posterior aspect of
• Hypoglossal nerve: CN12, CN XII carotid space, closely apposed with vagus nerve
o Exits carotid space anteriorly between jugular vein &
Synonyms internal carotid artery at inferior margin of posterior
• Twelfth cranial nerve belly of digastric muscle
• Trans-spatial component of CNl2
Definitions o After leaving carotid space, runs anteroinferiorly
• CN12: motor cranial nerve controlling intrinsic & toward hyoid bone, lateral to carotid bifurcation
extrinsic muscles of tongue o At level of occipital artery base, hypoglossal nerve
turns anterior, continuing as muscular branch below
posterior belly of digastric muscle
I Imaging Anatomy o Gives off superior root of ansa cervicalis from
horizontal segment CN12 to anastomose with lower
Overview root of ansa cervicalis
• Motor cranial nerve to intrinsic & extrinsic muscles of • Distal branches of imaging importance
tongue o Muscular branch travels on lateral margin of
o Only extrinsic muscle not innervated by CN12 is hyoglossus muscle in posterior sublingual space
palatoglossus muscle • Muscular branch innervates extrinsic
• Vagus nerve innervates palatoglossus muscle (styloglossus, hyoglossus & genioglossus) &
• Hypoglossal nerve anatomic segments intrinsic tongue muscles
o Intra-axial segment • Geniohyoid innervated by CI spinal nerve
o Cisternal segment o Ansa cervicalis: Formed from superior and inferior
o Skull base segment
(CI-C3 spinal nerves) roots
o Extracranial • Innervates infrahyoid strap muscles
Intra-Axial Segment (sternothyroid, sternohyoid, omohyoid)
• Hypoglossal nucleus
o Located in medulla between dorsal vagal nucleus &
midline IAnatomy-Based Imaging Issues
o Long, thin nucleus that is about same length as the Imaging Recommendations
ventrolateral olive
• MR is preferred imaging study
o Extends from level of hypoglossal eminence in floor
o Best delineates brainstem, cisterns, skull base &
of fourth ventricle just inferior to stria medullares to
suprahyoid neck
proximal medulla
• CECT with bone algorithm of skull base is excellent
o In axial section, hypoglossal nucleus is located in
for skull base & suprahyoid neck
dorsal medulla, medial to dorsal vagal nucleus
• Hypoglossal intra-axial axonal course Imaging "Sweet Spots"
o Efferent fibers from hypoglossal nucleus extend • Coverage of hypoglossal nerve requires CT or MR to
ventrally through medulla, lateral to medial visualize following anatomic areas
lemniscus o Brainstem, basal cistern & hypoglossal canal
o Efferent fibers exit between olivary nucleus & o Nasopharyngeal carotid space
pyramid at ventrolateral sulcus also called o Posterior belly digastric & carotid bifurcation
pre-olivary sulcus o Hyoid bone & sublingual space
Cisternal Segment Imaging Pitfalls
• Efferent fibers coalesce to form multiple rootlets • Failure to ima e to level of hyoid bOl1e will result in
• Rootlets fuse into hypoglossal nerve just as it exits missed diagnoses!
skull base through hypoglossal canal
• Hypoglossal filaments may merge with vagal fibers
Skull Base Segment I Clinical Implications
• Hypoglossal nerve exits the occipital bone via Clinical Importance
hypoglossal canal • Unilateral hypoglossal lesion causes tongue protrusion
o Hypoglossal canal is located in inferior occipital to "side of the lesion"
bone caudal to jugular foramen • Acute hypoglossal injury
o Variant anatomy of hypoglossal canal o Tongue fasciculates
• Osseous septa may bisect hypoglossal canal o Tongue deviates to side of injury when protruded
Extracranial Segment • Chronic hypogTossal injury
• Carotid space component of CNl2 o Tongue atrophy seen as fatty infiltration & volume
o Hypoglossal canal "empties" into medial loss on CT or MR
nasopharyngeal carotid space o Infrahyokl strap muscles also atrophy

254
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Hypoglossal canal

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Internal carotid artery

Medullary pyramid

Hypoglossal canal
Vertebral artery

Hypoglossal nerve Hypoglossal nerve

Vertebral artery

Pre-olivary sulcus Internal carotid artery

Hypoglossal rootlet Hypoglossal nerve

Hypoglossal nucleus location

Retro-olivary sulcus

(Top) Axial bone CT image at the level of the hypoglossal canal. Notice the margins of the hypoglossal canals are
well corticated. (Middle) First of two axial T2 MR images through lower medulla demonstrates cisternal segment of
hypoglossal nerves. Anatomy of cisternal segment is variable, but usually 12-16 rootlets emerge from pre-olivary
sulcus & merge into two trunks which penetrate dura to enter hypoglossal canal. The trunks abut or pass near the
vertebral arteries in the basal cisterns. (Bottom) Hypoglossal nerves emerge from medulla in pre-olivary sulcus
between olive & pyramid. Cisternal segment of the patient's left hypoglossal nerve is seen as a thick, discrete trunk
entering hypoglossal canal. Right hypoglossal nerve consists of multiple small rootlets.

257
 CN12 (HYPOGLOSSAL NERVE)
~ CORONAL BONE CT
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li:l
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li:l Jugular tubercle
•....
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Jugular foramen
Hypoglossal nerve location

Mastoid tip
Hypoglossal canal

Occipital condyle

Atlas (CI) lateral mass

Jugular tubercle Lateral semicircular canal

Hypoglossal canal
Facial nerve canal, mastoid
segment
Hypoglossal nerve location Stylomastoid foramen

Jugular foramen
Occipital condyle

Atlas (CI) lateral mass

Internal auditory canal

Cochlear aqueduct
Jugular tubercle Vestibule

Hypoglossal canal
Jugular foramen
Hypoglossal nerve location

Occipital condyle

Atlas (CI) lateral mass

(Top) In this first of three coronal bone CT images presented from posterior to anterior shows the hypoglossal canal
as a complete bony circle indicating the image is at the level of the entry into the canal. The location of CN12 is in
the upper medial quadrant within the hypoglossal canal. (Middle) In this image of the mid-hypoglossal canal the
surrounding bone appears as a "birds head & beak", with the head & beak made up of the jugular tubercle. The
jugular foramen is directly lateral to the hypoglossal canal. (Bottom) At the level of the distal hypoglossal canal the
hypoglossal nerve leaves the skull base to emerge inferiorly into the nasopharyngeal carotid space. Notice the lateral
jugular foramen also empties its contents into the carotid space including the jugular vein & cranial nerves 9, 10 &
11.
258
 CN12 (HYPOGLOSSAL NERVE)
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Internal auditory canal
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Jugular bulb

Hypoglossal nerve in hypoglossal Jugular foramen

canal
Occipital condyle

Atlas (Cl) lateral mass

Jugular tubercle
Hypoglossal nerve in distal
Hypoglossal nerve exiting hypoglossal canal
hypoglossal canal

Internal jugular vein Occipital condyle

Atlas (Cl) lateral mass

Dens

(Top) First of three sequential coronal Tl C+ MR images presented from posterior to anterior. In this MR image the
hypoglossal nerve is seen entering the proximal hypoglossal canal. The hypointense hypoglossal nerve is surrounded
by strongly enhancing venous plexus & is therefore easily seen on thin-section enhanced MR. (Middle) In this
coronal MR image of the mid-hypoglossal canal the low signal hypoglossal nerve is visible surrounded by enhancing
venous plexus just beneath the "bird's beak" of the jugular tubercle. (Bottom) In this coronal image through the
distal hypoglossal canal the hypoglossal nerves can be seen exiting inferolaterally into the nasopharyngeal carotid
space. Notice also the vein of the jugular foramen exiting inferiorly on the patient's right into this same
nasopharyngeal carotid space.
259
SECTION 6: Extrac:ranial Arteries

Aortic Arch and Great Vessels 1-262

Cervical Carotid Arteries 1-266
 AORTIC ARCH AND GREAT VESSELS
o Anteromedial to internal jugular vein
ITerminology o Branches into left ICA, ECA at level of upper thyroid
Abbreviations cartilage
• Aortic arch (AA); brachiocephalic trunk (BCT) • Left subclavian artery
• Right, left common carotid arteries (RCCA, LCCA) o Arises from AA just distal to LCCA
o Ascends into neck, passing lateral to medial border
• Right, left subclavian arteries (RSCA, LSCA)
of anterior scalene
• Congenital heart disease (CHD)
o Crossed anteriorly by thoracic duct, left phrenic
Definitions nerve
• "Great vessels": Major vessels arising from AA (BCT, o Branches
LCCA, LSCA) • Left internal thoracic (mammary) artery
• Left vertebral artery
• Left thyrocervical trunk
I Gross Anatomy • Left costocervical trunk

Overview Vascular Territory

• Thoracic aorta has four major segments (ascending • AA and great vessels supply neck, skull, entire brain
aorta, AA, aortic isthmus, descending aorta) Normal Variants, Anomalies
• Normal aortic arch has three major branches (BCT,
• Normal variants
LCCA, LSCA)
o Classic pattern with three branches seen in 80% of
cases
I Imaging Anatomy
• First branch is BCT, followed by LCCA, LSCA
o "Bovine" configuration (misnomer)
Overview • Common origin of BCT, LCCA (10-25% of cases)
• AA curves from right to left, slightly anterior to o LCCA arises from BCT in 5-7%
posterior in superior mediastinum o "Left brachiocephalic trunk:" (LCCA, LSCA share
common origin) in 1-2%
Anatomy Relationships o Left VA arises directly from AA in 0.5-1 %
• Anterior: Vagus nerve (CN1O) o Aortic "isthmus" (circumferential bulge beyond
• Posterior ductus) may persist -+ aortic "spindle"
o Trachea o Ductus diverticulum (focal bulge along anteromedial
oEsophagus aspect of aortic isthmus), found in 9% of adults
o Left recurrent laryngeal nerve • Anomalies
• Superior o LeftAA with aberrant RSCA
o Great vessels • Most common congenital arch anomaly (0.5-1%)
o Left brachiocephalic vein • 70%: RCCA, LCCA, LSCA, RSCA
• Inferior • 25%: Common stem for RCCA/LCCA, LSCA, RSCA
o Pulmonary trunk • 5%: Other variations with RSCA as last branch
o Left recurrent laryngeal nerve from AA
• +/- Aneurysmal dilation of RSCA ("ductus of
Branches Kommerell")
• Brachiocephalic trunk (innominate artery) o Right AA with mirror image branching
o First (largest) AA branch • Left brachiocephalic trunk, RCCA, RSCA
o Arises from superior convexity of AA • 98% prevalence of CHD
o Ascends anterior to trachea o Right AA with aberrant LSCA
o At sternoclavicular level, bifurcates into RSCA, • LCCA, RCCA, RSCA, LSCA
RCCA • 10% prevalence of CHD
o RSCA branches • May form true vascular ring
• Internal thoracic (mammary) artery (courses o Oouble aortic arch (multiple variations)
anteroinferiorly from RSCA) • Most common vascular ring
• Right vertebral artery (courses superiorly from • Right arch typically higher, larger than left
RSCA just distal to RCCA origin) • Right arch usually gives origin to RSCA, RCCA; left
• Thyrocervical trunk (gives off 2 major branches: to LCCA, LSCA
Inferior thyroid artery and its ascending cervical, • Rarely associated with CHD
laryngeal and pharyngeal branches; suprascapular
artery)
• Costocervical trunk (gives off superior intercostal, IAnatomy-Based Imaging Issues
deep cervical arteries)
o RCCA branches Imaging Recommendations
• Bifurcates into (lCA), (ECA) • Left anterior oblique (LAO) position best visualizes AA,
• Left common carotid artery great vessels
o Arises from AA distal to BCT • CTA, contrast-enhanced MRA rival DSA in depicting
o Ascends in front of, then lateral to, trachea AA, great vessels

262
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Left vertebral artery

Right subclavian artery

Left common carotid artery

Brachiocephalic trunk Left subclavian artery

Aortic arch

Ascending cervical artery,

thyrocervical trunk
Inferior thyroid artery,
thyrocervical trunk

Right vertebral artery

Costocervical trunk
Thyrocervical trunk
Arteria thyroidea ima Highest (superior) intercostal
artery

Internal thoracic (mammary) artery

Ascending cervical artery

Inferior thyroid artery

Left vertebral artery

Suprascapular branch, thyrocervical Thyrocervical trunk

trunk
Right vertebral artery Superior intercostal artery

Internal thoracic (mammary) artery

(Top) Three views of DSA obtained in slight LAO projection are shown. Early arterial phase shows aortic arch, "great
vessels," First branch is normally brachiocephalic trunk (innominate artery), which bifurcates into right subclavian
and common carotid arteries. Left common carotid artery, second major branch, typically originates very close to (or
sometimes from) brachiocephalic trunk. In this projection, origins of left common carotid and subclavian arteries
slightly overlap. (Middle) Mid-arterial phase shows origin of the right vertebral artery (VA). A tiny inconstant
branch, the thyroidea ima, arises from the BeT. (Bottom) Late arterial phase sh9wS more distal branches of the "great
vessels." The left vertebral artery is slightly larger than the right vertebral artery. The thyroiO gfand is seen as a faint
blush, in between the common carotid arteries.
264
265
 CERVICAL CAROTID ARTERIES
• Common origin with facial artery in 10-20% of
ITerminology cases
Abbreviations o Facial artery
• Aortic arch (AA); brachiocephalic trunk (BCT) • Originates just above lingual artery
• Common (CCA), internal (ICA), external (ECA) carotid • Curves around mandible, then passes
arteries anterosuperiorly across cheek
• Vertebral artery (VA), basilar artery (BA) • Supplies face, palate, lip, cheek
• Anastomoses with ophthalmic artery (ICA
branch), other ECA branches
I Gross Anatomy o Occipital artery
• Originates from posterior aspect of ECA
Overview • Courses posterosuperiorly between occiput and C1
• CCAs terminate by dividing into ECA, ICA • Supplies scalp, upper cervical musculature,
• ECA is smaller of two terminal branches posterior fossa meninges
o Supplies most of head, neck (except eye, brain) • Extensive anastomoses with muscular VA
o Has numerous anastomoses with ICA, VA (may branches
become important source of collateral blood flow) o Posterior auricular artery
• ICA has no normal extracranial branches • Arises from posterior ECA above occipital artery
• Courses superiorly to supply pinna, scalp, external
auditory canal, chorda tympani
I Imaging Anatomy o Superficial temporal artery
• Smaller of two terminal ECA branches
Overview • Runs superiorly behind mandibular condyle,
• CCAs across zygoma
o Right CCA originates from BCT; left CCA from AA • Supplies scalp, gives off transverse facial artery
o Course superiorly in carotid space, anteromedial to o Maxillary artery
internal jugular vein • Larger of two terminal ECA branches
o Divide into ECA, ICA at approximately C3-4 level • Arises within parotid gland, behind mandibular
• CervicallCAs neck
o 90% arise posterolateral to ECA • Gives off middle meningeal artery (supplies
o Carotid "bulb" cranial meninges)
• Focal dilatation of ICA at its origin from CCA • Runs anteromedially in masticator space
• Flow reversal occurs in carotid bulb • Within pterygopalatine fossa sends off terminal
o Ascending cervical segment branches to deep face, nose
• Courses superiorly within carotid space • Potential major source of collateral flow via
• Enters carotid canal of skull base (petrous inferolateral trunk of cavernous ICA,
temporal bone) ophthalmic and recurrent meningeal arteries
• No named branches in neck • Cervical VAs
• ECAs have 8 major branches o Originate from subclavian arteries, pass upwards in
o Superior thyroid artery transverse foramina
• First ECA branch (may arise from CCA o Numerous muscular branches, ECA anastomoses
bifurcation)
• Arises anteriorly, courses inferiorly to apex of
Normal Variants, Anomalies
thyroid • Normal variants (common)
• Supplies_ superior thyroid, larynx o CCA bifurcation can be from T2 to C2
• IAnastomoses with inferior thyroid artery (branch o Medial (not lateral) origin of ICA from CCA in
of thyrocervical trunk) 10-15%
o Ascending pharyngeal artery o Arch origin of VA (5%)
• Arises from posterior ECA (or CCA bifurcation) • Anomalies (rare)
• Coones superiorly between ECA, ICA o "Non bifurcating" CCA
• Visceral branches supply nasopharynx, • No ICA bulb; ECA branches arise directly from
oropharynx, eustachian tube CCA
• Muscular, tympanic branches supply middle ear, • High association with aberrant course of ICA in
prevertebral muscles middle ear!
• Neuromeningeal branches supply dura, CNs 9-11 o Persistent hypoglossal artery
• Numerous important (potentially dangerous) • Second most common carotid-basilar anastomosis
anastomoses with middle/accessory meningeal, • Arises from ICA at Cl-2 level, passes through
caroticotympanic and vidian arteries! hypoglossal canal to join BA
o Lingual artery o Proatlantal intersegmental artery
• Second anterior ECA branch • Arises from cervicallCA at C2-3
• Loops anteroinferiorly, then superiorly to tongue • Connects cervical ICA with VA
• Major vascular supply to tongue, oral cavity,
submandibular gland

266
267
 CERVICAL CAROTID ARTERIES
lJl
Q) LATERAL DSA CCA
Supraclinoid internal carotid artery

Cavernous internal carotid artery

("(j
Petrous internal carotid artery
c Pterygopalatine fossa
("(j
•....
u
("(j
•....
.•....
X
LU

Internal carotid artery, cervical

segment
External carotid artery

Common carotid artery

Occipital artery

Posterior auricular artery

External carotid artery

Ascending pharyngeal artery Internal carotid artery

Facial artery
Lingual artery
Superior thyroid artery

Superficial temporal artery

Superficial temporal artery

Maxillary artery branching within Posterior auricular artery

pterygopalatine fossa
Transverse facial artery Occipital artery
Superior alveolar artery

Muscular branches of occipital

Inferior alveolar artery artery

Facial artery

Lingual artery

(Top) Lateral unsubtracted DSA of a common carotid angiogram shows the relationship of the CCA bifurcation to
the cervical spine and skull base. The typical CCA bifurcation is usually around the C4-CS level. The internal carotid
artery normally arises posterior and lateral to the ECA. All branches of the carotid arteries below the skull base arise
only from the ECA. The pterygopalatine fossa, seen here behind the posterior maxillary sinus wall, contains the
terminal maxillary artery division into its deep facial branches. (Middle) Early arterial phase of the CCA angiogram is
shown with bony structures subtracted. The major ECA branches are opacified. (Bottom) Late arterial phase shows
opacification of the distal ECA branches. The main terminal ECA branch is the maxillary artery, shown here as it
divides within the pterygopalatine fossa.
268
 CERVICAL CAROTID ARTERIES
OBLIQUE DSA CCA

Supraclinoid internal carotid artery

Posterior genu, cavernous ICA
Anterior genu, cavernous ICA
Petrous ICA

Maxillary artery in pterygopalatine

fossa

Ascending pharyngeal artery

CD
lJl

Lingual artery

Superior thyroid artery

Superficial temporal artery

Maxillary artery
Occipital artery
Ascending pharyngeal artery

Facial artery
Muscular branches, occipital
artery

Lingual artery
Superior thyroid artery

Ophthalmic artery Superficial temporal artery

Occipital artery
Maxillary artery in pterygopalatine
fossa

Lingual artery

(Top) Unsubtracted oblique view of a left common carotid DSA shows the maxillary artery coursing towards its
terminal bifurcation within the pterygopalatine fossa. The ascending pharyngeal artery is a small branch that is often
obscured by larger vessels on standard lateral views. (Middle) Subtracted view shows both proximal, distal branches
of the cervicallCA. Note that the ascending pharyngeal branch, often not well seen on standard lateral or AP views,
is well visualized here as it courses superiorly towards the skull base. (Bottom) Late arterial phase shows the terminal
maxillary artery bifurcation within the pterygopalatine fossa. The superficial temporal and middle meningeal arteries
typically fill late on common carotid angiograms.

269
270
 CERVICAL CAROTID ARTERIES
MRA c::l
~
~
::J
Middle meningeal artery
m
X
,....,.
Maxillary artery """"

OJ
n
""""

Occipital artery OJ
:J
-.
OJ

Common origin of lingual, facial

Ascending pharyngeal artery
»
,....,.
""""
arteries
External carotid artery ro
""""

Superior thyroid artery ro

lJl

Common carotid artery Vertebral artery

Maxillary artery in pterygopalatine Superficial temporal artery

fossa

Occipital artery

Facial artery

Lingual artery
Vertebral artery

Thyrocervical trunk

Superficial temporal artery

"Hairpin" turn of STAover

Middle meningeal artery
zygoma
Maxillary artery

Facial artery
Lingual artery

Left vertebral artery

Thyrocervical trunk

(Top) MR angiogram of the cervical carotid and vertebral arteries profiles the carotid bifurcation. The major external
carotid artery branches are well seen. (Middle) Oblique view shows the bifurcation. The distal loop of the maxillary
artery at its termination within the pterygopalatine fossa can pe seen here. (Bottom) On this straight AP view, the
carotid bifurcation is obscured but distal ECA branches are well seen. The superficial temporal artery has a
characteristic tight "hairpin" turn as it passes over the zygomatic arch.

271
 CERVICAL CAROTID ARTERIES
lJ1
Q) LATERAL DSA DISTAL EXTERNAL CAROTID ARTERY

"Hairpin" turn of Superficial

Middle meningeal artery passing temporal artery over zygoma
through foramen spinosum

Middle deep temporal artery Superficial temporal artery

Maxillary artery Middle meningeal artery

Posterior auricular artery

Masseteric artery
Inferior alveolar artery

Anterior branch, middle meningeal

artery Posterior branch, middle
meningeal artery

Anterior deep temporal artery Superficial temporal artery

Middle deep temporal artery
Infraorbital artery Middle meningeal artery

Transverse facial artery

Sphenopalatine artery
Descending palatine artery
Superior alveolar artery Buccal, masseteric branches

Inferior alveolar artery

Orbital mucosal blush High nasopharyngeal mucosal

blush

Nasal conchae, septal blush

Palatal mucosal blush

Oropharynx mucosal blush

(Top) Selective distal external carotid artery angiogram, early arterial phase, lateral view, shows the distal external
carotid artery and its main proximal branches. The abrupt anterior angulation of the middle meningeal artery as it
passes intracranially through the foramen spinosum is well demonstrated. Note "hairpin" turn of the superficial
temporal artery as it courses over the zygomatic arch. (Middle) Mid-arterial phase shows the deep facial branches of
the ECA especially well. Most arise from the termination of the maxillary artery within the pterygopalatine fossa,
seen here as a distinct loop just behind the maxillary sinus wall. (Bottom) Late arterial phase shows very prominent
vascular blushes in mucosa of the sinuses, nose, orbit and oropharynx. This is a normal finding and should not be
mistaken for vascular malformation.
272
 CERVICAL CAROTID ARTERIES
AP DSA INTERNAL MAXILLARY ARTERY OJ
~
~
::J

Maxillary artery in
pterygopalatine fossa
Greater (descending) palatine
artery

Sphenopalatine artery

Nasal branches, sphenopalatine

Superficial temporal artery
artery

Greater (descending) palatine

artery

Posterior septal branches,

sphenopalatine artery

Posterior lateral nasal branches

Superior alveolar artery

(Top) Distal external carotid DSA, early arterial phase, AP view, shows the termination of the maxillary artery as it
loops within the pterygopalatine fossa. (Middle) Mid-arterial phase shows the sphenopalatine artery, the distal
continuation of the maxillary artery, as it passes medially through the sphenopalatine foramen into the nose.
Numerous small branches supply the vascular nasal mucosa. (Bottom) Late arterial phase shows a prominent
vascular blush along the nasal turbinates and palatal mucosa. Numerous small nasal branches of the sphenopalatine'
artery ramify over the conchae and meatuses and anastomose with branches of the ethmoidal arteries and nasal
branches of the greater palatine artery. The sphenopalatine artery ends on the nasal septum as posterior septal
branches.
273
 CERVICAL CAROTID ARTERIES
ULTRASOUND
"-
OJ
.•.... Platysma

«"-

~ Sternomastoid muscle
c
~ Carotid sheath
u
"-
~ Carotid wall
.•....
"-
X
lJ..J Intima Common carotid artery
Media (lumen)
Adventitia

Carotid wall

Carotid bulb with slow,

non laminar flow
Distal common carotid artery
Internal carotid artery lumen

Main trunk of external carotid

artery
Proximal ECA branch

(Top) M-mode ultrasound of normal carotid artery, longitudinal image, shows normal wall thickness without
evidence for atherosclerosis. Three lines are seen in the carotid wall: The white endoluminalline is the intimal
reflection. The darker line underneath represents the media. The thicker peripheral white line is the adventitia.
(Middle) Color Doppler ultrasound, longitudinal image, of normal carotid bulb. Flow in the main lumen of the
proximal internal carotid artery is laminar. Note the area of disturbed/reversed flow in bulbous portion of proximal
leA (mixed blue and red). (Bottom) Power Doppler shows normal external carotid artery with a proximal branch.

274
 CERVICAL CAROTID ARTERIES
ULTRASOUND O::l
""'t
C)
::J

(Top) Color Doppler of right common carotid artery with normal triphasic wave form. The peak systolic velocity (PS)
in this case is slightly high for physiological reasons. (Bottom) Color Doppler of right internal carotid artery. Notice
normal low resistance waveform. The PS of 61 cmls is normal. Note that the CCA waveform above shows higher
resistance features (sharp diastolic peak and little diastolic flow) as compared with the internal carotid which has
distinct low resistance features (broad systolic peaks, relatively large amount of diastolic flow).

271
SECTION 7: Intracranial Arteries

Intracranial Arteries Overview 1-278

Intracranial Internal Carotid Artery 1-282
Circle of Willis 1-292
Anterior Cerebral Artery 1-298
Middle Cerebral Artery 1-304
Posterior Cerebral Artery 1-312
Vertebrobasilar System 1-322
 INTRACRANIAL ARTERIES OVERVIEW
I Terminology
Abbreviations
• Anterior, middle, posterior cerebral arteries (ACA,
MCA, PCA)
• Anterior, posterior communicating arteries (ACoA,
PCoA)
• Basilar artery (BA)
• Vertebral artery (VA)
• Anterior, posterior inferior cerebellar arteries (AICA,
c:
eta PICA)
•..
CQ
• Anterior choroidal artery (AChoA)
• Recurrent artery of Heubner (RAH)
I Gross Anatomy
Anterior Circulation
• ICA and its branches + ACoA, PCoA
Posterior Circulation
• BA and its branches
I Imaging Anatomy
Overview
• Internal carotid artery
o Proximal to termination gives off ophthalmic artery,
AChoA, PCoA
o Terminal bifurcation into ACA (smaller, medial),
MCA (larger, lateral)
o ACA has 4 segments
• Horizontal or pre communicating (AI) segment
courses medially above optic chiasm, joined by
ACoA to contralateral Al
• Vertical or postcommunicating (A2) segment
courses superiorly in interhemispheric fissure,
around corpus callosum genu
• Distal (A3) segment courses posteriorly under
inferior free margin of falx cerebri, gives off
cortical branches
• Perforating arteries arise from AI, ACoA
• RAH arises from distal A1 or proximal A2
o MCA has 4 segments
• Horizontal (Ml) segment courses laterally to
sylvian fissure below anterior perforated
substance, bi- or trifurcates
• "Genu" or "knee" of MCA is gentle posterosuperior
turn towards lateral cerebral (sylvian) fissure
• Insular (M2) segments course within lateral
cerebral fissure, over insula
• Opercular (M3) segments begin at top of insula,
turn laterally in sylvian fissure to reach
overhanging frontal/parietal/temporal operculae
• Cortical (M4) branches emerge from lateral
cerebral fissure, course over hemispheric surface
• Perforating arteries arise from Ml
• Basilar artery
o Courses cephalad in prepontine cistern to terminal
bifurcation ventral to midbrain
• Gives off AICA, superior cerebellar arteries (SCAs),
pontine, midbrain perforating arteries
278
o Bifurcates into PCAs, each of which has 4 segments
• Mesencephalic or pre communicating (PI) segment
lies within interpeduncular cistern, curves
posterolaterally from BA to PCoA junction
• Ambient (P2) segment extends from PCA-PCoA
junction, curving around cerebral peduncles just
above tentorium, above oculomotor nerve
• Quadrigeminal (P3) segment extends
posteromedially from level of quadrigeminal plate
• Cortical (P4) branches arise from distal PCA at or
just before reaching calcarine fissure
• Perforating branches arise from PI
o Vertebral arteries
• Intracranial (V4) segments enter dura near
foramen magnum
• Give off anterior/posterior spinal arteries,
perforating arteries to medulla, PICA
Vascular Territory
• Vascular distribution of ACA, MCA, PCA vary from
individual to individual, have typical as well as
maximum, minimum territories
• Two vascular "watershed" zones exist at confluence
of territorial supply, are vulnerable to hypoperfusion
o Cortical watershed = subpial confluence of cortical
ACA/MCA/PCA branches
o Deep white matter watershed zone = confluence of
deep cortical penetrating branches, perforating
branches from circle of Willis (COW)
• ACA
o Perforating branches: Corpus callosum rostrum,
heads of caudate nuclei, anterior commissure,
anteromedial putamen/globus pallidus/anterior limb
internal capsule (if RAH present)
o Cortical branches: Inferomedial frontal lobes,
anterior 2/3 of medial hemisphere surface, 1-2 cm
over brain convexity
• MCA
o Perforating branches: Most of putamen, globus
pallidus, superior half of internal capsule, most of
caudate nucleus, some deep white matter
o Cortical branches: Most of lateral surface of cerebral
hemispheres, anterior tip (pole) of temporal lobe
• PCA
o Perforating branches: Much of central brain base
(thalamus, hypothalamus), midbrain, choroid
plexus
o Cortical branches: Most of inferior surface of
temporal lobe, occipital pole, variable amount of
posterolateral surface of hemisphere
• BA
o All of PCA territory (including perforating branches),
most of pons, superior cerebellum/vermis
• VA
o Most of medulla, cerebellar tonsils, inferior
vermis/cerebellar hemispheres
IAnatomy-Based Imaging Issues
Imaging Recommendations
• Late arterial (capillary) phase of DSA with "brain stain"
shows vascular territory
(D
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279
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Q)

280
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281
 IJ)
Q)
INTRACRANIAL INTERNAL CAROTID ARTERY
• Ophthalmic (C6) segment
ITerminology o Extends from distal dural ring at superior clinoid to
Abbreviations just below posterior communicating artery (PCoA)
• Internal carotid, ophthalmic arteries (lCA, OA) origin
• Cavernous sinus (CS) o Two important branches
• OA (originates from anterosuperior ICA, passes
through optic canal to orbit; gives off ocular,
!Gross Anatomy lacrimal, muscular branches; extensive
anastomoses with ECA)
Overview • Superior hypophyseal artery (courses
• Complex course with several vertical/horizontal posteromedially; supplies anterior pituitary,
segments, 3 genus (one petrous, two cavernous) infundibulum, optic nerve/chiasm)
• Six intracranial segments (cervicallCA = Cl) • Communicating (C7) segment
,0 Petrous (C2), lacerum (C3), cavernous (C4) o Extends from below PCoA to terminallCA
o Clinoig (CS), ophthalmic (C6), communicating (C7) bifurcation into anterior cerebral artery (ACA),
middle cerebral artery (MCA)
o Passes between optic (CN2), oculomotor (CN3)
!Imaging Anatomy nerves
o Major branches
Segments, Branches • Posterior communicating artery
• petrous (C2) segment • Anterior choroidal artery (courses posteromedial,
o Contained within carotid canal of temporal bone then turns superolateral in suprasellar cistern;
o Surrounded by extensive sympathetic plexus enters temporal horn at choroidal fissure; supplies
o Two C2 subsegments joined at genu choroid plexus, medial temporal lobe. basal
• Short vertical segment [anterior to internal jugular ganglia, posteIQinferior internal capsule)
vein (lJV)]
• "Genu" (where petrous ICA turns anteromedially
Normal Variants, Anomalies
in front of cochlea) • Petrous (C2) segment
• Longer horizontal segment o Aberrant ICA (aICA)
o Exits carotid canal at petrous apex • Presents as retrotympanic pulsatile mass; should
o Branches not be mistaken for glomus tympanicum tumor!
• Yidian artery (artery of pterygoid canal) • Absent vertical course; alCA courses more
anastomoses with external carotid artery (ECA) posterolaterally than normal (appears as mass in
• Caroticotympanic artery (supplies middle ear) hypotympanum abutting cochlear promontory)
• Lacerum (C3) segment o Persistent stapedial artery
o Small segment that extends from petrous apex above • Arises from vertical segment, crosses cochlear
foramen (f.) lacerum, curving upwards toward promontory and stapes footplate
cavernous sinus • Enlarges tympanic segment of facial nerve canal
o Covered by trigeminal ganglion • Terminates as middle meningeal artery
o No branches • Seen as "Y-shaped", enlarged geniculate fossa of
• Cavernous (C4) segment CN7 on CT
o Three subsegments joined by two genus (knees) • F. spinosum is absent
• Posterior vertical (ascending) portion • Cavernous (C4) segment
• Posterior (more medial) genu o Persistent trigeminal artery
• Horizontal segment • Most common carotid-basilar anastomosis
(.02-0,5%)
• Anterior '(more lateral) genu
• Anterior vertical (subclinoid) segment • Parallels course of CNS, passes posterolaterally
o Covered by trigeminal ganglion posteriorly around (or through) dorsum sellae
o Abducens nerve (CN6) is inferolateral • Connects ICA to vertebrobasilar system, forms
o Major branches "trident-shape" on lateral DSA, sagittal MR
• Meningohypophyseal trunk (arises from posterior • May supply entire vertebrobasilar (VB) circulation
genu, supplies pituitary, tentorium and c1ival distal to anastomosis (Saltzman type I) or fill
dura) superior cerebral arteries (SCAs) with posterior
• Inferolateral trunk arises from horizontal segment, cerebral arteries (PCAs) filled via patent PCoAs
supplies cavernous sinus (CS) dura/cranial nerves; (Saltzman type II)
anastomoses with ECA branches through f.
rotundum, spinosum, ovale
• Clinoid (C5) segment !Anatomy-Based Imaging Issues
o Between proximal, distal dural rings of cavernous Clinical
sinus
• Horner syndrome results from interruption of
o Ends as ICA enters subarachnoid space near anterior
periarterial sympathetic plexus around ICA (dissection,
clinoid process
"bruising" of plexus, etc.)
o No important branches unless OA arises within CS

282
(t)
CJl

283
 INTRACRANIAL INTERNAL CAROTID ARTERY
IJl
Q) AXIAL NECT
'-
Q)
.•...•
'-
«

Vidian canal (vidian artery)

Foramen ovale (artery of foramen
ovale, accessory meningeal artery
Foramen spinosum (middle
Foramen lacerum
meningeal artery)
Carotid canal (vertical segment
of petrous ICA)
Jugular foramen

Inferior orbital fissure

Pterygopalatine fossa
Foramen rotundum (artery of
foramen rotundum)

Carotid canal (horizontal segment C3 (lacerum) ICA segment

of petrous ICA) above foramen lacerum

Genu of petrous ICA

Inferior orbital fissure

Posterior genu, cavernous ICA

(Top) Series of six axial NECT scans from inferior to superior with bone windows shows the major basilar foramina.
The ICA follows a complex course through the petrous temporal bone. The C2 or petrous ICA enters the skull base at
the exocranial opening of the carotid canal, ascending in front of the internal jugular vein. The petrous ICA has a
short vertical and a longer horizontal segment. (Middle) Slightly more cephalad, the petrous ICA abruptly turns
anteromedially and forms the posterior genu of the ICA. The posterior genu is below and slightly in front of the
cochlea and middle ear cavity. The long horizontal petrous segment then courses anteromedially from the genu
towards the cavernous sinus. (Bottom) Section just below the cavernous sinus proper shows the posterior genu of the
cavernous ICA as it curves anteromedially into the cavernous sinus.
284
 INTRACRANIAL INTERNAL CAROTID ARTERY
AXIAL NECT O::l
~
~
::J

Sphenoid sinus
Carotid sulcus

Clivus
Petrous apex

Cribriform plate
o !factory recess

Superior orbital fissure

Sella turcica

Anterior genu, cavernous

internal carotid arteries
Optic canal

Dorsum sellae

(Top) Section through the middle of the cavernous sinus shows the bony grooves of the carotid sulcus along the
basisphenoid bone. The cavernous (C4) ICA segment courses along the sulcus. (Middle) At this level, the cavernous
internal carotid artery courses through the cavernous sinus proper and then turns superiorly towards the anterior
clinoid process. (Bottom) The two cavernous carotid arteries form bony grooves just under the anterior clinoid
processes as seen on this section. This represents the anterior genu of the cavernous ICAs as they curve upwards
towards the dural ring where they will enter the cranial subarachnoid space. This represents the very short CS
(clinoid) ICA segment. The C6 (ophthalmic segment) begins at the distal dural ring of the cavernous sinus. The
ophthalmic artery originates here and passes anteriorly through the optic canal.
285
 INTRACRANIAL INTERNAL CAROTID ARTERY
LATERAL DSA

Posterior communicating artery

Anterior choroidal artery
Tentorial branches of MHT
Ophthalmic artery (enlarged)
Meningohypophyseal trunk

Posterior cerebral artery

Anterior choroidal artery
Posterior communicating artery Meningohypophyseal trunk
Anterior genu, cavernous (C4) ICA
Posterior genu, cavernous (C4)
Inferolateral trunk ICA
Lacerum (C3) ICA segment Endocranial opening, petrous
carotid canal
Horizontal segment, petrous (C2) Vertical segment, petrous (C2)
ICA ICA
Genus, petrous (C2) ICA Exocranial opening, carotid
canal

Choroid plexus "blush"

Anterior choroidal artery

Posterior communicating artery
Posterior pituitary vascular
Ophthalmic artery blush (normal)

(Top) Lateral DSA of left internal carotid artery in a patient with a dural arteriovenous fistulas (dAVF) of left
transverse sinus demonstrates an enlarged tentorial marginal branch of the meningohypophyseal trunk (MHT), also
called the posterior trunk (Middle) Lateral DSA of right lCA of same patient shown above demonstrates normal small
meningohypophyseal artery. A small inferolateral trunk is also visualized. There is transient filling of the ipsilateral
posterior cerebral artery via a prominent posterior communicating artery. Approximate location of exo-, endocranial
openings of petrous carotid canal are shown. (Bottom) Later arterial phase shows the normal vascular pituitary
"blush" adjacent to the posterior genu of the cavernous lCA. The pituitary gland receives its arterial supply primarily
by cavernous branches of the lCA. Note choroid plexus blush from the anterior choroidal artery.
286
 INTRACRANIAL INTERNAL CAROTID ARTERY
OBL DSA o::l
"""
~
::J

Anterior genu, cavernous (C4) ICA Posterior genu, cavernous (C4)

ICA

Lacerum (C3) ICA segment

Genu, petrous ICA

Horizontal (C2) petrous ICA
segment Vertical segment, petrous (C2)
ICA

Supra clinoid ICA ("communicating"

or C7 segment)
Ophthalmic artery and C6 ICA
segment

Anterior choroidal artery

(Top) Series of three oblique views of a selective left internal carotid DSA are shown. The early arterial phase
demonstrates the complex course of the ICA as it passes through the petrous carotid canal and enters the cavernous
sinus. The vertical petrous ICA segment is much shorter than the horizontal segment. The C3 (lacerum) segment is a
short portion that courses above the foramen lacerum between the endocranial opening of the petrous carotid canal
and the petro lingual ligament. (Middle) Mid-arterial phase shows a small ophthalmic artery arising from the
ophthalmic (C6) ICA segment. (Bottom) Late arterial phase shows the anterior choroidal artery (AChoA) arising from
the C6 (communicating) ICA segment. The AChoA arises medially, coursing around the temporal lobe, before it
turns posterolaterally towards the choroidal fissure. I
287
 INTRACRANIAL INTERNAL CAROTID ARTERY
V)
Q) AP DSA

Posterior genu, cavernous ICA

Anterior genu, cavernous ICA Ophthalmic artery

Genu, petrous (C2) ICA

Endocranial opening, petrous segment
carotid canal (approximate) Vertical petrous ICAsegment
Horizontal petrous ICA segment

Anterior choroidal artery

Ophthalmic artery

Choroid "blush"

(Top) Series of three AP views, left internal carotid DSA, are illustrate. Early arterial phase shows the petrous and
cavernous ICA segments. The genu between the vertical and horizontal petrous ICA segments is well seen. The
approximate endocranial opening of the petrous carotid canal is indicated by the oval. The posterior and anterior
genus of the cavernous ICA are superimposed on this view. The posterior ICA genu is slightly medial to the anterior
genu. (Middle) Mid-arterial phase shows the ophthalmic and anterior choroidal arteries. (Bottom) Late arterial phase
shows a faint "blush" of the choroid plexus within the lateral ventricle.

288
 INTRACRANIAL INTERNAL CAROTID ARTERY

Clinoid (CS) ICA segment

Ophthalmic artery and C6 ICA

Anterior genu, cavernous (C4) ICA segment
Cavernous (C4) ICAsegment
Communicating (C7) ICA
segment and PCoA
Posterior genu, cavernous (C4) ICA
Lacerum (C3) ICAsegment
Horizontal segment, petrous (C2)
ICA
Genu, petrous (C2) ICAsegment

Anterior choroidal artery

Ophthalmic artery Posterior communicating artery

Anterior genu, cavernous (C4)

Posterior genu, cavernous (C4) leA ICA

Genu, petrous (C2) ICA

Horizontal segment, petrous
(C2) ICA
Vertical (C2) segment, petrous ICA

(Top) MRA is excellent for depicting the intracranial ICA. Note on this submentovertex reprojection that the
posterior genu of the cavernous ICA is more medial than its anterior genu. The clinoid, ophthalmic, and supraclinoid
(communicating) ICA segments are all medial to the cavernous ICA. (Middle) Lateral view shows the cavernous ICA
very well. Its small branches are typically not well seen. The ophthalmic artery, seen here as it originates from the
anterosuperior surface of the ICA, and the two major communicating segment branches (the posterior
communicating and anterior choroidal arteries) are well visualized. (Bottom) Oblique view nicely shows the three
knees or "genus" of the intracranial internal carotid artery: The petrous genus and the posterior and anterior genus of
the internal carotid artery. I
289
290
 INTRACRANIAL INTERNAL CAROTID ARTERY
eTA c;l
~
~
:J
:J
r-+
.....•
OJ
n
.....•
OJ
:J
OJ

»
.....•
r-+
CD
.....•
Communicating (C7) ICA segment CD
lJl
Anterior clinoid process Ophthalmic (C6) ICA segment

Anterior genu, cavernous (C4) ICA Anterior genu, cavernous ICA

Distal ICA bifurcation

Posterior communicating
arteries

(Top) Coronal MIP image from CTA shows relationship of the intracranial internal carotid artery to the anterior
clinoid processes. The ICAs pierce the dural ring medial to the anterior clinoid processes. The terminal ICA
bifurcation into the anterior and middle cerebral arteries is well seen. (Middle) Section just slightly posterior to the
above level shows the anterior genus of both cavernous ICAs, seen here as contrast-enhanced rounded densities
within the cavernous sinuses. (Bottom) Axial MIP shows the terminal ICA bifurcations. Two small posterior
communicating arteries arise from the communicating (C7) ICA segment.

291
 CIRCLE OF WilliS
o Hypoplastic/absent PCoA (25-33%)
ITerminology o Hypoplastic/absent Al (10-20%)
Synonyms o "Fetal" origin of PCA from ICA (15-25%)
• Circle of Willis (circulus arteriosus) • PCoA is same diameter as ipsilateral PCA
• PI is hypoplastic/absent
Definitions o Absent, duplicate or multichanneled ACoA 10-15%
• Central arterial anastomotic ring of brain o Junctional dilatation ("infundibulum") at PCoA
origin from ICA in 5-15%
• Should be 2 mm or less
I Cross Anatomy • Funnel-shaped, conical
• PCoA arises from apex
Overview • True anomalies rare
• Circle of Willis is an arterial polygon o ACA-ACoA complex
• Ten components • Infraoptic origin of ACA (t prevalence of
o Two internal carotid arteries (lCAs) aneurysms)
o Two proximal or horizontal (AI) anterior cerebral • Single (azygous) ACA (holoprosencephalies; t
artery (ACA) segments prevalence of aneurysms
o One anterior communicating artery (ACoA) o PCoA-PCA-BA complex
o Two posterior communicating arteries (PCoAs) • Persistent carotid-basilar anastomoses (trigeminal,
o Basilar artery hypoglossal)
o Two proximal or horizontal (PI) posterior cerebral
artery (PCA) segments
IAnatomy-Based Imaging Issues
IImaging Anatomy Key Concepts or Questions
• cow provides major source of collateral blood flow to
Overview brain; if one (or more) segments is hypoplastic,
• Entire COW rarely seen on single DSA but completely potential for collateral flow in case of large vessel
imaged on CTA/MRA occlusion may be severely limited
Anatomy Relationships Imaging Recommendations
• cow lies above sella, in suprasellar cistern • CTA/MRA best for imaging entire COW
• Surrounds ventral surface of diencephalon, • DSA requires multiple views +/- cross-compression of
inferolateral to hypothalamus contralateral carotid artery to visualize ACoA
• Horizontal (AI) ACA segments normally course above
optic nerves (CN2) Imaging Pitfalls
• PCoAs course below optic tracts, above oculomotor • Absent COW segment usually congenital
nerves (CN3) • If PCA not visualized at vertebral angiography,
anatomic variant with ICA ("fetal") origin more likely
Branches than occlusion
• Important perforating branches arise from all parts of
COW
• ACAs IEmbryology
o Medial lenticulostriate arteries
o Recurrent artery of Heubner Embryologic Events
• ACoA • ICAs develop from third aortic arches, dorsal aortae,
o Unnamed perforating branches to anterior vascular plexus around forebrain
hypothalamus, optic chiasm, cingulate gyrus, corpus • Embryonic ICAs divide into cranial, caudal divisions
callosum and fornix o Cranial divisions give rise to
o Occasionally a large vessel, median artery of corpus • Primitive olfactory, anterior/middle cerebral,
callosum, arises from ACoA anterior choroidal arteries
• PCoA • Anterior communicating artery forms from
o Anterior thalamoperforating arteries coalescence of a midline plexiform network,
• Basilar artery (BA), peAs connects developing ACAs
o Posterior thalamoperforating arteries o Caudal divisions
o Thalamogeniculate arteries • Become posterior communicating arteries
• Supply stems (proximal segments) of posterior
Vascular Territory cerebral arteries
• Entire central base of brain (including hypothalamus, • Paired dorsal longitudinal neural arteries fuse, form
internal capsule, optic tracts, thalamus, midbrain basilar artery
• Developing vertebrobasilar circulation usually
Normal Variants, Anomalies
incorporates PCAs
• Variations the rule, not exception
• Caudal ICA divisions regress, form PCoAs
o Absent/hypoplastic components (60%)

292
(!)
Vl

293
 CIRCLE OF WilliS
~ MRA

ctI Anterior communicating artery

C
ctI Left Al ACA
~ Right Al ACA
U
ctI
~
+-'
C
Right precommunicating (PI) PCA Left posterior communicating
artery

Left ICA

P2 PCA segment

Left internal carotid artery Posterior communicating artery

Basilar artery

A2 ACA segments
Horizontal (MI) MCA segment
Anterior communicating artery

Internal carotid artery Horizontal (AI) ACA segment

(Top) AP view of an MRA depicts the circle of Willis. The Al and PI segments of both the posterior and anterior
cerebral arteries are well seen, as is the basilar bifurcation. (Middle) Lateral view of the MRA shows the posterior
communicating arteries nicely. Neither the PI (precommunicating) PCA segments or the Al (horizontal) ACAs are
well seen in this projection. (Bottom) Oblique view of a right internal carotid MRA shows the horizontal (AI) ACA
segment and profiles the ACoA especially well. The vertical or post-communicating (A2) ACA segments are also well
seen as is the ICA bifurcation. The MeA, which is not part of the COW is also nicely visualized in this projection.
This is an excellent projection for evaluation of the ACoA and MCA for the presence of an intracranial aneurysm.

294
295
 CIRCLE OF WilliS
<Fl
Q) eTA
"-OJ
+-'
"-
<{

~
c Anterior communicating artery
~ DistallCA bifurcation
"-
u
~
"-
+-'
Left horizontal (AI) ACA
C Right supraclinoid ICA segment

s:::
res
10..
co

Right Al ACA Left Al ACA

Left posterior communicating

Right horizontal (PI) PCA artery
Basilar artery bifurcation

Superior cerebellar artery

Postcommunicating (A2) ACAs

Hypoplastic anterior
communicating artery
Hypoplastic right posterior
communicating artery Left horizontal (PI) PCA

Right horizontal (PI) PCA

(Top) AP section through pituitary gland, suprasellar cistern (MIP reconstruction) from high-resolution MDCT
angiogram is shown. In this view the supraclinoid ICAs, their bifurcations, and horizontal (AI) ACA segments of
COW are especially well seen. A very small ACoA is present connecting the two Al segments. (Middle)
Submentovertex view shows the right horizontal (PI) PCA and both horizontal (AI) ACA segments. The horizontal
MCA segments are also well seen here. The MCA is not part of the COW. A hypoplastic left PCoA is present.
(Bottom) Slightly higher submentovertex view shows the horizontal Al and PI segments. A hypoplastic ACoA can
be seen on this section. The right PCoA is also hypoplastic. Hypoplasia or absence of one or more COW segments is
both common and normal. These variants limit the potential for collateral blood flow in case of occlusion.
296
 CIRCLE OF WilliS

Posterior cerebral artery

Anterior choroidal artery

Posterior communicating artery
Supraclinoid leA

C'D
lJl

"Fetal" posterior cerebral artery

In ternal carotid artery

Posterior thalamoperforating
arteries
Anterior thalamoperforating
arteries Posterior cerebral artery
Posterior communicating artery

Basilar artery

(Top) Lateral view of DSA from an internal carotid angiogram shows the normal relationship of the posterior
communicating artery to the internal carotid and posterior cerebral arteries. Here the PCA fills transiently from the
ICA injection. (Middle) Lateral view from another DSA of a selective internal carotid angiogram shows a so-called
"fetal" origin of the posterior cerebral artery from the ICA. Here the posterior communicating artery is large and
continues posteriorly as the PCA. The vertebrobasilar study in this patient (not shown) had no filling of the
ipsilateral PCA as the precommunicating (PI) segment was congenitally absent. (Bottom) Lateral view of a
vertebrobasilar DSA shows contrast refluxing into a PCoA. Perforating branches from the PCoA and proximal PCAs
are especially well seen in this study.
297
 ANTERIOR CEREBRAL ARTERY
• Penetrating branches supply medial bas(J1gjinglia,
I Terminology corpus callosum genu, anterior limb of internal
Abbreviations ca sule
• Anterior cerebral, anterior communicating, internal Normal Variants, Anomalies
carotid arteries (ACA, ACoA, ICA)
• Normal variants (common)
o Hypoplastic/absent Al
o "Bihemispheric ACA" (distal ACA branches supply
!Gross Anatomy part of contralateral hemisphere)
Overview o ACoA can be absent, fenestrated, duplicated
• Anomalies (rare)
• Smaller, more medial terminal branch of supraclinoid
o "Azygous" ACA (typically associated with
ICA
holoprosencephaly)
• Three segments
• Single ACA arises from junction of both Al s
o Horizontal or precommunicating (AI) segment
• ACoA absent
o Vertical or postcommunicating (A2) segment
o Infraoptic ACA
o Distal (A3) segment and cortical branches
• Al passes under (not over) optic nerve
• ACoA connects right, left Al segments
• High prevalence of intracranial aneurysms

!Imaging Anatomy IAnatomy-Based Imaging Issues

Overview
Imaging Recommendations
• ACA excellent midline marker
• Multiple views/multi planar reconstruction required to
• Displacement from midline common with
profile ACoA
space-occupying lesions or hemisphere atrophy
• May need to compress contralateral carotid artery
Anatomy Relationships during DSA to force contrast across ACoA
• AI: Extends medially over optic chiasm/nerves Imaging Pitfalls
• A2: Runs superiorly in interhemispheric fissure,
• Lack of ACA filling on injection of ipsilateral carotid
anterior to corpus callosum rostrum
artery usually caused by absent/hypoplastic AI (both
• A3: Curves around corpus callosum genu, divides into
ACA territories fill from ICA)
pericallosal, callosomarginal arterie~ ..
• Rotation of head off midline causes ACA to appear
o Pericallosal, callosomarginal artenes course wlthm
displaced on AP DSA
interhemispheric fissure, under falx cerebri
Branches
• Cortical branches I Clinical Implications
o Orbitofrontal artery
• Arises from proximal A2
Clinical Importance
• Ramifies over inferior surface of frontal lobe • ACoA is common site for aneurysm formation
o Frontopolar artery • ACA occlusion much less common than middle,
• Arises from mid-A2 posterior cerebral artery involvement
• Extends anteriorly to frontal pole • Distal ACA occlusion may occur with severe subfalcine
o Pericallosal artery herniation of cingulate gyrus
• Arises from A2 near corpus callosum genu
• Larger of two major distal ACA branches
• Courses posterosuperiorly above corpus callosum, !Embryology
below cingulate gyrus Embryologic Events
o Callosomarginal artery
• 5 weeks gestation: ACA appears as secondary branch of
• Smaller of two distal ACA branches
primitive olfactory artery (branch of primitive internal
• Courses posterosuperiorly in cingulate sulcus,
carotid artery)
above cingulate gyrus
• 6 weeks: Each embryonic ACA extends towards
• Perforating branches (arise from Al or ACoA)
midline
o Medial lenticulostriate arteries
o Plexiform anastomosis forms, joining both ACAs in
• Arise from AI, ACoA; course superiorly through
midline (normally regresses to form definitive
anterior perforated substance
ACoA)
o Recurrent artery of Heubner
o Median artery of corpus callosum forms as branch
• Arises from distal AI or proximal A2
from developing ACoA, then regresses (may persist,
• Curves back laterally above Al to enter anterior
appear as "triplicate" A2s)
perforated substance
• 7 weeks: Definitive ACAs formed
Vascular Territory
• Cortical branches supply anterior 2/3 of medial
hemispheres, convexity

298
»
....•
,......
CD
....•
CD
Vl

299
 ANTERIOR CEREBRAL ARTERY
CJl
Q) LAT DSA

Contrast filling
contralateral ACA
(across ACoA) Pericallosal pial plexus

Callosomarginal artery
Peri callosal artery

Distal (A3) ACA

segment
Vertical (A2) ACA
Frontopolar artery segment

Orbitofrontal artery
Posterior cerebral artery
(origin from ICA)

Ophthalmic artery (ICA

branch)

Pericallosal pial plexus

Choroid of globe

(Top) Digital subtraction internal carotid angiogram, lateral view, mid-arterial phase, shows the ACA and its major
cortical branches. (Bottom) Late arterial phase, lateral view, shows the vascular plexi that delineate both the ocular
choroid (supplied by branches of the ophthalmic artery) and the superior surface of the corpus callosum (the
so-called pericallosal pial"blush").

300
 ANTERIOR CEREBRAL ARTERY
AP DSA o:l
~
~
::J

Callosomarginal artery
(right ACA)
Peri callosal artery
(right ACA) Pericallosal pial plexus

Distal (A3) segment

(anterior to corpus
Medial lenticulostriate callosum genu)
arteries
Vertical (A2) ACA
segment
Middle meningeal
artery (ophthalmic
origin) Orbitofrontal artery
(from left ACA)
Recurrent artery of
Heubner Horizontal (AI) ACA
segment
Ophthalmic artery
(from ICA)

Interhemispheric
fissure

Peri callosal pial plexus

Middle meningeal
artery (ophthalmic
origin)

(Top) Digital subtraction right internal carotid angiogram, AP view, mid-arterial phase shows the ACA and its
branches. Both distal ACAs fill from this injection because contrast has refluxed across the anterior communicating
artery (which is not well seen on this projection). Note the ACAs are generally positioned in the midline, although
they "wander" across the midline somewhat. This angiographic appearance is normal. (Bottom) Late arterial phase,
AP view from the same series, shows the typical vascular "blush" formed by small branches of the pericallosal arteries
as they course over the superior surface of the corpus callosum. Note that in this case, distal branches of both ACAs
were filled when the right internal carotid artery was injected. The right middle meningeal artery is opacified because
it originated from the ophthalmic artery, a normal variant seen in approximately 0.5% of cases.
301
 ANTERIOR CEREBRAL ARTERY
V'l
Q) MKA
•...
Q)
•...
+-'
«
(ij
Callosomarginal artery
c
(ij
•...
u Pericallosal branch of right
•...
(ij
ACA
+-'
C A2 segment, right ACA
Right middle cerebral artery
C A2 segment, left ACA
(ij
'-
CQ
Anterior communicating artery
Right anterior cerebral artery,
Al segment
Right internal carotid artery
Posterior communicating artery

Pericallosal branch of ACA

Callosomarginal branch of ACA

Anterior cerebral artery, A2 Posterior communicating artery

segment

Infundibulum of posterior
communicating artery

Callosomarginal branch of ACA

A2 segment, right anterior

cerebral artery

A2 segment, left anterior

Al segment, anterior cerebral artery cerebral artery

Anterior communicating artery

(Top) Submentovertex view from 3D TOF MRA shows the right internal carotid artery and its branches. The major
branches of the ACA are well seen although smaller branches (such as the medial lenticulostriate arteries and
recurrent artery of Heubner) are not well delineated. (Middle) Lateral view of MRA demonstrates both anterior
cerebral arteries and their major branches. (Bottom) Slightly oblique AP view of the right internal carotid artery
circulation shows the ACA and ACoA, which is especially well seen. Short perforating branches are not visualized.

302
 ANTERIOR CEREBRAL ARTERY
eTA

Bifurcation of right A2 into

peri callosal, callosomarginal
arteries

Vertical (A2) segment of the right

ACA Vertical (A2) segment of the left
ACA

Horizontal (AI) segment, right ACA Horizontal (AI) segment, left

ACA

Superior sagittal sinus Peri callosal artery and pial

plexus

Callosomarginal artery
Internal cerebral vein

Right, left A2 ACA segments

Frontopolar artery
Orbitofrontal artery
Hypoplastic anterior
communicating artery

Basilar artery

Medial lenticulostriate arteries Lateral lenticulostriate arteries

Recurrent artery of Heubner

Right horizontal (AI) ACA segment (from A2 ACA segment, not
seen)

Anterior communicating artery

(hypoplastic)

(Top) Axial 3D color volume rendering of circle of Willis obtained using 64 detector row CT angiography. Both
horizontal (AI) anterior cerebral artery (ACA) segments are symmetric. The anterior communicating artery is
hypoplastic and not well seen on this view. The A2 (vertical) segment of both arteries within the interhemispheric
fissure are seen in the midline. (Middle) Sagittal midline MIP image from same series clearly delineates both A2
segments as they course superiorly within the interhemispheric fissure in the cistern of the lamina terminalis. The
corpus callosum genu can be faintly seen in this section, as well as CSF within the lateral ventricle. (Bottom) AP MIP
section shows both horizontal (AI) ACA segments. Note hypoplastic anterior communicating artery, oriented in
near-vertical plane. The ACoA course and configuration vary widely from patient to patient. I
303
 <Jl
Q)
MIDDLE CEREBRAL ARTERY
• Runs in postcentral, then intraparietal sulcus
ITerminology o Posterior parietal artery
Abbreviations • Exits posterior end of sylvian fissure
<i:l • Runs posterosuperiorly along supramarginal gyrus
• Middle cerebral artery (MCA)
C
• Internal carotid artery (ICA) o Angular artery
<i:l
•.... • Most posterior branch exiting sylvian fissure
U Synonyms
<i:l • Runs posterosuperiorly over transverse temporal
•....
......, • Sylvian (lateral cerebral) fissure gyrus
c • Insula (island of Reil) o Temporooccipital artery
• Runs posteroinferiorly in superior temporal sulcus
Definitions o Posterior temporal, medial temporal arteries
• Operculae = parts of the frontal, parietal, and temporal • Extend inferiorly from sylvian fissure
lobes that "overhang" and "enclose" the sylvian fissure • Cross superior, middle temporal gyri
Vascular Territory
ICross Anatomy • Cortical branches
o Considerable variation in territory of individual
Overview branches
• Larger, lateral terminal branch of supraclinoid ICA o Most common pattern
• Four segments • Supply most of lateral surface of cerebral
o Horizontal (Ml) segment hemispheres except for convexity and inferior
o Insular (M2) segments temporal gyrus
o Opercular (M3) segments • Anterior tip of temporal lobe (variable)
o Cortical branches (M4) segments • Penetrating branches
o Medial lenticulostriate arteries (a few arise from
proximal MCA)
IImaging Anatomy • Medial basal ganglia, caudate nucleus
• Internal capsule
Overview o Lateral lenticulostriate arteries
• M2, M3 branches delineate insula, sylvian fissure • Lateral putamen, caudate nucleus
Anatomy Relationships • External capsule
• Horizontal (Ml) segment Normal Variants, Anomalies
o Extends from terminal ICA bifurcation to sylvian • High variability in branching patterns
fissure o "Early" MCA bi- or trifurcation (within 1 em of
o Lies lateral to optic chiasm, behind olfactory trigone origin)
o Courses laterally under anterior perforated substance • True anomalies (hypoplasia, aplasia) rare
o Usually bi- or trifurcates just before sylvian fissure o MCA duplication seen in 1-3'Y<1 of cases
o Postbifurcation trunks enter sylvian fissure then • Large branch arises from distal ICA just prior to
turn upwards in a gentle curve (MCA "genu") terminal bifurcation
• Insular (M2) segments • Parallels main Ml
o Six to eight "stem" arteries arise from postbifurcation o Accessory MCA (rare)
trunks, course superiorly within sylvian fissure, • Arises from anterior cerebral artery
ramify over surface of insula • High association with saccular aneurysm
o M2 segments end at top of sylvian fissure o Fenestrated MCA (rare)
• Opercular (M3) segments
o M3 segments begin at top of sylvian fissure, course
inferolaterally through sylvian fissure I Embryology
o Exit sylvian fissure at surface of brain
• Cortical (M4) segments Embryologic Events
o Exit sylvian fissure and ramify over lateral surface of • Definitive appearance of MCA intimately related to
hemisphere formation of sylvian fissure, insula
• Fetal brain initially smooth, unsulcated; MCA
Branches branches lie over surface
• Perforating branches (lenticulostriate arteries), • Shallow depressions on both sides of developing
anterior temporal artery arise from Ml hemispheres appear at 8-12 weeks' gestation
• Cortical branches (M4 segments) • Depressions deepen, become overlapped by edges
o Orbitofrontal (lateral frontobasal) artery (operculae) of developing frontal, parietal, temporal
o Prefrontal arteries lobes
o Precentral (prerolandic) artery o MCA branches follow depressions, infolding brain
• Runs between precentral and central sulci • Sylvian fissure forms, insula within its depths
o Central sulcus (rolandic) artery • MCA branches curve up/over insula, then turn
• Runs within central (rolandic) sulcus laterally, exit sylvian fissure, ramify over brain surface
o Postcentral sulcus (anterior parietal) artery

I
304
305
 MIDDLE CEREBRAL ARTERY
CD LAT DSA

Insular (M2) segments define

angiographic sylvian "triangle"

Central sulcus artery

Anterior parietal (postcentral
sulcus) artery
Precentral sulcus artery
Posterior parietal artery

Prefrontal arteries Angular artery

Orbitofrontal (lateral frontobasal)

artery Posterior cerebral artery

Anterior temporal artery

Posterior parietal artery

Angular artery

Temporooccipital artery

Anterior temporal artery &

branches

(Top) Three lateral views of a left internal carotid angiogram show the middle cerebral artery (MCA), beginning with
early arterial phase. Filling of the insular (M2) segments delineates the insula (sylvian "triangle"). (Middle)
Mid-arterial phase shows filling of the opercular (M3) and cortical (M4) MCA segments. Transient filling of the
ipsilateral posterior cerebral artery via the circle of Willis has occurred. (Bottom) Late arterial phase shows filling of
the distal MCA branches with "brain stain" (diffuse vascular "blush") of the cortex. Note that only the most anterior
aspect of the temporal lobe is opacified. Most of the temporal lobe is supplied by the posterior cerebral artery.

306
 MIDDLE CEREBRAL ARTERY
AP DSA

Angular artery with

angiographic "sylvian point"

Insular (M2) MCA segments

Lateral lenticulostriate arteries
(!)
Horizontal (MI) MCA MCA bifurcation lJl

Anterior temporal artery

Cortical (M4) MCA branches

Insular (M2) MCA segments Opercular (M3) MCA segments

Lateral lenticulostriate arteries

Anterior choroidal artery (from

ICA) Anterior temporal artery &
branches

Cortical (M4) MCA branches

Opercular (M3) MCA segments

Anterior temporal artery &

branches

(Top) Three AP views of left internal carotid angiogram illustrate normal middle cerebral artery (MCA) angiographic
anatomy. Only the horizontal (Ml) and insular (M2) segments are filled out on this early arterial phase image. The
MCA bifurcates within 1 cm of its origin, a so-called "early bifurcating" MCA. The angiographic "sylvian point" is the
highest, most medial insular loop of the MCA. (Middle) Mid-arterial phase demonstrates the insular (M2) and
opercular (M3) MCA segments as well as early filling of some cortical (M4) MCA branches. (Bottom) Late arterial
phase shows contrast has been washed out of the more proximal (Ml, M2) MCA segments. The distal cortical (M4)
MCA branches are now completely opacified. Note the "brain stain" caused by opacification of small branches within
the basal ganglia as well as the cortex. I
307
 MIDDLE CEREBRAL ARTERY
lJl
Q.) MRA

Angular artery

<i:1
C
<i:1 Apex of M2 loops define top of
•....
U insula Temporooccipital artery
<i:1
•....
+-'
C

Insular (M2) MCA segments Posterior cerebral artery

Posterior communicating artery

Cortical (M4) MCA segments Angular artery with "sylvian

point"
Opercular (M3) MCA segments

Insular (M2) MCA segments

MCA trifurcation (genu)

Horizontal (Ml) MCA segment

Anterior temporal artery

MCA bifurcation
Anterior temporal artery

Opercular (M3) MCA segments

Posterior communicating artery

Posterior cerebral artery

Cortical (M4) MCA branches

Angular artery with "sylvian
point"

(Top) Three views of 3T MR angiogram are shown from top to bottom. Lateral view is shown on top. (Middle) AP
view of the MR angiogram shows the MCA and its branches. The lateral lenticulostriate arteries are barely seen.
(Bottom) Submentovertex view is optimal for visualizing the MCA bi- or trifurcation (genu) & the opercular (M3)
segments. MCA aneurysms are often best delineated in this projection.

I
J08
309
 MIDDLE CEREBRAL ARTERY
l/1
Q) eTA

MCA bifurcation
Left anterior cerebral artery
Insular (M2) MCA segments

Horizontal (Ml) MCA segment

A2 ACA segments

Insular (M2) MCA segments

Anterior cerebral arteries (distal A2

segment, genu)

Pillars of fornix

Opercular (M3) MCA segments

Internal cerebral veins

Straight sinus

(Top) Three axial MIP views from a high-resolution CTA delineate the MCA & its branches. The lowest image, seen
here, locates the MCA bifurcation precisely & shows the Ml segment especially welL (Middle) Section slightly above
the top image shows the insular (M2) MCA segments, especially well seen on the left. (Bottom) Section through the
foramen of Monro shows the opercular (M3) MCA segments bilaterally.

310
 MIDDLE CEREBRAL ARTERY
eTA .,
O:l
~
:J
Left angular artery with
"sylvian point"
-.
:J
r-+
CJ
Right horizontal (A1) ACA segment Lateral lenticulostriate arteries -.
(')

CJ
:J
Horizontal (MI) MCA segment CJ

»
-.
-.
r-+
(D

(D
Vl

Opercular (M3) MCA segments

Insular (M2) MCa segments

Right lateral lenticulostriate arteries

Origin of left medial

lenticulostriate artery from M 1

Opercular (M3) MCA segments Insular (M2) MCA segment.

Anterior cerebral arteries (A2

segments)

(Top) Three coronal (AP) MIP images from CT angiogram demonstrate the lenticulostriate arteries especially well. CT
angiogram through the bifurcation of the internal carotid arteries. (Middle) Slightly more anterior view shows
origins of two prominent lenticulostriate arteries. The MCA gives rise to a few medial lenticulostriate arteries (most
arise from the horizontal or Al ACA segment). The more numerous group of perforating arteries, the lateral
lenticulostriate arteries, arises from the mid- and distal MI segments, and passes cephalad through the anterior
perforated substance into the lateral basal ganglia and external capsule. (Bottom) Most anterior view shows the A2
segments of both anterior cerebral arteries as well as opercular (M3) MCA branches on the right and an insular (M2)
segment on the left. Apex of insular loops marks the top of the insula.
311
 POSTERIOR CEREBRAL ARTERY
• Cortical branches
ITerminology o Anterior temporal artery arises from P2, courses
Abbreviations anterolaterally under parahippocampal gyrus of
• Posterior cerebral artery (PCA) inferior temporal lobe
• Posterior communicating artery (PCoA) o Posterior temporal artery arises from P2, courses
• Basilar artery (BA) posteriorly
• Internal carotid artery (ICA) o Distal PCA divides into two terminal trunks
• Medial branches: Medial occipital artery,
parietooccipital artery, calcarine artery, posterior
I Gross Anatomy splenial arteries
• Lateral branches: Lateral occipital artery, temporal
Overview arteries
• Main BA terminal branches = two PCAs Vascular Territory
• Four segments
• Penetrating branches: Midbrain, thalami, posterior
o Precommunicating (PI or mesencephalic) segment
limb of internal capsule, optic tract
o Ambient (P2) segment
• ventncular/choroidal branches: Choroid plexus of
o Quadrigeminal (P3) segment
third/lateral ventricles, parts of thalami, posterior
o Calcarine (P4) segment
commissure, cerebral peduncles
• PCoAs connect PCA to ICA at PI/P2 junction
• Splenial branches: Posterior body and splenium of
corpus callosum ..
• Cortical branches: Posterior 1/3 of medIal hemIsphere
I Imaging Anatomy surface; most of inferior temporal lobe, most of
Overview occipital lobe (including visual cortex)
• PCAs sweep posterolaterally around midbrain Normal Variants, Anomalies
Anatomy Relationships • "Fetal" origin of PCA
• PI (precommunicating) segment ... o Large PCoA gives direct origin to PCA .
o Extends laterally from BA bifurcatIOn to Juncllon o PI (precommunicating) PCA segment hypoplastIC or
with PCoA absent
o Courses above cisternal segment of oculomotor • Persistent carotid-basilar anastomoses
nerve (CN3) o PCAs supplied by persistent trigeminal artery or
• P2 (ambient) segment proatlantal intersegmental artery
o Extends from PI/PCoA junction
o Curves around cerebral peduncle within ambient
(peri mesencephalic) cistern [Anatomy-Based Imaging Issues
o Lies above tentorium, cisternal segment of trochlear Imaging Pitfalls
nerve (CN4)
• Absent PCA on vertebral angiogram usually due to
o Parallels optic tract, basal vein of Rosenthal
"fetal" origin, not occlusion
• P3 (quadrigeminal segment)
o Injection of ipsilateral carotid artery confirms
o Short segment within quadrigeminal cistern
presence of "fetal" PCA
o Extends behind midbrain (quadrigeminal plate
level) to calcarine fissure (occipital lobe)
• P4 (calcarine) segment
o PCA terminates above tentorium, in calcarine fissure
I Clinical Implications
Branches Clinical Importance
• Perforating (central) branches • PCA occlusion causes homonymous hemianopsia
o Posterior thalamoperforating arteries
• Arise from PI, pass posterosuperiorly in
interpeduncular fossa I Embryology
• Enter undersurface of midbrain Embryologic Events
o Thalamogeniculate arteries
• Definitive PCAs develop later than anterior, middle
• Arise from P2, pass posteromedially into midbrain
cerebral arteries
o Peduncular perforating arteries arise from P2, pass
• Circulation to fetal cerebral hemispheres initially
directly into cerebral peduncles
supplied entirely by embryonic ICA
• Ventricular/choroidal branches (arise from P2)
• Proximal PCAs sprout from caudal division of
o Medial posterior choroidal artery .
embryonic ICA
• Curves around brainstem, enters tela chorOidea
• Vertebral, basilar arteries form from fusion of dorsal
and runs anteriorly along roof of third ventricle
longitudinal neural arteries
o Lateral posterior choroidal arteries
• Anastomose with sprouting PCA stems
• In lateral ventricle choroid plexus, curves
• Distal PCAs sprout from proximal stems
anteriorly around thalamus

312
»
,....,.
""""

ro
""""

313
 POSTERIOR CEREBRAL ARTERY
Q3 LATERAL VA DSA

Lateral posterior choroidal artery l

Quadrigeminal (P3) PCA segment Parietooccipital artery

Anterior, posterior
Calcarine artery
thalamoperforating arteries
Calcarine (P4) PCA segment
Posterior communicating artery

Ambient (PZ) PCA segment

Lateral posterior choroidal artery -I Splenial artery

Medial posterior choroidal artery

Posterior temporal artery

Choroid plexus in body of lateral

ventricle

"Blush" of choroid plexus

Choroid plexus, vein in roof of
glomus in atrium
third ventricle

Midbrain, thalamic "blush"

(Top) A series of three lateral views from a vertebrobasilar angiogram shows the PCA and its branches. Early arterial
phase shows contrast reflux into the ipsilateral PCoA. Both anterior and posterior thalamoperforating arteries are
opacified. The lateral posterior choroidal artery has a prominent "3" shape that allows it to be identified easily on this
projection. The precommunicating (PI) PCA segment is not well seen but the P2 segment is shown as it curves
around and behind the midbrain. (Middle) Mid-arterial phase shows the posterior thalamoperforating and choroidal
arteries especially well. Note that PCA cortical branches are supplying the posterior third of the medial hemisphere
surface. (Bottom) "Capillary" early venous phase shows a prominent vascular blush in lateral ventricle. Note "brain
stain" depicting parietooccipital, midbrain PCA supply.
314
 POSTERIOR CEREBRAL ARTERY
APVA DSA

Calcarine (P4) PCA segment

Quadrigeminal (P3) PCA segment -I

Ambient (P2) PCA segment

Precommunicating (PI) PCA

segments

Calcarine arteries

Parietooccipital artery

Anterior temporal artery

Parietooccipital vascular blush.

Posterior temporal lobe vascular

"blush"

(Top) A series of three AP views of a vertebrobasilar angiogram depict the PCA segments and their branches. The
precommunicating (PI) segment is best seen in this projection. The PCAs sweep laterally and then posterosuperiorly
around the midbrain. (Middle) Mid-arterial phase shows several of the cortical PCA branches especially well. In this
view, anterior and posterior temporal arteries often overlap somewhat. In this projection the posterior
thalamoperforating arteries are seen as a faint vascular blush lying just above the terminal basilar artery bifurcation.
(Bottom) Late arterial phase shows the vascular blush of the PCA supply to the medial parietal and occipital lobes as
well as the temporal lobes. The unopacified vertical "filling defect" is the dura of the falx cerebri that separates the
two cerebral hemispheres.
315
 POSTERIOR CEREBRAL ARTERY
Vl
Q) LAT,AP leA DSA

"Fetal" origin of PCA

from ICA
Tentorial branch of
meningohypophyseal
trunk
Anterior temporal
branch of MCA Anterior temporal
branch of PCA

Calcarine (P4) PCA

segment
Quadrigeminal (P3)
PCA segment

Ambient (P2) PCA

segment
"Fetal" origin of PCA
from supraclinoid lCA

(Top) A common normal variant is origin of the PCA from the supraclinoid internal carotid artery, sometimes
termed a "fetal" origin of the PCA. In this instance the ipsilateral P2 segment is hypoplastic or absent and the
potential for collateral flow through the circle of Willis is anatomically limited. The meningohypophyseal trunk, a
branch of the cavernous ICA, is unusually prominent because it supplied a small dural arteriovenous fistula (not
shown) at the transverse sinus/sigmoid sinus junction. (Bottom) AP view shows the PCA is opacified from the
internal carotid injection. The vertebrobasilar angiogram in this patient (not illustrated) showed "absent" filling of
the right PCA. The most common cause of this finding, as occurred in this case, is "fetal" origin of the PCA from the
I ICA instead of the vertebrobasilar system.
316
 POSTERIOR CEREBRAL ARTERY
MRA O::l
~
$::oJ
:::::l

::J
,......
....•
Q)
Parietooccipital artery n
....•
Q)
::J
Ambient (P2) pCA segment
Calcarine artery Q)
Precommunicating (PI) PCA
segment »
....•
,......
Posterior communicating artery ro
....•
(cut off)
ro
Vl

Parietooccipital artery Calcarine (P4) PCA segment

Quadrigeminal (P3) PCA

segment
Posterior temporal artery Ambient (P2) pCA segment

Precommunicating (PI) pCA

Superior cerebellar artery segment

Left posterior communicating

Right posterior communicating artery
artery
Ambient (P2) PCA segment Precommunicating (PI) PCA
segments

Quadrigeminal (1'3) PCA

segment
Posterior temporal branches
Calcarine (P4) pCA segment

Parietooccipital artery Calcarine artery

(Top) First of three views of an MRA obtained at 3T show the PCA and its major cortical branches. This slightly
oblique lateral view shows the basilar bifurcation and the PI segment. (Middle) AP view shows both PCAs as they
sweep laterally and then posteriorly around the midbrain. Perforating arteries are not well seen on MRAs, even at 3T.
(Bottom) Submentovertex view shows the PCA segments and distal cortical PCA branches especially well. The
configuration of the PCA as it courses around the midbrain is highly variable. The PI (precommunicating) segments
vary significantly in both size, length, and tortuosity.

317
 POSTERIOR CEREBRAL ARTERY
IJ)
Q) APCTA

Thalamoperforating arteries

Lateral posterior choroidal

artery

Precommunicating (PI) PCA

segments

Parietal branch, parietooccipital

artery

Quadrigeminal (P3) PCA segment Basal vein of Rosenthal

Posterior temporal branches

Calcarine artery

Parietooccipital artery

Calcarine (P4) PCA segment Quadrigeminal plate and

cistern

(Top) Three coronal MIP reprojected views of a CTAdepict the segments of the posterior cerebral artery and some of
their branches. (Middle) The ambient (P2) PCA segments sweep posterosuperiorly around the midbrain just above
the tentorium cerebelli. The quadrigeminal (P3) segment is relatively short and begins at the level of the dorsal
midbrain near the quadrigeminal plate. The basal vein of Rosenthal is opacified on this eTA and should not be
mistaken for the more laterally-located PCA. (Bottom) This section, shown at the anterior end of the calcarine
fissure, depicts the terminal (P4) division of the right PCA into its lateral (parietooccipital) and more medial
(calcarine) branches particularly well.

318
 POSTERIOR CEREBRAL ARTERY
LATERAL eTA c::J
"'"
~
:J

Splenial branch of PCA

Pericallosal branch of ACA

Internal cerebral vein

Medial posterior choroidal artery

Posterior thalamoperforating
arteries (D
If)
Posterior communicating artery

Basilar artery

Splenial artery

Choroid plexus and lateral

posterior choroidal artery Parietooccipital artery
Calcarine (P4) PCA segment
Quadrigeminal (P3) PCA segment
and calcarine artery (cut off)

Choroid plexus and lateral

posterior choroidal artery Parietooccipital artery

Calcarine artery branches

(Top) First of six lateral views from a CTAdepicts the PCA and its branches. The medial posterior choroidal artery is
the small midline vessel lying just below the internal cerebral vein. Note the splenial branch of the PCA anastomoses
above the corpus callosum with pericallosal branches from the ACA. When either vessel is occluded, this may
provide an important source of potential collateral blood flow in addition to pial (watershed) collaterals. (Middle)
Vascular blush of the choroid plexus in the lateral ventricle is seen here. It is supplied by the lateral posterior
choroidal artery. (Bottom) The choroid plexus of the lateral ventricle, with its accompanying arteries and veins,
"dives" inferiorly through the foramen of Monro.

319
 POSTERIOR CEREBRAL ARTERY
LATERAL eTA

ro
Parietal branches
c
ro
l....
u Thalamostriate vein
ro
l....
-+-'
C
Quadrigeminal (P3) PCA segment

Ambient (P2) PCA segment

Calcarine branches
Lateral posterior choroidal artery

Posterior temporal artery

Anterior temporal artery

Choroid plexus glomus

Lateral posterior choroidal artery

Posterior temporal branches

(Top) More lateral section shows the parietal and occipital PCA branches very well. The posterior temporal artery is
also seen here. (Middle) The lateral posterior choroidal artery originates from the P2 PCA segment and sweeps
posterosuperiorly around the pulvinar of the thalamus to supply it as well as the choroid plexus. (Bottom) This
section through the posterolateral thalamus and atrium of the lateral ventricle shows the lateral posterior choroidal
artery and its supply to the glomus of the choroid plexus.

320
 POSTERIOR CEREBRAL ARTERY
AXIAL eTA ~
'""'I
~
::::l
Precommunicating (PI) PCA
segments

Left posterior communicating

artery
Ambient (P2) PCA segment

Medial posterior choroidal

artery

P2 PCA segment

Basal vein of Rosenthal

Calcarine artery
Medial posterior choroidal artery

Lateral posterior choroidal artery

Glomus of choroid plexus

Parietooccipital artery

Calcarine artery

(Top) First of three axial MIP reconstructions from CTA depicts the PCA segments especially well. Here, in the section
through the circle of Willis, two small posterior communicating arteries are visualized. Both precommunicating (PI)
PCA segments are quite prominent. (Middle) Section through the ambient and quadrigeminal cisterns shows their
vascular contents, which include the P2 and P3 PCA segments as well as the more medially-positioned basal veins of
Rosenthal. (Bottom) In this section near the tentorial apex, the lateral posterior choroidal arteries are seen as they
supply the glomi of the choroid plexus. The terminal division of the PCA into its parietooccipital and calcarine
branches occurs either in the distal quadrigeminal cistern or near the anterior aspect of the calcarine fissure.

321
 VERTEBROBASILAR
ITerminology
Abbreviations
• Vertebrobasilar (VB); vertebral artery (VA); basilar
artery (BA)
• Superior cerebellar arteries (SCAs); posterior inferior
cerebellar artery (PICA); anterior inferior cerebellar
artery (AICA)
• Internal carotid artery (ICA)
• Anterior, posterior spinal arteries (ASA, PSA)
I Gross Anatomy
Overview
• Four VA segments
a Extraosseous (VI) segment (arch -+ C6)
a Foraminal (V2) segment (C6 -+ CI)
a Extraspinal (V3) segment (CI -+ foramen magnum)
a Intradural (V4) segment (intracranial)
I Imaging Anatomy
Overview
• Ectasia, tortuosity, off-midline course, variations in
configuration/branching patterns common
Anatomy Relationships
• VA
a VI: Arises from subclavian artery, courses
posterosuperiorly to enter C6 transverse foramen
a V2
• Ascends through C6-C3 transverse foramina
• Turns superolaterally through the inverted
"L-shaped" transverse foramen of axis (C2)
• Courses short distance superiorly through CI
transverse foramen
a V3
• Exits top of atlas (CI) transverse foramen
• Lies on top of CI ring, curving posteromedially
around atlantooccipital joint
• As it passes around back of atlanto-occipital joint,
turns sharply anterosuperiorly to pierce dura at
foramen magnum
a V4
• After VA enters skull through foramen magnum,
courses superomedially behind clivus
• Unites with contralateral VA at/near
pontomedullary junction to form BA
• BA
a Courses superiorly in prepontine cistern (in front of
pons, behind clivus)
a Bifurcates into its terminal branches, PCAs, in
interpeduncular or suprasellar cistern at/slightly
above dorsum sellae
Branches
• VA
a VI: Segmental cervical muscular, spinal branches
a V2: Anterior meningeal artery, unnamed
muscular/spinal branches
a V3: Posterior meningeal artery
SYSTEM
a V4
• Anterior, posterior spinal arteries
• Perforating branches to medulla
• PICA: Arises from distal VA, curves around/over
tonsil, gives off perforating medullary, choroid,
tonsillar, cerebellar branches
• BA
a Pontine, midbrain perforating branches (numerous)
a AICA
• Lies ventromedial to CN? and 8
• Often loops into internal auditory meatus
a SCAs
• Arise from distal BA, course posterolaterally
around midbrain below CN3, tentorium
• Lie above CNS, often contact it
a PCAs (terminal BA branches)
Vascular Territory
• VA
a ASA: Upper cervical spinal cord, inferior medulla
a PSA: Dorsal spinal cord to conus medullaris
a Penetrating branches: Olives, inferior cerebellar
peduncle, part of medulla
a PICA: Lateral medulla, choroid plexus of fourth
ventricle, tonsil, inferior vermi~Lcerebellum
• BA
a Pontine perforating branches: Central medulla,
pons, midbrain
a AICA: lAC, CN7 and 8, anterolateral cerebellum
a SCA: Superior vermis, superior cerebellar peduncle,
dentate nucleus, brachium pontis, superomedial
surface of cerebellum, upper vermis
Normal Variants, Anomalies
• Normal variants
a VA: R/L variation in size, dominance common;
aortic arch origin SOlo
a BA: Variation in course, branching patterns
common (e.g., AICA/PICA may share common
trunk)
• Anomalies
a VA/BA may be fenestrated, duplicated (may have
increased prevalence of aneurysms)
a Embryonic carotid-basilar anastomoses (e.g.,
persistent trigeminal artery)
I Embryology
Embryologic Events
• Plexiform longitudinal anastomoses between cervical
intersegmental arteries -+ VA precursors
• Paired plexiform dorsal longitudinal neural arteries
(LNAs) develop, form precursors of BA
• Transient anastomoses between dorsal longitudinal
neural arteries, developing ICAs appear (primitive
trigeminal/hypoglossal arteries, etc.)
• Definitive VAs arise from 7th cervical intersegmental
arteries, anastomose with LNAs
• LNAs fuse as temporary connections with ICAs regress
-+ definitive BA, VB circulation formed

322
323
 tJ)
Q)

324
»
....•
,......
(D
....•

325
 VERTEBROBASILAR SYSTEM
Vl
Q) DSA
•...
Q)
•...
+-'
« C3 vertebral body
~
c Muscular branches
~
•... Anterior spinal branch
U
~
•...
+-' C4 vertebral body
C

C Spinal radicular artery

~
'-
CQ
CS vertebral body

Right V2 (foraminal) VA segment

C6 vertebral body'

Posterior inferior cerebral artery

V4 (intradural) VA segment

V3 (extraspinal) VA above Cl
VA in Cl transverse foramen ring

Muscular branches of VA
"L-shaped" bend through C2

Muscular branch of ECA

Spinal rami
V2 (foraminal) VA segment

V4 (intradural) VA segment VA turns anteromedially to

enter foramen magnum
Foramen magnum
V3 (extraspinal) VA above Cl
ring
VA in Cl transverse foramen

VA exits C2 transverse foramen

VA enters C2 transverse foramen

(Top) Close-up AP view of right vertebral DSA shows the extracranial VA as it courses cephalad in the transverse
foramina of C6 to C3. Segmental spinal rami and muscular branches arise from the V2 (foraminal) VAsegment. Here,
a prominent spinal ramus is large enough to reach the anterior median sulcus of the spinal cord where it divides into
ascending and descending branches. These anastomose with the anterior spinal artery, which arises from the
intradural VA. (Middle) Lateral DSA of vertebral angiogram shows the upper V2 (foraminal), V3 (extraspinal), and V4
(intradural) VAsegments. Note prominent spinal arteries and anastomosis with muscular branches of the ECA.
(Bottom) AP view shows VA course through the C2-Cl transverse foramina and above the Cl ring together with its
anterior turn into the foramen magnum forming a "half square."
326
327
 VERTEBROBASILAR SYSTEM
V1
Q) LATERAL DSA

ro
c
...
ro
u
...
ro
.•...
C
Posterior cerebral artery

Superior cerebellar artery (SCA)

PICA,posterior medullary segment

PICA,anterior medullary segment

Muscular branch of cervical VA

ramus

Parietooccipital artery

Posterior thalamoperforating artery

Superior vermian, cerebellar
arteries
Anterior thalamoperforating artery Calcarine artery (PCAbranch)
Posterior communicating artery Inferior vermian artery
Basilar artery
Posterior inferior cerebellar!
Basilar perforating arteries artery
Occipital artery (ECAbranch)
V3 (extraspinal) VAsegment

Lateral posterior choroidal artery

Medial posterior choroidal artery

Superior hemispheric branches
of SCA

Thalamoperforating arteries PICAbranches in great

horizontal fissure of cerebellum

Posterior inferior cerebral artery

PICAhemispheric branches

(Top) Lateral view of a left vertebral DSA, early arterial phase, shows the intracranial vertebrobasilar system. PICA
and its proximal loops are especially well seen. PICA has four segments and two distinct loops. The caudal or inferior
loop is along the inferior medulla and may be as low as C2. The second (cranial) loop occurs as PICA courses above or
across the cerebellar tonsil. (Middle) Mid-arterial phase shows distal branches of the VA and basilar artery. Note
important vascular anastomosis between muscular branches of the VA and the occipital artery (an external carotid
branch). The PCoA and its thalamoperforating branches are opacified. (Bottom) Late arterial phase shows normal
vascular "blush" in territory supplied by the vertebrobasilar system. This includes the brainstem, vermis, cerebellum,
I occipital lobe, posterior thalami and some choroid plexus.
328
 VERTEBROBASILAR SYSTEM

Rlgh' po,"doc ,,"b'" "'''Y I Left posterior cerebral artery

Superior cerebellar artery
ro
VI

Right AICA -I Left AICA

Right PICA (posterior medullary Left PICA

segment)
Unopacified blood in left VA
Right vertebral artery

Cerebellar hemispheric
branches

AICA looping into lAC

Anterior medullary segment of
left PICA

Falx cerebri

Calcarine cortex

Tentorium cerebelli

Cerebellar hemisphere

Cerebellar tonsils

(Top) AP view of right vertebral DSA, early arterial phase, shows origins of the major vertebral (VA)and basilar (BA)
branches. Contrast has refluxed into the left VA,which is partially filled with unopacified blood. In this case, both
the (PICAs) and (AICAs) arise separately, from the vertebral and basilar arteries respectively. (Middle) Mid-arterial
phase shows the hemispheric branches of both PICAs, AICAs and superior cerebellar arteries. The right AICA is seen
as it loops into the internal auditory canal (lAC). (Bottom) Later phase shows a dense vascular "blush" of the entire
cerebellum and occipital lobes, and nicely demonstrates the vertebrobasilar vascular territory. The tentorium and falx
are seen as thin, unopacified areas between the cerebellar hemispheres and occipital lobes.

329
 VERTEBROBASILAR SYSTEM
MRA

Left posterior cerebral artery

Right posterior cerebral artery

Superior cerebellar artery

Anterior inferior cerebellar artery Tonsillar (cranial loop) of PICA

Anterior medullary segment of Caudal loop of PICA

PICA

Right posterior cerebral artery Left posterior cerebral artery

Left superior cerebellar artery

Right superior cerebellar artery

Anterior inferior cerebellar artery

Posterior inferior cerebellar artery Left AICA-PICA trunk

Left PCoA
Right PCoA
BA bifurcation

PI (precommunicating) PCA
segment

Parietooccipital artery and branches

(Top) Slightly oblique lateral view of an MRA shows the intracranial vertebrobasilar circulation. Here the posterior
inferior and anterior inferior cerebellar arteries are especially well seen. (Middle) AP view shows the distal basilar
bifurcation and more proximal branches. Two prominent superior cerebellar arteries are well seen here. On the left, a
prominent VAbranch is an AlCA-PlCA trunk. Common origin of these two branche$ from the VAis a frequent
normal variant. (Bottom) Submentovertex view shows the basilar artery bifurcation especially well. The posterior
cerebral and superior cerebellar branches are superimposed and loop laterally around the midbrain.

330
331
SECTION 8: Veins and Venous Sinuses

Intracranial Venous System Overview 1-334

Dural Sinuses 1-342
Superficial Cerebral Veins 1-352
Deep Cerebral Veins 1-358
Posterior Fossa Veins 1-372
Extracranial Veins 1-378
 Vl
(l)
INTRACRANIAL VENOUS SYSTEM OVERVIEW
Vl
::J
• Deep cerebral structures (central/deep white
C I Terminology matter, basal ganglia) drained by
rJ)
Vl Abbreviations medullary/subependymal veins to ICVs, VofG, SS;
::J medial temporal lobe via DMCV /BVR to VofG
o • Superior sagittal sinus (SSS)
C • Inferior sagittal sinus (ISS) Anatomy Relationships
(l)
• Internal cerebral vein (ICV)
>
-C
• Straight sinus (SS)
• Dural venous sinuses
o Communicate with extracranial veins directly (via
C • Great cerebral vein (vein of Galen, VofG) diploic veins in calvarium, emissary veins through
~ • Transverse sinus (TS) basilar foramina)
Vl • Superior/inferior petrosal sinuses (SPS/IPS) o Receive venous blood from superficial (cortical)
C
• Cavernous sinus (CS) veins, deep (subependymal) veins
(l)
• Internal jugular vein (IJV)
> • Basal vein of Rosenthal (BVR)
• Cerebral veins
o Superficial (cortical) veins lie in SAS, mainly follow
s:::
.~
a...
• Superficial, deep middle cerebral veins (SMCV; DMCV)
Definitions
sulci
o Subependymal veins outline ventricles
a:l
• Dural sinuses are large, endothelial-lined trabeculated
venous channels encased within folds/reflections of
dura that define, form their walls I Imaging Anatomy
• Cerebral veins are thin-walled, valveless structures Overview
that cross SAS, pierce arachnoid/inner dura to enter
dural venous sinus • Dural venous sinuses
o Visualization at DSA varies widely
• Almost always: SSS, SS, TS, sigmoid sinus, internal
jugular veins (IJVs)
I Gross Anatomy • Sometimes: ISS, SPS/IPS
Overview • Rare/inconstant: CS, sphenoparietal sinus,
• Dural venous sinuses (divided into two groups) occipital sinus, clival (basal) venous plexus
o Anteroinferior group (CS, SPS/IPS, clival, • Cerebral veins
sphenoparietal) o Superficial cortical veins almost always seen
o Posterosuperior group (SSS, ISS, SS, TS, sigmoid, (number, configuration vary)
occipital) o Deep veins almost always seen on late venous phase
• Cerebral veins (divided into 3 groups) of DSA, only largest (e.g., thalamostriate veins) seen
o Superficial ("external") veins (3 subgroups) on MR/MRV
• Superior: 8-12 smaller cortical veins over o ICVs, VofG almost always seen on DSA, CTV, MRV
hemispheres, vein of Trolard
• Middle: SMCY, vein of Labbe
• Inferior: DMCV, BVR IAnatomy-Based Imaging Issues
o Deep ("internal") veins
Imaging Recommendations
• Subependymal veins
• Obtain source images for MR venogram perpendicular
• ICVs (formed by thalamostriate, septal veins)
to main axis of dural sinus (e.g., coronal for SSS)
• Great cerebral vein (VofG)
• MRV, CTV excellent for general overview of dural
o Brainstem/posterior fossa veins (3 subgroups)
sinuses, cerebral veins but DSA best for detailed
• Superior (galenic) group
delineation
• Anterior (petrosal) group
• Posterior (tentorial) group Imaging Pitfalls
• Venous vascular territories • TSs often asymmetric, hypoplastic/atretic segment
o More variable, less well-known than arterial common (do not misdiagnose as occlusion)
territories • Saturation bands on MR disguise flow
o General concepts • Jugular bulb flow often very asymmetric, turbulent
• Venous drainage generally radial, centrifugal (pseudolesion)
(exception = deep cerebral structures) • Unopacified venous blood streaming into dural sinus
• Much of middle/superior brain surfaces (cortex, on DSA should not be mistaken for filling defect
subcortical white matter) drained by cortical veins (thrombus)
to SSS • "Giant" arachnoid granulations appear as round/ovoid
• Posterior/inferior temporal lobe, adjacent parietal CSF-equivalent filling defects in dural sinuses
lobe drained by vein of Labbe to TS (especially TS), are a normal variant, should not be
• Insular cortex, parenchyma around sylvian mistaken for thrombus
(middle cerebral) fissure drained by sphenoparietal • Acute dural sinus, cortical vein thrombi isointense
sinus to CS with brain on T1 WI so T2* (GRE) or T1 C+ imaging
very helpful
• Subacute clot is hyperintense on T1WI (do not mistake
for enhancement)

334
 I
335
 INTRACRANIAL VENOUS SYSTEM OVERVIEW
<Jl
CJ) AXIAL CECT
<Jl
:J
C
r../) Falx cerebri
<Jl
:J
o
C
CJ)
>
~ Cavernous sinus Cavernous sinus
c
(1j

<Jl
C
CJ)
>

Anterior cerebral artery

Basal vein of Rosenthal

Lateral mesencephalic vein

Tentorium cerebelli

Pillars of fornix

Choroid plexus Septal vein

Superior vermian vein

Tentorium cerebelli with tentorial

veins

(Top) Series of six selected axial CECT images through the brain from inferior to superior are shown. Contrast in the
lateral dural wall of the cavernous sinus is seen on this section. (Middle) Section through the midbrain shows dura of
the tentorium cerebelli with adjacent basal veins of Rosenthal and lateral mesencephalic veins. (Bottom) Section
through the foramen of Monro shows septal veins as they curve around the pillars of the fornix behind the frontal
horns of both lateral ventricles. The larger, midline enhancing area represents choroid plexus as it is passing
inferiorly from the lateral ventricles and forming the posterior border of the foramen of Monro. The anterior border
is formed by the pillars of the fornix.

336
 INTRACRANIAL VENOUS SYSTEM OVERVIEW
AXIAL CECT o::l
~
~
::::l
<
ro
::J
lJ)

0.>
Septal vein ::J
Q...

<
ro
::J
Vein of Galen o
C
lJ)

C../'l
::J
C
Straight sinus lJ)
ro
lJ)

Thalamostriate veins

Internal cerebral veins (paired)

Vein of Galen
Precentral cerebellar vein
Apex of tentorium

Straigh t sin us

Falx cerebri

Anterior caudate vein

Choroid plexus, veins

Pineal gland (calcified)
Superior vermian cistern

Straight sinus

(Top) Scan at the level of the upper foramen of Monro. The vein of Galen, a "U-shaped" structure, is seen here with
its anterior and posterior segments seen as two contrast-filled "dots" that curve above the pineal gland and under the
corpus callosum splenium. (Middle) Section through the internal cerebral veins, paired paramedian structures, shows
their extent from the thalamostriate tributaries anteriorly to the vein of Galen posteriorly. (Bottom) Scan through
the upper ventricles and tentorial apex is depicted. Anterior caudate veins are subependymal tributaries of the
thalamostriate veins. The septal and thalamostriate veins join to form the internal cerebral veins.

337
 INTRACRANIAL VENOUS SYSTEM OVERVIEW
rJl
Q.) AXIAL T1 C+ MR
rJl
:J
C
V'l
rJl
:J
o
C
Q.)
>
""0 Pterygoid venous plexus
C
(\j
rJl jugular bulb
C
Q.) Sigmoid sinus
>

Pterygoid venous plexus

Venous plexus in foramen

Inferior petrosal sinus ovale

Choroid plexus in lateral recess,

Sigmoid sinus fourth ventricle

Inferior ophthalmic vein

Cavernous sinus
Clival venous plexus

Petrosal vein
Superior petrosal sinus

(Top) Series of nine axial T1 C+ MR scans from inferior to superior are depicted. Note inhomogeneous flow in the
jugular bulb. This is normal and should not be mistaken for a mass or thrombus (jugular "pseudolesion"). (Middle)
Section through the lateral recesses of the fourth ventricle shows the inferior petrosal sinuses, tributaries of the
jugular bulb. The pterygoid venous plexus and the venous plexus in the foramen ovale are connected through the
skull base to the cavernous sinus. These intra- to extra cranial connections may provide an important source of
collateral venous drainage if the CS becomes occluded. (Bottom) Section through the cavernous sinus shows
connections with the clival plexus and the orbit (inferior ophthalmic vein). Petrosal veins in the cerebellopontine
I angle cistern are prominent but normal in this case.
338
 INTRACRANIAL VENOUS SYSTEM OVERVIEW
AXIAL T1 C+ MR OJ
~
~
::l
<
ro
::J
lJl

OJ
Cavernous sinus ::J
0...
Anterior pontomesencephalic <
ro
venous plexus ::J
Petrosal vein
Superior petrosal sinus o
C
lJl

Transverse sinus

Superior ophthalmic vein

Sphenoparietal sinus
Sphenoparietal sinus

Infundibular stalk
Intercavernous plexus
(surrounding diaphragma
sellae)

Tentorial veins

Transverse sinus

Deep middle cerebral vein,

tributaries
Superficial middle cerebral vein

Insular veins

Basal vein of Rosenthal

Choroid plexus, veins in temporal

horn of lateral ventricle

Straight sinus

(Top) The cavernous sinus is especially well seen on this scan. Again note prominent petrosal veins in the upper
cerebellopontine angle cisterns. The faint enhancement seen along the anterior belly of the pons is the anterior
pontomesencephalic venous plexus and is normal, should not be mistaken for meningitis or leptomeningeal
carcinomatosis. (Middle) Section through the upper cavernous sinus shows the intercavernous plexus surrounding
the opening of the diaphragm a sellae, which contains the infundibular stalk. Superior ophthalmic vein drains
posteriorly into the cavernous sinus. (Bottom) Section through upper vermis shows the left BVRcurving around
midbrain, coursing posteriorly towards its confluence with the lCVs at the vein of Galen. The SMCV drains into the
sphenoparietal sinus (shown on the lower section, above). DMCV drains into BVRand VofG. I
39
 INTRACRANIAL VENOUS SYSTEM OVERVIEW
CD AXIAL T1 C+ MR
tJl
::J
C
V'J
tJl
::J
o
C
Q)

>
""0 Internal cerebral veins
C
~
tJl
C
Q)

> Basal veins of Rosenthal

Septal vein

Thalamostriate vein Anterior caudate vein

Internal cerebral veins

Cortical vein Cortical vein

(Top) The paired internal cerebral veins as they terminate in the vein of Galen are shown. Note the basal veins of
Rosenthal terminating with the ICVs to form the great cerebral vein (of Galen). (Middle) Section through the
foramen of Monro shows the septal, anterior caudate vein and thalamostriate tributaries of the internal cerebral
veins. (Bottom) Most cephalad section shows prominent frontal superficial cortical veins, tributaries of the superior
sagittal sinus.

I
340
 INTRACRANIAL VENOUS SYSTEM OVERVIEW
LAT, ORL & AP MRV

Superior sagittal sinus Superficial cortical veins

<
([)
:)
tJl

OJ
:)
Internal cerebral veins (paired)
Vein of Galen 0...
Superficial middle cerebral vein Straight sinus <
([)
:)
Vein of Labbe sinus confluence (torcular o
C
Herophili) tJl
Common facial veins V'l
Sigmoid sinus
:)
C
tJl
Internal jugular vein ([)
tJl

Superior sagittal sinus

Vein of Galen

Internal cerebral veins

Straight sinus

Vein of Labbe Vein of Labbe

Transverse sinus

Sinus confluence (torcular

Herophili)

Suboccipital venous plexus

Superior sagittal sinus

Scalp veins

Vein of Labbe Vein of Labbe

Transverse sinus

Sigmoid sinus
Jugular bulb

Suboccipital venous plexus

(Top) Lateral view from an MRV demonstrates cerebral venous drainage. Dural venous sinuses and superficial cortical
veins are well depicted on this lateral view. (Middle) Oblique view of the MRV shows dural sinuses draining
posteroinferiorly to torcular Herophili, which splits into two nearly symmetric transverse sinuses. (Bottom) AP view
shows superimposed superior sagittal and straight sinuses, which demonstrates slight but normal asymmetry of
transverse sinuses. Larger (left) and smaller (right) veins of Labbe are seen here as they drain into the TS. The vein of
Labbe can be quite large and drain a significant territory over the inferolateral cerebral hemisphere. If the TS becomes
occluded, the vein of Labbe may also thrombose and cause a large venous infarct.

341
 V'l
(l)
DURAL SINUSES
V'l
::J
C
V)
ITerminology o Terminate by becoming internal jugular veins
• Cavernous sinuses (CS)
V'l Abbreviations o Irregularly-shaped, trabeculated venous
::J • Internal cerebral vein (ICV) compartment along sides of sella turcica
o
C • Superior/inferior petrosal sinuses (SPS/IPS) o Contained within a prominent lateral, thin (often
(l) inapparent) medial dural wall
>
""0
o Extends from superior orbital fissure anteriorly to
clivus and petrous apex posteriorly
C I Gross Anatomy o Contains cavernous ICA, CN6 (inside CS itself) and
res
V'l Anatomy Relationships 3, 4, VI and V2 (within lateral dural wall)
c • Endothelial-lined, contained within outer (periosteal), o Tributaries include superior/inferior ophthalmic
(l) inner (meningeal) dural layers veins, sphenoparietal sinus
> • Often fenestrated, septated, multi-channeled o Communicate inferiorly with pterygoid venous
t: • Contain arachnoid granulations, villi plexus, medially with contralateral CS, posteriorly
on; o Extension of subarachnoid space (SAS)+ arachnoid with superior/inferior petrosal sinus, clival venous
l-
through dural wall into lumen of venous sinus plexus
ce o Returns cerebrospinal fluid (CSF) to venous o Inconstantly visualized at digital subtraction
circulation angiography
• Miscellaneous dural venous sinuses
o Superior petrosal sinus (runs along petrous ridge
I Imaging Anatomy from CS to sigmoid sinus)
o Inferior petrosal sinus (runs along petro occipital
Overview fissure from clival venous plexus to jugular bulb)
• Superior sagittal sinus (SSS) o Sphenoparietal sinus (runs along lesser sphenoid
o Appears as curvilinear structure that hugs inner wing from sylvian fissure to CS or IPS)
calvarial vault o Occipital sinus (from foramen magnum to torcular)
• Originates from ascending frontal veins anteriorly o Clival venous plexus (network of veins along clivus
• Runs posteriorly in midline at junction of falx from dorsum sellae to foramen magnum)
cerebri with calvarium
Normal Variants, Anomalies
o Collects superficial cortical veins, increases in
diameter as it courses posteriorly • Common variants
o Terminates at venous sinus confluence (often runs o Absent anterior SSS(may begin posteriorly near
off midline posteriorly) coronal suture)
o Important hemispheric tributary: Vein of Trolard o "Off-midline" SSSterminating directly in TS
o Absence or hypoplasia of part/all of TS
• Inferior sagittal sinus (ISS)
o Smaller, inconstant channel in inferior (free) margin o Jugular bulbs can vary greatly in size, configuration
(can be "high-riding", have jugular diverticulum,
of falx cerebri
o Lies above corpus callosum, from which it receives dehiscent jugular bulb)
o "Giant" arachnoid granulations (round/ovoid
tributaries
o Terminates at falcotentorial apex, joining with vein CSF-equivalent filling defects in dural sinuses)
of Galen (VofG) to form straight sinus • Anomalies
o Persistent embryonic falcine sinus (usually with
• Straight sinus (SS)
o Runs from falcotentorial apex posteroinferiorly to VofG malformation)
sinus confluence o Lambdoid-torcular inversion with high sinus
o Receives tributaries from falx, tentorium, cerebral confluence (with Dandy-Walker spectrum)
hemispheres
• Torcular Herophili (venous sinus confluence)
o Formed from union of SSS,SS, transverse sinuses IAnatomy-Based Imaging Issues
o Often asymmetric, interconnections between TS Imaging Recommendations
highly variable
• Examine source images (not just reprojected views) of
• Transverse (lateral) sinuses (TSs)
MRV/CTV
o Contained between attachment of tentorial leaves to
• DSA rarely required to diagnose dural sinus occlusion
calvarium
• Acute dural sinus thrombus is isointense with brain on
a Extends laterally from torcular to posterior border of
TI WI, profoundly hypointense on T2WI (may mimic
petrous temporal bone
"flow void") so T2* or TI C+ imaging very helpful
o Often asymmetric (right side usually larger than left)
• Subacute clot hyperintense on TI WI so pre-contrast
o Hypoplastic/atretic segment common
scan needed to compare to TI C+ images
o Tributaries from tentorium, cerebellum, inferior
temporal/occipital lobes Imaging Pitfalls
o Important tributary: Vein of Labbe • TSs often asymmetric, hypoplastic/atretic segment
• Sigmoid sinuses common (do not misdiagnose as occlusion)
o Anteroinferior continuation of TSs • Jugular bulbs often very asymmetric, turbulent flow
o Gentle S-shaped inferior curve (pseudoocclusion)

342
<
ro
~
CJ>

~
~
0....
<
ro
~
o
c
CJ>
(j)

~
c
CJ>
ro
CJ>

I
343
 <Jl
Q)
<Jl
:J
C
V'l
<Jl
:J
o
C
Q)

>
""0
c
(1j
<Jl
C
Q)

>

344
 DURAL SINUSES
LATleA DSA
Unnamed superficial cortical
Superior sagittal sinus veins
<
(i)

:J
CJl

III
:J
a...
Straight sinus
Vein of Galen <
(i)
Vein of Labbe :J
o
C
CJl
Superficial middle cerebral vein
V'l
:J
Sphenoparietal sinus C
CJl
(i)
CJl
Pterygoid venous plexus

"Giant" arachnoid granulation

Inferior sagittal sinus
Vein of Galen

Internal cerebral vein Straight sinus

Basal vein of Rosenthal Sinus confluence (torcular

Herophili)
Superficial middle cerebral veins

Cavernous sinus Sigmoid sinus

Jugular bulb & internal jugular

Pterygoid venous plexus
vein

Arachnoid granulation
Internal cerebral vein
Thalamostriate vein
Vein of Galen

Septal vein

Cavernous sinus
Occipital emissary vein

Clival venous plexus

(Top) Series of three lateral views of an internal carotid DSAare illustrated. Early venous phase shows the superficial
cortical and anastomotic veins are most prominent and the venous sinuses are only faintly opacified. (Middle)
Mid-venous phase shows prominent opacification of the dural venous sinuses. The cavernous sinus is well seen,
along with its interconnections with the pterygoid venous plexus. (Bottom) Late venous phase shows contrast has
been washed out of most of the cortical veins. The subependymal veins are quite prominent at this stage and are well
seen with the disappearance of contrast from overlying cortical veins. A very prominent filling defect in the
descending segment of the superior sagittal sinus, caused by a large arachnoid granulation, is now well seen. The
transverse and sigmoid sinuses are a more common location for arachnoid granulations.
345
 DURAL SINUSES
<fl
Q) AP leA DSA
<fl
::J
C
Superior sagittal sinus
Vl
<fl
::J
o
C
Q)

>
-0 Vein of Galen
c
(Ij
Internal cerebral vein
<fl
C
Q) Basal vein of Rosenthal
>

Superior sagittal sinus

Inferior sagittal sinus

Vein of Galen

Right transverse sinus

Basal vein of Rosenthal

Superficial middle cerebral vein

Arachnoid granulation

Medullary veins (converging on

subependymal veins)
Internal cerebral vein

Thalamostriate vein

Occipital emissary vein Cavernous sinus

Pterygoid venous plexus

(Top) Series of three AP venous phase angiograms are illustrated. Early venous phase shows prominent filling of
numerous superficial cortical veins. The anterior aspect of the superior sagittal sinus is faintly opacified. If the AP
view is perfectly straight, as it is in this case, the SSS,ISS, ICV, and VofG overlap in the midline. (Middle)
Mid-venous phase shows major dural venous sinuses. The right transverse sinus is dominant and fills prominently
even though contrast was injected into the left internal carotid artery. (Bottom) Late phase shows subependymal
veins especially well. A less well-visualized segment of the left TS is seen, a normal variant that should not be
mistaken for venous occlusion. Filling defect in the SSSis caused by a very large arachnoid granulation. The ICV arcs
I posteriorly to the VofG from its origin at the anterior thalamostriate vein.
346
 DURAL SINUSES
OBL leA DSA ..,
O:l
~
::J
<
([)
::J
Vl
Superior sagittal sinus
~
::J
Vein of Galen Q..

Straight sinus Internal cerebral vein <

([)
::J
Left transverse and sigmoid o
sinus C
Vl
Superficial middle cerebral vein
Vl
::J
C
Vl
([)
Vl

Superior sagittal sinus

"Giant" arachnoid granulation

Vein of Galen & straight sinus Inferior sagittal sinus

Internal cerebral vein
Vein of Labbe

Superficial middle cerebral vein

Cavernous sinus

Giant arachnoid granulation

Inferior sagittal sinus

Occipital (mastoid) emissary vein

Cavernous sinus

(Top) A series of three oblique AP views of a right internal carotid DSA are illustrated. The early venous phase shows
prominent superficial cortical veins. The superior sagittal and transverse sinuses are faintly opacified. This view is
ideal for visualizing sinus occlusion. (Middle) In this mid-venous phase, both superficial and deep veins are
visualized well, as are the major dural venous sinuses. In this case, the superior sagittal sinus arcs posteriorly all the
way from the crista galIi anteriorly to the sinus confluence posteriorly. (Bottom) Late venous phase shows a
prominent filling defect in the superior sagittal sinus caused by a giant arachnoid granulation, a normal variant.

347
 DURAL SINUSES
V1
<J) AXIAL T1 C+ MR
V1
::J
C
V)
V1
::J
o
C
<J)
>
-0
c
(1j
Inferior petrosal sinus
V1 Jugular bulb
C
<J) Sigmoid sinus
>
c:
C'tS
I-
c:Q

Right Meckel cave

Inferior petrosal sinus

Transverse/sigmoid sinus junction

Sphenoparietal sinus
Cavernous sinus
Clival venous plexus

Superior petrosal sinus

Transverse sinus

(Top) Series of nine axial Tl C+ MR scans from inferior to superior are illustrated. Section through the lower medulla
and jugular foramen shows the sigmoid sinuses and right jugular bulb. Asymmetry of the jugular bulbs, seen here, is
very common as is inhomogeneous flow and enhancement pattern. (Middle) Scan through the mid-pons includes
the junction of the transverse with the sigmoid sinuses. (Bottom) Scan through the cavernous sinus shows its
interconnections with the sphenoparietal sinuses anteriorly and the clival venous plexus posteriorly. The left
superior petrosal sinus is shown draining into the transverse sinus.

348
 DURAL SINUSES
AXIAL T1 C+ MR

<
(D
Sphenoparietal sinus ::J
<.r>
Superficial middle cerebral vein
~
::J
Q..

<
(D
::J
o
C
Tentorial veins <.r>
(j)

::J
C
<.r>
(D
Sinus confluence (torcular Transverse sinus <.r>
Herophili)

Superficial middle cerebral vein

Basal veins of Rosenthal

Precentral cerebellar vein

Straight sinus

Superficial middle cerebral vein

Internal cerebral veins

Vein of Galen
Basal veins of Rosenthal
Straight sinus

Superior sagittal sinus (cut

across)

(Top) The superficial middle cerebral veins are shown on the right and the sphenoparietal sinus on the left. Note
prominent tentorial veins draining into both transverse sinuses. (Middle) Section through the upper lateral cerebral
(sylvian) fissure shows the superficial middle cerebral vein on the right. Both basal veins of Rosenthal are well seen.
The junction between the straight sinus and torcular Herophili is included. (Bottom) Scan through the tentorial apex
shows the internal cerebral veins and basal veins of Rosenthal forming the vein of Galen.

349
 DURAL SINUSES
IJl
Q) AXIAL T1 C+ MR
IJl
:J Superior sagittal sinus (anterior
C
aspect)
r../)
IJl
:J
o Septal vein
C
Q)

>
""0
Thalamostriate vein Anterior caudate vein
c
rtl Internal cerebral veins
IJl
C
Q) Upper end of vein of Galen
> Straight sinus

Superior sagittal sinus (posterior

aspect)

Frontal cortical vein

Frontal cortical vein

Superior sagittal sinus

Superior sagittal sinus (anterior

end)

Inferior sagittal sinus

Superior sagittal sinus (posterior

end)

(Top) Scan through the foramen of Monro shows the thalamostriate and anterior caudate veins (cut across). The left
septal vein is faintly seen in front of the frontal horn of the lateral ventricle. Both the small anterior and larger
posterior aspects of the superior sagittal sinus are seen. (Middle) Section through the upper bodies of the lateral
ventricles shows prominent unnamed frontal cortical veins draining into the anterior aspect of the superior sagittal
sinus. Note "flow void" in the posterior aspect of the superior sagittal sinus, a normal finding caused by fast venous
flow. (Bottom) The anterior and posterior aspects of the SSSare depicted on this upper section. A small portion of
the inferior sagittal sinus can be identified in the interhemispheric fissure. The SSSincreases in size as it passes
posteriorly and collects cortical hemispheric veins
350
 DURAL SINUSES
AP, LAT & ORt MRV

<
(t)
Superior sagittal sinus ::J
V"l

~
::J
Scalp vein 0....
Vein of Labbe <
(t)
::J
Transverse sinus o
C
Sigmoid sinus V"l

Jugular bulb V'l

Internal jugular vein ::J
Suboccipital venous plexus C
V"l
(t)
V"l

External jugular vein

Superior sagittal sinus

Internal cerebral veins Vein of Galen

Straight sinus

Vein of Labbe
Cavernous sinus
Clival venous plexus/inferior
petrosal sinus
Facial veins
Suboccipital venous plexus

Superior sagittal sinus

Internal cerebral veins

Right and left veins of Labbe

Jugular bulbs

(Top) AP view of an MR venogram depicts the major dural venous sinuses well. If large, anastomotic veins such as
the vein of Labbe can be visualized on MRV. (Middle) Lateral view of the MRV shows the intracranial dural sinuses,
anastomotic vein of Labbe, and some of the major extra cranial veins. (Bottom) Oblique view of the MRV shows the
transverse sinuses sweep anterolaterally from occipital protuberance to the posterior petrous bone where they join
with superior petrosal sinus to form the sigmoid sinus. The superior sagittal sinus has a variable origin and may
extend all the way from the crista galli to the sinus confluence. Some SSSs are formed near the coronal suture. In this
case, the SSSis formed in the mid-frontal region by confluence of some prominent cortical veins. Note asymmetry of
the jugular bulbs, a common normal variant.
351
 SUPERFICIAL CEREBRAL VEINS
ITerminology
Abbreviations
• Superficial middle cerebral vein (SMCV)
• Deep middle cerebral vein (DMCV)
• Vein of Trolard (VofT)
• Vein of Labbe (VofL)
• Basal vein of Rosenthal (BVR)
• Superior, inferior sagittal sinus (SSS; ISS)
• Cavernous sinus (CS)
• Sphenoparietal sinus (SPS)
• Great cerebral vein (of Galen, VofG)
Synonyms
• Cortical veins: Superficial or external veins
I Gross Anatomy
Overview
• Highly variable in number and configuration
• Located within subarachnoid space (SAS), cisterns
• Organized anatomically into three groups (superior,
middle, inferior)
• Superior group
o 8-12 superficial cortical veins
o Follow sulci, ascend to convexity
o Cross subarachnoid space
o Pierce arachnoid, inner dura, join SSS at right angles
• Middle group
o Superficial middle cerebral vein
• Inconstant, variable size/dominance
• Begins over surface of lateral (sylvian) fissure
• Collects numerous superficial veins from frontal,
temporal, parietal operculae
• Curves anteromedially around temporal lobe
• Terminates in CS or SPS
• Inferior group
o Orbital surface of frontal lobe drains superiorly to
SSS
o Temporal lobe, anterior cerebral veins anastomose
with deep middle cerebral and basal veins
o Basal vein (of Rosenthal)
• Begins near anterior perforated substance
• Receives anterior cerebral, DMCV tributaries (from
insula, basal ganglia, para hippocampal gyrus)
• Curves posteriorly around cerebral peduncles
• Drains into great cerebral vein (of Galen)
• Three major named large anastomotic cortical veins
o Vein of Trolard: Major superior anastomotic vein
o Vein of Labbe: Major inferior anastomotic vein
o Superficial middle cerebral vein: Major middle
anastomotic vein
Anatomy Relationships
• Anastomotic veins
o Have reciprocal relationship (if one is large, others
typically smaller or absent)
o Abundant anastomoses with each other as well as
deep (internal) cerebral veins, orbit, extra cranial
venous plexi
Vascular Territories
• Superior group (cortical veins + SSS, ISS)
I
352
o Superolateral hemispheric surfaces
o Most of medial hemispheric surfaces between ISS,
SSS
o Most of frontal lobes except for perisylvian area
• Middle group (SMCV plus cavernous sinus)
o Perisylvian area, anterior temporal lobes
• Inferior group
o BVR: Inferior insula, basal ganglia, medial temporal
lobes
o VofL (plus TS): Posterior temporal, lower parietal
lobes
I Imaging Anatomy
Overview
• Highly variable in appearance with asymmetry
between hemispheres common
• Superior group
o Lateral DSA
• Arranged in spoke-like pattern
• Converge with SSS at right angles
• Prominent VofT from sylvian fissure to SSS usually
seen coursing over parietal lobe
o AP DSA: "Stepladder" appearance from front to back
• Middle group
o Lateral DSA: SMCV has single or multiple trunks
that follow sylvian fissure, curve over temporal tip
o AP DSA: SMCV drains into CS, SPS, or through
foramen ovale into pterygoid venous plexus
• Inferior group
o Lateral DSA: BVR curves somewhat inferiorly as it
passes around midbrain
o AP DSA: BVR curves laterally around midbrain to
VofG
IAnatomy-Based Imaging Issues
Imaging Recommendations
• MRV: Obtain source images perpendicular to veins of
interest
Imaging Pitfalls
• VofT variable in size, position; may appear quite
posterior on axial MR/CT scans
I Embryology
Embryologic Events
• 8 weeks: Primitive, thin-walled plexus of
undifferentiated vascular channels covers brain surface
o Persistence of primitive leptomeningeal vascular
plexus, paucity of normal cortical veins -+
Sturge- Weber syndrome
• 10-12 weeks: Progressive anastomosis, retrogressive
differentiation causes plexi to coalesce into definitive
cortical venous channels
o Failure to coalesce -+ persistence of primitive,
plexiform veins (common with malformations of
cortical development)
<
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354
 SUPERFICIAL CEREBRAL VEINS
LATleA DSA
Superficial cortical veins

Superior sagittal sinus

<
ro
::J
VI
Inferior sagittal sinus
CJ
::J
Q..
Straight sinus
Basal vein of Rosenthal <
ro
Vein of Labbe ::J
o
Superficial middle cerebral vein C
VI
(j)
Superior petrosal sinus
Cavernous sinus ::J
C
VI
ro
VI
Clival venous plexus & inferior
Pterygoid venous plexus petrosal sinus

Frontal cortical veins

Vein of Labbe
Basal vein of Rosenthal
Superficial middle cerebral vein

Superior ophthalmic vein Cavernous sinus & dival

venous plexus

Deep middle cerebral vein & Superior petrosal sinus

tributaries
Sphenoparietal sinus

Superior sagittal sinus

Vein of Trolard (superior
anastomotic vein)
Inferior sagittal sinus

Vein of Labbe (inferior

Superficial middle cerebral vein anastomotic vein)

Superior petrosal sinus

Sphenoparietal sinus Clival venous plexus

(Top) A series of three venous phase lateral ICA DSAsfrom different cases are shown to illustrate the superficial
cerebral veins. Several superior cortical veins are present without a dominant, identifiable vein of Trolard. Here the
superficial middle cerebral vein is large and a smaller vein of Labbe is present. The major drainage of the SMCV is
into the pterygoid plexus, with a smaller pathway through a hypoplastic superior petrosal sinus into the sigmoid
sinus. (Middle) In this case, a prominent superficial middle cerebral vein is present. Note filling of the superior
ophthalmic vein, which communicates with the cavernous sinus (not well seen) and facial veins. (Bottom) In this
case, all three anastomotic veins are visualized. All are approximately equal in size, with no dominant anastomotic
pattern. This is a relatively unusual finding.
355
 SUPERFICIAL CEREBRAL VEINS
lJ1
Q.) AP DSA
lJ1
:J
C
(f)

lJ1
:J Unnamed cortical veins
o Superior sagittal sinus (anterior
C aspect)
Q.)
> Superior sagittal sinus
""'0 (posterior aspect)
C Internal cerebral vein
(\j
lJ1
Torcular Herophili
C
Q.)
> Insular and deep middle
cerebral veins
Cavernous sinus

Vein of Trolard (superior

anastomotic vein)
Superior sagittal sihus
Superficial cortical veins

Internal cerebral vein

Basal vein of Rosenthal

Deep middle cerebral vein

Vein of Trolard (superior

anastomotic vein)

Inferior sagittal sinus

Thalamostriate vein (outlining

lateral ventricle)

Superficial middle cerebral vein

Sphenoparietal sinus

Inferior petrosal sinus

(Top) A series of three AP venous phase angiograms are shown. Here, a slightly oblique view shows several unnamed
cortical veins. On AP views, the cortical veins form a "stepladder" appearance as they drain from the hemispheric
surface up to the superior sagittal sinus. The SSSincreases in size as it passes from front to back. (Middle) A different
case shows a very prominent vein of Trolard (superior anastomotic vein). Other unnamed smaller cortical veins have
the classic "stepladder" appearance on this projection. (Bottom) This case has a prominent vein of Trolard (superior
anastomotic vein) that originates at the sylvian fissure and passes superiorly over the hemisphere. A smaller
superficial middle cerebral vein is seen draining into the sphenoparietal sinus. No vein of Labbe (inferior anastomotic
I vein) is seen. A small ISS is present, seen overlying the SSS.
356
 SUPERFICIAL CEREBRAL VEINS
MRV, CTV

<
ro
Vein of Trolard
Frontal cortical veins :J
lJl

~
:J
Internal cerebral vein Q..
Vein of Galen
<
ro
Superficial middle cerebral vein Vein of Labbe :J
o
Superior petrosal sinus C
Basal vein of Rosenthal lJl

Vl
:J
C
lJl
ro
lJl

Vein of Trolard

Vein of Labbe

Superficial cortical veins Superior sagittal sinus

Internal cerebral veins

Basal vein of Rosenthal

Vein of Labbe (inferior
Straight sinus anastomotic vein)

Transverse sinus
Sinus confluence (torcular
Herophili)

(Top) Lateral view MRV demonstrates prominent vein of Trolard and superficial middle cerebral vein. The vein of
Labbe (inferior anastomotic vein), is relatively small. Prominent frontal veins contribute to the origin of the superior
sagittal sinus. (Middle) AP view, MRV,shows a prominent right vein of Trolard. A small vein of Labbe is seen. In this
case, the transverse sinuses are equal size. (Bottom) This cutaway view of a CT venogram shows the orientation of
the superficial cortical veins to the superior sagittal sinus. The veins drain superiorly in an almost radial or "spoke
wheel" pattern. When seen on a straight AP view, the cortical veins resemble a stepladder. In this case, there is no
dominant superior anastomotic vein (of Trolard) and all the cortical veins are of relatively equal size. The BVRand
rcvs are shown forming the vein of Galen. I
357
 lJl
Q)
DEEP CEREBRAL VEINS
lJl
::l
C
V)
ITerminology o On DSA appear as tiny, relatively uniform
contrast-filled linear structures that terminate at
lJl Abbreviations right angles to the ventricular subependymal veins
::l • Septal, thalamostriate, internal cerebral veins (SV,TSV, • Subependymal veins
o
C lCV)
o DSA, lateral view
Q)
• Vein of Galen (VofG); basal vein of Rosenthal (BVR) • "Dots" of contrast at subependymal/medullary
>
-0
• Inferior sagittal sinus (IS5); straight sinus (SS) vein junction define roof of lateral ventricle
o DSA, AP view
C Definitions • TSV defines size, configuration of lateral ventricle;
C\3
lJl • Cavum veli interpositi: Space within double-layered characteristic "double curve" appearance
C tela choroidea of third ventricle, communicates • BVR, tributary of VofG, begins at medial temporal
Q) posteriorly with quadrigeminal cistern lobe, curves around midbrain, looks like "frog leg"
> o T1 C+ MR usually shows TSV, caudate and septal
c veins; smaller subependymal veins usually
of; I Cross Anatomy inapparent

=•••
Overview
• Medullary veins
• Deep paramedian veins
o DSA, lateral view
• ICV follows gently undulating posterior course
o Small, linear veins originate 1-2 cm below cortex from foramen of Monro to VofG
o Course towards ventricles, terminate in • VofG forms prominent arc, curving back/up
subependymal veins around corpus callosum splenium
• Subependymal veins o DSA, AP view
o Septal veins • ICVs 1-2 mm off midline, seen as ovoid/elliptical
• Course posteriorly along septum pellucidum collection of contrast
• Join with TSVs to form ICVs at interventricular o T1 C+ MR, axial view: ICVs seen as contrast-filled
foramen linear paramedian structures just above third
o TSVs ventricle
• Receive caudate/terminal veins that course o CTV/MRV: ICVs, VofG well seen
anteriorly between caudate nucleus, thalamus
• Curve over caudate nuclei Normal Variants, Anomalies
• Terminate at interventricular foramen (of Monro) • Variations common; true anomalies rare
by uniting with septal veins to form lCVs • Vein of Galen malformation
• Deep paramedian veins o Primitive median prosencephalic vein (MPV) persists
o ICVs as outlet for diencephalic, choroidal venous
• Paired, paramedian drainage
• Course posteriorly in cavum veli interpositi o Persisting falcine sinus +/- absent/hypoplastic SS
• Terminate in rostral quadrigeminal cistern by
uniting with each other, BVRs to form VofG
o VofG (great cerebral vein) IAnatomy-Based Imaging Issues
• Short, U-shaped midline vein formed from union
Imaging Recommendations
of ICVs, BVRs
• Curves posteriorly and superiorly under corpus • MRV/CTV delineate dural sinuses, large deep veins
callosum splenium in quadrigeminal cistern (e.g., ICV, BVR)
• Unites with ISS at falcotentorial apex to form SS • DSA best for detailed delineation of deep
veins/tributaries
Anatomy Relationships
• Deep veins course under ventricular ependyma, define
ventricular margins I Embryology
• ICVs above third ventricle, pineal gland; under
fornices, corpus callosum splenium Embryologic Events
• 5th fetal week: Arterial supply to choroid plexus forms
Vascular Territory from meninx primitiva
• ICVs, VofG and tributaries drain ovoid area • 7th-8th fetal week
surrounding lateral/third ventricles o Choroid plexus drains via single temporary midline
• Caudate nuclei, putamen/globus pallidus, thalamus, vein (MPV)
internal capsule, deep cerebral (medullary) white o MPV courses posteriorly toward developing
matter, medial temporal lobes interhemispheric dural plexus (falcine sinus)
• 10th week
o ICVs annex drainage of choroid plexus
I Imaging Anatomy o MPV regresses, caudal remnant unites with
developing ICVs -+ definitive VofG formed
Overview
• Medullary veins

I
358
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359
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360
 DEEP CEREBRAL VEINS
LAT & AP leA DSA o:l
"""l
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lJl

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Terminal vein Q..
Roof of lateral ventricle with
ependymal veins
Direct lateral vein
<
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Anterior caudate, thalamostriate
Internal cerebral vein
o
veins C
lJl

Septal vein Basal vein of Rosenthal

Vl
::J
C
lJl
ro
lJl

Inferior sagittal sinus Medullary (white matter) veins

Anterior caudate vein Direct lateral vein

Thalamostriate vein
Vein of Galen
Medial atrial vein
Septal vein
Basal vein of Rosenthal
Superficial middle cerebral vein

Sphenoparietal sinus Emissary vein

Pterygoid venous plexus

Vein of Trolard

Medial atrial vein

Thalamostriate vein
Internal cerebral vein
Lateral atrial vein

Septal vein

(Top) Two lateral DSAviews from different patients, mid-venous phase, are shown. The deep white matter
(medullary) veins converge on the ependymal veins, outlining the roof of the lateral ventricle (seen here as "dots" of
contrast). (Middle) On the lateral view, venous phase, of this DSA, a long septal vein joins the thalamostriate and
direct lateral veins well behind the foramen of Monro, a normal variant. The "brush-like" linear contrast collections
seen near the roof of the lateral ventricle are the medullary (white matter) veins. (Bottom) AP view, mid-venous
phase, of a DSA shows the thalamostriate vein as it outlines the lateral margin of the ventricle.

361
 DEEP CEREBRAL VEINS
Vl
Q) AXIAL T1 C+ MR
Vl
:J
C Septal vein
V"J
Vl Anterior caudate vein
:J
o Thalamostriate vein Pillars of fornix
C
Q)

>
~ Internal cerebral vein
C
<'tl
Vl
Lateral atrial vein
C Vein of Galen
Q)

>

Internal cerebral veins

Medial atrial vein

Straight sinus

Caudate vein

Choroid veins

Inferior sagittal sinus (cut across)

(Top) Series of three axial Tl C+ MR scans from inferior to superior is shown. Section through the foramen of Monro
shows the septal veins as they curve posteriorly from the frontal horns around the pillars of the fornix. They join
together with the thalamostriate veins to form the internal cerebral veins. (Middle) The paired internal cerebral veins
are seen here as the course posteriorly in the velum interpositum, above the third ventricle. (Bottom) Scan through
the bodies of the lateral ventricles shows the enhancing choroid plexus coursing anteriorly along the stria thalamic
groove. Choroid veins are the prominent tortuous vessels running over the choroid plexus.

362
 DEEP CEREBRAL VEINS
CORONAL T1 C+ MR

Superior sagittal sinus

<
(t)
:J
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OJ
:J
0-
Choroid plexus & veins
<
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Internal cerebral veins :J
Lateral atrial vein o
C
V'l

(j)

:J
C
V'l
(t)
V'l

Vein of Trolard

Medullary & subependymal

vein confluence

Lateral vein draining into

Internal cerebral vein terminal vein

Anterior caudate vein

Internal cerebral vein Thalamostriate vein
Septal vein
Basal vein of Rosenthal
Deep middle cerebral vein

(Top) Series of three coronal Tl C+ scans from posterior to anterior are shown. Section through the atria of the
lateral ventricles shows the choroid plexus and its veins as well as the internal cerebral veins coursing posteriorly
within the velum interpositum. (Middle) Section through the bodies of the lateral ventricles shows faint
enhancement along the superolateral margin of the ventricle representing confluence of the deep medullary (white
matter) veins draining into a subependymal vein. (Bottom) Section just behind the foramen of Monro shows the
septal and thalamostriate veins forming the internal cerebral vein.

I
363
 DEEP CEREBRAL VEINS
<Jl
Q) CORONAL T2 MR
<Jl
::J
C
CJ) Inferior sagittal sinus
<Jl
::J Vein of Galen/straight sinus
o junction
C
Q) Occipital horn, lateral ventricle
>
-0
c Tentorium cerebeIli
C\j
<Jl
C
Q)

>

Internal cerebral veins

Choroid plexus & veins

Internal cerebral veins (in
velum interpositum)
Basal vein of Rosenthal
Precentral cerebellar vein

(Top) Series of six coronal T2 MR images from posterior to anterior is shown. Section through the occipital horn of
the lateral ventricle demonstrates confluence of the vein of Galen with the inferior sagittal sinus at the apex of the
falcotentorial junction. (Middle) Internal cerebral veins are shown just prior to joining vein of Galen. (Bottom) Basal
vein of Rosenthal and internal cerebral veins course posteriorly before anastomosing with vein of Galen. The
precentral cerebellar vein courses superiorly in front of the central lobule of the vermis to join the vein of Galen.
Even though it drains posterior fossa structures, this vein is generally considered part of the so-called "Galenic group"
of veins.

364
 DEEP CEREBRAL VEINS
CORONAL T2 MR OJ
~
~
::s
<
([)

::J
Medial atrial vein Fornix (fl

Internal cerebral vein tl.l

::J
Lateral atrial vein Q..

Basal veins of Rosenthal <

([)
::J
o
C
(fl

(j)

::J
C
(fl
([)
(fl

Fornix
Internal cerebral vein

Pineal gland

Basal vein of Rosenthal

Lateral mesencephalic vein

Petrosal veins

Septum pellucidum
Pillars of fornix
Choroid plexus
Foramen of Monro
Internal cerebral vein

Third ventricle

(Top) Medial and lateral atrial veins drain into the internal cerebral veins. The basal veins of Rosenthal are seen here
as they course superomedially around cerebral peduncles within the ambient and quadrigeminal cisterns. They will
join the ICVs to form the vein of Galen. The BVRsare actually superficial cerebral veins, although their drainage
pattern is into the deep venous system. (Middle) The internal cerebral veins are seen here as they course posteriorly
within the velum interpositum, above a cystic pineal gland. The velum interpositum is a CSF-containing
subarachnoid cistern and is anatomically an anterior extension of the quadrigeminal cistern. It lies beneath the
fornices and above the third ventricle. Some posterior fossa veins are also seen in this section. (Bottom) Scan
through the foramen of Monro shows origin of the internal cerebral veins.
365
 DEEP CEREBRAL VEINS
~ AXIALCTV
t/)
:::J
C
CJ)
t/)
:::J
o
C
OJ
>
"D Basal vein of Rosenthal
c Posterior cerebral artery
~
t/)
Internal cerebral vein
c
Vein of Galen
OJ
>
Straight sinus

Septal vein

Thalamostriate vein
Caudate vein

Internal cerebral vein

Direct lateral vein

Medial atrial vein
Basal vein of Rosenthal
Vein of Galen

Straight sinus

Direct lateral vein

Internal cerebral veins

Medial atrial vein

Vein of Galen
Straight sinus

(Top) First of three axial CT source images from a CT venogram are shown from inferior to superior. This section
shows the basal veins of Rosenthal, posterior aspect of the internal cerebral veins, and vein of Galen. The BVRs,P2
posterior cerebral artery segments, and the trochlear nerve all course through the ambient cisterns and are in close
proximity to one another. (Middle) This view shows the ICVs as they are formed from the thalamostriate and septal
veins. Numerous ventricular tributaries are present. (Bottom) This view shows the internal cerebral veins, vein of
Galen, and straight sinus. So-called "direct lateral" veins collect tributaries from the caudate body as they course
along the stria terminalis, which demarcates the border between the caudate and thalamus. Sometimes these veins
I are quite prominent, as seen in this case.
366
 DEEP CEREBRAL VEINS
AP CTV

Direct lateral vein

Internal cerebral vein

Internal cerebral veins

Posterior cerebral artery

Basal veins of Rosenthal

Vein of Galen

Posterior cerebral artery

(Top) First of three AP views of CT venogram with section through the basilar bifurcation shows a large direct lateral
vein draining into the internal cerebral vein. Its upper aspect runs along the caudate nucleus; its lower aspect curves
over the thalamus. The stria terminalis is at the junction of these two segments. (Middle) The internal cerebral veins
and both basal veins of Rosenthal are seen here just before they converge to form the vein of Galen. The posterior
cerebral artery lies lateral to the BVRs.Both curve posteriorly around the midbrain, running in the ambient cistern.
(Bottom) Image at the tentorial apex shows the vein of Galen. The posterior cerebral artery is seen here, dividing
into its parietooccipital and calcarine arteries.

367
 DEEP CEREBRAL VEINS
Vl
Q.) SAGITTAL CTV
Vl
:J
C
(f)

Vl
:J
PeriCallosal artery & branches
o
C
Q.)
Vein of Galen
>
-0 Internal cerebral veins
C
r\l Precentral cerebellar vein Straight sinus
Vl
C
Q.)
Anterior pontomesencephalic
> venous plexus
Inferior vermian vein

Choroid plexus, lateral

Caudate veins ventricle

Terminal vein

Posterior cerebral artery

Choroid plexus, veins Lateral atrial vein

Lateral posterior choroidal artery

Basal vein of Rosenthal

Posterior cerebral artery

(Top) Series of three sagittal views of a CT venogram are shown from medial to lateral. Midline view shows the
internal cerebral veins as they follow a sinusoidal course, running posteriorly in the velum interpositum above the
roof of the third ventricle. The vein of Galen and one of its tributaries, the precentral cerebellar vein, are well seen
here. (Middle) Slightly more lateral view shows the choroid plexus of the lateral ventricle as it courses anteriorly
along the striothalamic groove between the caudate nucleus and thalamus. This represents the stria terminalis. A
so-called "terminal vein," seen here, may course along this groove and join the caudate and septal veins to form the
thalamostriate vein. (Bottom) Both the basal vein of Rosenthal and posterior cerebral artery curve around the
I midbrain within the ambient cistern and are seen on this section.
368
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369
 DEEP CEREBRAL VEINS
(f)

Q) MRV
(f)

:J
C
(f)
(f)
Superior sagittal sinus
:J
0
C
Q)

>
-0
c
C'j
(f)

c Sigmoid sinus Jugular bulb & internal jugular

vein
Q)

> Transverse sinus

c:
~
c:c
"- Sinus confluence (torcular
Herophili)

Internal cerebral veins (paired)

Thalamostriate veins

Septal vein
Vein of Labbe
Cavernous sinus, dival plexus

Internal cerebral veins

(Top) A series of three different projections from a 3T MR venogram is illustrated. The submentovertex view is
especially good for evaluating patency of the major dural venous sinuses but overlap of many vessels largely obscures
the deep cerebral veins. (Middle) Lateral view of the MRV demonstrates the major deep cerebral veins. Blood flow
from deep venous system drains into internal cerebral vein before emptying into vein of Galen. This view is ideal for
evaluating patency of the internal cerebral veins, vein of Galen and straight sinus. The subependymal and medullary
veins are not generally visualized on standard MR venograms. (Bottom) Oblique AP view shows the major dural
venous sinuses as well as the Galenic system. The normal sinusoidal course of the internal cerebral veins as well as
their relationship to the vein of Galen are especially well seen.
370
 DEEP CEREBRAL VEINS
MRV ~
.,
~
::J
<
ro
~
(fl

Thalamostriate vein ~
~
Internal cerebral vein Q..

Basal vein of Rosenthal <

ro
Vein of Labbe ~
0
c
(fl

Vl
~
C
(fl
ro
(fl

Internal cerebral vein

Vein of Galen Basal vein of Rosenthal

Deep middle cerebral vein

External jugular vein

Superior sagittal sinus

Anterior caudate vein

Terminal vein
Anterior caudate vein
Direct lateral vein

Medial atrial vein

Medullary (deep white matter)

veins Medullary (deep white matter)
veins

Lateral atrial vein

(Top) Straight AP view shows the internal cerebral vein is superimposed on the superior sagittal sinus. The
thalamostriate vein, well seen here, defines the outer margin of the lateral ventricle. A prominent vein of Labbe is
present on the left. (Middle) Oblique AP view demonstrates drainage of basal vein of Rosenthal into internal cerebral
vein. One of its small but important tributaries, the deep middle cerebral vein, is well seen. (Bottom) Here a close-up
view of axial contrast-enhanced susceptibility-weighted 3T MR venogram shows details of the deep venous drainage
system and its tributaries. In this high-resolution study, the white matter (medullary) veins are seen converging on
the subependymal veins at the margins of the lateral ventricles. The medullary (deep white matter veins) are not well
seen on routine MRVs, even on 3T studies. (Courtesy J. Tsuruda, MD).
371
 trl
Q)
POSTERIOR FOSSA VEINS
trl
:::J o Midbrain, pons, superior surface of cerebellar
C ITerminology hemispheres, upper vermis
rJ)
trl Abbreviations • Anterior (petrosal) group
:::J o Anterior (petrosal) surface of cerebellar hemispheres,
o • Vein of Galen (VofG)
• Precentral cerebellar vein (PCV)
lateral pons, brachium pontis, medulla, flocculus,
C
Q)
• Anterior pontomesencephalic vein/venous plexus nodulus
> (APMV) • Posterior (tentorial) group
""0 o Inferior/posterior surfaces of cerebellar hemispheres,
C
• Superior vermian vein (SVV)
• Inferior vermian vein (IVV) inferior vermis, tonsils
~
trl • Cerebellopontine angle (CPA)
C • Internal auditory canal (lAC)
Q)
• Superior petrosal sinus (SPS) I Imaging Anatomy
> • Subarachnoid space (SAS) Overview
Definitions • Superior ("galenic") group
• Venous drainage for midbrain, pons, medulla, o Veins of this group generally course over superior
cerebellum, vermis surfaces of cerebellum, vermis as well as anterior
surface of midbrain, pons and medulla
o Superior cerebellar veins course over hemispheres
I Gross Anatomy o Galenic veins typically drain into VofG or directly
into straight sinus (SS)
Overview o Cerebellar hemispheric veins also may drain laterally
• Three major posterior fossa/midbrain drainage systems into transverse sinus (TS), SPS, or directly into small
o Superior (galenic) group drains up into vein of dural sinuses within tentorium
Galen, has three major named veins • Anterior (petrosal) group
• Precentral cerebellar vein: Single, midline; lies o Demarcates middle of cerebellopontine angle cistern
between lingula/central lobule of vermis; o Petrosal vein courses superiorly to drain into SPS
terminates behind inferior colliculi by draining • Posterior (tentorial) group
into VofG o Demarcates inferior vermis
• Superior vermian vein: Originates near declive of
Normal Imaging
vermis, courses up/over top of vermis (culmen),
joins PCV and enters VofG • DSA, lateral view
o PCV: Anteriorly convex curve, lies halfway between
• Anterior ponto mesencephalic vein: Superficial
venous plexus covers cerebral peduncles, anterior tuberculum sellae and torcular Herophili
surface of pons o APMV: Outlines pons, midbrain; lies approximately
o Anterior (petrosal) group 1 cm behind clivus at closest point
• Petrosal vein: Prominent trunk in CPA that o SVV:Outlines superior vermis; normally is 2-3 mm
collects numerous tributaries from cerebellum, below straight sinus
pons, medulla o IVV: Outlines inferior vermis; normally is at least 1
o Posterior (tentorial) group cm from inner table of skull
• Inferior vermian veins: Paired paramedian • DSA, AP view
structures; curve posterosuperiorly under pyramis, o Petrosal vein: May form prominent venous "star" in
uvula of vermis CPA cistern
o SVVs/IVVs should lie in or near midline
Anatomy Relationships • Tl C+ MR
• PCV o APMV seen as faint plexiform enhancement along
o Courses over roof of fourth ventricle, anterior pial surface of pons, medulla
(superior) medullary velum in midline • Seen on both sagittal, axial scans
o Lies between lingula, central lobule of vermis • CECT
o Upper end (at VofG level) lies below, behind o Axial: Scans cut obliquely through tentorium so
quadrigeminal plate and pineal gland superior cerebellar veins, SVVs appear as
• SW linear/serpentine areas of enhancement
o Courses over vermian apex o Coronal: May show bridging veins crossing SAS
o Lies under tentorium between cerebellum/vermis, tentorium
• APMV
o Lies under vertebrobasilar artery
o Closely adherent to pial surface of pons IAnatomy-Based Imaging Issues
• Petrosal vein
o Courses anterolaterally below CNS (trigeminal Imaging Pitfalls
nerve) • APMV enhancement along pontine/medullary surface
o Enters SPS just above lAC is normal; should not be mistaken for meningitis!

Vascular Territory
• Superior (galenic) group

372
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373
 POSTERIOR FOSSA VEINS
CD LAT DSA
IJl
::J
C
(j)

IJl Superior choroid veins/choroid

::J plexus "blush"
o Vein of Galen
C
<J) Internal cerebral vein
>
~
c
(ij
IJl
C
<J)
>

Internal cerebral vein

Vein of Galen
Thalamic vein
Superior vermian vein
Posterior mesencephalic vein
Precentral cerebellar vein
Lateral mesencephalic vein

Anterior pontomesencephalic
venous plexus Inferior vermian vein

Petrosal venous plexus

Vein of Galen Straight sinus

Posterior mesencephalic vein Precentral cerebellar vein

Petrosal vein & tributaries Inferior vermian vein

Clival venous plexus

Cerebellar hemispheric vein
Inferior petrosal sinus

Suboccipital veins

(Top) Series of three lateral views of a vertebrobasilar DSA are shown. Late arterial/very early venous phase of a lateral
DSA shows a prominent choroid plexus "blush" and early opacification of the internal cerebral vein, a normal finding
on posterior fossa angiograms. (Middle) Mid-venous phase shows the anterior ponto mesencephalic venous plexus
outlining the belly of the pons and undersurface of the cerebral peduncles. Note numerous tiny pontine tributaries.
(Bottom) Late venous phase shows prominent suboccipital veins, a normal finding. The clival venous plexus is
opacified and is shown draining into the jugular vein via the inferior petrosal sinus. There is faint opacification of
the superior sagittal sinus because the posterior cerebral arteries were opacified on the arterial phase of this study (not
shown).
374
 POSTERIOR FOSSA VEINS
AP VA DSA C::l
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l:lJ
::J
<
(D
:J
lJl

OJ
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Left transverse sinus :J
Inferior vermian vein o
C
lJl
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V'l

:J
C
lJl
(D
lJl

Superior sagittal sinus

Superior petrosal sinus

Petrosal vein

Emissary vein

Suboccipital venous plexus

(Top) Series of three AP views of a vertebrobasilar DSA are shown. Early venous phase shows numerous cerebellar
hemispheric and vermian veins as well as cortical veins of the occipital lobe (the posterior cerebral arteries were
opacified on earlier arterial phase, not shown here). Note significant asymmetry between the sigmoid sinuses and
jugular bulbs, a normal variant. (Middle) Mid-venous phase shows the petrosal veins draining into the superior
petrosal sinuses, which in turn drain into the transverse sinuses. Note that the superior sagittal sinus deviates from
the midline as it descends towards the right transverse sinus, a normal variant. (Bottom) Late venous phase shows
opacification of very prominent suboccipital veins on the right, a normal finding.

375
 POSTERIOR FOSSA VEINS
Vl
Q) AXIAL T1 C+ MR
Vl
:J
C
V'l
Vl
:J
o Internal jugular vein
C
Q)

>
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Clival venous plexus

c Marginal venous plexus of foramen

~
Vl magnum
Suboccipital venous plexus
C
Q)

>

Hypoglossal venous plexus

Jugular bulb

Sigmoid sinus

Emissary vein

Clival venous plexus

Inferior petrosal sinus

Choroid plexus of fourth

Inferior vermian veins (cut across) ventricle in lateral recess

Tonsillar vein

(Top) Series of six axial TIC+ fat-saturated MR scans through the posterior fossa are shown. Section through the
foramen magnum shows the clival venous plexus and a striking marginal venous plexus around the rim of the
foramen magnum. An inconstant dural sinus, the occipital sinus, may connect the marginal plexus with the torcular
Herophili. Inhomogeneous signal within the I]V, as seen on this scan, is a normal finding. (Middle) Section through
the jugular bulbs demonstrates the typical, normal side-to-side asymmetry and inhomogeneous enhancement. The
enhancing structures medial to the bulbs are venous plexi that accompany CN12 as it passes through the hypoglossal
canal. (Bottom) Scan through the lateral recesses of the fourth ventricle shows the inferior petrosal sinuses especially
well. The IPS connects the clival venous plexus with the jugular bulb.
376
 POSTERIOR FOSSA VEINS
AXIAL T1 C+ MR c:l
"'"
~
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Cavernous sinus
<
ro
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:J
V"l

Vein of Labbe C)
:J
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Superior petrosal sinus
<
ro
:J
o
C
V"l

(j)

:J
C
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ro
V"l

Sphenoparietal sinus

Anterior pontomesencephalic
venous plexus
Petrosal vein

Superior petrosal sinus

Transverse sinus
Superior vermian vein (cut
across)

Superficial middle cerebral vein (cut

across)

Lateral mesencephalic vein

Tentorial vein

Sinus confluence (torcular

Herophili)

(Top) Section through the upper petrous ridges shows the right superior petrosal sinus. A hypoplastic vein of Labbe is
present. The prominent venous structures in the cerebellopontine angle cistern are petrosal veins. (Middle) Scan
through the upper pons shows prominent petrosal veins bilaterally with numerous tributaries within the
cerebellopontine angle cistern. The faint enhancement covering the pial surface of the pons is the anterior
ponto mesencephalic venous plexus and is a normal finding that should not be mistaken for meningitis. (Bottom)
Scan through the upper cerebellum and midbrain shows very prominent tentorial veins that drain into the transverse
sinuses.

377
 EXTRACRANIAL VEINS
o Internal jugular vein
ITerminology • Caudal continuation of sigmoid sinus
Abbreviations • Jugular bulb = dilatation at origin
• Internal jugular vein (I]V) • Courses inferiorly in carotid space posterolateral
• Internal carotid artery (lCA) to ICA, CCA
• Common carotid artery (CCA) • Unites with subclavian vein to form
• Inferior, superior ophthalmic veins (lOV, SOY) brachiocephalic vein
• Cavernous sinus (CS) • Size highly variable; significant side-to-side
asymmetry common
Definitions o Vertebral venous plexus
• Extracranial veins include scalp, skull (diploic), face, • Suboccipital venous plexus
neck veins • Tributaries from basilar (clival) plexus, cervical
musculature
• Interconnects with sigmoid sinuses, cervical
I Gross Anatomy epidural venous plexus
• Terminates in brachiocephalic vein
Overview
• Scalp veins connect via emissary veins to cranial dural
sinuses I Imaging Anatomy
o Superficial temporal vein collects numerous scalp,
auricular tributaries Overview
• Descends into parotid space • Extracranial veins highly variable, inconstantly
• Together with maxillary vein forms visualized on DSA/CTA/MRA
retromandibular vein o Scalp, emissary veins
• Diploic veins • Rarely opacified on normal DSA but often seen on
o Large, irregular endothelial-lined channels in diploic fat-saturated Tl C+ MRs
spaces of calvarium • May become prominent if dAVF,dural sinus
o May form large venous "lakes" occlusion, sinus pericranii present
o Connect freely with dural sinuses, meningeal veins o Orbital veins
• Emissary veins connect intra- and extra cranial veins • Flow in SOY is normally from EXTRA-to
o Traverse cranial apertures, foramina INTRACRANIAL
o Connect venous sinuses, extracranial veins • Rarely prominent at DSA unless vascular
o Highly variable malformation (e.g., C-C fistula) or CS occlusion
• Orbital veins (two major) present (flow reverses)
o SOY connects face/orbit with CS o Face, neck veins
olaV is smaller, less conspicuous • Inconstantly visualized
• Facial veins • Pterygoid plexus often prominent on both DSA,
o Facial vein T1 C+ MR scans
• Begins at angle between eye, nose
Variations, Anomalies
• Descends across masseter, curves around mandible
• Joins I]V at hyoid level • Extracranial venous drainage highly variable
• Tributaries from orbit (supraorbital, superior • Sinus pericranii
ophthalmic veins), lips, jaw, facial muscles o Abnormal communication between dural venous
o Deep facial vein sinus, extracranial veins
• Receives tributaries from deep face, connects facial o Seen as vascular scalp mass that communicates with
vein with pterygoid plexus dural sinus via transcalvarial vein (through
o Pterygoid plexus well-defined bone defect)
• Network of vascular channels in masticator space o Association with intracranial developmental venous
between temporalis/lateral pterygoid muscles anomaly common (+/- venous varix)
• Connects cavernous sinuses, clival venous plexus
with face/orbit tributaries
• Drains into maxillary vein IAnatomy-Based Imaging Issues
o Retromandibular vein
Imaging Pitfalls
• Formed from union of maxillary, superficial
• Diploic veins, venous "lakes" ("lacunae") may form
temporal veins
sharply marginated, well-corticated skulllucencies (do
• Lies within parotid space
not mistake for metastases or myeloma)
• Passes between external carotid artery (ECA) and
• Prominent, persistent SOY opacification on DSA is
CN? to empty into I]V
nearly always abnormal but normal on CECT,
• Neck veins
enhanced MR
o External jugular vein
• Asymmetric I]Vs are common; one I]V may be many
• From retromandibular, posterior auricular veins
times the size of the contralateral I]V
• Receives tributaries from scalp, ear, face
• Extracranial venous plexuses (pterygoid, suboccipital)
• Size, extent highly variable
can normally be very prominent

378
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380
 EXTRACRANIAL VEINS
SAGITTAL CECT OJ
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artery Jugular bulb VI

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plexus o
C
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VI
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VI

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masticator space)

Internal jugular vein

(Top) Series of two reconstructed sagittal views from thin-section axial CECT scan shows the internal jugular vein
and its relationship to the skull base. Note proximity of the IJV and jugular bulb to the petrous temporal bone and
internal carotid artery. The IJV descends inferiorly within the carotid space. (Bottom) Internal jugular veins vary
significantly in size. Significant side-to-side asymmetry is common. This IJV is average in size and configuration.·

381
 EXTRACRANIAL VEINS
~ CORONAL CECT
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Jugular bulb Hypoglossal venous
c plexus
~
lJl
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vein

Left internal jugular

vein

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plexus draining into
Right internal jugular left I]V
vein

External jugular vein

(Top) A series of two coronal views from a thin-section CECT scan of the neck show the internal jugular veins and
some tributaries that arise near the skull base. This view shows significant side-to-side asymmetry of the two IJVs, a
common normal variant. (Bottom) Extensive interconnections between the intra- and extra cranial venous systems
are normally present. The hypoglossal venous plexus, petrosal sinuses, dival venous plexus, cavernous sinus and
pterygoid plexus are extensively interc~mnected.

382
 EXTRACRANIAL VEINS
AXIAL T1 C+ MR o::l
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Internal jugular vein

External jugular vein

Retromandibular vein
Epidural venous plexus

Suboccipital venous plexus

Mandibular vein
Pterygoid venous plexus
(surrounding mandibular
nerve) ,

Posterior auricular vein

Condylar emissary vein

Emissary vein

(Top) A series of six axial Tl C+ MR scans are shown from inferior to superior. The upper cervical epidural venous
plexus is seen on this section. Vessels within the carotid space are well-delineated. The cervical internal carotid artery
lies anteromedial to the internal jugular vein in this space. (Middle) Section through the foramen magnum shows
the interconnections between the lower dival, upper cervical epidural, and suboccipital venous plexi. Condylar
emissary veins also connect the intra- and extracranial veins around the foramen magnum and upper cervical spinal
canal. (Bottom) A more inferior section through the upper part of the extracranial internal jugular veins shows the
inhomogeneous signal caused by spin dephasing. Unusually large condylar emissary veins are present, connecting
with the suboccipital veins.
383
 EXTRACRANIAL VEINS
<Jl
(]) AXIAL T1 C+ MR
<Jl
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<Jl
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c Extracranial internal jugular vein Retromandibular vein
(\l
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C Hypoglossal venous plexus
(])

> Emissary vein Emissary vein

Pterygoid venous plexus

Hypoglossal venous plexus

Clival plexus

Emissary vein Sigmoid sinus

Mandibular nerve surrounded

by pterygoid venous plexus
Internal carotid artery
Jugular bulb

Sigmoid sinus

Emissary vein

Scalp vein

(Top) Scans continue superiorly. Section through the medulla, just above the foramen magnum, shows the
hypoglossal venous plexus and its interconnections with the dival venous plexus and large condylar emissary veins.
Note asymmetry of the jugular bulbs at this level, a common normal variant. (Middle) Section through the inferior
clivus at the level of the hypoglossal canals shows prominent venous plexi traversing the hypoglossal canals. Note
interconnections between the dival venous plexus and extra cranial internal jugular vein via the hypoglossal venous
plexi. (Bottom) This scan shows the jugular bulbs nicely.

384
 EXTRACRANIAl VEINS
CORONAL T1 C+ MR CtI
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o
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Epidural venous plexus CJ>
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Sigmoid sinus

Suboccipital venous plexus

Epidural venous plexus

Superior petrosal sinus

Internal jugular vein and bulb

Hypoglossal venous plexus in
hypoglossal canal

Vertebral venous plexus

External jugular vein

Epidural venous plexus

(Top) A series of six coronal fat-saturated Tl C+ MR scans from posterior to anterior demonstrate the numerous
anastomoses between the posterior fossa dural venous sinuses and the extensive venous plexi that surround the
upper cervical spine. These interconnections may provide a source for collateral venous drainage if the jugular vein
becomes occluded. (Middle) Section through the cervicomedullary junction demonstrates prominent veins in and
around the spine and posterior skull base. (Bottom) Section through the middle of the upper cervical spine and
foramen magnum nicely demonstrates the numerous interconnections between prominent suboccipital veins,
vertebral venous plexus and epidural venous plexus.

385
 EXTRACRANIAl VEINS
<Jl
Q) CORONAL T1 C+ MR
<Jl
:J
C
(./)

<Jl
:J
o
C
Q)
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>
-0 Jugular foramen
C
~ Hypoglossal venous plexus
<Jl within hypoglossal canal
C
Q) Cl lateral mass Occipital condyle
>
Vertebral veins surrounding
vertebral artery
External jugular vein

Inferior petrosal sinus

Internal carotid artery

Deep facial vein

Retromandibular vein (embedded

within parotid gland)

Posterior external jugular vein

Clival venous plexus

Pterygoid venous plexus

(Top) More anteriorly this section is directly through the jugular foramen. Note intensely enhancing internal jugular
vein seen superolateral to the occipital condyles. The jugular tubercles and occipital condyles together resemble the
outline of two eagles. The head of the eagle (jugular tubercle) separates the internal jugular bulb and vein from the
hypoglossal canal and its venous plexus, nicely seen here. (Middle) Scan just anterior to the internal jugular veins
shows the internal carotid artery running cephalad within the carotid space. The ICA lies anteromedial to the I]V.
(Bottom) Scan through the mandibular condyles and lower clivus shows prominent enhancing veins under the skull
base within the pterygoid muscles. These constitute the pterygoid venous plexus which is usually opacified on Tl C+
MR scans of the neck.
386
 EXTRACRANIAL VEINS
GRAPHIC & AXIAL CECT O:::l
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ro
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0.>
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Q..
Common carotid artery
<
ro
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Internal jugular vein (in carotid o
space) C
CJl

Vertebral vein

Common facial vein (in buccal

space)

Pterygoid venous plexus

Retromandibular vein

External carotid artery

Vertebral venous plexus
Internal jugular vein

Vertebral artery

Anterior jugular vein

External jugular vein

Internal jugular vein

External jugular vein

Vertebral vein

(Top) Graphic and accompanying axial CECT scans depict the venous structures within the mid-neck. The internal
jugular vein lies posterolateral to the carotid artery within the carotid space. (Middle) Axial CECT depicts the neck
vessels at the Cllevel. (Bottom) This image depicts the neck vessels at the level of the hyoid bone.

387
 PART II
Head & Neck

Temporal Bone and Skull Base

Orbit, Nose and Sinuses

Suprahyoid and Infrahyoid Neck

Oral Cavity
SECTION 1: Temporal Bone and Skull Base

Skull Base Overview 11-2

Anterior Skull Base 11-12
Central Skull Base 11-26
Posterior Skull Base 11-36
Temporal Bone 11-46
Cochlea 11-62
Intratemporal Facial Nerve 11-66
Middle Ear and Ossicles 11-76
Temporomandibular Joint 11-82
 SKULL BASE OVERVIEW
• Optic canal: CN2, ophthalmic artery (a)
ITerminology • Superior orbital fissure: CN3, CN4, CNVI & CN6
::J & superior ophthalmic vein (v)
..Y. Abbreviations
V) • Inferior orbital fissure: Infraorbital a, v, nerve
""0
• Skull base (SB)
• Carotid canal: ICA, sympathetic plexus
c Definitions • Foramen rotundum: CNV2, artery of foramen
ru
Q) • SB: Bony undulating surface which delimits inferior rotundum & emissary veins
c boundary of cranial vault • Foramen ovale: CNV3, lesser petrosal nerve,
o accessory meningeal branch maxillary artery &
CO emissary vein
ru
•.... I Imaging Anatomy • Foramen spinosum: Middle meningeal artery &
o vein, meningeal branch of mandibular nerve
CL Overview • Foramen lacerum: Not true foramen;
E
Q)
• 5 bones make up base of skull cartilaginous floor of anteromedial horizontal
o Paired bones: Frontal & temporal bones petrous ICA canal
I-
~
.. o Unpaired bones: Ethmoid, sphenoid & occipital
bones
• Vidian canal: Vidian artery & nerve
• PSB
u
Q) • Two surfaces o Contents: Occipital & posterior T-bones
Z o Endocranial surface: Faces brain, cisterns, cranial o Foramina & structures transmitted
"'C nerves (CN) & intracranial vessels • Internal acoustic meatus: CN7, CN8,
c:: o Exocranial surface: Faces extracranial head & neck labyrinthine a
(';$ • Anterior portion: Nasal cavity, frontal & ethmoid • Hypoglossal canal: CN12
"'C sinuses, orbits • Foramen magnum: Spinal portion CNll,
(';$
Q) • Central portion: Anterior pharyngeal mucosal vertebral arteries & medulla oblongata
J: space, masticator, parotid & para pharyngeal • Jugular foramen: Pars nervosa: CN9, Jacobson
spaces nerve & inferior petrosal sinus
• Posterior portion: Posterior pharyngeal mucosal • Jugular foramen: Pars vascularis: CNlO, Arnold
space, carotid, retropharyngeal, perivertebral nerve, CNll, jugular bulb & posterior meningeal a
spaces
• Three regions
o Anterior, central & posterior skull base IAnatomy-Based Imaging Issues
o Anterior skull base (ASB)
• Anterolateral boundary: Frontal bones Key Concepts or Questions
• Inferior relationships: Nasal vault, ethmoid & • Imaging of SB best done as combination of focused
frontal sinuses; orbit and orbital canals MR & bone CT
• Superior relationships: Frontal lobes, CNI o MR requires Tl, T2 & T1 C+ with fat-saturation for
• ASB-CSB boundary: Lesser wing of sphenoid full SB evaluation
(sphenoid ridge) & planum sphenoidale o Bone CT defines bone changes
o Central skull base (CSB) • Suprahyoid neck spaces/structures abut SB allowing
• Inferior relationships: Anterior roof of pharyngeal extracranial tumor to access intracranial area via
mucosal space, masticator, parotid & perineural tumor
para pharyngeal spaces o Masticator space: CNV3
• Superior relationships: Temporal lobes, pituitary, o Parotid space: CN7
cavernous sinus, Meckel cave, CNl-4, CN6, o Orbit: CNVl, CN3, 4, and 6
CNVl-3 o Sinus and nose, pterygopalatine fossa: CNV2
• CSB-PSB boundary: Dorsum sella & posterior
clinoid processes medially, petrous ridges laterally
Imaging Recommendations
o Posterior skull base (PSB) • Bone CT
• Inferior relationships: Posterior pharyngeal o Axial thin-slices with coronal reformations
mucosal space, carotid, retropharyngeal, o Edge enhancing algorithm & wide window settings
perivertebral spaces (> 2000 HU) necessary to evaluate bony anatomy
• Superior relationships: Brainstem, cerebellum, o Narrow windows (200-400 HU) & smoothing
CN7-8, CN9-12, transverse-sigmoid sinuses algorithm to inspect regional soft tissues
• Posterior boundary: Occipital bone o If MR available, contrast unnecessary
• MR: Thin-slices (::;;4 mm), axial & coronal, Tl, T2 &
Internal Structures-Critical Contents Tl C+ fat-saturated
• ASB o Pre-contrast T1 images use native fatty marrow for
o Contents: Frontal, ethmoid bones "contrast"
o Foramina & structures transmitted o Use MRA & MRV for arteries and veins
• Cribriform plate: CNl, ethmoid arteries
Imaging Pitfalls
• CSB
o Contents: Sphenoid bone & anterior T-bones • Prominent foramen cecum, accessory foramina can be
o Foramina & structures transmitted normal variants
• MR flow in jugular foramen may mimic a mass

II
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 SKULL BASE OVERVIEW
AXIAL BONE CT

Frontal bone
Orbital roof

Anterior cranial fossa

Middle cranial fossa Posterior clinoid process

Temporal bone, squamous

portion

Mastoid air cells

Posterior cranial fossa Occipital bone

Frontal bone

Orbital roof

Anterior clinoid process

Lesser wing of sphenoid bone

Sella
Posterior clinoid process

Temporal bone, squamosal

portion

Mastoid air cells

Petrous apex

Occipitomastoid suture
Occipital bone

Frontal sinus
Frontal crest
Frontal bone

Optic canal

Sphenoid sinus Anterior clinoid process

Sella

Dorsum sella
Petrous apex

Occipitomastoid suture

(Top) First of twelve axial bone CT images of skull base presented from superior to inferior. At level of orbital roof,
brain within anterior, middle and posterior fossae is cradled above respective regions of skull base. Anterior skull
base, central skull base, posterior skull base. (Middle) At level of the upper sella, the lesser wings of sphenoid and the
planum sphenoidale, which demarcate the ASB-CSBborder, are barely visible. More posterior, the petrous apices
divide CSB from PSB. PSB houses the cerebellum, covered superiorly by tentorium cerebelli, which attaches to
posterior clinoid processes. (Bottom) At the level of the anterior clinoid, the optic canals pass through the sphenoid
bone, bounded by the anterior clinoid process laterally and the sphenoid sinus medially. The dorsum sella marks the
anteromedial border of the PSB. II
5
 SKULL BASE OVERVIEW
Q)
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AXIAL BONE CT
ro
co Frontal sinus Frontal bone

:J Crista galli
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(f)
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Greater wing of sphenoid bone
C
ro Superior orbital fissure
Q) Sphenoid sinus
c Optic canal (CN2)
o Dorsum sella
CO
Middle cranial fossa
ro
•.... Petrous apex
o
Q.. Internal auditory canal (CN? & 8) Temporal bone
E
Q)
f- Posterior cranial fossa

.:::e.
u Occipital bone
Q)
Z
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Frontal bone
c:
t'j Crista galli
"'C

t'j
Q)
Greater wing of sphenoid bone
:::c
Superior orbital fissure Superior orbital fissure

Basisphenoid
Petrooccipital fissure Petrous apex

Jugular bulb roof Cochlea

Sigmoid sinus
Mastoid air cells
Occipitomastoid suture

Foramen cecum remnant

Lamina papyracea
Crista galli
Anterior ethmoid artery canal
Ethmoid air cells

Superior orbital fissure

Sphenoid sinus

Petrooccipital fissure Basisphenoid portion of clivus

Horizontal petrous ICA

Jugular bulb
Pars vascularis, jugular foramen
Sigmoid sinus
Pars nervosa, jugular foramen
Occipitomastoid suture

(Top) In this image the crista galli superior tip is just visible. The optic canal transmits CN2 & ophthalmic artery to
the orbit while the superior orbital fissure contains CN3, CN4, CNVl, CN6 & superior ophthalmic vein. Notice the
close approximation of the optic canal and superior orbital fissure (SOF).The internal auditory canal is on the medial
wall of the T-bone. (Middle) The crista galli provides attachment for falx cerebri and divides anterior aspect of ASB
into 2 symmetric halves. Note that ethmoid air cells extend superior to cribriform plate. Sphenoid sinus is
immediately below the sella and medial to superior orbital fissure. The apex of petrooccipital fissure is visible at
medial tip of petrous apex. (Bottom) At the anterior base of crista galli is foramen cecum remnant. The petrooccipital
II fissure is the most common location for skull base chondrosarcoma.
6
 SKULL BASE OVERVIEW
AXIAL BONE CT

Foramen cecum remnant

Crista galli

Greater wing of sphenoid bone

Infratemporal fossa
Superior orbital fissure
Sphenooccipital synchondrosis
Temporal bone
Horizontal petrous ICA canal Petrooccipital fissure

Sigmoid sinus

Occipitomastoid suture
Occipital bone

Frontal sinus
Cribriform plate of ethmoid
Lamina papyracea bone

Ethmoid sinus
Greater wing of sphenoid bone
Sphenoid sinus

Sphenooccipital synchondrosis Temporal bone

Horizontal petrous internal carotid Vertical petrous internal carotid
artery canal artery
Pars vascularis, jugular foramen CN7, mastoid segment
Petrooccipital fissure Sigmoid sinus
Jugular tubercle

Cribriform plate of ethmoid bone

Inferior orbital fissure Greater wing of sphenoid bone

Sphenooccipital synchondrosis
Foramen ovale
Foramen lacerum
Inferior petrosal sinus
Vertical petrous internal carotid
artery
Occipitomastoid suture
Foramen magnum

(Top) At the level of the upper clivus the sphenooccipital synchondrosis is visible delineating the more anterior
basisphenoid from the more posterior basiocciput. Posterolaterally the petrooccipital fissure is seen separating the
more medial occipital bone from the more lateral temporal bone. (Middle) At the level of the cribriform plate of the
ethmoid bone the frontal, ethmoid and sphenoid sinuses are all visible. Also note the vertical and horizontal
segments of the petrous internal carotid arteries. (Bottom) Notice the inferior orbital fissure is bounded by the
sphenoid sinus posteromedially and the greater wing of the sphenoid bone laterally. It contains the infraorbital
artery, vein and nerve. The petrooccipital fissure has given way to the inferior petrosal sinus.
II
7
 SKULL BASE OVERVIEW
~ AXIAL BONE CT
(lj

CO

Anterior ethmoid sinus

Posterior ethmoid sinus

Inferior orbital fissure

Foramen rotundum (CNV2)

Vidian canal Foramen ovale (CNV3)

Ci:l Foramen spinosum
Sphenooccipital synchondrosis
'-
o
Q..
Stylomastoid foramen
E
Q)
Foramen magnum
Hypoglossal canal
I-
~
u
Q)
Z
-0
c:
(lj

-0
(lj
Q) Pterygopalatine fossa
:c Pterygomaxillary fissure

Zygomatic arch
Vidian canal
Body of sphenoid bone
Foramen ovale

Foramen spinosum Mandibular condyle

Basioccipital portion of clivus

Occipital bone Hypoglossal canal

Sphenopalatine foramen

Pterygopalatine fossa

Zygomatic arch
Pterygomaxillary fissure
Greater wing of sphenoid bone

Clivus Mandibular condyle

Occipital condyle
Mastoid tip

Foramen magnum

(Top) At the level of inferior orbital fissure and foramen rotundum the vidian canal is also seen. Foramen rotundum
provides a conduit for CNV2 to access the cephalad margin of pterygopalatine fossa. CN3 traverses sphenoid bone
via foramen ovale. The hypoglossal canal is seen in the inferior occipital bone. (Middle) This image is at the level of
the hypoglossal canal in the low occipital bone. Anteriorly the pterygomaxillary fissure is the lateral opening of the
pterygopalatine fossa. (Bottom) At the inferior margin of the foramen magnum the mastoid tips are still visible. The
pterygopalatine fossa is well seen connecting medially with nasal cavity via sphenopalatine foramen and laterally
with the masticator space through the pterygomaxillary fissure. The foramen rotundum and vidian canals also lead
II into the pterygopalatine fossa.
8
II
9
 SKULL BASEOVERVIEW
~ SAGITTAL BONE CT & T1 MR
ro
Q)

~
~
V)
""0

C
ro
Q)
c
o
Q)
Crista galli
Cribriform plate,
ro ethmoid bone
•.... Frontal bone
o Sellaturcica
0...
E
Q)
Dorsum sella
Nasal bone
~
~ Basisphenoid
u
Q)
Z Posterior ethmoid sinus
""0 Basiocciput
C
ro
""0

('Ij
Q)
I
Palatine process, Vomer
maxillary bone

Frontal bone

Frontal sinus

Cribriform plate of
ethmoid bone
Nasal bone

Crista galli

Basisphenoid

Posterior ethmoid sinus

Basiocciput

(Top) Paramedian sagittal bone CT through anterior skull base shows the intimate relationship of the skull base to
the paranasal sinuses. From anterior to posterior note the frontal and nasal bones, crista galli, cribriform plate
basisphenoid and basiocciput. Notice that the sella is entirely embedded in the sphenoid bone. (Bottom) Paramedial
sagittal Tl MR through the skull base shows the anterior, central and posterior skun base. The anterior skull base in
this image is made up of frontal bone, crista galli and cribriform plate of ethmoid bone. The crista galli is high signal
secondary to fatty marrow. The central skull base in the midline is often called the basisphenoid. It is made up of the
sphenoid bone-sinus and cradles the pituitary gland. The sphenooccipital synchondrosis separates the basisphenoid
II from the basiocciput of the posterior skull base.
10
 SKULL BASE OVERVIEW
AXIAL T1 MR :r:
ro
~
Nasal bone 0-
~
Anterior ethmoid sinus :::::l
0-
Crista galli
Z
Gyrus rectus ro
~
;::-
-I
Optic nerve (CN2) ro
Supraclinoid internal carotid 3
-0
artery
Dorsum sellae o
Infundibulum
....•
~
c::o
o
:::J
ro
~
:::J
Q...
V'l
;::-
C

Anterior ethmoid sinus

Posterior ethmoid sinus

Sphenoid sinus

Cavernous internal carotid artery

Meckel cave
Petrous apex marrow
Internal auditory canal

Maxillary sinus

Zygomatic arch
Infraorbital nerve

Pterygopalatine fossa Vidian canal

Pneumatized pterygoid process,
Mandibular nerve (CNV3),
sphenoid bone
foramen ovale
Middle meningeal artery, foramen
spinosum Vertical petrous internal carotid
artery
Clivus
Jugular foramen

(Top) First of three axial T1 MR images through the skull base from superior to inferior shows the high signal fatty
marrow in the crista galli. Adjacent to this are gyri recti of the frontal lobes. (Middle) Image through the cavernous
sinus reveals ethmoid sinuses in the ethmoid bones of the anterior skull base and the sphenoid sinus in the sphenoid
bone of the central skull base. The petrous apex fatty marrow is high signal with Meckel cave seen on its anterior
margin. (Bottom) At the level of the pterygopalatine fossa the infraorbital nerve can be seen exiting anterolaterally.
The vidian canal, another sphenoid bone structure, is visible connecting to the medial pterygopalatine fossa. Middle
meningeal artery and CNV3 are noted passing through the foramen spinosum and ovale respectively. More
posterolaterally the carotid canal and jugular foramen can be seen. II
11
 ANTERIOR SKULL BASE
o Relationships: Medial aspect of ethmoid, supports
ITerminology olfactory bulbs
:::l
~ Abbreviations Development of Anterior Skull Base
rJ)
• Anterior, central skull base (ASB, CSB)
""0 • Overview
c: • Greater wing (GWS) & lesser wing (LWS) of sphenoid o SB originates largely from cartilaginous precursors
C'tl
Definitions • Minimal contribution from membranous bone
OJ o > 100 ossification centers in SB development
c: • ASB: Skull base (SB) anterior to LWS & planum
o sphenoidale o Ossifies posterior to anterior & lateral to medial
CO o Ossification is orderly & constant in 1st 2 years
C'tl • Does not correspond to exact age however
•.... • Birth: ASB develops primarily from cartilage with
o I Imaging Anatomy limited ossification at birth
Q..
E Overview o Early ethmoid air cells may be seen but unossified
crista galli is faint
OJ • ASB is floor of anterior cranial fossa and roof of nose,
..
f-
.:I.
ethmoid sinuses & orbits
• Bones forming ASB
• 1 month: Ossification begins from ethmoidal
labyrinth & turbinates; proceeds medially
U • 3 months: Roof of nasal cavity & tip of crista galli
Q.J o Cribriform plate & ethmoid sinus roof of ethmoid
bone centrally begin to ossify
Z
o Orbital plate of frontal bone laterally o Ethmoid air cells still inferior to cribriform plate
"'C
c: o Planum sphenoidale & lesser wing of sphenoid • 6 months: Nasal roof is well-ossified; > 90% of
patients have partial ossification nasal roof on every
"'
"'C
posteriorly
• Boundaries of ASB coronal CT image

"'
J:
Q.J o Anterolaterally: Frontal bone
o Posteriorly: LWS & planum sphenoidale
• Relationships of ASB
o Superior: Frontal lobes, CN1
o Inferior: Nasal vault & ethmoid sinus medially, orbit
laterally
Bony landmarks of Anterior Skull Base
• Frontal crest: Anterior midline ridge between frontal
bones; falx cerebri attaches here . fuse with ossified vomer, most patients still have a gap
• Crista gal1i: Midline upward triangular process of
ethmoid; anteroinferior falx cerebri attaches here
• Anterior clinoid processes: Medial aspect of LWS; free
edge of tentorium cerebelli attaches here
• Lesser wing of sphenoid: Forms sphenoid ridge;
separates anterior from central skull base
• Planum sphenoidale: Sphenoid bone superomedial
plate anterior to tuberculum sellae
Foramina and Fissures of Anterior Skull Base
• Foramen cecum
o Transmits: Variably transmits small emissary vein
from nasal mucosa to superior sagittal sinus
o Location: In margin between posterior aspect of
frontal bone & anterior aspect of ethmoid
o Relationships: Small midline pit found immediately
anterior to crista galli
• Anterior ethmoidal foramen
o Transmits: Anterior ethmoidal artery, vein, nerve
o Location: Slit between ethmoid and frontal bones
o Relationships: Just anterior to cribriform foramina
• Posterior ethmoidal foramen
o Transmits: Posterior ethmoidal artery, vein, nerve
o Location: Found at seam between sphenoid and
ethmoid bones
o Relationships: Just posterior to cribriform foramina
• Foramina of cribriform plate
o Transmits: Afferent fibers from nasal mucosa to
olfactory bulbs (CN1)
o Location: - 20 perforations within cephalad
ethmoid bone plate
o Perpendicular plate of ethmoid begins to ossify
o Ethmoid sinus extends above cribriform plate plane
• 12 months: Crista galli is well-ossified; more than 70%
of patients have ossified posterior cribriform plate
• 18 months: Ethmoid air cells now extend above plane
of cribriform plate and orbital plates of frontal bones
help form early fovea ethmoidalis
• 24 months: Fovea ethmoidalis achieves more mature
appearance; perpendicular plate of ethmoid begins to
between nasal & ethmoid bones
• > 24 months
o ASB nearly completely ossified; small gaps persist in
nasal roof until early 3rd year
o Foramen cecum ossifies as late as 5 years
o Majority of cribriform plate & at least some of crista
galli should be ossified
IAnatomy-Based Imaging Issues
Key Concepts or Questions
• ASB ossification constant but variable in first 5 years
• Understanding of normal development will avoid
confusion or misdiagnoses
• Anterior neuropore closes in 4th gestational week
Imaging Recommendations
• MR to search for anterior neuropore anomalies
Imaging Approaches
• Bone CT viewed at wide windows (> 2000 HU)
• Reformat at least two orthogonal planes
Imaging Pitfalls
• Apparent small gaps in ASB under age 3 are normal
• Do not confuse non-ossified foramen cecum for
anterior neuropore anomaly
• Beware fatty marrow in crista galli or ossified falx
cerebri is not pathology!

II
12
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II
14
 ANTERIOR SKULL BASE
AXIAL BONE CT
Frontal sinus
Frontal crest
Frontal bone

Frontal lobe
Orbit
Orbital roof

Sphenoid sinus Optic canal

Anterior clinoid process
Tuberculum sellae
Dorsum sellae

Frontal sinus

Crista galli OJ
C>
lJl
Fovea ethmoidalis (t)

Gyrus rectus

Optic canal

Cavernous internal carotid artery

Superior orbital fissure
Sella
Dorsum sella
Tuberculum sellae

Frontal sinus

Anterior ethmoid air cells

Crista galli

Gyrus rectus
Posterior ethmoid air cells

Greater wing of sphenoid

Superior orbital fissure

Sphenoid sinus

(Top) First of nine axial bone CT images of anterior skull base from superior to inferior. This image is at the level of
the orbital roof. Notice that the medial aspect of the frontal lobes extend more inferior than the lateral aspect. On
this image, optic canal is seen passing medial to anterior clinoid process, lateral to the sphenoid sinus. The optic
canal is thin and can be obscured by volume-averaging. (Middle) More inferiorly, cephalad tip of crista galli is seen
in the midline where it and frontal crest give attachment to falx cerebri. Superior orbital fissure and optic canal are
both visible. (Bottom) In this image the frontal, anterior and posterior ethmoid and sphenoid sinuses are all seen.
Each sinus is named based on the bone in the skull base where it forms.
II
15
 ANTERIOR SKULL BASE
~ AXIAL BONE CT
ro
CO
Foramen cecum remnant pit
:J
~
Vl
Crista galli
'"'0
c Anterior ethmoid air cells
ro
Q)
c Posteriorethmoidal foramen
o Greater wing of sphenoid
CO
ro
•...
o Sphenoid sinus Superiororbital fissure
D-
E
Q)
I-
~
u
OJ
Z
"'C

C Foramen cecum remnant pit

~
"'C

~
Q)
Crista galli
:r: Anterior ethmoidal foramen
Lamina papyracea
Posteriorethmoid air cells
Greater wing of sphenoid
Superiororbital fissure

Sphenoid sinus

Foramen cecum remnant pit

Crista galli

G
Posteriorcribriform plate

Sphenoid sinus
Middle cranial fossa

(Top) At this level the cephalad margin of the foramen cecum remnant pit is visible just anterior to the crista galli.
The posterior ethmoidal foramen can be identified at the posterior margin of the cribriform plate (not seen on this
image). Although not seen, the olfactory bulb is nestled between the ethmoid sinuses and the crista galli. (Middle) In
this image the ethmoid air cells are laterally bounded by the lamina papyracea, the paper-thin medial wall of the·
orbit. The anterior ethmoidal foramen can also be seen bilaterally along the lateral wall of the ethmoid sinuses. This
foramen contains the anterior ethmoidal artery, vein and nerve. (Bottom) In this image the posterior cribriform
plate has come into view. Notice the cribriform plate is inferomedial to the ethmoid sinuses themselves.
II
16
 ANTERIOR SKULL BASE
AXIAL BONE CT

Crista galli
Lateral lamella

Cribriform Rlate •

Posterior ethmoid air cells

Orbital apex
Sphenoid sinus ostium
Sphenoid sinus

Sphenooccipital synchondrosis

Crista galli
Anterior ethmoid air cells Cribriform plate

Posterior ethmoid air cells

Inferior orbital fissure

Sphenoid sinus

Crista I galli base

Anterior ethmoid air cells
Olfactory mucosa in olfactory
Ethmoid bone, perpendicular plate
recess

Posterior ethmoid air cells

Inferior orbital fissure

Sphenoid sinus

(Top) In this image through the cribriform plate the perforated bone is visible. Notice the lateral lamella represents
the vertical bony wall of the ethmoid sinus that projects inferiorly from the fovea ethmoidalis (ethmoid sinus roof)
down to the cribriform plate. This is far better seen on coronal sinus CT. (Middle) The cribriform plate has a variable
relationship to the roof of the ethmoid sinuses (fovea ethmoidalis). The more inferior to fovea ethmoidalis the
cribriform plate is found, the larger the dimension of the lateral lamella and the more easily a sinus surgery
complication may occur. (Bottom) This image is found just below the cribriform plate. The perpendicular plate of
the ethmoid bone if visible as is the olfactory mucosa in the olfactory recess of the nasal cavity. The olfactory mucosa
is the site of origin of esthesioneuroblastoma. II
17
 ANTERIOR SKULL BASE
~ CORONALBONECT
ro
o::::l
Planum sphenoidale Optic canal

Anterior clinoid process

Sphenoid sinus
Inferior orbital fissure

Pterygopalatine fossa
Foramen rotundum (CNV2)
Pterygomaxillary fissure

Sphenopalatine foramen

Planum sphenoidale
Optic canal
Anterior clinoid process

Superior orbital fissure

Inferior orbital fissure
Optic strut
Pterygopalatine fossa

Sphenopalatine foramen
Masticator space

Planum sphenoidale

Lesser wing, sphenoid bone Superior orbital fissure

Inferior orbital fissure

Pterygopalatine fossa
Maxillary sinus

Greater palatine foramen

(Top) First of six coronal sinus bone CT images presented from posterior to anterior shows the transition from
central to anterior skull base. Notice the optic canal medial to the anterior clinoid processes. The inferior orbital
fissure is seen inferolateral to the optic canal. The planum sphenoidale is the posterior sphenoid sinus roof. (Middle)
Inferior to planum sphenoidale and lateral to the sphenoid sinus is the complex anatomy of the orbital apex. The
most superomedial structure of the orbital apex is the optic canal, divided from superior orbital fissure by a small
bony spur called the optic strut. The inferior orbital fissure communicates inferiorly with the pterygopalatine fossa.
(Bottom) At level of orbital apex the lesser wing of the sphenoid bone is visible as the posterior orbital roof. The
II planum sphenoidale is the anterior roof of the sphenoid bone.
18
 ANTERIOR SKULL BASE
CORONAL BONE CT I
("0

~
0..
Frontal bone ~
::::s
Cribriform plates, ethmoid 0..
Fovea ethmoidalis bone Z
("0

("\

Olfactory mucosa in olfactory ~

recess -i
Perpendicular plate, ethmoid bone (!)
:3
-0
o
...,
C>

CO
o
::::s
(!)
C>
::::s
0...
Vl
A
C
Crista galli, ethmoid bone
Orbital roof, frontal bone

Cribriform plate, ethmoid bone

Lateral lamella
Fovea ethmoidalis, frontal bone

Lamina papyracea
Perpendicular plate, ethmoid bone

Frontal bone

Frontal crest

Frontal sinus

Nasal bone

(Top) At the level of the posterior cribriform plate the fovea ethmoidalis is seen sloping gradually toward the
midline. In the midline the cribriform plates themselves are visible. (Middle) At the level of the crista galli it is
possible to see the multiple pieces of the ethmoid bone. The crista galli is the most cephalad portion of the ethmoid
bone, extending directly inferiorly into the perpendicular plate of the ethmoid bone. Just lateral to the base of the
crista galli are the cribriform plates, lateral lamellae & fovea ethmoidalis portions of the frontal bone. (Bottom) In
this image through the frontal bone & sinus note the anteroinferior nasal bone. Do not confuse the more
anterosuperior frontal crest (part of frontal bones) with crista galli (part of ethmoid), not seen on this image.
II
19
 ANTERIOR SKULL BASE
~ AXIAL BONE CT DEVELOPMENT
~
c::!:)
Anterior neuropore
Foramen cecum area
Crista galli area
Anterior ethmoid air cells
Vertical plate, ethmoid bone
Posterior ethmoid air cells

~
•....
o
Q..

E
Q)
I-
~
u
Q)
Z
-C
C
C\l
-C
C\l
Q)
:r: Frontal bone
Foramen cecum area
Crista galli

Ethmoid bone

Frontal sinus

Foramen cecum remnant pit

Crista galli
Anterior ethmoid air cells

Posterior ethmoid air cells

Sphenoid sinus

(Top) Axial bone CT through the anterior skull base in a newborn. The unossified gap between the nasal and frontal
bones normally contains dura at this age and represents the regressing anterior neuropore. The area of the foramen
cecum, crista galli, cribriform plate and perpendicular plate of the ethmoid bone are all normally unossified in the
newborn. (Middle) Axial bone CT through the anterior skull base at 12 months. Crista galli is now well-ossified. The
foramen cecum area is still not ossified. The foramen cecum is still open but the margins cannot be defined.
(Bottom) Axial bone CT through the anterior skull base in an adult. The ethmoid air cells now extend far above the
horizontal plane of the cribriform plate. Crista galli is thickened and heavily ossified. Although closed, the foramen
II cecum still demonstrates a small remnant pit.
20
 ANTERIOR SKULL BASE
CORONAL BONE CT DEVELOPMENT I
ro
~
0-
~
:J
0-
Z
ro
~
7'
Crista galli site Cribriform plate site -i
(D
""0
:3
Perpendicular plate, ethmoid bone o
....•
CJ

OJ
o
:J
(D
CJ
:J
0-
(j)

7'
C

Cribriform plate
Crista galli
Fovea ethmoidalis

Anterior ethmoid air cells

Lateral lamella

Orbital roof, frontal bone Crista galli

Fovea ethmoidalis, frontal bone

Cribriform plate, ethmoid bone Lateral lamella

Olfactory recess with olfactory
mucosa Perpendicular plate, ethmoid
bone

(Top) Coronal bone CT through the anterior skull base in a newborn. Anterior skull base is largely unossified,
including crista galli, cribriform plate and perpendicular plate of ethmoid bone. There is a large gap between the
orbital plates of frontal bones. Ethmoid air cells are not yet developed (Middle) Coronal bone CT through anterior
skull base at 12 months. Ethmoid bone is now mostly ossified, particularly crista gaJli & posterior cribriform plate.
Until age 2-3, unossified gaps in anterior cribriform plate & foramen cecum (not shown) can be normal. Note
developing lateral lamella & fovea ethmoidalis are small. (Bottom) Coronal bone CT through anterior skull base in
an adult. Anterior skull base is completely ossified. Ethmoid air cells extend superolateral to plane of the cribriform
plate. Fovea ethmoidalis connected to cribriform plate by lateral lamella. II
21
 ANTERIOR SKULL BASE
~ CORONAL T2 MR DEVELOPMENT
ro
CO

:J
....Y.
V)
""0

c
ro
Q)
c
o Crista galli
CO
ro
'-
o Fovea ethmoidalis Cribriform plate
CL
E
Q)
r- Olfactory recess

Perpendicular plate,
ethmoid bone

Crista galli

Cribriform plate

Fovea ethmoidalis

Developing ethmoid
sinus
Olfactory recess

(Top) Coronal T2 MR through the anterior skull base in a newborn. The anterior skull base is poorly ossified at birth.
The cartilaginous crista galli and cribriform plate have an intermediate signal intensity. (Bottom) Coronal T2 MR
through the anterior skull base at 6 months. Notice the distance between the cribriform plate-fovea ethmoidalis and
the olfactory recess of the nose is enlarging with the development of ethmoid sinuses.

II
22
 ANTERIOR SKULL BASE
CORONAL T2 MR DEVELOPMENT ::I:
ro
~
Q..
~
:J
Q..

Z
ro
~
7'
Crista galli -i
ro
Cribriform plate
""0
3
Fovea ethmoidalis
o
"'""
Lateral lamella ~

Anterior ethmoid sinus

Perpendicular plate,
ethmoid bone

Gyrus rectus Crista galli

Fovea ethmoidalis,
frontal bone
Lateral lamella

Anterior ethmoid sinus

Cribriform, ethmoid
bone
Perpendicular plate,
ethmoid bone

(Top) Coronal T2 MR through the anterior skull base at 12 months. The crista galli, cribriform plate, lateral lamella
and fovea ethmoidalis are largely ossified at this age. As a result the anterior skull base appears as low signal intensity
form cortical bone. Notice the ethmoid sinus aeration now projects cephalad to the level of the crista galli base. The
lateral lamella connects the fovea ethmoidalis to the lateral cribriform plate. (Bottom) Coronal T2 MR image
through the anterior skull base in an adult. By adulthood, there is a significant amount of high signal fat in the
well-ossified crista galli. Gyri recti appear to extend far more inferiorly than in childhood because the ethmoid air
cell have enlarged superiorly. II
23
 ANTERIOR SKULL BASE
~ SAGITTAL T1 MR DEVELOPMENT
~
a:l

Foramen cecum Cribriform plate/fovea

ethmoidalis

Fonticulus frontalis
Pituitary gland
Body, sphenoid bone
Chondrocranium, anterior skull
base

Cribriform plate
Frontal bone
Crista galli Planum sphenoidale

Dorsum sella
Nasal bone

Foramen cecum Sphenooccipital synchondrosis

Basiocciput (clivus)

Body of sphenoid bone

Frontal bone

Frontal sinus
Planum sphenoidale
Nasal bone

Crista galli Sphenoid sinus

Basiocciput (clivus)

(Top) Sagittal Tl MR of anterior skull base in a 6 month old infant. The area of cribriform plate/fovea ethmoidalis
has begun to ossify, hence the low signal line. Foramen cecum margins are difficult to discern as a result of absent
ossification in the area. (Middle) Sagittal T1 MR of anterior skull base in 18 month old. There is rapid ossification of
this area in 1st year of life. Note high signal fatty marrow in crista galli. Foramen cecum is visible anterior to crista
galli, normally containing thin dural stalk that will obliterate by 5 years of age. (Bottom) Sagittal T1 MR of anterior
skull base in an adult. Crista galli is readily visible because its fatty marrow. Foramen cecum is not seen because it is
now fused. The frontal bone is distinguishable from the nasal bone anteriorly.
II
24
 ANTERIOR SKULL BASE
SAGITTAL T2 MR DEVELOPMENT

Planum sphenoidale

Chondrocranium

Frontal bone
Crista galli Planum sphenoidale

Dorsum sellae
Foramen cecum remnant pit
Body sphenoid bone
Nasal bone Sphenooccipital synchondrosis
Basiocciput (clivus)
Cribriform plate

Frontal bone

Frontal sinus
Planum sphenoidale
Nasal bone

Crista galli

Cribriform plate Sphenoid sinus

(Top) Sagittal T2 MR of anterior skull base in a newborn. The chondrocranium is mostly intermediate signal
intensity. Large "gaps" of the anterior skull base are seen because there is little ossification, particularly anteriorly.
(Middle) Sagittal T2 MR of anterior skull base at 18 months. As anterior skull base progressively ossifies, crista galli
becomes more conspicuous. The frontal and sphenoid bones are higher signal due to fatty marrow. Both the
sphenoid and frontal sinuses continue to pneumatize well into the teenage years. Cribriform plate ossification is
signaled by dark line anterior to planum sphenoidale. (Bottom) Sagittal T2 MR of anterior skull base in an adult.
Crista galli is fully ossified and filled with high signal fatty marrow. Foramen cecum is fused & therefore not visible.
The sphenoid sinus is fully pneumatized. II
25
 Q)
Vl
CENTRAL SKULL BASE
~
co • Foramen ovale
I Terminology o Transmits: CNV3, lesser petrosal nerve, accessory
~
~ Abbreviations meningeal branch of maxillary artery & emissary
tJ)
• Anterior, central, posterior skull base (ASB,CSB, PSB) vein
"0
• Greater, lesser wings of sphenoid (GWS), (LWS) o Completely within GWS
c o Provides direct connection to masticator space
~
Q)
Definitions • Foramen spinosum
c • CSB:Skull base posterior to LWS/planum sphenoidale o Transmits: Middle meningeal artery & vein,
a & anterior to petrous ridge/dorsum sella meningeal branch of CNV3
co o Within GWS, posterolateral to foramen ova Ie
~ • Foramen lacerum
L-

a
a.
I Imaging Anatomy o Not true foramen
o Between temporal & sphenoid bones
E Overview o Cartilaginous floor of medial part of horizontal
Q)
• CSB is floor of middle cranial fossa & roof of sphenoid petrous internal carotid artery canal
I-
sinus and GWS • Vidian canal
~ • Bones forming CSB o Transmits: Vidian artery and nerve
u o Sphenoid bone, basisphenoid & GWS
Q) o Formed by sphenoid bone, inferomedial to foramen
Z o Temporal bone anterior to petrous ridge rotundum
"0 • Boundaries of CSB
c: o Anteriorly boundary: Planum sphenoidale posterior Development of Central Skull Base
n:s margin (tuberculum sellae) medially & LWS laterally • CSB formed by > 2S ossification centers
"0
o Posterior boundary: Dorsum sella medially & • Ossification occurs from posterior to anterior
n:s petro us ridges laterally • Important ossification centers: Orbitosphenoids,
Q)
J: • Relationships of CSB alisphenoids, pre- and postsphenoid, basiocciput
o Superior: Temporal lobes, pituitary, cavernous sinus, o Orbitosphenoids => LWS, alisphenoids => GWS
Meckel cave, CNI-4, CN6, CNVI-3 o Presphenoid and postsphenoid fuse at - 3 months
o Inferior: Anterior roof of pharyngeal mucosal space, o Postsphenoid and basi occiput fuse => clivus
masticator, parotid & parapharyngeal spaces • Sphenooccipital synchondrosis
o Between postsphenoid and basiocciput
Bony landmarks of Central Skull Base o Responsible for most of postnatal SBgrowth
• Sella turcica: Contains pituitary gland o One of last sutures of SB to fuse
• Anterior clinoid processes: Extend posteromedially o Open until 14 years, fuses by - 16 years in girls & -
off lesser wing of sphenoid 18 years in boys
• Posterior clinoid processes: Extend posterolaterally
off dorsum sellae; attachment for tentorium cerebelli Variant Anatomy
• Chiasmatic sulcus: Just posteroinferior from posterior • Persistent craniopharyngeal canal
margin of planum sphenoidale; optic chiasm here o Remnant of Rathke pouch
• Tuberculum sellae: Anterosuperior margin of sella o Vertical cleft in sphenoid body at site of fusion of
turcica pre- & postsphenoid; just posterior to tuberculum
sellae area in adult
Foramina and Fissures of Central Skull Base o Extends from sella turcica to nasopharynx
• Optic canal • Extensive pneumatization of sphenoid sinus
o Transmits: CN2 with dura, arachnoid & pia, CSF & o Can cause endosinal vidian canals & foramen
ophthalmic artery rotundum
o Formed by LWS, superomedial to superior orbital o Pneumatized clinoid processes
fissure • Canaliculus innominatus
• Superior orbital fissure (SOF) o Variant canal for lesser superficial petrosal nerve,
o Transmits: CN3, CN4, CNVI & CN6 and superior medial to foramen spinosum
ophthalmic vein • Foramen of Vesalius
o Formed by cleft between LWS & GWS o Transmits emissary vein from cavernous sinus to
• Inferior orbital fissure (IOF) pterygoid plexus
o Transmits: Infraorbital artery, vein & nerve o Anterior to foramen ovale
o Formed by cleft between body of maxilla & GWS
• Carotid canal
o Transmits: Internal carotid artery & sympathetic IAnatomy-Based Imaging Issues
plexus
o Formed by GWS & temporal bone Imaging Pitfalls
• Foramen rotundum • Beware sphenoid MR signal changes!
o Transmits: CNV2, artery of foramen rotundum & o Sphenoid sinus: Low signal cartilage until 2 years ...•
emissary veins high signal fat until 6 years ...•low signal air (adult)
o Completely within sphenoid bone; superolateral to o Clivus low signal until 2S years, then high signal fat
vidian canal • Do not confuse pneumatized clinoid processes with
o Provides direct connection to pterygopalatine fossa vascular flow voids on MR

II
26
-I
([)

:3
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o
~
OJ

OJ
o
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27
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co
:)
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Cf)
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('\l
Q)
c
o
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Q)
Z
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c:
~
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II
28
 CENTRAL SKULL BASE
AXIAL BONE CT

Sphenoid sinus Posterior ethmoid air cells

Superior orbital fissure

Optic canal

Anterior clinoid process

Posterior clinoid process
Tuberculum sellae

Dorsum sella

Cribriform plate

Posterior ethmoid air cells

Greater wing, sphenoid bone
Superior orbital fissure
Sphenoid sinus in sphenoid
body
Sella turcica

Middle cranial fossa

Dorsum sella

Posterior ethmoid air cells Greater wing, sphenoid bone

Sphenoid body Superior orbital fissure

Floor of sella

Dorsum sella

(Top) First of nine axial bone CT images of the central skull base presented from superior to inferior. Note that the
posterior clinoids merge with the dorsum sella. The optic canal is bound by sphenoid sinus medially and anterior
clinoid process laterally. lnferolateral to optic canal is superior orbital fissure. (Middle) At the level of sella turcica,
the superior orbital fissure is seen as the medial opening of the orbit into the middle cranial fossa. It lies below optic
canal. between the greater wing of the sphenoid and the sphenoid sinus. The sella turcica is bound by the dorsum
sella posteriorly. (Bottom) In this image the body of the sphenoid bone is seen to be made up of the sphenoid sinus,
sella turcica and the dorsum sella. Anterior to the sphenoid bone is the ethmoid bone.
II
29
 CENTRAL SKULL BASE
~ AXIAL BONE CT
<i:l
CCl

Posterior ethmoid air cells

Greater wing, sphenoid bone

Superior orbital fissure
Sphenoid sinus

<i:l
~
o Basisphenoid part of clivus
0... Petrous apex
E
Q)
r-
~
u
Q)
Z
"'0
t:
<i:l
"'0
~
Q)
Pterygomaxillary fissure
:r: Inferior orbital fissure
Pterygopalatine fossa
Sphenoid sinus

Foramen rotundum

Cavernous internal carotid

artery

Sphenooccipital synchondrosis Petrous ridge

Infraorbital nerve Infraorbital nerve

Pterygomaxillary fissure
Pterygopalatine fossa
Foramen rotundum Foramen rotundum

Sphenooccipital synchondrosis

Horizontal petrous internal carotid Petrooccipital fissure

artery canal
Basiocciput part of clivus

(Top) In this image the clivus can be seen forming the medial posterior boundary of central skull base while the
petrous ridge defines its lateral margin. (Middle) This image shows that pneumatization of sphenoid extending up to
the sphenooccipital synchondrosis, which is partly unfused in this young adult. Note the foramen rotundum empties
anteriorly into the pteryzopalatine fossa which connects laterally with the masticator space through the
pterygomaxillary fissure. (Bottom) At the level of foramen rotundum both pterygopalatine fossae are clearly visible.
The maxillary division of trigeminal nerve (CNV2) exits the skull base through the foramen rotundum & continues
as infraorbital nerve into orbit via inferior orbital fissure. Malignant tumors of the skin of the cheek orbit &
II sinonasal area may all use CNV2 as a perineural route to ,gilin intracranial access.
30
 CENTRAL SKULL BASE
AXIAL BONE CT

Pterygomaxillary fissure

Sphenopalatine foramen
Pterygopalatine fossa

Vidian canal Vidian canal

Foramen ovale
Forman lace rum
Foramen spinosulll

Vertical petrous internal carotid

artery canal Petrooccipital fissure

Sphenooccipital synchondrosis

Pterygomaxillary fissure

Sphenopalatine foramen
Pterygopalatine fossa
Sphenooccipital synchondrosis
Vidian canal

Forman ovale
Foramen lace rum Foramen spinosum

Vertical petrous internal carotid

artery canal Petrooccipital fissure

Pterygopalatine fossa
Sphenoid sinus
Sphenooccipital synchondrosis
Foramen ovale
Foramen spinosum
Foramen lacerum
Bony eustachian tube
Vertical petrous internal carotid Petrooccipital fissure
artery canal

(Top) In this image the vidian canal is visible connecting pterygopalatine fossa anteriorly to carotid canal floor
(foramen lacerum) posteriorly. A malignant tumor that has accessed the pterygopalatine fossa may reach the carotid
canal of the skull base via perineural spread on the vidian nerve in the vidian canal. There is a medial connection
•i .;I
between the pterygopalatine fossa & nose the sphenopalatine foramen. Juvenile angiofibroma begins along the nasal
margin of this foramen. (Middle) In this image note the foramen ovaIe is located in the greater wing of the sphenoid
bone. Extracranial perineural malignancy on CNV3 enters the intracranial area via foramen ovale. (Bottom) In this
image note the foramen spinosum is posterolateral to the foramen ovale in the greater wing of the sphenoid bone.
The middle meningeal artery passes intracranially via the foramen spinosum. II
31
 CENTRAL SKULL BASE
~ CORONAL BONE CT
~
co

Greater wing, sphenoid bone Sphenoid body

Foramen lacerum

Adenoids of nasopharyngeal
mucosal space

~
'-
o Nasopharyngeal airway
Q..
E
Q.)
f-
~
u
C1)
Z
""C
c: Vidian canal
(OJ

""C
(OJ Greater wing of sphenoid
Vidian canal
C1)
:c Foramen ovale
Foramen ovale

Adenoids
Torus tubarius

Anterior clinoid process

Foramen rotundum
Foramen rotundum

Vidian canal Vidian canal

Medial pterygoid plate

Lateral pterygoid plate

Hamulus

(Top) First of three coronal bone CT images of the central skull base presented from posterior to anterior. The
foramen lacerum is seen as a large defect between the greater wing of the sphenoid bone and the sphenoid body.
Foramen lacerum is not a true foramen. It represents the cartilaginous floor of the anteromedial horizontal segment
of the petrous internal carotid artery canal. (Middle) In this image the foramen ovale is evident lateral to the vidian
canal and anterolateral to foramen lacerum. It transmits CNV3 from the middle cranial fossa to the masticator spac~.
(Bottom) More anteriorly, foramen rotundum and vidian canal are both seen running in the transverse plane. Both
foramen rotundum and vidian canal open into the pterygopalatine fossa. Also note the pterygoid plates inferiorly.
II
32
 CENTRAL SKULL BASE
AXIAL T1 C+ MR

Posterior ethmoid air cells

Greater wing, sphenoid bone

Superior orbital fissure

Sphenoid sinus

Oculomotor nerve
Pituitary gland
Cavernous internal carotid artery
Dorsum sella

Greater wing, sphenoid bone

Sphenoid sinus

Cavernous sinus Temporal lobe

Meckel cave
Abducens nerve

Basisphenoid part of clivus

Greater wing, sphenoid bone

Pterygopalatine fossa

Sphenoid sinus
Trigeminal ganglion
Cavernous internal carotid artery
Meckel cave
Abducens nerve
Basiocciput part of clivus

(Top) First of six axial Tl C+ MR images of the central skull base presented from superior to inferior. The enhancing
venous plexus of the cavernous sinus is seen surrounding the cavernous internal carotid artery. Medially, the
enhancing pituitary gland in the sella turcica is bound by the dorsum sella posteriorly and the sphenoid sinus
anteriorly. (Middle) In this image the upper basisphenoid part of the clivus is seen. Cerebrospinal fluid-filled Meckel
cave is seen along the posterior border of the cavernous sinus. (Bottom) In this image the basiocciput part of the
clivus is visible. The u er clivt!s above the fused sphenooccipital synchondrosis is part of the s henoid b e while
the lower cliYu~is part of the occipital bon~. Notice the marrow space of the clivus enhances.
II
33
 CENTRAL SKULL BASE
&; AXIAL T1 C+ MR
ru
CO

~
.:::t:. Inferior orbital fissure
(../)

""D
Maxillary sinus
Pterygopalatine fossa
c
ru
Q)
Sphenoid sinus
c Foramen rotundum
o
CO Anterior genu of horizontal
Meckel cave petrous ICA
ru
•....
o Clival occipital bone
0...
E
Q)
~
~
u
Q)
Z
"'0
s:::
~
"'0
~
Q)
:r: Pterygopalatine fossa Maxillary nerve (CNV2)

Foramen rotundum
Maxillary nerve (CN2)

Mandibular nerve (CNV3)

Mandibular nerve (CNV3)

Clival occipital bone

Internal maxillary artery

Pterygopalatine fossa
Pterygoid process of sphenoid
Vidian canal bone
CNV3 in foramen ovale

CNV3 in foramen ovale Middle meningeal artery in

foramen spinosum
Middle meningeal artery in Body, sphenoid bone
foramen spinosum
Horizontal petrous ICA

Clival occipital bone

(Top) Image through superior pterygopalatine fossa with its anterolateral connection to the inferior orbital fissure
visible. The anteriorly projecting foramen rotundum can also be seen. The sphenoid bone is partially pneumatized
(sphenoid sinus). (Middle) In this image the maxillary nerve (CNV2) is seen as a linear low intensity structure in the
foramen rotundum on the right. On the left this same nerve can be seen exiting the foramen rotundum into the
pterygopalatine fossa. (Bottom) At the level of the foramen ovale the mandibular nerve (CNV3) is seen bilaterally.
Also note the middle meningeal artery passing through the foramen spinosum. The vidian canal is clearly visible
medial to the foramen ovale. The clival occipital bone should be distinguished from the body of the sphenoid bone
II even though the sphenooccipital fissure cannot be discerned.
34
 CENTRAL SKULL BASE
SAGITTAL T1 & T2 MR DEVELOPMENT

Intersphenoidal synchondrosis

Sphenooccipital synchondrosis
Presphenoid

Postsphenoid

Basiocciput

Sella turcica
Sphenooccipital synchondrosis
Sphenoid

Basiocciput

Planum sphenoidale Dorsum sella

Sphenoid sinus Sphenooccipital synchondrosis

area
Basiocciput

(Top) Sagittal T2 MR of the CSB in a newborn shows the important synchondroses of this area. The intersphenoidal
suture separates presphenoid from postsphenoid while the sphenooccipital synchondrosis separates postsphenoid
from basiocciput. (Middle) Sagittal T1 MR of central skull base at 6 months. The intersphenoidal suture closes at
about 3 months age resulting in formation of the sphenoid body from the presphenoid and postsphenoid. There is
normal high signal fat within what used to be presphenoid. The sphenooccipital synchondrosis will remain open
until adolescence. (Bottom) Sagittal T2 MR of central skull base in an adult. Typically, pneumatization extends
throughout the entire sphenoid body up to the fused sphenooccipital synchondrosis. The sphenooccipital
synchondrosis is one of last sutures of skull base to close. It fuses completely by about 16-18 years. II
35
 POSTERIOR SKULL BASE
• Transmits CNlO, Arnold nerve, CNll, jugular
I Terminology bulb & posterior meningeal artery
:J • Larger than pars nervosa
~ Abbreviations
(J)
• Posterior & central skull base (PSB, CSB) • Groove for sigmoid sinus
""C
• Temporal bone (TB) o Groove in medial mastoid temporal bone; cradles
c: sigmoid sinus
C'I:l • Jugular foramen OF)
Q) • Hypoglossal canal
c: Definitions o Transmits: CN12
a • PSB: Skull base (SB) posterior to dorsum sella & petrous o Formed in condylar occipital bone
co ridges o Inferomedial to jugular foramen
C'I:l • Foramen magnum
L-
a o Transmits: CNll (cephalad component), vertebral
c.. I Imaging Anatomy arteries & medulla oblongata
E o Formed completely by occipital bone
Q) Overview • Stylomastoid foramen
I-
• PSB is made up of posterior temporal bones & occipital o Transmits: CN7
J.au bone and transmits CN7-12, medulla oblongata & o Found in exocranial skull base surface between
IV jugular vein mastoid tip & styloid process
Z • Bones of PSB o Extends directly into parotid space
"'C o Temporal bones posterior to petrous ridges
o Occipital bone (3 parts) Development of Posterior Skull Base
C
tU • Basilar part (basiocciput): Quadrilateral part • Occipital bone has 4 major ossification centers around
"'C
anterior to foramen magnum foramen magnum
tU o Supraoccipital, basioccipital & paired exoccipital
Q) • Condylar part (exoccipital): Occipital condyles
here; lateral to foramen magnum • PSB is nearly completely ossified by birth
J: • Sutures of PSB remain unfused until 2nd decade
• Squamous part: Large bony plate posterosuperior
to foramen magnum o Intraoccipital sutures fuses between 8 & 16 years
• Boundaries of PSB o Petrooccipital & occipitomastoid sutures are among
o Anterior boundary: Dorsum sella medially and last to close (15-17 years)
petrous ridges laterally • Kerckring ossicle
o Posterior boundary: Occipital bone o Small ovoid ossicle at posterior margin of FM
• Relationships of PSB o Unfused & separate in 50% of term newborns
o Inferior relationships: Posterior roof of pharyngeal o Kerckring-supraoccipital suture fuses by 1 year
mucosal space, carotid, parotid, retropharyngeal, Variant Anatomy of Posterior Skull Base
perivertebral spaces & cervical spine
• Posterior condylar canal
o Superior relationships: Brainstem, cerebellum,
o Inconstant canal for emissary vein & meningeal
CN7-8, CN9-12, transverse-sigmoid sinuses
branch of ascending pharyngeal artery
Bony landmarks of Posterior Skull Base o One of largest emissary foramina of SB
• Petrous ridge of temporal bone • Asymmetric petrous apices
o Divides CSB from PSB o Can contain high signal fat or low signal air
o Attachment for fixed edge of tentorium cerebelli • Mastoid foramen
• Jugular tubercle o Variably transmits emissary vein from sigmoid sinus
o Roof of hypoglossal canal seen well on coronal • Persistent Kerckring ossicle
imaging
o "Eagle's head" on coronal images is jugular tubercle
IAnatomy-Based Imaging Issues
Foramina and Fissures of Posterior Skull Base
• Internal acoustic meatus Key Concepts or Questions
o Transmits: CN7-8, labyrinthine artery • PSB is largely ossified at birth but PSB sutures are last
o Opening in posterior wall TB superior to jugular in SB to fuse
foramen • PSB is intimately related to carotid & parotid spaces
o Porus acusticus: Internal opening of internal
Imaging Recommendations
acoustic meatus
• Bone CT with edge enhancement algorithm & wide
• Jugular foramen
o Two parts: Pars nervosa & pars vascularis partially windows (> 2000 HU)
divided by jugular spine • Use coronal imaging to examine normal "double
o Between temporal & occipital bones eagles" of hypoglossal canal & jugular foramen area
o Carotid space extends directly up to JF Imaging Pitfalls
o Pars nervosa • Watch for asymmetric petrous apex air and/or fat
• Transmits CN9, Jacobson nerve & inferior petrosal • Beware of jugular foramen pseudolesion from MR flow
sinus phenomenon
• Anteromedial but contiguous with pars vascularis • Beware open synchondroses/suture as pseudofracture
o Pars vascularis

II
36
II
37
 :J
.:L
Vi
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c
Ci:l
<lJ
C
o
CO

II
38
 POSTERIOR SKULL BASE
AXIAL BONE CT

Dorsum sellae
Internal auditory canal
Petrous apex
Porus acusticus

Sigmoid plate

Occipitomastoid suture
Internal occipital crest

Clivus
Sphenooccipital synchondrosis
Petrous apex

Jugular bulb
Jugular bulb roof
Mastoid air cells
Sigmoid plate

Occipitomastoid suture

Occipital bone, squamous part

Sphenooccipital synchondrosis
Petrous apex

Pars nervosa, jugular foramen

Horizontal petrous internal carotid
artery Jugular spine

Pars vascularis, jugular foramen

Sigmoid sinus

Occipitomastoid suture

Occipital bone, squamous part

(Top) First of a nine axial bone CT images presented from superior to inferior shows the dorsum sella and the petrous
temporal bone as the anterior margin of the posterior skull base. Posteriorly the midline is demarcated by the bony
internal occipital crest which provides attachment for the falx cerebelli. Porus acusticus is the most superior foramen
of posterior skull base and transmits CN? and 8. (Middle) At the level of mid-cochlea the posterior cranial fossa is
completely divided from middle cranial fossa by the clivus and petrous temporal bone. Laterally, the sigmoid plate
separates the mastoid air cells from the sigmoid sinus. The jugular bulbs are visible bilaterally. (Bottom) At level of
mid-jugular foramen note smaller anteromedial pars nervosa (CN9, Jacobsen nerve, inferior petrosal sinus) & larger
pars vascularis (jugular bulb, Arnold nerve, CNI0 and 11). II
39
 POSTERIOR SKULL BASE
~ AXIAL BONE CT
~
CO

:J Sphenooccipital synchondrosis Horizontal petrous ICA

...:::£
c./)
""0 Petrous apex
c
~ Petrooccipital fissure Pars nervosa
Q)
c
o Pars vascularis
CO
~ Sigmoid sinus
o
"'-
Occipitomastoid suture jugular tubercle
Q..
E
Q)
f- Occipital bone, squamous part Internal occipital protuberance
~
u
Q)
Z
-0
C Clival occipital
n:l Sphenooccipital synchondrosis bone/basi occiput
-0
n:l Foramen lacerum
Q) Petrooccipital fissure
:r:
Temporomandibular joint
Vertical petrous internal carotid
artery canal
jugular foramen

jugular tubercle, occipital bone

Sigmoid Sinus

Occipitomastoid suture
Occipital bone

Sphenooccipital synchondrosis
Petrooccipital fissure

Clival occipital bone

Carotid canal entrance

jugular foramen
Foramen magnum
Occipitomastoid suture

Occipital bone, condylar (lateral)

portion

Occipital bone, squamous part

(Top) Image of posterior skull base shows the sphenooccipital synchondrosis, the petrooccipital fissure and the
occipitomastoid suture all in the same plane. The sphenooccipital synchondrosis has not yet fused in this young
adolescent. (Middle) Image through the jugular tubercle the clivus is made up almost completely of anterior
occipital bone. The upper third of the clivus is above the sphenooccipital synchondrosis and is therefore part of the
sphenoid bone. (Bottom) In this image the lower clivus (below the sphenooccipital synchondrosis) is clearly made
up of occipital bone. The petrooccipital fissure separates the temporal bone from the occipital bone. The
occipitomastoid suture separates the mastoid sinus from the squamosal portion of the occipital bone.
II
40
 POSTERIOR SKULL BASE
AXIAL BONE CT

Foramen ova Ie
Vidian canal
Foramen spinosum
Clivus (basi occiput)
Mandibular condyle

Nasopharyngeal carotid space Hypoglossal canal

Occipital bone, condylar
Stylomastoid foramen (CN?) portion

Sphenoid bone

Occipital bone, basilar portion

(clivus)
Hypoglossal canal, inferior margin
Occipital condyle

Basilar occipital bone (clivus)

Styloid process

Occipital condyle
Mastoid tip

(Top) This image passes directly through the hypoglossal canal and stylomastoid foramen. This canal transmits only
the hypoglossal nerve. Notice that as soon as the nerve exits the hypoglossal canal it immediately enters the
nasopharyngeal carotid spaceto join the glossopharyngeal (CN9), vagus (CNlO) and accessory (CNll) cranial nerves.
(Middle) In this image the inferior margin of the hypoglossal canal runs within occipital bone, between the basilar
(dival) and condylar portions. The inferior surface of the condylar occipital bone are the occipital condyles.
(Bottom) In this image through the occipital condyle the inferior-most junction of the basilar (dival) occipital bone
& the condylar occipital bone is visible. The occipital condyles rest the cranium upon the lateral masses of atlas (Cl
vertebral body). II
41
 POSTERIOR SKULL BASE
~ CORONAL BONECT
(ij
co
:J
...::£
Vl
Jugular tubercle
-0
c Mastoid air cells
(ij

(]) Jugular foramen (CN9-11)

c Hypoglossal canal
o
co Foramen magnum
(ij Occipital condyle
•....
o
0..
Odontoid process (C2)
E
(])
Lateral mass of atlas (Cl
vertebral body)
f-
~
u
OJ
Z
-C
c
~
-C
~ Jugular foramen
OJ
J:
Condylar (lateral) occipital bone Mastoid segment, CN7

Mastoid process
Stylomastoid foramen
Atlanto-occipital joint

Lateral mass of atlas (Cl vertebral

body)

Porus acusticus, posterior margin

Cochlea aqueduct

Jugular tubercle
Jugular foramen
Hypoglossal canal
Occipital condyle

Lateral mass of atlas (Cl vertebral

body)

(Top) First of six coronal bone CT images of left posterior skull base presented from posterior to anterior. The
hypoglossal canal passes through the condylar (lateral) portion of the occipital bone. In the coronal plane with both
sides visible this area has been referred to as the "double eagle". Notice that the eagle's head & beak are the jugular
tubercle. (Middle) In this image through the mastoid (descending) portion of intratemporal facial nerve canal the
condylar part of the occipital bone is outlined. (Bottom) This image shows the classic "eagle" of posterior skull base
with the "beak" of jugular tubercle separating the jugular foramen from the hypo&lossal canal. Lesions of the
hypoglossal canal affect the undersurface of the beak while lesions of the jugular foramen affect the extermil surface
II of the beak ..
42
 POSTERIOR SKULL BASE
CORONAL BONE CT

Internal auditory canal

Porus acusticus

Jugular tubercle Jugular foramen

Carotid space, superior margin

Hypoglossal canal, external
opening

Lateral mass of atlas (Cl)

Tegmen tympani
Internal auditory canal

Porus acusticus

Petrooccipital fissure

Basiocciput (lower clivus)

Anterior arch, Cl

Horizontal petrous internal

carotid artery canal
Condylar fossa

Basiocciput (lower clivus)

Mandibular head
Petrooccipital fissure

(Top) In this image of left skull base and temporal bone notice both the hypoglossal canal and the jugular foramen
"empty" into the cephalad carotid space. The upper carotid space therefore contains CN9-12 as well as the internal
jugular vein. (Middle) In this image through the mid-internal auditory canal the petrooccipital fissure is visible
separating the basioccipital portion of the occipital bone from the temporal bone. (Bottom) In this image through
the condylar fossa of the temporomandibular joint the petro occipital fissure is seen between the basiocciput and the
temporal bone. The basiocciput is a large quadrilateral portion of the occipital bone that extends anterosuperiorly
from the anterior margin of the foramen magnum to reach the sphenoid bone approximately 2/3 of the way up the II
clivus.
43
 POSTERIOR SKULL BASE
~ AXIAL T1 C+ MR
ro
CO

:J
~
(./)
Inferior petrosal
""0
sinus/petrooccipital fissure
C
ro Internal carotid artery
Q)
c Clival occipital bone
o (basiocciput)
CO Jugular bulb within jugular
foramen
ro
•... Sigmoidsinus
o
Q..
Sigmoid sinus

Q)
E
I-
~
u
Q)
Z
"'C
C
ro
"'C
ro
Q)
J: Clival occipital bone
(basiocciput)
Internal carotid artery

Jugular bulb Jugular bulb

Sigmoidsinus
Hypoglossalnerve
Hypoglossalnerve

Internal carotid artery

Internal jugular vein
Nasopharyngeal carotid space
Medulla oblongata

Mastoid emissary vein Vertebralartery

Cerebellartonsils

(Top) First of three axial fat-saturated Tl C+ MR images of the posterior skull base presented from superior to
inferior. On the patient's right the high signal enhancing sigmoid sinus can be seen connecting anteromedially with
the jugular bulb. (Middle) At the level of the hypoglossal canals the hypoglossal nerves can be seen as linear low
intensity structures surrounded by the enhancing high signal basiocciput venous plexus. The complex signal seen in
both jugular bulbs should not be mistaken for a lesion. (Bottom) At the level of the foramen magnum the internal
jugular vein and internal carotid artery of the carotid space are visible. The vertebral arteries, medulla oblongata and
inferior cerebellar tonsils are normally seen at this level.
II
44
 POSTERIOR SKULL BASE
CORONAL T1 C+ MR I
(l)
PJ
Q..
PJ
::J
Q..

Z
Jugular tubercle (l)
("')

7'
Jugular bulb -1
Hypoglossal nerve ro
""'0
:3
Occipital condyle o
.,
Atlanto-occipital joint
~
Lateral mass Cl

Jugular tubercle

Jugular bulb
Hypoglossal canal
Hypoglossal nerve
Hypoglossal nerve
Occipital condyle
Atlanto-occipital joint

Lateral mass Cl Dens

Pons

Vertebral artery
Jugular tubercle

Basiocciput
Internal jugular vein
Occipital condyle

Lateral mass Cl Dens

Body C2

(Top) First of three coronal Tl C+ MR images of the posterior skull base presented from posterior to anterior shows
the jugular bulb within the jugular foramen. The low signal hypoglossal nerve is seen just below the "eagle's head" in
the hypoglossal canal. The high signal perineural basiocciput venous plexus is visible surrounding the hypoglossal
nerve. (Middle) In this image the classic "double eagle heads" are visible (jugular tubercles) with the hypoglossal
nerve seen exiting the inferior hypoglossal canal. (Bottom) In this image the anterior jugular tubercle can be seen
meeting the inferior basiocciput. The jugular bulb has connected inferiorly with the internal jugular vein. The
internal jugular vein is within the nasopharyngeal carotid space.
II
45
 TEMPORAL BONE
• Includes vestibule (utricle &. saccule), semicircular
ITerminology ducts, scala media of cochlea, endolymphatic duct
::J &. sac
~ Abbreviations
(f)
• Temporal bone (T-bone) • Endolymph = fluid within structures of
-0 membranous labyrinth
c Definitions o Cochlea: - 2 1/2 turns; modiolus; 3 spiral chambers
tiJ
Q) • T-bone: Paired bones located in posterolateral floor of (scala tympani, scala vestibuli &. scala media)
C middle &. posterior cranial fossae made up of petrous o Semicircular canals (SCC), superior (S), lateral (L) &.
a pyramid &. mastoid complex posterior (1')
C!:l
• SSCC: Projects cephalad; bony ridge over SSCC in
tiJ roof of petrous pyramid called arcuate eminence
L-
a I Imaging Anatomy • LSCC: Projects into middle ear with tympanic
0... CN? on under side
E Overview • PSCC: Projects posteriorly parallel to petrous ridge
Q)
• 5 bony parts to T-bone • Petrous apex: Anteromedial to inner ear
I-
o Squamous: Forms lateral wall of middle cranial fossa o CN6 passes over superior margin of medial PA
~ o Mastoid: Aerated posterolateral T-bone • Intratemporal facial nerve
u o Petrous: Pyramidal shape medial T-bone containing
Q) o CN? segments: lAC, labyrinthine, tympanic,
Z inner ear, internal auditory canal &. petrous apex mastoid segments
""C o Tympanic: V-shaped bone forming bony EAC o Geniculate ganglion = anterior genu
c o Styloid: Forms styloid process after birth o Posterior genu: Tympanic segment bends inferiorly
~ • Major components of temporal bone to become mastoid segment
""C o External auditory canal (EAC) o Stylomastoid foramen: CN? exits skull base here
~ o Middle ear-mastoid (ME-M)
Q) • Petrous internal carotid artery (ICA): C2 segment
:c o Inner ear (IE) o ICA: Vertical &. horizontal T-bone segments
o Petrous apex (PA) o Vertical segment: Rises to genu beneath cochlea
o Internal auditory canal (lAC) o Horizontal segment: Projects anteromedially to turn
o Facial nerve (CN?) cephalad as cavernous ICA
o Petrous internal carotid artery (lCA) • Muscles of T-bone
o Tensor tympani muscle
Internal Structures-Critical Contents • Dampens sound; hyperacusis if injured
• EAC: Tympanic bone medially, fibrocartilage laterally • Innervation: V3 branch
o Medial border is tympanic membrane • Location: Anteromedial wall, mesotympanum
o Nodal drainage to parotid chain • Attachment: Tendon inserts on malleus
• Middle ear-mastoid o Stapedius muscle
o Epitympanum (attic): Middle ear above line from • Dampens sound; hyperacusis if injured
scuta I tip to tympanic CN? • Innervation: CN?
• Tegmen tympani: Roof of middle ear cavity • Location: Muscle belly in pyramidal eminence
• Prussak space = lateral epitympanic recess • Attachment: Tendon attaches on head of stapes
o Mesotympanum: Middle ear proper
• Posterior wall: 3 key structures = facial nerve
recess, pyramidal eminence, sinus tympani IAnatomy-Based Imaging Issues
• Medial wall: Lateral semicircular canal, tympanic
segment CN?, oval &. round window Key Concepts or Questions
o Hypotympanum: Shallow trough in floor of ME • Assign lesion to one of following T-bone areas: EAC,
o Mastoid sinus: 3 key structures ME-M, IE, PA or intra temporal CN?
• Aditus ad antrwn: Connects epitympanum to o Construct location-specific differential diagnosis
mastoid antrum o Match imaging findings to differential diagnosis list
• Mastoid antrum: Large, central mastoid air cell
• Koerner septum: Part of petrosquamosal suture
running posterolaterally through mastoid air cells I Embryology
• Inner ear components
o Bony labyrinth: Bone confining cochlear, vestibule Embryologic Events
&. semicircular canals • EAC forms from 1st branchial groove
o Perilymphatic spaces • Tympanic cavity forms from 1st branchial pouch
• Perilymphatic spaces include area in vestibule • Ossicles form from 1st &. 2nd branchial arch
surrounding utricle &. saccule, semicircular canals • Endolymphatic system forms from otocyst
around semicircular ducts, within scala tympani &. • Perilymphatic space &. otic capsule forms from
vestibuli of cochlea surrounding mesenchyme
• Perilymph = fluid within bony labyrinth that
"bathes" endolymph-containing membranous Practical Implications
labyrinth structures • In EAC atresia, IE spared as it forms from otocyst
o Membranous labyrinth migration independent of EAC-ME formation

II
46
II
47
 Q)
<fl
ro
co
~
..::L.
(/)

""'0
c
ro
Q)
c
o
CO
ro
"-
o
0..
E
Q)
f-
~
u
Q)
Z
"'C
c::
('lj

"'C
('lj
Q)
J:

II
48
II
49
 TEMPORAL BONE
~ AXIAL BONE CT
ro
CO

:J
~
Vl
-0 Squamous T-bone
c
ro
Q.)
c Superior semicircular canal
o
CO Petrous apex
ro
"--
o Mastoid air cells
Q...
E
Q.)
f- Sigmoid sinus

~
u
Q.)
Z
""0

c:
~
""0

~
Q.)
:r:
Petrous apex Epitympanum

Internal auditory canal

Aditus ad antrum
Crus communis
Koerner septum

Bony vestibular aqueduct

Sigmoid plate
Mastoid antrum

Labyrinthine segment CN?

Malleus head in epitympanum
Petrous apex
Porus acusticus of lAC
Prussak space

Lateral semicircular canal

Vestibule Koerner septum

Fovea of bony vestibular aqueduct
Mastoid antrum

Posterior semicircular canal

(Top) First of twelve..axial bone CT images of the left temporal bone presented from sUQ~riorto inferior.. Superior
semicircular canal projects cephalad from inner ear. Bony cover over top of this semicircular canal is called arcuate
eminence. (Middle) At the level of upper internal auditory cana.l the aditus ad antrum (L. "entrance to the cave") is
seen connecting the epitympanum to .mastoid antrum (L. "cave"). Notice Koerner septum separating the mastoid
antrum from squamous portion of the mastoid air cells. (Bottom) ,At the level of the lateral semicircular canal the
opening to the internal auditory canal, the porus acusticus is particularly well seen. The fovea of the bony vestibular
aqueduct along the posterior wall of the T-bone houses the intradural endolymphatic sac. Prussak space is visible as
II the portion of the epitympanum lateral to the ossicles.
50
 TEMPORAL BONE
AXIAL BONE CT

Labyrinthine portion CN? canal

Malleus head
Petrous apex marrow
Prussak space
Internal auditory canal

Vestibule Mastoid antrum

Koerner septum
Fovea of bony vestibular aqueduct

Short process incus

Sigmoid sinus co
o
:J
(t)
C)
:J
Q...
Vl
7'
C
Geniculate ganglion
Tympanic segment CN? canal
Cephalad aspect of cochlear 1st
turn Epitympanic cog
Petrous apex marrow space Malleus head

Body incus

Short process incus

Singular nerve canal
Posterior genu CN?

Posterior semicircular canal

Tympanic segment CN? canal

Cochlear aperture

Facial nerve posterior genu

Oval window
Facial nerve recess
Singular nerve canal Pyramidal eminence/stapedius
muscle
Sinus tympani

(Top) Image through the labyrinthine segment of the facial nerve shows this structure just cephalad to the cochlea.
Prussak space is now visible as the lateral epitympanic recess. This is the first area the typical pars flaccida
cholesteatoma involves in the middle ear. (Middle) In this image the tympanic segment of the facial nerve is seen
from the anteromedial geniculate ganglion to the posterior genu where it changes to become the mastoid segment.
The cog is seen crossing the anterior epitympanum. (Bottom) In this image three key structures on posterior wall of
micidle ear cavity are well seen. From medial to lateral they are the sinus tympani, pyramidal eminence and the facial
nerve recess. Also note the Qval window along the medial wall of the mesotympanum just anterior to the sinus
tympani. II
51
 TEMPORAL BONE
~ AXIAL BONE CT
~
CD

:J
..:::t.
(f)

-0 Cochleariform process
c Modiolus
~ Malleus neck
OJ Cochlear aperture Incus long process
C
o
CD Facial nerve recess
Round window
~
~ Mastoid segment CN?
o jugular bulb apex
Q.. Stapedius muscle in pyramidal
E Sta pes posterior crus eminence
OJ
f-
~
u
Q)
Z
-0
c:
~
-0
~ Cochleariform process
Q)
J: Cochlea, basal turn Tendon of tensor tympani
muscle
Malleus neck
Scutum
Cochlear aqueduct
Incus, lenticular process
Round window
jugular bulb Mastoid segment CN?
Stapedius muscle
Incudostapedial articulation

Tensor tympani muscle

Cochlea, basal turn

Manubrium of malleus
External auditory canal
Cochlear aqueduct

Mastoid segment CN?

jugular bulb
Round window niche
Sigmoid sinus

(Top) Image at the level of the cochlear aperture the cochleariform process can be seen high on the cochlear
promontory. The cochleariform process is the annulus through which the tendon of the tensor tympani muscle turns
toward the more lateral malleus. Stapes crura visible. Stapedius muscle in pyramidal eminence is now distinguishable
from mastoid segment of facial nerve. (Middle) Mid-cochlear image shows both the cochleariform process and the
tendon of the tensor tympani muscle extending over to the malleus. The incudostapedial articulation is visible
between the lenticular process of the incus & the stapes head. Also.note the round window at the base of the basal.
turn of the cochlea. (Bottom) At the level of the low mesotympanum pote the cochlear aqueduct on the medial wall
II inferior to the internal auditory canal. The manubrium of the malleus is also visible.
52
 TEMPORAL BONE
AXIAL BONE CT I
(t)
~
a..
Inferior margin porus trigeminus ~
:J
a..
Tensor tympani muscle Z
(t)
I"'l
7'
Cochlear basal turn Manubrium of malleus
-1
Cochlear aqueduct Chorda tympani nerve ro
3
-0
Jugular foramen
Mastoid segment CN?
-.
o
OJ

OJ
Sigmoid plate o
:J
ro
OJ
:J
Q...
V'l
A
C

Tensor tympani muscle Hypotympanum

Condylar fossa
Horizontal petrous internal carotid
artery
Tympanic membrane
Par nervosa, jugular foramen
Chorda tympani nerve
Jugular spine
Mastoid segment CN?
Par vascularis, jugular foramen

Occipitomastoid suture

Foramen ovale
Foramen spinosum
Mandibular condyle

Basiocciput (clival occipital bone)

Vertical petrous internal carotid
artery
Internal jugular vein
Hypoglossal canal
Stylomastoid foramen

Condylar occipital bone

Occipitomastoid suture
Mastoid tip

(Top) In this image the normal cortex of the sigmoid plate is well seen. The sigmoid plate separates the mastoid air
cells from the sigmoid sinus. Notice the cochlear aqueduct on the medial T-bone wall. (Middle) At the level of the
hypotvmpanum normal gossamer tympanic membrane is just barely visible. The horizontal petrous internal carotid
artery canal is seen running anteromedial toward the cavernous sinus. Notice the pars nervosa & par vascularis of the
jugular foramen partially separated by the jugular spin~. (Bottom) The mastoid tip is seen in this inferior image. Just
anteromedial to the mastoid tip is the stylomastoid foramen where the facial nerve exists the skull base. :-.loticethe
entrance to the vertical segment of the petrous internal carotid artery canal just medial to the condylar fossa. The
occipitomastoid suture should not be mistaken for a fracture line. II
53
 TEMPORAL BONE
~ CORONAL BONECT
ru
co
Tegmen mastoideum
:J
~
c../)
Posterior semicircular canal
"D Bony vestibular aqueduct
c Mastoid antrum
ru
a.> Jugular foramen
c
o
co Jugular tubercle
Mastoid segment CN?
ru
•...
o Hypoglossal canal Stylomastoid foramen
0...
E
Q.) Mastoid tip
~
~
u
Q,)
Z
"D
C Tegmen mastoideum
C';l
-0 Posterior semicircular canal
C';l
Q,)
J: Jugular foramen Mastoid antrum

Jugular tubercle
Mastoid segment CN?
Jugular tubercle diverticulum

Hypoglossal canal
Styloid process
Occipital condyle

Arcuate eminence

Superior semicircular canal

Lateral semicircular canal
Internal auditory canal
Posterior genu eN?
Vestibule
Pyramidal eminence
Sinus tympani
Mesotympanum
External auditory canal

Styloid process

(Top) First of twelve coronal bone CT images presented from posterior to anterior. In this most posterior image the
stylomastoid forame~ and distal mastoid segment of the facial nerve can be seen to be protected by the mastoid tip.
The mastoid sinus grows into this protective position in the first decade of life. (Middle) In this image the
mid-mastoid segment of the facial nerve is seen. The jugular foramen and the hypoglossal canal are separated by the
"eagle's beak,", a portion of the jugular tubercle. (Bottom) In this image of posterior mesotympanum the 3 critical .
posterior wall structures are seen. From medial to lateral these structures are sinus tympani, pyramidal eminence&
. facial nerve reces.swith the posterior genu of CN? in its depth. Note that it is possible to see the stapedius muscle as a
II small, round soft tissue density within pyramidal eminence.
54
 TEMPORAL BONE
CORONAL BONE CT

Arcuate eminence

Superior semicircular canal

Mastoid antrum
Lateral semicircular canal
Porus acusticus
Tympanic CN7
Vestibule

Round window niche External auditory canal

Tympanic annulus

Arcuate eminence

Lateral semicircular canal

Superior semicircular canal
Tympanic segment CN7

Oval window
Stapes crura
Basal (1st) turn cochlea
Tympanic membrane

Tympanic annulus

Arcuate eminence
Lateral semicircular canal
Superior semicircular canal
Tympanic segment eN7

Macula cribrosa Short process incus

Scutum
Oval window --..-
Stapes head
Cochlear promontory
Tympanic annulu~

(Top) In this image the posterior tympanic segment of the facial nerve is visible under the lateral semicircular canal.
The.round window nich~ is a small air-filled area off the medial mesotympanum that leads to the round window
membrane. (Middle) At the level of the oval window niche the basal turn of the cochlea becomes visible. Notice the
tympanic membrane is barely seen when it is normal. Its inferior attachment, the tympanic annulus is a useful
landmark separating the middle ear from the medial external ear. (Bottom) In this image the short process of the
incus is seen projecting posteriorly into the aditus ad antrum. Both the tympanic membrane attachments can be
seen, the superior scutum and the inferior tympanic annulus. Notice the cochlear promontory projects out into the
.rnesotym.panum.. Glomus tympanicum paragangliomas occur here. ' II
55
 TEMPORAL BONE
~ CORONAL BONECT
~
co

Superior semicircular canal

Tegmen tympani
Tympanic segment CN?
Crista falciformis Epitympanum
Short process incus
Cochlear aperture
Basal turn cochlea Prussak space

~ Hypotympanum Lenticular process incus

'-
o Stapes
Q..
E
Q)
I-
~
u
Q)
Z
-0
C
~
-0 Tegmen tympani
~
Q) Anterior tympanic segment CN?
:r:
.!E.£us body
.;...
~i1byrinthine segment CN?
P!ussak spac~
Cgch,le'!.,
Scutum

Vertical petrous internal carotid Umbo of malleus

artery
Hypotympanum Tympanic annulus

Anterior tympanic segment CN? Cochleariform process

Labyrinthine segment CN?

Incus body
2nd turn cochlea Manubrium of malleus
1st turn cochlea

Vertical petrous internal carotid

artery Condylar fossa of TMJ

Tympanic annulus

(Top) Image through the mid-mesotympanum shows the more superior epitympanum with the long and short
processes of the incus forming the medial margin and the lateral epitympanic wall the lateral margin of Prussak
space. Pars flaccida cholesteatoma involve the middle ear cavity first in Prussak space. (Middle) In this image the
tegmen tympani (L. "roof of the cave") can be seen as the superior wall of the epitympanum. Note its normal variable
thickness. Just above the cochlea the facial nerve canal is seen emerging from the fundus of the internal auditory
canal to become the labyrinthine segment CN? (Bottom) Three key structures are seen together in this image, the
labyrinthine segment CN? anterior tympanic CN? and the cochleariform process. Note the tendon of the tensor
II tympani muscles projecting from the cochleariform process to attach to the malleus.
56
 TEMPORAL BONE
CORONAL BONE CT I
ro
~
0..
~
::J
Anterior tympanic segment CN? 0..
Z
Labyrinthine segment CN? Cochleariform proces.s ro
("')
~
2nd turn of cochlea Incus body
-l
1st turn of cochlea Malleus head ro
Manubrium of malleus ""'0
3
Horizontal petrous internal carotid
artery o
.....•
Tendon of tensor tympani
muscle
~
CO
o
~
ro
\:l)
~
Q..
(j)
7\
C

Tegmen tympani
Geniculate ganglion

1st turn of cochlea Malleus head

Anterior scutum
2nd turn of cochlea Tympanic membra~e
Horizontal petrous internal caroti9
artery Anterior .!}'mpanic annulus

Geniculate ganglion

Petrous apex
Epitympanum
Tensor tympani muscle
Mesotympanum
Horizontal petrous internal carotid
artery
Hypotympanum

(Top) The labyrinthine segment of CN? is seen here merging together with the anterior tympanic CN? above the
cochlea, The cochleariform process and tendon of the tensor tympani muscle are both visible. The petrous internal
carotid horizontal segment can be seen below the cochlea. (Middle) In this image the tegmen tympani is thick and
well-defined. The geniculate ganglion in the geniculate fossa is seen on the superolateral cochlea with the horizontal
petrous internal carotid artery below the cochlea. Both the scutum and tympanic annulus are visible between the
gossamer tympanic membrane. (Bottom) In the most anterior middle ear cavity the ossicles are not see!1.The
geniculate ganglion.in the geniculate fossa along with the tensor tympanic muscle are visible. The horizontal petrous
internal carotid artery is now projecting anteromedially. II
57
 TEMPORAL BONE
~ SAGITTAL T2 MR
('lj

CO

:J
..:L-
V)
-0
c
('lj Superior vestibular nerve
Q)
c Facial nerve
o Crista falciformis
CO Cochlear nerve
('lj

"- Inferior vestibular nerve

o Basal (1st) turn of cochlea
Q...
E
Q)
~
~
u
Q)
Z
""0

C
Co;:!
""0

Co;:!
Q)
:c
Facial nerve Superior vestibular nerve
Cochlear nerve Inferior vestibular nerve

Facial nerve Cerebellopontine angle cistern

Vestibulocochlear nerve

(Top) First of three high-resolution oblique sagittal '1'2 MR images presented from lateral to medial of internal
auditory canal shows facial nerve to be anterosuperior & cochlear nerve to be anteroinferior. This fundal view reveals
crista falciformis seen as a vague low signal line dividing eN? & the superior vestibular nerve from the cochlear and
inferior vestibular nerves. (Middle) In the mid-internal auditory canal four discrete nerves are visible. Notice the
anterosuperior facial nerve is normally slightly smaller than the anteroinferior cochlear nerve. The superior and
inferior vestibular nerves are often joined by connecting fibers as in this example. (Bottom) At the level of the porus
acusticus the vestibulocochlear nerve has the appearance of a "catcher's mitt" with the facial nerve looking like the
II "ball in the mitt".
58
 TEMPORAL BONE
AXIAL T2 MR ::r:
('t)
~
0..
~
:::::l
Meckel cave 0..
Z
('t)
Petrous apex ~
;:::-
Internal auditory canal Superior semicircular canal --l
(1)

:3
-0
Posterior semicircular canal
o
~
Mastoid air cells CJ
OJ
o
:J
(1)

CJ
:::::l
Q...
(j)
A
C

Labyrinthine segment, CN7

Facial nerve (CN7)
Vestibule

Lateral semicircular canal

Superior vestibular nerve
Posterior semicircular canal
Crus communis

Meckel cave
Labyrinthine segment, CN7
Apical 1st turn cochlea
Facial nerve (CN7) Anterior tympanic segment,
CN7
Lateral semicircular canal
Superior vestibular nerve
Posterior semicircular canal
Vestibule

(Top) First of six axial high-resolution thin-section T2 MR images presented from superior to inferior through the left
temporal bone shows the superior internal auditory canal and semicircular canals. (Middle) In this image the facial
nerve is visible anterior to the superior vestibular nerve in the superior aspect of the internal auditory canal. The fluid
spaces of the membranous labyrinth are high signal within the dark signal of the bony labyrinth. (Bottom) In this
image the labyrinthine and anterior tympanic segments of the facial nerve are visible. As they are not surrounded by
cerebrospinal fluid as is eN7 in the internal auditory canal they are more difficult to see.

II
59
 TEMPORAL BONE
~ AXIAL T2 MR
~
CO

:J
~
Vl
""0

c Scala tympani
~
Q)
c Modiolus Scala vestibuli
o
CO Facial nerve Vestibule
~
•... Vestibulocochlear nerve Posterior semicircular canal
o Inferior vestibular nerve
Q..
E
Q)
I-
~
u
Q)
Z
-0
C
C'j
-0
C'j
Q)
::c
Basal 1st turn of cochlea 2nd turn of cochlea

Cochlear aqueduct

Scala tympani
2nd turn of cochlea

Cochlear aqueduct Scala vestibuli

(Top) In this image through the cochlear aperture the modiolus of the cochlea is seen as an intermediate signal
structure at the hub of the cochlea. The two larger cochlear chambers of the are visible. The anterior chamber is the
scala vestibuli while the posterior chamber is the scala tympani. The scala media is not routinely resolvable, (Middle)
In this image both the first and second turns of the cochlea are visible. The osseous spiral lamina within the cochlea
is seen as a fine low signal line within the fluid of the cochlear membranous labyrinth. (Bottom) The cochlear
aqueduct is a tubular-shaped structure on the medial wall of the temporal bone inferior to the internal auditory
canal. No definite function can be assigned to this structure.
II
60
 TEMPORAL BONE
CORONAL T2 MR :r:
~
~
a..
~
:J
Temporal lobe a..
Arcuate eminence Z
Internal auditory canal ~
n
Preganglionic segment CNS Superior semicircular canal
Lateral semicircular canal '--l"
Facial nerve Vestibule (D
Vestibulocochlear nerve 3
-0
Cerebellar flocculus Basal turn of cochlea o
.,
\l)

CO
o
:::l
(D
\l)
:::l
Q..
Vl
7'\
C

Tegmen tympani
Crista falciformis

Porus acusticus
Vestibule
Basal turn of cochlea
Internal auditory canal

Mastoid tip

Geniculate ganglion

2nd turn of cochlea

1st turn of cochlea

(Top) First of three coronal T2 MR images of the left ear presented from posterior to anterior. The membranous
labyrinth of the inner ear is visible as high signal fluid. Notice the superior and lateral semicircular canals adjacent to
the vestibule. (Middle) In this image through the internal auditory canal an unusually long crista falciformis is seen
in the fundus. The area of the tegmen tympani is marked but no landmarks in the middle ear are visible because
both air and bone are low signal on MR imaging. (Bottom) At the level of the cochlea the snail shape is particularly
obvious displaying both the first and second turns. The geniculate ganglion is barely visible above and lateral to the
cochlea. Again note the lack of middle ear definable structures.
II
61
 COCHLEA
ITerminology IAnatomy-Based Imaging Issues
:J
..:L Abbreviations Key Concepts or Questions
V)
""0
• Temporal bone (T-bone) • Creation of hearing
o Movement of stapes results in transmission of fluid
C
Ci:l
Definitions waves via oval window through vestibule to
C])
• Cochlea: (L. "snail shell") coiled, tapered tube inside cochlear recess
C the inner ear, responsible for transmitting sound to o Cochlear recess fluid wave transmitted to scala
o organ of Corti (sensory organ of hearing) vestibuli (ascending spiral) of cochlea
CO
o Fluid waves (sound waves) enter perilymph of scala
Ci:l vestibuli and are then transmitted via vestibular
•....
o Ilmaging Anatomy membrane into endolymph of cochlear duct
0.. o This transmission causes displacement of basilar
E Overview
C])
membrane, which stimulates hair cell receptors in
• Inner ear organization: 3 components organ of Corti
l-
~
.. o Bony labyrinth: Bone confining cochlea, vestibule
& semicircular canals
o Hair cell movement generates electronic potentials
u o Perilymphatic spaces: Area in vestibule
converted to action potentials in cochlear nerve
OJ • High frequency sounds converted at cochlear base
Z surrounding utricle & saccule, semicircular canals • Low frequency sound converted at cochlear apex
"'0 around semicircular ducts & within scala tympani &
s::: vestibuli of cochlea Imaging Recommendations
~ • Perilymph "bathes" membranous labyrinth • T-bone CT: Evaluates bony aspects of cochlear diseases
"'0
structures o Otosclerosis, labyrinthine ossificans, bony details of
~ o Membranous labyrinth
OJ complex inner ear dysplasias .
:c • Vestibular utricle & saccule, semicircular ducts, • T-bone MR: Evaluates membranous labyrinth diseases
scala media of cochlea, endolymphatic duct & sac o Tl C+ MR: Labyrinthitis, intralabyrinthine
all contain endolymph schwannoma
• Endolymph is functional fluid within structures o T2 high-resolution MR: Cochlear nerve size in
of membranous labyrinth; bathes & nourishes its cochlear implant candidates
sensory epithelium
Internal Structures-Critical Contents
• Cochlea contains - 2 1/2 turns
I Clinical Implications
• Cochlear ••perture: Opening to cochlea from lAC Clinical Importance
fundus . • Cochlea responsible for hearing as it transforms fluid
• Modiolus: Central bony axis of cochlea motion into electrical energy
o Houses spiral ganglion (cell bodies of cochlear o Any disease that affects cochlear nuclei, cochlear
nerve) nerve, cochlea can cause sensorineural hearing loss
• Osseous spiral lamina: Thin bony plate projecting to
basilar membrane from modiolus
o Provides supportive function & allows organized IEmbryology
transmission of cochlear nerve fibers to each
segment of cochlea Embryologic Events
• 3 spiral chambers of cochlea • Cochlea development occurs between 3rd & 8th fetal
o Scala tympani weeks
• Posterior chamber of cochlea • Otic placode (3rd week) invaginates to becomes otic
• Descending spiral containing perilymph pit (4th week)
o Scala vestibuli • Otic pit becomes otocyst (otic vesicle) at week 5
• Anterior chamber of cochlea • Otocyst migrates to inner ear location during week 5
• Ascending spiral containing perilymph • Cochlear duct (scala media) forms (6th week)
• Perilymph connects to subarachnoid space via • 2 1/2 turn cochlea forms (by end of 8th week)
cochlear aqueduct • Fetus "hears" by 24th week with maturation of organ
o Scala media (cochlear duct) of Corti
• Separated from anterior scala vestibuli by
vestibular (Reissner) membrane Practical Implications
• Separated from posterior scala tympani by basilar • Inner ear forms as separate event from external &
membrane middle ear
• Contains organ of Corti (hearing apparatus); sits o EAC atresia usually presents with normal inner ear
on basilar membrane • Injury to organ of Corti may occur long after cochlear
• Cochlear nerve cell bodies = spiral ganglion infrastructure forms
o Spiral ganglion bipolar cells o Normal cochlea on imaging often seen in setting of
o Send antegrade axon to organ of Corti profound sensorineural hearing loss
o Send retrograde axon to form cochlear nerve

II
62
II
63
 COCHLEA
~ AXIAL BONE CT
('j
CO

::J
....Y
c./)
-0 Cochlear promontory
c 1st turn of cochlea
('j

(]) Manubrium of malleus

c Cochlear aperture Long process of incus
o
CO
Oval window
('j
Vestibule
•....
o
Q...
E
(])
Posterior semicircular canal

I-
~
u
CIJ
Z
"'C
c:
("j

"'C
("j Apical1f2 turn of cochlea
Modiolus
CIJ
J: 1st turn of cochlea 2nd turn of cochlea

Cochlear aperture
Round window membrane

Apical 1/2 turn of cochlea

2nd turn of cochlea

Cochlear promontory
1st turn of cochlea
Round window membrane

Round window niche

(Top) First of three axial bone CT images presented from superior to inferior shows the membranous labyrinth fluid
space of the cochlea as low density compared to the high density bony labyrinth. (Middle) In this image through the
mid-cochlea the full cochlear aperture is visible at the base of the cochlea. Just inside the cochlear base the modiolus
is seen. The modiolus looks like a higher density crown-shaped structure. Notice that the cochlear turns are well seen
in this image. (Bottom) In this image through the basal 1st turn of the cochlea it is possible to see the posterolateral
origin of the basal turn at the round window membrane. The middle ear wall of the cochlea is referred to as the
cochlear promontory.
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64
 COCHLEA
AXIAL T2 MR

Scala vestibuli
Osseous spiral lamina

Scala tympani

Vestibule
Facial nerve

Superior vestibular nerve

Posterior semicircular canal

Scala vestibuli

Scala tympani
Modiolus
Cochlear nerve Osseous spiral lamina
Vestibule
Cochlear aperture

Posterior semicircular canal

Apical 1/2 turn of cochlea

2nd turn of cochlea

1st turn of cochlea

Cochlear nerve
Vestibule
Cochlear aperture Lateral semicircular canal

Posterior semicircular canal

(Top) First of 3 axial T2 MR images of inner ear presented from superior to inferior reveals high signal membranous
labyrinth within the low signal bony labyrinth. The cochlea is divided by osseous spiral lamina into an anterior scala
vestibuli & a posterior scala tympani. Note that the scala vestibuli & tympani have equal transverse dimensions.
(Middle) In this image through the mid-cochlea the cochlear nerve is visible in the anteroin.ferior lAC. The cochlear
nerve exits the fundus of the internal auditory canal to enter the cochlea through the cerebrospinal fluid filled
cochlear aperture. The modiolus is visible as a intermediate intensity structure at the cochlear base. (Bottom) The 1st
and 2nd turns and the apical 1/2 turn of the cochlea are all visible on this image. Also notice the cochlear nerve in
the cochlear aperture on its way to the modiolus. II
65
 INTRATEMPORAL FACIAL NERVE
• Arches anterosuperiorly to enter middle ear cavity
I Terminology • Courses across middle ear cavity passing between
::J malleus & incus
~ Abbreviations
r.J)
• Facial nerve: CN? • Exits anterior wall of middle ear cavity
""0
• Carries taste fibers from anterior 2/3 tongue
C Definitions retrograde & parasympathetic fibers antegrade to
~
• lntratemporal facial nerve: CN? as it passes through sublingual & submandibular glands
CI)
c temporal bone from its entrance into internal auditory o Terminal motor branches
o canal (lAC) to its exit at stylomastoid foramen • Beyond chorda tympani branch of CN? mastoid
CO segment has only motor fibers
~ • Pure motor CN? exits stylomastoid foramen to
•...
o I Imaging Anatomy become extracranial CN?
D... • Facial nerve arteries
E Overview o Superficial petrosal branch (petrosal artery) of
CI) • CN? enters temporal bone as a mixed cranial nerve middle meningeal artery supplies greater superficial
I-
with motor, parasympathetic & taste functions petrosal nerve & geniculate ganglion
~ • Intratemporal segment is one of four o Stylomastoid branch of posterior auricular artery
u o Intra-axial, cisternal & extracranial are other three supplies mastoid & tympanic segments of CN?
Q)
Z • Intratemporal CN? extends from porus acusticus of
""0 lAC to stylomastoid foramen
C IAnatomy-Based Imaging Issues
~ Internal Structures-Critical Contents
""0
• CN? intratemporal segment divided into four Key Concepts or Questions
~ subsegments: lAC, labyrinthine, tympanic & mastoid • In all temporal bone imaging studies (CT or MR),
Q)
• lAC segment intracranial CN? radiologist must inspect entire course of facial nerve!
J: o Extent: Porus acusticus to lAC fundus
o Relationship: Anterosuperior position above crista Imaging Recommendations
falciformis • Enhanced, thin-section fat-saturated MR best for
o Branches: None peripheral facial nerve paralysis
• Labyrinthine segment intratemporal CN? o If lesion found along intratemporal segments of
o Extent: Connects fundal CN? to geniculate ganglion CN?, T-bone CT vital to further assess anatomy &
o Relationship: Passes through bony labyrinth just characterize lesion
superior to cochlea • In peripheral facial nerve paralysis, be sure scan
o Branches: None includes brainstem, CPA, lAC, T-bone & parotid
• Geniculate ganglion (anterior genu)
Imaging Pitfalls
o Extent: Single site anterosuperior to cochlea
o Branches: Greater superficial petrosal nerve • Imaging routine Bell palsy unnecessary
• Tympanic segment intratemporal CN? (horizontal • Mild enhancement of labyrinthine segment,
segment) geniculate ganglion & anterior tympanic segment of
o Extent: Connects anterior to posterior genu CN? is normal on enhanced Tl MR
o Relationship: Passes immediately under lateral o Results from circumneural arteriovenous plexus
semicircular canal o This enhancement may be amplified by fundal
o Branches: None acoustic schwannoma
• Posterior genu
o Extent: Elbow of CN? turning tympanic segment
into mastoid segment I Clinical Implications
• Mastoid segment intratemporal CN? Clinical Importance
o Extent: Connects posterior genu to stylomastoid
• Peripheral facial nerve paralysis results from injury to
foramen
"peripheral facial nerve"
o Relationship: Passes inferiorly in bone just posterior
o "Peripheral facial nerve" defined as CN? from its
to facial nerve recess
brainstem nucleus, through CPA, lAC, temporal
o Branches: Stapedius nerve & chorda tympani nerve
bone to extracranial component
• Facial nerve branches
o Injury to specific locations along peripheral facial
o Greater superficial petrosal nerve
nerve results in CN? paralysis with addition
• Arises from geniculate ganglion, passing
location-specific symptoms
anteromedially to exit T-bone via facial hiatus
• If lesion occurs proximal to geniculate ganglion,
• Carries parasympathetic fibers on way to lacrimal
lacrimation, sound dampening & taste affected
gland
• If CN6 also injured, lesion should be in pons
o Stapedius nerve
• If CN8 also injured, lesion should be in CPA-lAC
• Arise from high mastoid segment CN?
• If lacrimation, sound dampening & taste variably
• Provides motor innervation to stapedius muscle
affected, intratemporallesion most likely
o Chorda tympani nerve
• If CN? special functions spared but peripheral
• Arises from lower mastoid segment of CN?
CN? paralysis present, parotid space implicated

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66
II
67
 INTRATEMPORAL FACIAL NERVE
Q)
<Jl
AXIAL BONE CT
~
CCl

:J
...Y.
c../) Geniculate ganglion
""0 Labyrinthine segment CN?
C
~ Lateral epitympanic space
Q) (Prussak space)
Internal auditory canal
C
0
CCl Vestibule

~ Mastoid antrum
'--
0
Q..
E
Q)
I-
~
u
Q)
Z
"'0

c:
~
"'0
Geniculate ganglion Epitympanic cog
~
Q)
:r: Distal cochlear 1st turn
Tympanic segment CN?
Internal auditory canal
Posterior genu CN?
Vestibule

Anterior tympanic segment CN?

Facial nerve recess

Sinus tympani Superior mastoid segment CN?

Stapedius muscle in pyramidal
eminence

(Top) First of six axial bone CT images of left ear presented from superior to inferior. In this image the labyrinthine
segment of the facial nerve can be seen as a semilunar canal that exits the anterosuperior fundus of the internal
auditory canal and·terminates in the geniculate ganglion. This curved canal is in the bony labyrinth just above the
cochlea. (Middle) In this image the entire course of the tympanic segment of the facial nerve is seen from its origin
in the geniculate ganglion to its junction with the posterior genu. The tympanic segment of CN? passes under the
lateral semicircular canal. (Bottom) The superior mastoid segment of the facial nerve is seen in this image posterior
to the facial nerve recess in the posterior wall of the middle ear cavity. Do not mistake the stapedius muscle for the
II mastoid segment of CN?
68
 INTRATEMPORAL FACIAL NERVE
AXIAL BONE CT :r:
ro
~
0..
~
:::J
Cochleariform process Tendon of tensor tympani 0..
muscle
Z
ro
f'\
Facial nerve reces,;; ;:::-
-I

Sinus tympani
Mastoid segment CNI
- . ""0
ro
:3
Stapedius muscle in pyramidal
eminence 0
....•
~
OJ
0
::::J
(1)
OJ
::::J
0..
Vl
A
C

OJ
OJ
(fl
(1)
Manubrium of malleus
Chorda tympani nerve canal

Mastoid segment CN?

Stapedius muscle
Mastoid air cells

Hypotympanum Tympanic annulus

Styloid process marrow

Pars vascularis of jugular foramen Inferior mastoid segment CN?

Mastoid canaliculus (Arnold nerve)

Mastoid air cells

(Top) The posterior wall of the middle ear cavity has 3 important contours. From medial to lateral they are the sinus
tympani, pyramidal eminence and facial nerve' recess. The mastoid segment of CN? is found just posterior to the
faciaLnerve recess while the belly of the stapedius muscle is seen just medial to this at the base of the pyramidal
eminence. (Middle) At the level of the low mesotympanum the mastoid segment of CN? is visible in the posterior
wall of the middle ear. The inferior aspect of the belly of the stapedius muscle is seen just medial to the mastoid
segment of CN? Also notice the chorda tympani nerve exiting into the middle ear cavity. (Bottom) At the level of
low mastoid segment of the facial nerve the styloid process marrow is seen anteriorly. Also note the mastoid
canaliculus (canal of Arnold nerve) emerging from the lateral jugular foramen. II
69
 INTRATEMPORAL FACIAL NERVE
CORONAL BONE CT

:J
.::::L.
Vi
""D
c Mastoid antrum
C'O

Q)
C
o
D:l
Mastoid segment CN?
C'O
\.- Stylomastoid foramen
o
Q..
E
Q)
Mastoid tip
I-
~
u
Q)
Z
""0

c
C':l
""0

C':l
Q)
:::c Mastoid antrum

Mid-mastoid segment CN?

Jugular foramen

Styloid process

Vestibule Lateral semicircular canal

Round window niche Posterior genu CN?

Sinus tympani Pyramidal eminence

(Top) First of six coronal bone CT images of the left ear presented from posterior to anterior. In this image the low
mastoid segment of the facial nerve is visible. The stylomastoid foramen marks the transition from mastoid to
extracranial segments of the facial nerve. The chorda tympani nerve exits from this area. (Middle) In this image the
mid-mastoid segment of the facial nerve is seen just posterior to the facial nerve recess. The stapedius nerve exits in
this area. (Bottom) The posterior genu can be seen just lateral to the pyramidal eminence. The posterior margin of
the lateral semicircular canal is also visible on this image as are the sinus tympani and pyramidal eminence.

II
70
 INTRATEMPORAL FACIAL NERVE
CORONAL BONE CT :r:
('D
~
a.
~
~
a.
Lateral semicircular canal
Z
('D
~
~
Oval window Tympanic segment CN7
--I
Cochlear promontory Mesotympanum (1)
:3
-0
o
.,
~
c:o
o
:J
(1)
~
:J
Q..
Vl
7'\
C

Labyrinthine segment CN7

Anterior tympanic segment
Internal auditory canal CN7

Cochlea

Cochleariform process
Vertical petrous internal carotid
artery

Geniculate ganglion

Cochlea Scutum
Horizontal petrous internal carotid
artery
Cochleariform process

(Top) The mid-tympanic segment of CN? is seen along the inferior surface of the lateral semicircular canal. A thin
bony covering for CN? is visible. Notice the position of the nerve relative to the inferomedial oval window. When
oval window atresia is present, the tympanic segment is seen closer to or within the oval window niche as a .
associated finding. (Middle) In this image the labyrinthine segment of CN? can be seen to exit the anterosuperior
internal auditory canal. Also note the anterior tympanic segment of CN? canal high on the medial wall of the middle
ear cavity. Just inferiorly on the medial wall is the cochleariform process which through which the tendon of the
tensor tympani tendon passes. (Bottom) Superolateral to the cochlea the geniculate ganglion is visible.
II
71
 INTRATEMPORAL FACIAL NERVE
~ AXIAL BONE CT CHORDA TYMPANI NERVE
Ci:l
CO

Condylar fossa of
temporomandibular joint

Basal turn of cochlea External auditory canal

Chorda tympani nerve

Ci:l
>-
o
0... Mastoid segment CN?
E
OJ
f--
~
u
OJ
Z
""0

l::
~
""0 Mandibular condyle
~
OJ
:::c
External auditory canal

Chorda tympani nerve

Cochlear aqueduct

Mastoid segment CN?

Mandibular condyle

Tympanic annulus

External auditory canal

Hypotympanum
Chorda tympani nerve

Mastoid segment CN?

(Top) First of three magnified axial bone CT images of the left ear presented from superior to inferior demonstrating
the canal of the chorda tympani nerve. In this image the chorda tympani nerve is seen just before exiting into the
middle ear cavity. Remember the chorda tympani nerve contains efferent parasympathetic fibers to submandibular
and sublingual glands as well as afferent anterior 2/3 tongue taste fibers. (Middle) In this image the chorda tympani
nerve can be seen approaching its origin from the low mastoid segment of the facial nerve. (Bottom) The chorda
tympani nerve is visible in this image budding from the lateral margin of the low mastoid segment of the facial
nerve. Notice that this image is taken through the upper margin of the tympanic annulus and is therefore at the level
II of the hypotympanum.
72
 INTRATEMPORAL FACIAL NERVE
CORONAL BONE CT CHORDA TYMPANI NERVE

Pyramidal eminence

Posterior genu CN?

Sinus tympani

Mastoid segment CN?

Origin of chorda tympani nerve

Stylomastoid foramen

Pyramidal eminence
Facial nerve recess
Vestibule
Sinus tympani

Chorda tympani nerve

Mastoid segment CN?

Stylomastoid foramen

Motor nucleus CN?

Solitary tract nucleus (taste)
Superior salivatory nucleus

Greater superficial petrosal

nerve

Stapedius nerve
Chorda tympani nerve Parasympathetic fibers of
chorda tympani nerve

Anterior 2/3 of tongue taste

Stylomastoid foramen fibers
Motor branch of CN?

(Top) First of two coronal bone CT images of the left ear presented from posterior to anterior shows the mastoid
segment of the facial nerve from its origin at the posterior genu and its skull base exit at the stylomastoid foramen.
The site of origin of the chorda tympani nerve from the mastoid segment can be seen along its lateral margin.
(Middle) This image reveals the distal mastoid segment of the facial nerve. The canal of the chorda tympani nerve is
visible as a cephalad projecting channel branching from the lateral mastoid segment. (Bottom) Magnified sagittal
graphic of intratemporal CN? & its branches. Chorda tympani branch of CN? is seen approximately 2/3 of way down
mastoid segment of facial nerve. Note the chorda tympani nerve has efferent parasympathetic fibers to II
submandibular & sublingual gland and efferent taste fibers from anterior 2/3 of tongue.
 INTRATEMPORAL FACIAL NERVE
~ AXIAL T2 MR
ro
CO

:J
~
Vl
""0
c
ro lAC segment CN?
Q)
c Labyrinthine segment CN?
o
CO Lateral semicircular canal
ro Superior vestibular nerve
Posterior semicircular canal
"-
o
Q.. Crus communis
E
Q)
f--
~
u
Q)
Z
"'C
r::
ro
"'C
ro
Q) Labyrinthine segment CN?
Geniculate ganglion
I

Distal 1st turn of cochlea

Anterior tympanic segment
CN?
Lateral semicircular canal
CPA cistern segment CN?
Posterior semicircular canal
lAC segment CN?

lAC fundus

CPA cistern segment CN? Cochlea

Vestibule

Vestibulocochlear nerve Posterior semicircular canal

(Top) First of three axial high-resolution thin-section T2 MR images of left ear presented from superior to inferior. In
this image the internal auditory canal segment of the facial nerve is visible in the anterosuperior quadrant. At the
fundus of the lAC the anterior curving soft tissue structure is the labyrinthine segment of the facial nerve. (Middle)
In this image the labyrinthine segment can be seen passing just superior to the cochlea in the bony labyrinth. It
terminates in the geniculate ganglion (anterior genu), then turns and becomes the tympanic segment of the facial
nerve which projects posterolaterally to run underneath the lateral semicircular canal. (Bottom) The CPA cistern
segment of the facial nerve is visible in this image just anterior to the vestibulocochlear nerve. This more anterior
II position persists across the cerebellopontine angle cistern.
74
 INTRATEMPORAL FACIAL NERVE
AXIAL T1 C+ MR

Meckel cave
Greater superficial petrosal nerve

Geniculate ganglion Cochlea

Labyrinthine segment CN7

Tympanic segment CN7

Lateral semicircular canal

Vestibule

Sigmoid sinus

Tensor tympani muscle

Cochlea

Interna auditory canal

Mastoid segment CN7
Vestibule
Posterior semicircular canal

Petrous apex marrow space

Tensor tympani muscle
Cochlea
External auditory canal

Mastoid segment CN7

Posterior semicircular canal

(Top) First of three axial Tl C+ MR images without fat-saturation of the right temporal bone presented from superior
to inferior. These magnified 3T MR images amplify areas of enhancement. Notice the circumneural arteriovenous
plexus enhancing the greater superficial petrosal nerve, geniculate ganglion and anterior tympanic segment of the
facial nerve. The labyrinthine segment does not normally enhance. (Middle) In this image the tensor tympani
muscle is enhancing just below the anterior tympanic segment of the facial nerve (not seen on this image). Do not
mistake one for the other. The superior mastoid segment of the facial nerve and the area of the posterior genu may
also enhance normally. (Bottom) The superior mastoid segment of CN7 is seen normally enhancing in this image.
The circumneural arteriovenous plexus is thought to be responsible for this appearance. II
75
 MIDDLE EAR AND OSSICLES
o Malleus (hammer)
ITerminology • Location: Anterior epitympanum &
:J mesotympanum
..:L Abbreviations
CJ)
• Temporal bone (T-bone) • Components: Head, neck, lateral process, anterior
""0
• Middle ear (ME) process & manubrium
C • Ligaments: Superior, anterior, lateral mall ear
(i)
Q)
Definitions ligaments & tendon of tensor tympani muscle
c • Ossicles: 3 smallest bones in human body (malleus, o Incus (anvil)
o incus & stapes) in the middle ear that amplify sound • Location: Posterior epitympanum &
CO
vibrations, conveying them from tympanic membrane mesotympanum
to oval window • Components: Body, short, long & lenticular
•...
(i)

o • Middle ear: Six-sided cavity between external ear & processes

0... inner ear, containing 3 ossicles, 2 muscles & opening • Ligament: Posterior incudalligament
E
Q)
to eustachian tube o Stapes (stirrup)
I- • Location: Medial mesotympanum
• Components: Head, anterior & posterior crura &
~ IImaging Anatomy footplate
u
Q) • Ligament: Ligament of stapedius muscle attaches
Z Anatomy Relationships to stapes
"'C • ME sits in T-bone between external & inner ears • Stapes superstructure: Stapes portion derived
c Internal Structures-Critical Contents
from 2nd branchial arch = head, crura, tympanic
(\:l
portion of footplate
"'C • Middle ear subdivisions • Vestibular portion of footplate of stapes & annular
(\:l o Epitympanum (attic): Tegmen tympani is roof with
Q) ligament derived from otic capsule
:c floor defined by line between scutum & tympanic
segment of facial nerve
• Tympanic membrane (TM)
o Separates external from middle ear
• Prussak space: Lateral epitympanic recess o Upper 1/3 = pars flaccida; lower 2/3 = pars tensa
• Anterior epitympanic recess: Epitympanic recess o Malleus umbo & lateral process embedded in TM
anteromedial to epitympanic "cog"; medial wall is o Three layers of TM
anterior tympanic segment CN? • External layer continuous with skin of EAC =
• Tegmen tympani (L. for "roof of cavity"): Thin ectoderm
bony roof between epitympanum & middle • Inner layer continuous with middle ear mucosa =
cranial fossa dura endoderm
• Aditus ad antrum (L. for "entrance to cave"): • Intermediate fibrous layer = mesoderm
Connects epitympanum of middle ear to mastoid o Superior attachment: Scutum (L. for "shield")
antrum o Inferior attachment: Tympanic annulus
o Mesotympanum: Middle ear cavity between line
connecting scutum & tympanic segment CN? above
& line connecting tympanic annulus & base of I Clinical Implications
cochlear promontory below
• Posterior wall (posterior tympanum) has 3 Clinical Importance
important structures: Facial nerve recess, • EAC-tympanic membrane-ossicles-oval window
pyramidal eminence & sinus tympani o Conductive chain disruption results in conductive
• Medial wall: Lateral semicircular canal, tympanic hearing loss
segment CN?, oval & round window found here
o Hypotympanum: Shallow trough in floor of middle
ear cavity I Embryology
• Middle ear muscles
o Tensor tympani muscle Embryologic Events
• Muscle found anteroinferior to anterior tympanic • EAC forms from 1st branchial groove
segment CN? • Middle ear forms from 1st branchial pouch
• Tendon passes through cochleariform process, • Ossicles form from 1st & 2nd branchial arches
then attaches to neck of malleus o 1st branchial arch: Head & neck of malleus, body &
• Innervated by CNV3 short process of incus
o Stapedius muscle o 2nd branchial arch: Manubrium of malleus, long &
• Muscle found just medial to upper mastoid lenticular processes of incus, stapes superstructure
segment CN?
• Tendon emerges from apex of pyramidal Practical Implications
eminence, then attaches to head or posterior crura • EAC atresia is 1st & 2nd branchial apparatus lesion
of stapes • Ossicular rotation & deformity part of imaging
• Innervated by CN? motor branch of mastoid appearance
segment • Oval window atresia mayor may not be associated
• Ossicles of middle ear with EAC atresia

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II
77
 MIDDLE EAR AND OSSICLES
~ AXIAL BONE CT
~
CO

::J Malleus head

...Y. Epitympanic cog
t/')
Malleoincudal articulation
-0
c Anterior epitympanic recess
Incus body
~
Q) Epitympanum Prussak space
c Incus short process
o
CO
Koerner septum
~ Lateral semicircular canal
"--
o Mastoid antrum
Q..
E
Q)
I-
~
u
OJ
Z
"'0

c Epitympanic cog
~ Anterior epitympanic recess
"'0
Anterior mallear ligament
~
OJ Head of malleus
Geniculate ganglion
I Malleoincudal articulation
Labyrinthine segment CN? Body of incus
Short process of incus in fossa
Internal auditory canal
incudius

Mastoid antrum

Cochleariform process
Malleus neck
Oval window
Scutum

Incus body
Vestibule

Posterior genu CN?

(Top) First of six magnified axial bone CT images of the left ear from superior to inferior shows malleus head
articulating with the body of the incus at the malleoincudal articulation. Prussak space (lateral epitympanic recess) is
seen lateral to the ossicles. The short process of the incus is "p.oin1ing" into the aditus ad antrum. (Middle) In this
image through the level of the geniculate ganglion it is possible to see the anterior epitympanic recess defined by the
epitympanic cog laterally and the anterior tympanic segment of the facial nerve. Diseases affecting this area may
cause facial nerve paralysis. (Bottom) At the level of the oval window the malleus neck and incus body are seen in
the upper mesotympanum. The facial nerve is transitioning from its tympanic segment to its mastoid segment as the
II posterior genu.
78
 MIDDLE EAR AND OSSICLES
AXIAL BONE CT

Tensor tympani tendon

Manubrium of malleus
Stapes anterior crus
Scutum
Stapes footplate Long process incus

Stapes posterior crus Mastoid segment CN?

Sinus tympani

Stapedius muscle

Incudostapedial articulation Manubrium of malleus

Stapedius head

Lenticular process of incus

Pyramidal eminence Facial nerve recess
Mastoid segment CN?
Sinus tympani Stapedius muscle

Tensor tympani muscle

Umbo of malleus

Round window membrane

Mastoid segment CN?

(Top) In this image the anterior & posterior crura of the stapes are visible with the stapes footplate/oval window in
between. The tensor tympani tendon can be seen reachingTrom the cochleariform process to the manubrium of the
malleus. Both the stapedius muscle & the mastoid segment of the facial nerve are seen in the posterior tympanum
wall. (Middle) In this image the ridges & recesses of the posterior tympanum are well seen. From medial to lateral
they are the sinus tympani, pyramidal eminence & facial nerve recess. Behind these structures observe the stapedius
muscle & the mastoid segment of CN? Note the incudostapedial articulation connecting the lenticular process of the
incus to the head of the stapes. (Bottom) The inferior tip of the manubrium is the umbo. At the round window
membrane level the mastoid segment of CN? is now seen without the stapedius muscle. II
79
 MIDDLE EAR AND OSSICLES
~ CORONAL BONE CT
ro
co
:J
~
c.f)
-0
C Lateral semicircular canal
ro Tympanic segment CN?
Q)
Oval window/stapes footplate Incus short process
c
o
co Hypotympanum Stapes head
ro
'-
o
0... Tympanic annulus
E
Q)
I-
~
u
Q)
Z
""C
C
~
""C
~
Q)
:r:
Epitympanum
Incus body
Incus long process
Stapes anterior crura
Incus lenticular process
Hypotympanum

Tympanic annulus

Anterior tympanic segment CN?

Incus body

Prussak space
Malleus umbo Scutum

Tympanic annulus

(Top) First of six coronal bone CT images of the left ear presented from posterior to anterior. In this image through
the oval window notice how thin the normal stapes footpIate is. (Middle) At the level of the anterior oval window
margin the body, long process and lenticular process of the incus can be seen. (Bottom) In this image the body of
the incus is seen at same level as umbo of malleus. The tympanic membrane is barely visible strung between the
superior scutum and inferior tympanic annulus. The epitympanum is defined as the area of the middle ear cavity
above a line drawn between the tip of the scutum and the tympanic segment of the facial nerve.

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 MIDDLE EAR AND OSSICLES
CORONAL BONE CT

Anterior tympanic segment CN7

Incus body
Cochleariform process
Manubrium of malleus
Tendon of tensor tympani muscl~

Malleus neck Incus body

Anterior tympanic segment CN7
Lateral mallealligament

Cochleariform process Lateral process of malleus

Tendon of tensor tympani muscle

Geniculate ganglion Superior mallealligament

Malleus head

Mesotympanum

Tympanic annulus

(Top) In this image through the anterior tympanic cavity the tendon of the tensor tympani muscle is seen turning
90 degrees in the cochleariform process, then projecting over to the manubrium of the malleus. (Middle) The lateral
process of the malleus and the umbo are both embedded in the medial surface of the tympanic membrane. The
tendon of the tensor tympani muscle inserts on the medial surface of the manubrium of the malleus. (Bottom) In
this image the head of the malleus can be seen in the anterior epitympanum. The mesotympanum can be defined as
the middle ear cavity below the line connecting the tympanic segment of the facial nerve and the inferior tip of the
scutum and above the line connecting the superior tip of the tympanic annulus and the inferior margin of the
cochlear promontory. II
81
 TEMPOROMANDIBULAR JOINT
• Funnel-shaped
ITerminology • Extends inferiorly from temporal bone to attach
::J to condylar neck
~ Abbreviations
V)
• Temporomandibular joint (TMJ) o TMJ ligaments
""0
• Temporomandibular ligament: Lateral ligament
c Definitions attached to tubercle on zygoma root above &
(1j
• TMJ: Articulation between mandible & temporal bone lateral surface of mandibular neck below
a.;
c • Sphenomandibular ligament: Medial ligament
o that attaches above on spine of sphenoid & below
CO
I Imaging Anatomy to lingula of mandibular foramen
•...
(1j
Overview MR Appearances of TMJ
o
Q.. • Complex diarthrodial joint with 2 functional • Articular disc
E movements o Articular disc: Low signal on both TI & T2
a.; o Rotatory movement in inferior compartment • Articular disc movement
I- o Initially upon mouth opening, inferior joint rotates
between mandibular condyle & articular disc
~ o Sliding (translational) component in superior o When mouth fully opens, mandibular condyle slides
u compartment between disc & mandibular fossa forwards & downwards onto articular eminence
Q)
o Articular disc slides in same direction until its
Z Internal Structures-Critical Contents posterior fibroelastic attachments are stretched to
""C
c • Articular surfaces of TMJ their limits
~ o Undersurface of squamosal portion of T-bone • Closed mouth sagittal MR
""C contains mandibular fossa & articular eminence o Disc is "sigmoid shaped" in anterior half of joint
~ • Mandibular fossa (articular fossa) located anterior space on sagittal closed mouth MR
Q)
:c to external auditory meatus
• Articular eminence (articular tubercle) located
o Junction between low signal posterior band of disc
& intermediate signal bilaminar zone is at "12
anterior to mandibular fossa o'clock" position relative to mandibular condyle
o Mandibular condyle o Anterior band is located immediately inferior to
• Condylar head & neck: Posterior protrusion from articular eminence
ramus of mandible • Open mouth sagittal MR
• Articular disc o Disc is "bow tie shaped" anteroinferiorly beneath
o Oval "dumbbell-shaped" plate condylar eminence & above mandibular condyle
• Disc superior surface: Concavoconvex to fit
articular eminence & mandibular fossa
• Disc inferior surface: Concave to conform to IAnatomy-Based Imaging Issues
condylar head
o Intermediate zone of disc found between anterior Imaging Recommendations
& posterior bands • Most TMJ imaging is requested for internal
o Anterior band derangement (abnormal disc position) or TMJ
• Anteriorly attaches to joint capsule degenerative disorders
• Portion is integrated into superior aspect of lateral • MR is best imaging modality to evaluate TMJ soft
pterygoid muscle tissues, especially articular disc
o Posterior band: Posterior disc margin is bilaminar = • Sagittal MR is mainstay of TMJ imaging evaluation
bilaminar zone o Coronal closed mouth TI, sagittal Tl & T2 with
• Superior portion composed of loose fibroelastic closed & open mouth acquisitions needed
tissue; attached to posterior mandibular fossa o Fat-saturated T2 best for evaluation of joint effusion
• Inferior portion com posed of taut fibrous • Bone CT may be needed to assess osseous structures
material; attached to posterior margin of o Multislice bone CT scan with 1 mm axial images
mandibular condyle o Sagittal & coronal reformations helpful
o Medially & laterally disc attaches to joint capsule as
Imaging Pitfalls
well as medial & lateral mandibular condyle
• In cases with apparent limited motion between open
• TMJ compartments
o Disc creates superior & inferior compartments and closed mouth series, look closely for articular disc
o Superior joint compartment abnormalities
• Between disc & mandibular fossa of T-bone
o Inferior joint compartment
• Between disc & condyle; two distinct recesses I Clinical Implications
• Anterior recess: Anterior to condylar head Clinical Importance
• Posterior recess: Posterior to condylar head, deep
• "TMJ disorder" is general term including both
to posterior insertion of articular disc onto
abnormalities of TMJ itself & muscles of mastication
posterior condylar neck
• Estimated to cost $30 billion a year in lost productivity
• TMJ capsule & ligaments
in USA
o Joint capsule

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II
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 ::l
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 TEMPOROMANDIBULAR JOINT
BONE CT

Zygomatic arch

Foramen rotundum Articular eminence

Foramen ovale
Temporomandibular joint
Foramen spinosum
Mandibular condyle
External auditory canal
Stylomastoid foramen (CN?)
Mastoid process OJ
o
:J
ro
tlJ
:J
Q...
Vl
A
C

Squamous portion, temporal bone

Mandibular fossa Petrous apex air cells

Horizontal segment lCA

Condylar head

Condylar neck

Ramus of mandible

Mandibular fossa
Articular eminence
Mastoid air cells
External auditory canal
Coronoid process
Condylar head

Condylar neck
Ramus of mandible
Mastoid process

Angle of mandible

(Top) Axial bone CT image shows the relationship of the mandibular condyles to the articular eminences of the TMJ.
Foramen spinosum, transmitting the middle meningeal artery is immediately anteromedial to the TM]. In this plane,
the articular eminence is seen as posterior attachment of zygomatic arch. (Middle) Coronal bone CT image of the
right TMJ shows the coronal relationship of right mandibular condyle and fossa of the TMJ. The coronal plane in
closed mouth position shows horizontal segment of carotid canal medial to TMJ and variable aeration of temporal
bone air cells superior to the TMJ. (Bottom) Sagittal bone CT reformatted image shows the sagittal relationship of
osseous TMJ, with the mandibular condyle normally seated within mandibular fossa in closed mouth position.
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 TEMPOROMANDIBULAR JOINT
Q)
lJ)
SAGITTAL T1 MR
C\3
ro
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..:::£
Cf)
""D
c
C\3
OJ Mandibular fossa
C
0 Posterior band of disc
ro Bilaminar zone
C\3
•.... Articular eminence
0 Posterior recess,
Q.. inferior compartment
E Superior compartment
OJ
r- Condylar head
..:::£
Anterior band of disc
U
Q)
Condylar neck
Z Anterior recess, inferior
compartment
""C
C
C\3
""C
C\3
Q)
:r:

Mandibular fossa

Articular eminence

Posterior band of disc

Anterior band of disc

Condylar head

Condylar neck

(Top) Closed mouth sagittal T1 MR image shows the condylar head seated in the mandibular fossa. The low signal
articular disc has a "sigmoid shape" & is seen in the anterior half of the joint space. The junction between the low
signal posterior band of the disc & intermediate signal of the bilaminar zone is normally found at "12 o'clock"
relative to the condylar head in the closed mouth position. (Bottom) Open mouth sagittal T1 MR image. The
condylar head has translated anteroinferiorly onto the articular eminence. The articular disc has moved to a position
between the articular eminence & mandibular condyle, taking on a "bow tie" appearance. Both disc & mandibular
condyle must complete this anterior movement for the TMJ to function normally. When the disc fails to complete
II this movement, internal derangement of the TMJ results. (Images courtesyjuan Fuentes, MD).
86
 TEMPOROMANDIBULAR JOINT
SAGITTAL T2 MR I
ro
PJ
0..
PJ
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0..
Z
ro
("\

7'
Mandibular fossa -l
Posterior band of disc ro
Bilaminar zone ""'0
3
Articular eminence o
.....•
Posterior recess, C>
Superior compartment inferior compartment

Anterior band of disc Condylar head

Condylar neck
Anterior recess, inferior
compartment

Superior compartment Mandibular fossa

Articular eminence

Anterior band of disc Posterior band of disc

Mandibular condyle
Inferior compartment

Condylar neck

(Top) Closed mouth sagittal T2 MR image shows the condylar head seated in mandibular fossa. The low signal
articular disc is has a "sigmoid shape" & is seen in the anterior half of the joint space. Notice that the the junction
between the low signal posterior band of the disc & the intermediate signal of the bilaminar zone is normally found
at "12 o'clock" relative to the condylar head in the closed mouth position. (Bottom) Open mouth T2 MR sagittal
image reveals the condylar head has translated anteroinferiorly onto the articular eminence. The disc has also moved
to a position between the articular eminence & mandibular condyle, taking on a "bow tie" appearance in the process.
Both disc & mandibular condyle must complete this anteroinferior movement for the TMJ to function normally. II
(Images courtesy Juan Fuentes, MD).
87
SECTION 2: Orbit, Nose and Sinuses

Orbit Overview 11-90

Bony Orbit and Foramina 11-94
Optic Nerve/Sheath Complex 11-98
Globe 11-102
Sinonasal Overview 11-104
Ostiomeatal Unit (OMU) 11-114
Pterygopalatine Fossa 11-118
 rJl
<l)
ORBIT OVERVIEW
rJl
::J o Drainage via puncta at medial lower lids --.
C ITerminology canaliculi --. lacrimal sac --. nasolacrimal duct
CJ)
"'0 Abbreviations • Anterior periorbita
C • Cranial nerves o Tarsal plates
Ci:l • Dense connective tissue plates within eyelids
o Optic nerve (CN2)
<l) o Orbital septum
rJl o Oculomotor nerve (CN3)
o o Trochlear nerve (CN4) • Fascia arising from orbital periosteum
Z o Trigeminal nerve (CNS) • Inserts into aponeurosis and fascia of lids at
• Branches (VI, V2 and V3) margins of superior and inferior tarsi
.£) o Abducens nerve (CN6)
•...
a.. • Orbital structures
o Superior/inferior ophthalmic veins (SOV/IOV) IAnatomy-Based Imaging Issues
~ o Superior/inferior orbital fissures (SOF/IOF)
u Key Concepts or Questions
Q) o Extra-ocular muscles (EOM)
• Approach to orbital lesions
Z o Localize to region and involved structures
"'C • Globe: Intraocular vs. transscleral
c: I Imaging Anatomy • Optic nerve vs. nerve-sheath complex
~
"'C Internal Structures-Critical Contents • Intraconal vs. conal vs. extra conal orbit
~ • Intraorbital nerves • Lacrimal gland: Unilateral vs. bilateral (systemic)
Q)
• Isolated vs. multifocal vs. trans-spatial process
:r: o CN2: Discussed separately
• Intracranial: Direct extension vs. secondary
o CN3: Motor to medial, superior, and inferior recti,
and levator palpebrae; parasympathetic motor to iris o Assess CT, MR, and/or ultrasound characteristics
o CN4: Motor to superior oblique • Solid or cystic; heterogeneity
o CN6: Motor to lateral rectus • Fluid, fat, blood, or soft tissue
o CNS: Sensory from orbit and eyelids (VI) • Bony remodeling vs. destruction
• Ophthalmic artery • Well-defined vs. infiltrative
o Major arterial supply of the orbit • Degree and homogeneity of enhancement
o First intradural branch of internal carotid artery Imaging Recommendations
(lCA); passes through optic canal, pierces dural
• General comments
sheath laterally at apex o CT & MR are complementary techniques; both
o Major branches: Central retinal, posterior ciliary, indicated for evaluation of complex lesions
muscular, lacrimal, supraorbital, ethmoidal, and
nasofrontal • CT
o Excellent evaluation of orbit aided by natural
• Ophthalmic veins contrast between fat, bone, air & soft tissues
o SOY: Located between CN2 and superior rectus; o Easily detects calcifications
drains through superior fissure into cavernous sinus o Noncontrast CT alone for thyroid orbitopathy
o IOV: Located adjacent to inferior rectus; drains
• MR
through inferior fissure into pterygoid plexus o Optimal soft tissue contrast for globe, optic nerve,
• Extraocular muscles orbital structures, and intracranial findings
o Recti o Stronger gradients, faster sequences, surface coils,
• Superior, inferior, lateral, medial routine use of fat suppression ± gadolinium improve
• Origins at annulus of Zinn image quality
• Insertions at corneoscleral surface • Ultrasound
o Superior oblique o First line modality for intraocular lesions
• Origin at medial margin of annulus of Zinn o Noninvasive, readily available
• Passes through trochlea at superomedial rim
• Inserts posterolaterally on sclera superiorly Imaging Approaches
o Inferior oblique • Imaging protocols
• Origin at anteroinferior orbital rim oCT
• Insertion posterolaterally on sclera inferiorly • Axial + coronal planes; thin-sections (~ 2 mm)
o Levator palpebrae superioris • Multislice isovoxel acquisition with MPR
• Origin at annulus of Zinn • Soft tissue algorithm; bone in at least one plane
• Courses above superior rectus, divides in two • Contrast for masses or inflammatory disease
• Superior aponeurosis insertion at upper eyelid • Noncontrast only when in conjunction with MR
• Inferior Muller insertion at tarsal plate o MR
• Nasolacrimal apparatus • Axial: Above orbital roof to orbital floor
o Lacrimal gland • Coronal: Back of pons through globe
• Orbital lobe: Larger, lies in bony fossa at anterior • Thin-section (3-4 mm); small FOV (12-16 cm)
aspect of superotemporal orbit • Tl pre-contrast (axial + coronal)
• Palpebral lobe: Smaller, lies inferiorly, separated • STIR or T2 FSEfat-saturation (axial + coronal)
by levator aponeurosis • II C+ with fat-saturation (axial + coronal)
• Whole brain axial FLAIRand Tl C+

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III
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 ORBIT OVERVIEW
<Jl
Q) CORONAL T1 MR
<Jl
:J
C
V'l
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c
~
Q)
<Jl
o
Z
Superior rectus muscle Superior oblique muscle
..n
•...
o Lateral rectus muscle Medial rectus muscle

Inferior rectus muscle

Levator palpebrae superioris muscle

Superior rectus muscle

Superior ophthalmic vein

Superior oblique muscle
Optic nerve/sheath complex
Lateral rectus muscle Medial rectus muscle

Inferior rectus muscle

Inferior ophthalmic vein

Levator palpebrae superioris muscle

Superior rectus muscle

Lacrimal gland

Globe
Lateral rectus muscle Medial rectus muscle

Inferior rectus muscle

Inferior oblique muscle

(Top) First of three coronal Tl MR images presented from posterior to anterior at the level of the orbital apex shows
close proximity of extraocular muscles, nerve-sheath complex and ophthalmic vessels. (Middle) Image in the
mid-orbit shows the muscle cone formed by the EOMs, with the nerve-sheath complex centrally in the intraconal
space. Complex and variable branches of the ophthalmic artery are seen as small flow voids within the intraconal
and extraconal fat. (Bottom) Image at the level of the globe shows the flattened and thinned tendinous contours of
the EOMs near their insertions. The inferior oblique muscle is evident at this level. The lacrimal gland is isointense
and located in the anterior aspect of the superotemporal extraconal space.
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 ORBIT OVERVIEW
OBLIQUE SAGITTAL T1 MR

Levator palpebrae
superioris muscle o
.....•
CJ
Muller muscle

Levator aponeurosis Superior rectus muscle

z
o
Vl
Superior ophthalmic (D
Orbital septum vein OJ
:J
Optic nerve/sheath 0..
compl~x Vl
Globe :J
C
Vl
(D
Inferior rectus muscle Vl

Inferior oblique muscle

Levator palpebrae
superioris muscle
Superior rectus muscle
Muller muscle

Levator aponeurosis
Superior ophthalmic
Orbital septum vein

Ophthalmic artery

Globe

Inferior rectus muscle

Inferior oblique muscle

(Top) First of two oblique sagittal TI MR images at the mid-orbit, from medial to lateral. The intimate relationship
between the superior oblique and levator palpebrae superioris muscles is evident in this plane. The distinct division
of the Milller muscle and levator aponeurosis anteriorly is evident. Inferiorly, the inferior oblique muscle is seen in
oblique cross-section, distinct from the inferior oblique muscle. (Bottom) Image at the lateral aspect of the orbital
apex shows the ophthalmic artery as it exits the dural sheath laterally and courses over the nerve-sheath complex.
The orbital septum is visible as a discrete low signal fibrous band that separates the preseptal periorbita from the
remainder of the orbit. The SOY is visible in its expected location.
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 rJl BONY ORBIT AND FORAMINA
CJ.)
rJl
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C ITerminology I Imaging Anatomy
V"l
-0 Abbreviations Anatomy Relationships
C • Bones, foramina, and fissures • Major foramina
(\l
o Greater wing of sphenoid (GWS) o Optic canal
CJ.)
rJl o Lesser wing of sphenoid (LWS) • Formed completely by LWS
o o Optic canal (OpC) • Separated from SOF by optic strut
Z o Superior orbital fissure (SOF) o Superior orbital fissure
o Inferior orbital fissure (IOF) • Formed by LWS medially, GWS laterally
..n
•.... o Foramen rotundum (FR) • Primary connection orbit +-+ intracranial
o o Foramen ovale (FO)
o Vidian canal (Ve)
o Inferior orbital fissure
• Formed by GWS and zygomatic bone laterally,
o Pterygopalatine fossa (PPF) maxillary and ethmoid bones medially
• Cranial nerves • Mostly contiguous with SOF, separated only at
o Optic nerve (CN2) posterior aspect by short bony roof of FR
o Oculomotor nerve (CN3) • Anterior continuation of FR
o Trochlear nerve (CN4)
o Trigeminal nerve (CNS)
Internal Structures-Critical Contents
• Ophthalmic branch (VI) • Contents of foramina
• Maxillary branch (V2) o Optic canal: CN2 and OA
• Mandibular branch (V3) o Superior orbital fissure: CN3, 4, S (VI), & 6, SOY
o Abducens nerve (CN6) o Inferior orbital fissure: CNS (V2), IOV
o Foramen rotundum: CNS (V2)-proximal segment
• Vessels
o Ophthalmic artery (OA) o Foramen ovale: CNS (V3)
o Superior ophthalmic vein (SOV) o Supraorbital foramen: Supraorbital nerve (VI)
o Inferior ophthalmic vein (IOV) o Infraorbital foramen: Infraorbital nerve (V2)

Definitions
• MPR: 2D multi planar reformations IAnatomy-Based Imaging Issues
Key Concepts or Questions
I Gross Anatomy • Pathways of orbit-sinus disease spread
o Orbit ....•intracranial
Bones of the Orbit • SOF and IOF: Common pathway; extends into
• Frontal bone cavernous sinus and Meckel cave, involves CN3-6
o Forms superior rim and anterior portion of roof • OpC: Involves optic nerve, dura
(orbital process) o Orbit ....•deep face
• Zygomatic bone • SOF and IOF: Communicate with PPF
o Forms inferolateral rim, anterior portion of lateral o Sinus ....•orbit
wall (orbital process), and anterior portion of lateral • Ethmoid: Common pathway via lamina papyracea
floor (maxillary process) • Frontal: Especially post-obstructive process
• Maxillary bone
o Forms inferomedial rim (frontal process) & anterior
Imaging Recommendations
portion of inferomedial wall (orbital surface) • CT
• Nasal bone o Preferred for assessing bony structures and foramina
o Forms bridge of nose • MR
o Anteromedial to frontal process of maxillary bone o Preferred for evaluation of tumor and inflammation
• Ethmoid bone o Foramina not as easily seen as CT, but can be
o Forms mid portion of medial wall discerned by superimposing image of CT
o Very thin bone (lamina papyracea) Imaging Pitfalls
• Lacrimal bone • Assessing foramina
o Forms anterior portion of medial wall, just posterior o Optic canal oriented obliquely
to frontal process of maxillary bone • Complete ring not visible in coronal plane
o Fossa for lacrimal sac • MPR orthogonal to long axis may be required to
• Sphenoid bone demonstrate intact canal
o Forms posterior portion of lateral wall (GWS) and o FR and VC often mistaken
posterior portion of medial roof (LWS) • FR appears superolateral in coronal plane
o Complex contours between GWS and LWS create • FR appears short compared to longer/curvilinear
elaborate apical fissures VC
• Palatine bone • Artifacts
o Forms small portion of inferomedial wall posteriorly o Dental artifact troublesome on direct coronal images
o Located between orbital portions of ethmoid & • Axial multislice source with coronal MPR preferred
maxillary bones if dental amalgam present

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 BONY ORBIT AND FORAMINA
<Jl
(l) AXIAL BONE CT
<Jl
:::J Nasal bone
C
(./)
Maxillary bone (frontal process)
-0
C Nasolacrimal duct
(ij Lacrimal bone
(l)
<Jl
o Maxillary bone and sinus
Zygomatic bone
Z
Inferior orbital fissure
..0 Pterygopalatine fossa
l-

o Foramen rotundum
Foramen rotundum
~
u
Q)
Z
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c
(ij
""0

(ij
Q) Nasomaxillary suture
::c
Lacrimal bone

Ethmoid bone (lamina papyracea)

Sphenozygomatic suture
Greater wing of sphenoid

Sphenotemporal suture

Superior orbital fissure

Central sphenoid bone and sinus

Frontal bone
Frontal recess

Zygomatic bone
Ethmoid sinus

Greater wing of sphenoid

Superior orbital fissure

Optic canal
LWS (optic strut)
Sella turcica

(Top) First of three axial bone CT images presented from inferior to superior. The short, horizontally oriented
foramen rotundum is seen at the posterior margin of the PPF with the IOF extending anterolaterally in roughly the
same plane. Anteriorly, reiationships between the medial bony orbit and nasolacrimal structures are evident.
(Middle) Image at the level of the mid-orbit. The SOF is seen as a gap at the orbital apex. The thin ethmoid bone
forms the bulk of the medial orbital wall. (Bottom) Image at the level of the upper orbit. The optic canals show
characteristic angles as the nerves approach the chiasm, which is located above the sella. The SOF is inferior and
lateral to the optic canal, from which it is separated by the bony optic strut of the LWS. Sinus air space within the
II paramedian portions of the frontal bones Is seen anteriorly.
96
 BONY ORBIT AND FORAMINA
CORONAL BONE CT

Optic canat

Anterior clinoid process

Superior orbital fissure
Optic strut Foramen rotundum
o
Vidian canal Sphenoid sinus (with lateral
recess)
z
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Frontal bone (orbital process) (!)
{Jl

Frontozygomatic suture
Ethmoid bone (lamina
Zygomatic bone papyracea)

Inferior orbital fissure

Maxillary bone and sinus

Frontal sinus
Frontal bone

Lacrimal bone

Nasolacrimal duct

Zygomatic bone
Infraorbital canal

Zygomaticomaxillary suture

Maxillary bone & sinus

(Top) First of three coronal bone CT images presented from posterior to anterior. The obliquely oriented optic canals
show characteristic ovoid shape. The SOF is located inferolaterally relative to the optic canal, with the optic strut and
attached clinoid process of the LWSseparating the two. Further inferolaterally is the foramen rotundum. The vidian
canal is inferior and medial to rotundum, noting a prominent lateral recess of the sphenoid sinus separating the two
foramina. (Middle) Image at the level of the mid-orbit. Contours of the bony orbit, including integrity of the thin
lamina papyracea of the medial wall, are best seen in this plane. (Bottom) Image at the level of the anterior orbit.
Contours of the bony orbital rim are best evaluated in the coronal plane. The nasolacrimal structures, as well as
anterior sinonasal spaces, are well demonstrated. II
97
 OPTIC NERVE/SHEATH COMPLEX
• Exits sheath laterally at orbital apex
ITerminology o Central retinal artery
Abbreviations • Major branch of OA, supplies retina
• Optic nerve-sheath complex (ONSC) • Enters CN2 ~ 1 cm posterior to nerve head
o Central retinal vein
• Optic nerve (CN2)
• Ophthalmic artery (OA) • Accompanies central retinal artery
• Superior/inferior ophthalmic vein (SOV/IOV) • Drains directly into cavernous sinus

Definitions
..0 • Optic nerve, chiasm & tract: Afferent visual CNS
•... pathways that extend from retina to visual nuclei of
o midbrain
• Optic sheath: Dural encasement of intraorbital CN2
I Gross Anatomy
Overview
• Optic nerve and tract
o Anatomically a CNS tract
• Composed of oligodendrocytes
o Different from other cranial nerves
• Composed of Schwann cells
• Optic sheath
o Dural encasement of nerve
• Contiguous with intracranial dura
• All 3 membrane layers of meninges present
including pia, arachnoid & dura mater
o CSF-filled arachnoid space surrounds nerve
• Contiguous with suprasellar cistern
• Transmits intracranial pressure changes
I Imaging Anatomy
Extent
• Optic nerve
o From optic nerve head to chiasm
o Optic nerve segments
• Intraocular: Within nerve head (1 mm)
• Orbital: Nerve head to optic canal (30 mm)
• Canalicular: Within optic canal (10 mm)
• Cisternal: Optic canal to optic chiasm (10 mm)
• Optic chiasm
o Within suprasellar cistern
• Just anterior to pituitary stalk
o Decussation of half ofaxons
• Represents nasal portion of retina
• Each half of visual field from each eye is afferent
to contralateral visual cortex
• Optic tract
o From optic chiasm to visual nuclei of midbrain
Anatomy Relationships
• Optic canal
o Transmits ONSC and OA
o Separated from superior fissure by optic strut
Internal Structures-Critical Contents
• Vascular supply
o Ophthalmic artery
• First intradural branch of ICA
• Major arterial supply to orbit
• Passes through optic canal in dural sheath
IAnatomy-Based Imaging Issues
Key Concepts or Questions
• Orientation of optic nerve
o Intraorbital segment
• Posteromedial oblique sagittal long axis
• Roughly horizontal plane
• Position varies with eye movement
• Nerve longer than distance from apex to globe,
tends to form an "S-shaped" contour
o Canalicular segment
• Oblique axis results in non-orthogonal "ovoid"
cross sectional appearance on coronal images
o Cisternal segment
• Angle changes relative to intraorbital segment as it
courses posteriorly
• Oblique sagittal long axis ~ 30° medially and
superiorly
Imaging Recommendations
• Routine orbital approach appropriate for most
nerve/sheath lesions
• Special circumstances
o Sheath mass (possible meningioma)
• May benefit from noncontrast CT to detect
calcification
• Additional brain imaging may be necessary to
define extent of intra-axial tumor
o Inflammatory nerve work-up (optic neuritis)
• Requires concomitant brain imaging
• High incidence of demyelinating disease
Imaging Approaches
• Dedicated optic nerve MR imaging
o Axial sequences
• 3.0 mm, anterior fossa floor through floor of orbit
o Coronal sequences
• 3.5 mm, back of pons through globe
o Tl WI, STIR, and Tl C+ with fat suppression
• Both axial and coronal
• May substitute axial T2WI FSE+ fat suppression
for STIR
Imaging Pitfalls
• Motion artifacts on MR
o Common due to irrepressible eye motion
• Surface coils
o Generally not adequate to visualize entire ONSC
I Clinical Implications
Nerve vs. sheath masses
• Important distinction, very different therapies
• Best with coronal STIR and Tl C+ with fat suppression

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 OPTIC NERVE/SHEATH COMPLEX
QJ CORONAL & AXIAL T1 MR
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c
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Q)
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..n Superior ophthalmic

>-
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~
u Optic sheath
Q) Lacrimal & zygomatic
Z arterial branches
""0

Optic nerve
c:
~
""0
Muscular & ciliary
~ arterial branches Perioptic fluid (CSF)
Q)
:r:
Inferior ophthalmic
vein

Lacrimal gland

Perioptic fluid (CSF)

Optic nerve
(intraorbital segment)

Ophthalmic artery
branches Ophthalmic artery

Optic nerve
(intracanalicular
Optic strut
segment)

(Top) Coronal high-resolution Tl MR of the intraconal orbit. The optic nerve/sheath complex is centered within the
EOM cone. Perioptic fluid is contiguous with intracranial CSF,and is seen as hypointense signal between the nerve
centrally and the dural sheath peripherally. Intraconal branches of the ophthalmic artery are in proximity with the
nerve/sheath complex; considerable variation exists in the order and anastomotic connections of these branches.
(Bottom) Axial high-resolution Tl MR of the mid-orbit. The optic nerve/sheath complex angles medially within the
muscle cone as it courses toward the optic canal. The ophthalmic artery is visible near the apex as it exits laterally
II from within the dural sheath just beyond the optic canal.

100
 OPTIC NERVE/SHEATH COMPLEX
CORONAL & AXIAL STIR MR

Superior rectus muscle

o

Optic nerve z
o
V1
(!)

Partial volume ClJ

Perioptic fluid (CSF) :J
averaging of globe Q...

Optic nerve Vl
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V1
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V1

Anterior segment of
eye
Lens

Vitreous chamber of
eye

Medial & lateral rectus

muscles
Perioptic fluid (CSF)

Optic nerve
(intraorbital segment)

Optic nerve
Optic nerve
(intracanalicular (chiasmatic segment)
segment)

Internal carotid artery Optic chiasm

Optic tract

(Top) Coronal T2 STIR image of the orbits. STIR technique provides reliable and effective suppression of intraorbital
fat, making the fluid signal of the perioptic cerebrospinal fluid appear conspicuous. Extraocular muscles appear
relatively hypointense on STIR. Remember the arachnoid space surrounding the optic nerve is contiguous with the
suprasellar cistern. Its size will therefore vary with intracranial pressure. (Bottom) Axial T2 STIR image of the orbits.
A slightly oblique plane allows for demonstration of both intraorbital and cisternal segments of CN2. Because of the
normal angulation of the nerves proximally, the chiasm and tracts are usually demonstrated on images superior to
those depicting the intraorbital nerves. The anterior segment of the eye includes both the anterior and posterior
chambers in front of the lens.
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 GLOBE
I Gross Anatomy I Imaging Anatomy
Segments Overview
• Anterior segment of globe • Primary imaging approaches
o Portion of eye in front of anterior margin of vitreous o Direct funduscopy is first line technique
(hyaloid face) o Sonography readily available at most eye clinics
• Ciliary body, suspensory ligaments and lens • Cross-sectional modalities (MR and CT)
• Anterior and posterior chambers o Particularly useful in eyes with opaque media (Le.,
• Iris obscured by vitreous or aqueous opacity)
..0 • Cornea o Routine imaging as part of orbital evaluation
••....
o • Posterior segment of globe
o Vitreoretinal portion of the eye and its layers
• Extraocular extension of ocular disease
• Ocular involvement of orbital process
~ • Vitreous chamber
u Internal Structures-Critical Contents
Q) • Retina
Z • Choroid • Anterior segment
• Sclera o Aqueous chambers exhibit fluid signal
"'C
t:: o Lens moderately hyperdense on CT, isodense on
~ Chambers Tl WI, hypodense relative to fluid on T2WI
"'C • Anterior chamber o Ciliary body and iris variably distinguishable but not
~ o Major chamber of anterior segment diagnostic detail
Q)
:c o Between cornea and iris
o Filled with aqueous humor which provides nutrition
• Posterior segment
o Vitreous chamber exhibits fluid signal
and structure
• Posterior chamber
o Small potential space posterior to iris and anterior to jAnatomy-Based Imaging Issues
lens/ligament complex
o Contiguous with anterior chamber through pupil Imaging Recommendations
• Vitreous chamber • CT
o Large chamber that fills posterior segment o Preferred in some circumstances
o Filled with viscoelastic transparent gel o Evaluation of calcification (e.g., retinoblastoma)
o Evaluation in a child without sedation
Tunicae
• MR
• Tunica interna (retina) o Preferred for evaluation of extraocular extent of
o Multilayered sensorineural organ disease
• Photoreceptor cells (rods and cones) overlie o T2WI useful for evaluating vitreous and aqueous
pigment epithelium at outermost layer chambers; otherwise limited utility in eye
• Bipolar and ganglion cells form inner layer (next o Tl WI pre- and post-contrast better for assessing
to vitreous), & assemble & convey sensory signals uveoretinal structures
o Regions and extent o Surface coils improve signal and resolution in globe
• Macula: Central portion, daylight & color vision but may be limited in assessment of posterior orbit
• Fovea: Macular center, highest spatial resolution
• Peripheral: Outer portion, night vision & motion Imaging Pitfalls
• Ora serrata: Anterior margin of retina • MR
• Tunica vasculosa (uvea) o Irrepressible globe movement results in ubiquitous
o Pigmented, vascular loose connective tissue motion artifact
o Choroid
• Layer between retina and sclera
• Vascular supply to photoreceptor layer I Embryology
o Ciliary body
• Uveal structure anterior to ora serrata Embryologic Events
• Attached to lens via zonule fibers • Optic fissure
• Contractile function provides for lens o Extends along inferonasal aspect of optic disc &
accommodation stalk
• Source of aqueous production o Fissure fusion (about 5th week) required for normal
o Iris globe and nerve formation
• Thin elastic tissue overlying lens o Failure of fusion results in coloboma
• Sphincter muscle provides pupillary response • Primary vitreous
• Tunica fibrosa (sclera) o Embryonic fibrovascular hyaloid, with hyaloid
o Outer fibrous layer artery in Cloquet canal
o Attachment site for extraocular muscles o Normally regresses about 7 months gestation
o Contiguous with dura of optic sheath as well as • Visible in premature infant
fibrous diaphragm (lamina cribrosa) at nerve head o Failure of regression results in persistent hyperplastic
o Contiguous with cornea anteriorly primary vitreous

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 SINONASAL
ITerminology
Abbreviations
• Sinonasal (SN)
Definitions
• SN: Nasal cavity, paranasal sinuses (maxillary, frontal,
ethmoid, and sphenoid), and surrounding structures
..0
l....
IImaging Anatomy
o pneumatization; close relationship to optic nerve
~ Overview
u • Nasal cavity: Triangle divided in midline by septum
Q)
o Roof: Cribriform plate
Z o Floor: Hard and soft palate
"'0
o Lateral: Lateral nasal wall with attached turbinates
r::
~ o Nasal septum
"'0 • Bony septum: Perpendicular plate of ethmoid
~ posterosuperiorly and vomer posteroinferiorly
Q)
• Cartilage: Septal cartilage anteriorly
:c o Turbinates
• Bony superior, middle, and inferior turbinates
project inferomedially into nasal cavity
• Define region below as superior, middle, and
inferior meati, respectively
• Middle turbinate attaches superiorly to cribriform
plate via vertical lamella and posteriorly and
laterally to lamina papyracea via basal lamella
o Meati
• Superior meatus: Receives drainage from
posterior ethmoid cells at sphenoethmoidal recess
• Middle meatus: Ethmoid bulla: Large ethmoid
air cell positioned at superior aspect of ostiomeatal
complex (OMC), receives drainage from anterior
ethmoid air cells
• Middle meatus: Hiatus semilunaris: Semilunar
region between uncinate process and ethmoid
bulla, receives drainage from anterior ethmoid air
cells and maxillary sinus via infundibulum
• Inferior meatus: Receives drainage from
nasolacrimal duct anteriorly
Extent
• Nasal cavity and paranasal sinuses aerate the
maxillary, frontal, sphenoid, and ethmoid bones
Anatomy Relationships
• Maxillary sinus: Paired air cells within maxillary bone
o Drain via maxillary ostium located along superior
aspect of medial wall into infundibulum then into
hiatus semiJunaris at the middle meatus
• Ethmoid sinus: Paired groups of 3-18 air cells within
ethmoid labyrinths
o Separated into anterior and posterior groups
separated by basal lamella (lateral attachment of
middle turbinate to lamina papyracea)
o Ethmoid bulla: Dominant anterior ethmoid air cell
that protrudes inferomedially into infundibulum or
hiatus semilunaris
o Anterior drainage: Anterior recess of hiatus
semilunaris and middle meatus via ethmoid bulla
o Posterior drainage: Superior meatus and
sphenoethmoidal recess
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OVERVIEW
• Frontal sinus: Paired air cells within frontal bone
o Drainage through frontal recess into middle meatus
• Sphenoid sinus: Paired air cells within sphenoid bone
o Drainage into sphenoethmoidal recess
• Extramural paranasal air cells
o Infraorbital ethmoid cells (Haller) = ethmoid cells
that extend into inferomedial orbital floor
o Agger nasi cells = most anterior air cells that
involve lacrimal bone or maxilla
o Sphenoethmoidal cells (Onodi) = posterior
ethmoid air cells with prominent superolateral
Internal Structures-Critical Contents
• Pterygopalatine fossa (PPF)
o Major crossroads between nasal cavity, masticator
space, orbit, and middle cranial fossa
• Sphenoethmoidal recess (SER)
o Receives drainage from sphenoid sinus and variable
drainage from posterior ethmoid air cells
• Olfactory tract and bulb
o Nasal mucosa and sensory nerves traverse cribriform
plate and synapse with secondary neurons in
olfactory bulb and olfactory tracts
IAnatomy-Based Imaging Issues
Key Concepts or Questions
• Majority of SN imaging depicts complete absence or
sporadic (nonobstructive) mild disease
Imaging Recommendations
• Common rhinosinusitis symptoms case best imaged
with NECT, bone algorithm
o Multislice CT can acquire 1 mm axial sections &
reconstruct coronal & sagittal images
• Sinusitis complications can be imaged with CECT, but
CEMR better evaluates surrounding structures
Imaging Approaches
• Coronal sinus CT used in presurgical work-up and
follow-up of inflammatory sinonasal disease
• MR: If enhanced scan needed to define complex
inflammatory or neoplastic disease, use enhanced MR
o Fat-saturation should be utilized on at least one
post-contrasted sequence
Imaging Pitfalls
• Be aware of variations in sinus pneumatization
IClinical Implications
Clinical Importance
• Rhinosinusitis accounts for over 2 million office visits
and $2 billion in direct medical costs yearly
I Embryology
Embryologic Events
• Paranasal sinuses develop as diverticula from the nasal
vault with a contiguous mucosal surface
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 SINONASAL OVERVIEW
lJl
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lJl
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Cl)
lJl
o Anterior cranial fossa
Z

...
..0
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Nasal septum

Anterior ethmoid complex

Lamina papyracea
Posterior ethmoid complex

Middle cranial fossa Sphenoid sinuses

Nasolacrimal ducts

Infraorbital nerve
Inferior turbinate
Maxillary sinus
Retromaxillary fat pad

Pterygomaxillary fissure
Masticator space (infratemporal
fossa)
Pterygopalatine fossa

(Top) First of three axial bone CT images of the sinuses presented from superior to inferior. This image shows the
frontal sinuses, with their midline septum, and thin posterior wall, separating the sinuses from the anterior cranial
fossa. Frontal sinus disease can extend posteriorly into the cranial vault. (Middle) This image shows the ethmoid air
cells and sphenoid sinuses. The thin lamina papyracea is the lateral wall of the ethmoid sinuses. Ethmoid air cell
disease can extend through the lamina papyracea to create a post-septal subperiosteal abscess. (Bottom) This image
through the maxillary sinuses shows their intimate relationship to the nasolacrimal ducts, pterygopalatine fossa and
retromaxillary fat pad. Notice the infraorbital nerve anteriorly just before it exits through the infraorbital foramen.
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 SINONASAL OVERVIEW
CORONAL BONE CT I
(t)
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a.
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Sphenoid sinuses
Foramen rotundum
Vidian canal

Lateral pterygoid plate

Medial pterygoid plate

Hamulus

Sphenoid sinuses
Optic canal
Superior orbital fissure
Sphenopalatine foramen
Inferior orbital fissure
Pterygomaxillary fissure
Pterygopalatine fossa

Middle turbinate
Inferior turbinate

(Top) First of nine coronal bone CT non contrasted images through the paranasal sinuses are presented from
posterior to anterior. This image shows the sphenoid sinuses, superior to the nasopharynx. (Middle) This image
shows the pterygoid plates, posterior to the maxillary sinuses. Inferolateral to the sphenoid sinus note the foramen
rotundum and the vidian canal. (Bottom) This image shows the complex anatomic landscape surrounding the PPE
The lateral exit of the PPF is the pterygomaxillary fissure through which it exits into the masticator space. Superiorly
the PPF exits into the inferior orbital fissure. The medial exit from the PPF is through the foramen rotundum into the
posterolateral nose.
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 SINONASAL OVERVIEW
rJl
Q) CORONAL BONE CT
rJl
:J
C
Vl
Sphenoid sinuses
-0
c
(ij Sphenoethmoidal recess Sphenoethmoidal recess
Q)
rJl
o Middle turbinate Inferior orbital fissure
Z Pterygopalatine fossa
Pterygomaxillary fissure
..0 Maxillary sinus
o'-- Inferior turbinate

Greater palatine foramen

Anterior ethmoid air cells

Lamina papyracea Ethmoid bulla

Infraorbital nerve

Middle turbinates
Posterior middle meatus

Inferior turbinate Inferior meatus

Crista galli
Cribriform plate
Olfactory recess, nasal vault Fovea ethmoidalis

Anterior ethmoid artery canal

Lamina papyracea Anterior ethmoid air cells
Ethmoid bulla
Middle meatus
Maxillary infundibulum Uncinate process
Middle turbinate
Nasal septum Inferior meatus

Inferior turbinate

(Top) In this image the sphenoethmoidal recess is visible as vertical air-filled slits in the posterosuperior nose into
which both the posterior ethmoid sinus and the sphenoid sinus empty. Note the greater palatine canal exiting the
lateral hard-soft palate junction. Perineural mali,gnanry may travelfrom the palate tothe pt~rY&9palatine...fos.~jl Yia
the greater palatine nerve. (Middle) In this image through the;mterior ethmoiaair cells the ethmoId bulla is seen
projecting inferiorly into the middle meatus. The shared wall with between the anterior ethmoid air cells and the
orbit is paper thin, hence the term lamina papyracea. (Bottom) Image through the ostiomeatal complex shows the
maxillary infundibulum draining the maxillary sinuses into the middle meatus. The uncinate process, middle
II meatus, maxillary infundibulum and ethmoid bulla are the components of OMC.
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 SINONASAL OVERVIEW
CORONAL BONE CT

Crista galli Cribriform plate

Olfactory recess, nasal vault Fovea ethmoidalis

Lamina papyracea
Anterior ethmoid air cells o
Ethmoid bulla
Middle turbinate Infraorbital nerve
z
o
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Inferior meatus (t)

Inferior turbinate Q)
::J
Q..
Vl
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C
(fl
(t)
(fl

Frontal sinus
Lamina papyracea
Frontal sinus drainage
Nasolacrimal sac
Nasolacrimal duct

Maxillary sinus
Inferior turbinate

Frontal sinus

Air in nasolacrimal sac

Agger nasi cells

Nasal septum

(Top) In this image through the anterior aspect of the anterior ethmoid complex the fovea ethmoidalis (roof of
ethmoid), cribriform plate and crista galli can all be seen along the roof of the sinuses and nose from lateral to
medial. The olfactory recess of the nasal vault contains the nasal mucosa. From the nasal mucosa arises
esthesioneuroblastoma. (Middle) This image shows the close relationship of the nasolacrimal ducts to the maxillary
sinuses. Remember the nasolacrimal duct drains into the anterior recess of the inferior turbinate. (Bottom) In this
image through the frontal sinuses the anteroinferior ~xtramuraLethmoid_aiLcells also called the agger nasi air cells
can be seen. Notice the normal air-filled left naso[acrimal sac just lateral to the agger nasi cells.
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 SINONASAL OVERVIEW
lJl
Q) SAGITTAL BONE CT
lJl
:::::l
C
Vl
-0
c
ctl
Q)
lJl

o
Z
Anterior ethmoid air
Frontal sinus cells
...D
•....
o Posterior ethmoid air
cells
~
U
Q) Maxillary
Z infundibulum Sphenoid sinus
""0

s::
ctl
Nasolacrimal duct
""0 Pterygopalatine fossa
ctl
OJ
Anterior recess inferior
I meatus
Maxillary sinus

Greater palatine
foramen

Anterior ethmoid air

Posterior ethmoid air
cells
cells

Ethmoid bulla

Sphenoid sinus

Hiatus semilunaris

Uncinate process Inferior turbinate

(Top) First of four sagittal bone CT noncontrasted images through the paranasal sinuses presented from lateral to
medial. This image shows the nasolacrimal duct, draining into the inferior meatus. Also note the pterygopalatine
fossa posterior to the maxillary sinus. (Bottom) In this image the uncinate process can be seen just inferior to the
ethmoid bulla. The gap between these two structures is the hiatus semilunaris.

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 SINONASAL OVERVIEW
SAGITTAL BONE CT

Anterior ethmoid air

cells
Frontal recess
Posterior ethmoid air
cells
z
o
r.r>
CD
Sphenoid sinus tl)

Ethmoid bulla
::J
0..
Basal lamella of middle
Vl
turbinate
::J
C
r.r>
Hiatus semilunaris Middle turbinate CD
r.r>

Inferior turbinate

Frontal bone
Anterior ethmoid air
cells

Frontal recess of frontal Posterior ethmoid air

sinus cells

Agger nasi air cell

Sphenoid sinus

Basal lamella of the

middle turbinate

Middle turbinate

Inferior turbinate

(Top) This image shows the middle and inferior turbinates, as well as the basal lamella of the middle turbinate.
(Bottom) In this image the anteroinferior ethmoid air cell (agger nasi cells) are seen extending anteroinferiorly to the
frontal recess of the frontal sinus. If this cell is infected, the frontal sinus recess and frontal sinus will also become
infected secondarily.

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 SINONASAL OVERVIEW
lJl
Q) AXIAL T1 MR
lJl
~
C Fat in nasal bone
(f)

-0 Anterior ethmoid artery

C
ru
Q) Anterior ethmoid air cells
lJl
o Fat in crista galli Lamina papyracea
Z
Posteriorethmoid air cells
..D
~
o Optic nerve
Sphenoid sinus

Extraconal fat
Anterior ethmoid air cells
Lamina papyracea
Medial rectus muscle
Posteriorethmoid air cells

Sphenoid sinus

Cavernous carotid artery

Nasolacrimalduct

Middle turbinate

Ethmoid bulla Middle meatus

Inferior rectus muscle
Maxillarysinus

Infraorbital nerve Inferior orbital fissure

Maxillarynerve (CNV2)
Sphenoid sinus

(Top) First of six axial pre-contrasted Tl MR images presented from superior to inferior, through the paranasal
sinuses and the nasal vault. In this image the anterior ethmoid artery is visible piercing the lamina papyracea into
the anterior ethmoid air cells. (Middle) In this image through the mid-globes the close relationship of the ethmoid
air cells to extra conal fat and medial rectus muscle is seen. The thin lateral wall of the ethmoid sinus (lamina
papyracea) is is all that separates the orbit from the sinus. If the ethmoid sinuses become infected, inadequate
treatment can lead to orbital infection. (Bottom) In this image through the superior portion of the maxillary sinus
the ethmoid bulla, middle meatus and middle turbinate are seen in the axial plane. Notice the fluid-filled normal
II nasolacrimal duct in the anterior aspect of the lateral nasal wall.
112
 SINONASAL OVERVIEW
AXIAL T1 MR

Nasolacrimal duct

Middle turbinate
Middle meatus o
Maxillary sinus

Internal maxillary artery Pterygopalatine fossa

z
o
trl
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Nasal septum
Nasolacrimal duct opening into
Nasal cavity inferior meatus

Maxillary sinus Inferior turbinate

Pterygopalatine fossa Retromaxillary fat pad

Lateral pterygoid plate

Medial pterygoid plate

Inferior turbinate

Inferior meatus
Maxillary sinus

Posterior nasal cavi ty Retromaxillary fat pad

Nasopharyngeal airway

(Top) At the level of the pterygopalatine fossa the internal maxillary artery can be seen as its principal occupant. The
medial exit from the pterygopalatine fossa is the sphenopalatine foramen. Juvenile angiofibroma originates along the
nasal margin of the sphenopalatine foramen. Often the first route of spread for this tumor is through this foramen
into the pterygopalatine fossa. (Middle) In this image the nasolacrimal duct is visible emptying inferiorly into the
anterior recess of the inferior meatus. The inferior turbinate is the largest of the turbinates and can be mistaken for a
mass when large and asymmetric. (Bottom) At the level of the mid-maxillary sinus the posterior nasal cavity can be
seen in direct continuity with the nasopharyngeal airway. The retromaxillary fat pad sits behind the maxillary sinus.
It is the superior extension of the buccal space. II
113
 <Jl
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OSTIOMEATAL UNIT (OMU)
<Jl
~ o Concha bullosa: Aeration of nasal turbinate, most
C ITerminology commonly middle turbinate
CJ)
"""0 Abbreviations • When inflamed, concha bullosa may obstruct
C • Ostiomeatal unit (OMU), ostiomeatal complex (OMC) OMU at middle meatus
~ • Complete obstructive OMU pattern with frontal,
C],)
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Definitions maxillary, and anterior ethmoid opacification
o • OMU: Complex anatomic region where drainage of o Haller cell (infraorbital ethmoid air cell): Air cell
Z frontal, anterior ethmoid and maxillary sinuses occurs located inferolateral to orbit and lateral to maxillary
infundibulum
..0 • When inflamed, may obstruct maxillary
•.... I Imaging Anatomy infundibulum creating isolated maxillary
o infundibular pattern of sinus disease
~ Overview • Infundibular pattern: Only maxillary sinus is
u • OMU includes superomedial maxillary sinus, maxillary diseased with sparing of ethmoid sinuses
Q)
infundibulum, uncinate process, ethmoid bulla, hiatus o Agger nasi air cell: Most anterior ethmoid air cells
Z semilunaris and middle meatus • Found lateral to lamina papyracea, adjacent to
"'0
frontal recess
c Extent
ctl • When inflamed, agger nasi air cell may obstruct
"'0 • OMU is area superolateral to middle meatus that frontal recess causing isolated opacification of
ctl receives drainage of frontal, anterior ethmoid and frontal sinus without involving anterior ethmoid
Q) maxillary sinuses or maxillary sinuses
:r:
Anatomy Relationships
• Middle meatus is most complicated of meati,
receiving drainage from multiple sinuses IAnatomy-Based Imaging Issues
o Anterior ethmoid air cells drain mostly into Key Concepts or Questions
ethmoid bulla
• Sinus CT used in presurgical work-up and follow-up of
• Ethmoid bulla: Large ethmoid air cell positioned
inflammatory sinonasal disease
at superior aspect of OMU, immediately superior
to hiatus semilunaris Imaging Recommendations
o Frontal sinus drains into anterior aspect of middle • Common rhinosinusitis symptom cases are best
meatus imaged with bone algorithm CT
• If uncinate process inserts on middle turbinate or o Coronal plane CT optimally depicts OMU
skull base, frontal sinus drains through frontal
recess into ethmoid infundibulum then middle Imaging Approaches
meatus • Multislice scanners can acquire thin (1 mm) supine
• If uncinate process inserts on lamina papyracea, sections with reconstruction of coronal and sagittal
frontal recess drains into anterior middle meatus images
directly • If older scanner is available only, prone hyperextended
• Frontal recess: Drainage funnel for frontal sinus coronal acquisitions may be preferable to move
o Maxillary sinus drains through maxillary potential fluid in maxillary sinus away from OMU
infundibulum into middle meatus via maxillary
ostium
• Hiatus semilunaris: Semilunar trough between tip of I Clinical Implications
uncinate process and ethmoid bulla seen best from
endoscopic vantage point Clinical Importance
o Hiatus semilunaris difficult to see on coronal sinus • Sinus disease is single most common chronic
CT complaint in USA
o OMU is most important anatomic region for
Internal Structures-Critical Contents potential surgical treatment
• Middle meatus: Space between middle turbinate and • Clinical presentation of OMU obstruction
medial wall of maxillary sinus o Facial fullness, pressure, loss of sense of smell and
• Maxillary infundibulum: Drainage channel of postnasal drainage
maxillary sinus • OMU can also be obstructed secondary to anatomic
o Defined laterally by orbit and medially by uncinate variations or local noninfectious inflammatory
process processes such as allergic rhinitis
o Drains into middle meatus via maxillary ostium
• Uncinate process: Upper medial maxillary sinus wall Function-Dysfunction
o Defines medial wall of maxillary infundibulum • Normal mucociliary pattern within paranasal sinuses
• Ethmoid bulla: Dominant anterior ethmoid air cell is movement of secretions towards natural ostia
that protrudes inferomedially into infundibulum and • Recirculation disorders may result despite endoscopic
upper middle meatus creation of surgical ostia
• Normal aeration variants in vicinity of OMU

II
114
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 OSTIOMEATAL UNIT (OMU)
<Jl
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<Jl
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Aerated tip uncinate process Hiatus semilunaris
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Anterior ethmoid complex

Ethmoidal bulla
Maxillary infundibulum
Uncinate process
Concha bullosa
Concha bullosa

Anterior ethmoid complex

Ethmoidal bulla
Maxillary infundibulum
Middle meatus

Middle turbinate

Inferior meatus
Inferior turbinate

(Top) First of three coronal bone CT images through the normal ostiomeatal complex. This image shows the typical
appearance of the maxillary infundibulum and ethmoid bulla. Notice the right superior tip of the uncinate process is
pneumatized. (Middle) In this image bilateral aerated uncomplicated concha bullosa are visible. Notice the the
attenuated maxillary infundibulum. If the concha bullosa becomes infected (complicated), early obstruction of the
middle meatus causes opacification of the ipsilateral maxillary, anterior ethmoid and frontal sinuses. (Bottom) Image
through a normal ostiomeatal unit with Haller air cell (infraorbital air cell) seen protruding into maxillary
infundibulum. If the Haller cell becomes infected it can cause an "infundibular pattern" of sinus disease where the
II maxillary sinus is opacified without ethmoid involvement.
116
 OSTIOMEATAL UNIT (OMU)
SAGITTAL BONE CT

Frontal sinus Anterior ethmoids

Frontal recess Posterior ethmoids

Sphenoethmoidal recess
Agger nasi air cells
Ethmoid bulla Sphenoid sinus

Basal lamella of middle

Nasolacrimal duct turbinate
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Posterior ethmoids
Frontal recess Ethmoid bulla
Sphenoethmoidal recess
Agger nasi air cell Sphenoid sinus
Hiatus semilunaris
Superior turbinate

Middle turbinate Basal lamella of middle

turbinate
Nasopharynx
Inferior turbinate

Frontal sinus Anterior ethmoids

Frontal recess Posterior ethmoids

Agger nasi air cell

Superior turbinate
Concha bullosa
Sphenoid sinus
Basal lamella of middle
Middle turbinate turbinate
Inferior turbinate

(Top) First of three sagittal bone CT reformations of the sinonasal region presented from lateral to medial
demonstrating the structures of the ostiomeatal unit and its vicinity. In this image the middle meatus can be seen
just inferior to the ethmoid bulla. The nasolacrimal duct is visible emptying inferiorly into the anterior aspect of the
inferior meatus. (Middle) In this image middle and inferior turbinates, as well as the basal lamella of the middle
turbinate are seen. Also note the curvilinear hiatus semilunaris. The frontal recess is visible extending around the
agger nasi air cell. The sphenoethmoidal recess receives the secretions of the posterior ethmoid and sphenoid sinuses.
(Bottom) Notice the air cell in the anterior middle turbinate (concha bullosa) in this image. The basal lamella of the
middle turbinate is also visible. II
117
 PTERYGOPALATINE FOSSA
o Vidian canal: Posterior opening below foramen
I Terminology rotundum that extends posteriorly to foramen
Abbreviations lacerum (transmits vidian nerve)
• Pterygopalatine fossa (PPF) o Inferior orbital fissure: Anterior opening into orbit
(transmits infraorbital nerve and artery)
Synonyms o Pterygopalatine canal: Inferior canal leading to
• Sphenopalatine fossa greater & lesser palatine foramina to oral cavity
(transmits descending palatine nerve and artery)
Definitions
..Q
• PPF: Major crossroads deep within deep face between Imaging Recommendations
the nasal cavity, oral cavity, masticator space, orbit, • Like many lesions near skull base, both bone CT (for
o'- and the middle cranial fossa bone evaluation) and enhance MR (for soft tissue
evaluation) may be required for complete evaluation
of PPF mass
I Gross Anatomy Imaging Approaches
Overview • Thin (1 mm or less), bone algorithm, noncontrasted
• Pterygopalatine fossa is a 3 dimensional box axial sections best delimitate osseous structures
o Anterior wall: Posterior wall of maxillary sinus surrounding PPF
o Posterior wall: Pterygoid plates and inferior aspect of • Contrasted MR of deep face best evaluates soft tissue
lesser wing of sphenoid bone abnormalities of PPF
o Roof: Inferior orbital fissure o Similar to many lesions of extra-cranial head and
o Floor: Narrowing to palatine canals neck, often pre-contrasted T1 MR series best show
o Medial wall: Perpendicular plate of palatine bone lesions of PPF
with sphenopalatine foramen
Imaging "Sweet Spots"
o Lateral wall: Narrowing to pterygomaxillary fissure
• Axial T1 weighted pre-contrasted images often best
demonstrate subtle lesions of the PPF
• Similar to most of head and neck imaging, clinical
I Imaging Anatomy information is critical
Overview Imaging Pitfalls
• PPF is important anatomic landmark for potential • Beware of fat-saturation artifact
routes of spread of disease throughout deep face o Blooming at air-tissue interface may obscure PPF as
Extent result of maxillary sinus air directly anterior to PPF
• Small, but important deep face cavity with osseous • Dental amalgam artrifact may also obscure subtle
borders lesions of PPF

Anatomy Relationships
• Boundaries
o Anterior: Posterior wall maxillary sinus
o Posterior: Pterygoid process of sphenoid bone
o Medial: Perpendicular plate of palatine bone
Internal Structures-Critical Contents
• Pterygopalatine ganglion
• Maxillary nerve (CNV2) enters via foramen rotundum
• Distal internal maxillary artery enters via
pterygomaxillary fissure
IAnatomy-Based Imaging Issues
Key Concepts or Questions
• Communications
o Pterygomaxillary fissure: Lateral opening into
nasopharyngeal masticator space, between the
maxilla and lateral pterygoid plate
o Sphenopalatine foramen: Medial opening into
superior meatus; covered with mucosa
o Foramen rotundum: Posterior opening to middle
cranial fossa that transmits maxillary nerve (CNV2)
I Clinical Implications
Clinical Importance
• PPF serves as crossroads of deep face
o Perineural tumor from hard-soft palate may follow
palatine nerves superiorly into PPF
o Perineural tumor from cheek skin, maxillary sinus
or orbit may follow infraorbital nerve to PPF
o PPF tumor may access intracranial compartment via
foramen ovale or vidian canal
Function-Dysfunction
• Pterygopalatine ganglion contains post-synaptic
parasympathetic nerve cell bodies and sympathetic
fibers
o Parasympathetic fibers from superior saliva tory
nucleus in brainstem enter via vidian nerve, greater
superficial petrosal nerve, and nervus intermediate
root of facial nerve
o Sympathetic fibers from vidian nerve communicate
autonomic impulses to greater and lesser palatine
nerves and branches of CNV2
• Supplying lacrimal gland, glands of nasal cavity,
paranasal sinus, and roof of oral cavity

II
118
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 PTERYGOPALATINE FOSSA
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Sphenoid sinus

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o'- Middle cranial fossa

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canal

Maxillary sinus

Pterygomaxillary fissure Sphenopalatine foramen

Pterygopalatine fossa

Vidian canal
Vidian canal

Foramen ovale

Foramen spinosum

Maxillary sinus
Maxillary sinus

Greater palatine foramen Gn~ater palatine foramen

Lesser palatine foramen
Lesser palatine foramen
Medial pterygoid plate Lateral pterygoid plate

(Top) First of three axial bane CT images presented from superiar to. inferior through the pterygapalatine fassa and
surrounding structures. This image shaws the faramen rotundum through which the maxillary nerves traverse. Note
the clase relatianship af the lateral walls af the sphenaid sinus to. the superiar aspect af the pterygapalatine fassa.
(Middle) Image through the pterygapalatine fassa demanstrates this crossroads of the deep face. The vidian canals
are visible cannecting the pterygapalatine fassa to. the petrous carotid canal. Don't mistake the vidiaf-lcanal for the
superolateral faramen rotundum. (Bottom) This inferiar image demanstrates the greater and lesser palatine faramen,
which transmit the greater and lesser palatine nerves respectively from the pterygapalatine fossa inferiarly to the
II palate.
120
 PTERYGOPALATINE FOSSA
CORONAL BONE CT

Foramen rotundurh Sphenoid sinus

Rotundum notch
Vidian canal
Vidian canal

Medial pterygoid plate Lateral pterygoid plate

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Foramen rotundum
Pterygopalatine fossa Pterygopalatine fossa

Greater palatine canal Greater palatine canal

Greater palatine foramen Greater palatine foramen

Superior orbital fissure

Sphenoid sinus
Inferior orbital fissure Inferior orbital fissure
Pterygopalatine fossa
Pterygopalatine fossa
PterygomaxillilfY fissure
Sphenopalatine foramen

Greater palatine canal

(Top) First of three coronal bone CT images presented from posterior to anterior. This image shows the
communication routes from the pterygopalatine fossa to the middle cranial fossa. Foramen rotundum is seen in the
normal position, superior and lateral to the vidian canal. (Middle) Image through the posterior pterygopalatine fossa
and through the vertical aspect of the greater palatine canal shows this canal connecting the pterygopalatine fossa
above with the greater palatine foramen below. The greater palatine nerve which provides sensory innervation to the
posterior 2/3 of the soft palate uses tnegreater palatine to canal to access the palate. (Bottom) Image through the
anterior pterygoid fossa shows the communication routes to the nasal vault and infratemporal fossa. The
sphenopalatine foramen is covered by mucosa, but is a potential route of spread of disease. II
121
 PTERYGOPALATINE FOSSA
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Maxillary sinus

Greater palatine canal

Hard palate Greater palatine foramen

Superior orbital fissure

Inferior orbital fissure

Pterygopalatine fossa

Greater palatine canal

Maxillary sinus

(Top) First of three sagittal bone CT images through the pterygopalatine fossa from medial to lateral. This image
show the medial pterygopalatine fossa, and the anterior vidian canal extending posteriorly towards the foramen
lacerum. Notice the well-aerated sphenoid sinus seen immediately superior to the pterygopalatine fossa. (Middle)
This image nicely demonstrates the greater palatine canal, extending inferiorly from the pterygopalatine canal to the
palate. This again demonstrates the importance of the PPF, with potential routes of spread of diease from the oral
cavity, sinonasal region, orbit, infratemporal fossa, and intracranial cavity. (Bottom) This image demonstrates the
greater palatine canal, extending inferiorly from the pterygopalatine canal to the palate. The superior orbital fissure,
II is an important connection between the pterygopalatine fossa and the orbit.
122
 PTERYGOPALATINE FOSSA
AXIAL T1 MR

Sphenoid sinus Inferior orbital fissure

Foramen rotundum o
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segment
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Sphenopalatine foramen
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Pterygopalatine fossa
Pterygopalatine ganglion
Infraorbital nerve
Pterygomaxillary fissure

Aerated pterygoid plate

Vidian canal

Vidian canal

Maxillary sinus

Retromaxillary fat pad

Pterygomaxillary fissure

Pterygopalatine fossa
Palatine nerves

Lateral pterygoid plate

Lateral pterygoid muscle

(Top) First of three axial Tl MR images presented from superior to inferior. This image shows the foramen rotundum,
transmitting cranial nerve V2 from the cavernous sinus to the pterygopalatine fossa. The borders of the cavernous
sinus are shown to be concave in this normal case, anterior to Meckel cave, containing the cavernous segments of
the internal carotid arteries. (Middle) This image shows the pterygopalatine fossa and its connections to the deep
face. Medially it communicates with the nose through the sphenopalatine foramen. Laterally it communicates with
the masticator space via the pterygomaxillary fissure. The vidian canal connects the petrous carotid canal to the
pterygopalatine fossa. (Bottom) In this image the inferior pterygopalatine fossa is visible with the palatine nerves
visible as low signal dots in the fat of the fossa. II
123
SECTION 3: Suprahyoid and Infrahyoid Neck

Suprahyoid and Infrahyoid Neck Overview 11-126

Para pharyngeal Space 11-140
Pharyngeal Mucosal Space 11-148
Masticator Space 11-160
Parotid Space 11-170
Carotid Space 11-180
Retropharyngeal Space 11-186
Perivertebral Space 11-194
Posterior Cervical Space 11-202
Visceral Space 11-208
Hypopharynx-Larynx 11-214
Thyroid Gland 11-230
Parathyroid Glands 11-238
Cervical Trachea and Esophagus 11-244
Cervical Lymph Nodes 11-252
..:L. SUPRAHYOID AND INFRAHYOID NECK OVERVIEW
U
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Z o Importance: Perineural tumor on CNV3; sarcoma
""0
ITerminology
Abbreviations
o o Contents: Parotid gland, extracranial CN?, nodes,
>- • Suprahyoid neck (SHN)
....c
~ • Infrahyoid neck (IHN)
~ o Fascia: PS surrounded by SL-DCF
'-+-
C Definitions
""0 • SHN: Spaces from skull base to hyoid bone (excluding
c orbit, sinuses &: oral cavity) including parapharyngeal
~ (PPS), pharyngeal mucosal (PMS), masticator (MS),
""0
parotid (PS), carotid (CS), buccal (BS), retropharyngeal
o (RPS) &: perivertebral (PVS) spaces
>- • IHN: Spaces below hyoid bone with some continuing
....c
~ into mediastinum including visceral space (VS),
~ artery
0... posterior cervical space (PCS), anterior cervical space
::) (ACS), CS, RPS &: PVS
rJ)
~ carcinoma nodes along superficial margin
u I Imaging Anatomy
Q)
Z o Location: Posterior to PMS in SHN &: VS in IHN
Overview
"'C
C • Key to understanding SHN &: IHN spaces is fascia
~ • :3 layers of deep cervical fascia cleave neck into spaces
"'C o Superficial layer, deep cervical fascia (SL-DCF)
~ • SHN: Around MS &: PS; part of carotid sheath
Q)
J: • IHN: Invests neck by surrounding strap,
sternocleidomastoid &: trapezius muscles
o Middle layer deep cervical fascia (ML-DCF)
• SHN: ML-DCF defines P-MSdeep margin;
contributes to carotid sheath
• IHN: Circumscribes VS; part of carotid sheath
o Deep layer, deep cervical fascia (DL-DCF)
• SHN &: IHN: Surrounds perivertebral space
• SHN &: IHN: Contributes to carotid sheath
• SHN &: IHN: Alar fascia is slip of DL-DCF
providing lateral wall to RPS &: OS; also posterior
wall to RPS separating RPS from OS
Spacesof Suprahyoid & Infrahyoid Neck
• Parapharyngeal space
o Location: SHN from skull base to posterior
submandibular space
o Contents: Fat &: pterygoid venous plexus
o Importance: Pattern of displacement helps define
SHN mass space of origin
• Pharyngeal mucosal space
o Location: SHN space medial to PPS, anterior to RPS
o Contents: Mucosa, minor salivary glands, PMS
lymphatic ring, constrictor muscles
• Nasopharyngeal, oropharyngeal &:
hypopharyngeal mucosal surfaces
• PMS of nasopharynx: Torus tubarius, adenoids,
superior constrictor &: levator palatini muscles
• PMS of oropharynx: Anterior &: posterior tonsillar
pillars, palatine &: lingual tonsils, soft palate
o Fascia: PMS on airway side of ML-DCF
o Importance: Squamous cell carcinoma &: NHL here
• Masticator space
o Location: Anterolateral to PPS in SHN
o Contents: Ramus &: condyle of mandible, CNV3,
masseter, medial &: lateral pterygoid &: temporalis
muscles, pterygoid venous plexus
o Fascia: MS surrounded by SL-DCF
II
126
• Parotid space
o Location: Lateral to PPS in SHN
retromandibular vein, external carotid artery
o Importance: Intraparotid CN?; parotid nodes;
perineural tumor on CN?
• Carotid space
o Location: Posterior to PPS in SHN; lateral to VS &:
RPS in IHN
• Begins at inferior jugular foramen &: carotid canal
of skull base; extends to aortic arch
o Contents: CN9-12, internal jugular vein, carotid
o Fascia: All 3 layers, deep cervical fascia
o Importance: CNIO &: carotid here; squamous cell
• Retropharyngeal space
• Begins at clivus; traverses SHN-IHN to T3 level
o Contents: Nodes &: fat in SHN; no nodes in IHN
o Fascia: Anterior fascia is ML-DCF, lateral &: posterior
fascia is DL-DCF (alar fascia)
o Importance: Inferior communication with OS allows
infection access to mediastinum
• Danger space
o Posterior to RPS in SHN &: IHN; continues inferiorly
into mediastinum
• Perivertebral space
o Location: Behind RPS &: around spine in SHN &: IHN
• Defined from skull base above to clavicle below
o Contents: Prevertebral &: paraspinal components
• Prevertebral: Vertebral body, veins &: arteries,
prevertebral &: scalene muscles, brachial plexus &:
phrenic nerve
• Paraspinal: Posterior elements of vertebra, levator
scapulae &: paraspinal muscles
o Fascia: Surrounded by DL-DCF
• Divided by DL-DCF slip into prevertebral &:
paraspinal components
o Importance: PVS malignancy may be epidural
• Visceral space
o Location: IHN only; extends into mediastinum
o Contents: Thyroid &: parathyroids, paratracheal
nodes, esophagus, trachea, recurrent laryngeal nerve
o Fascia: VS surrounded by ML-DCF
o Importance: Trachea &: esophagus traverse VS
• Posterior cervical space
o Location: SHN PCS begins at mastoid tip, extends to
clavicle; most PCS volume in IHN
o Contents: Fat, CN11, spinal accessory nodes
o Fascia: Between SL- &: DL-DCF
o Importance: Spinal accessory nodal diseases
Key Spatial Relationships
• SHN spaces surrounding PPS
o Medial is PMS: PMS mass displaces PPS laterally
o Anterior is MS: MS mass displaces PPS posteriorly
o Lateral is PS: PS mass displaces PPS medially
o Posterior is CS: CS mass displaces PPS anteriorly
o Posteromedial is lateral RPS: Lateral RPS nodal mass
displaces PPS anterolaterally
II
127
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 SUPRAHYOID AND INFRAHYOID NECK OVERVIEW
AXIAL CECT SUPRAHYOID NECK

Pharyngeal mucosal
space/surface
Masseter muscle Retromaxillary fat pad (buccal
space)
Temporalis muscle
Masticator space
Lateral pterygoid muscle
Para pharyngeal space
Styloid process
-Parotid space
Internal jugular vein
Carotid space
Internal carotid artery

Hamulus, medial pterygoid plate

Retromaxillary fat pad (buccal
Masseter muscle space)

Medial pterygoid muscle Masticator space

Retromandibular vein
Parotid space
Styloid process
Mastoid tip
- Parapharyngeal space
Carotid space

Maxillary ridge

Parotid duct Buccinator muscle

Masseter muscle
Medial pterygoid muscle Pharyngeal mucosal space
Mandibular foramen
Para pharyngeal space
Retromandibular vein
Parotid space
External carotid artery
Styloid process Anterior arch Cl
Internal jugular vein
Internal carotid artery

(Top) First of 12 axial contrast-enhanced CT images of both the suprahyoid & infrahyoid aspect of the extracranial
head & neck presented from superior to inferior. This image at the level of the nasopharynx shows the four key
spaces surrounding the parapharyngeal space, the pharyngeal mucosal, masticator, parotid lnd carotid spaces.
(Middle) In this image at level of inferior maxillary sinus the styloid process is seen anterolateral to the carotid space.
The superficial layer of deep cervical fascia defines the masticator and parotid spaces. The more anterior buccal space
has no fascial definition. (Bottom) At the level of the maxillary ridge, the area of the pharyngeal mucosal space is
outlined between the paired fat-filled parapharyngeal spaces. Posterior to the pharyngeal mucosal space are the
tightly packed retropharyngeal and perivertebral spaces. II
131
 SUPRAHYOID AND INFRAHYOID NECK OVERVIEW
AXIAL CECT SUPRAHYOID NECK

Palatine tonsil
Parapharyngeal space
Masseter muscle
Medial pterygoid muscle Masticator space
""0

c Posterior belly digastric muscle

ro Parotid space.
""0 Retropharyngeal space fat
o Sternocleidomastoid muscle Posterior cervical space
>-
....c Prevertebral component,
ro
•.... perivertebral space
Q..
:J Paras pinal com ponent,
(f)
Trapezius muscle perivertebral space
~
u
Q)
Z
"'C
c
~
"'C
~ Platysma muscle
Q)
I Submandibular gland
jugulodigastric node
Pharyngeal mucosal space
Retropharyngeal space Parotid space
Prevertebral component, PVS
Sternocleidomastoid muscle Posterior cervical space
Perivertebral space
Paraspinal component, I'VS
Trapezius muscle

Submandibular gland,

Epiglottis, free margin

Platysma muscle
Facial vein Vallecula
External carotid artery
Internal jugular vein Retropharyngeal space
Internal carotid artery
Sternocleidomastoid muscle Posterior cervical space

Trapezius muscle

(Top) In this image at the level of the mandibular body the .posterior belly of the digastric muscle can be seen
dividing the paro1id taiUrom the carotid s.pace.The direction of displacement of this muscle can define whether a
lesion is in the parotid space (posteromedial displacement) or in the carotid space (anterolateral displacement) .. '
(Middle) In this image through the low oropharynx the pharyngeal mucosal space has been outline anterior to the
perivertebral space. The space between the two is the retropharyngeal space. The alar fascia that makes up the lateral
borders of the retropharyngeal space are not shown. (Bottom) At the level of the free margin of epiglottis the
retropharyngeal space is outline behind the pharyngeal mucosal space. The posterior cervical space contains fat"
II accessory cranial nerve (CNll) and the spinal accessory nodal chain (levelS nodes) ..
132
 SUPRAHYOID AND INFRAHYOID NECK OVERVIEW
AXIAL CECT INFRAHYOID NECK

Platysma muscle
Submandibular space
Hyoid bone Prevertebral component,
Prevertebral muscles perivertebral space
Carotid space
Common carotid artery
Internal jugular vein Vagus nerve location
Sternocleidomastoid muscle
Posterior cervical space
Levator scapulae muscle
Paraspinal component,
Paraspinal muscles perivertebral space
Trapezius muscle

Platysma muscle
Submandibular space
Prevertebral strap muscles
Retropharyngeal space fat
Thyroid cartilage
External jugular vein
Sympathetic chain location
Sternocleidomastoid muscle
Prevertebral muscles Posterior cervical space
Levator scapulae muscle
Paras pinal muscles Paraspinal component,
perivertebral space
Trapezius muscle

Platysma muscle
lnfrahyoid strap muscles Anterior cervical space

Sternocleidomastoid muscle Visceral space

External jugular vein
Prevertebral muscles Carotid space
Vertebral artery/vein Posterior cervical space
Levator scapulae muscle Prevertebral component,
perivertebral space
Retropharyngeal space fat
Trapezius muscle

(Top) Axial CT image at the level of the hyoid bone shows the carotid space now contains the common carotid
artery, internal jugular vein and vagus nerve ,only. The large, fat-filled submandibular space is seen anteriorly.
(Middle) In this image at the level of the supraglottis of the larynx the large sternocleidomastoid and trapezius.
muscles are seen in the lateral neck. Both muscles are innervated by the accessory cranial nerv~. (Bottom) In this
image at the level of the glottis of the larynx the visceral space contains the hypopharynx, larynx and infrahyoid
strap muscle~. Just behind the hypopharynx is the retropharyngeal space which contains only fat in the infrahyoid
neck. Notice that the inferior extension of the submandibular space into the infrahyoid neck is the anterior cervical
space. II
133
 SUPRAHYOID AND INFRAHYOID NECK OVERVIEW
.:::£ AXIAL CECT INFRAHYOID NECK
U
Q)
Z
""0

Thyroid cartilage
o Visceral space
>- Platysma muscle
...c Anterior cervical space
ro
"'-
'-+- Infrahyoid strap muscle
C Cricoid cartilage
Sternocleidomastoid muscle
""0
Thyroid gland Recurrent laryngeal nerve
C
ro Anterior scalene muscle location
Brachial plexus root location
""0
Middle scalene muscle
o Posterior scalene muscle Posterior cervical space
>- Levator scapulae muscle
...c Paraspinal component,
ro perivertebral space
"'- Paras pinal muscles
Q..
::J Trapezius muscle
(./)

~
u
Q)
Z
""0

C Cricoid cartilage
C\l Anterior cervical space
""0
Platysma muscle
C\l
Q) Sternocleidomastoid muscle
J: External jugular vein Visceral space
Carotid space
Anterior scalene muscle Prevertebral component,
perivertebral space
Middle scalene muscle
Esophagus Posterior cervical space
Levator scapulae muscle Paraspinal component,
perivertebral space
Trapezius muscle

Infrahyoid strap muscles

Thyroid gland
Common carotid artery
External jugular vein Visceral space
Internal jugular vein
Tracheoesophageal groove
Anterior scalene muscle
Prevertebral component,
Middle & posterior scalene muscles
perivertebral space
Esophagus Posterior cervical space
Levator scapulae muscle Paraspinal component,
Paraspinal muscles perivertebral space

(Top) At cricoid cartilage level the visceral space now contains the upper thyroid gland. The low density brachial
plexus root projects anterolaterally from the neural foramen to pass between the anterior and middle scalene muscles
in the prevertebral component of perivertebral space. (Middle) In this image the visceral space contains the high
density thyroid gland, the upper cervical esophagus and the cricoid cartilage. The middle layer of the deep cervical
fascia circumscribes the visceral space. (Bottom) At the level of upper !;:ervlcaLtrachea the visceral space is filled with
thyroid gland, parathyroid glands (not visible), trachea & cervical esophagus. The area of tracheoesophageal groove
contains the recurrent laryngeal nerve & the paratracheal nodal chai~. It is via the paratracheal nodal chain that
II differentiated thyroid carcinoma accesses the mediastinum:
734
 SUPRAHYOID AND INFRAHYOID NECK OVERVIEW
AXIAL CECT CERVICOTHORACIC JUNCTION

Infrahyoid strap muscles

Thyroid gland Visceral space

Prevertebral muscles Carotid space
Anterior scalene muscle
Posterior cervical space
Brachial plexus root
Middle scalene muscle Prevertebral component,
perivertebral space
Posterior scalene muscle
Vertebral artery

Levator scapulae muscle Paraspinal component,

perivertebral space
Paraspinal muscles
Trapezius muscle

Visceral space

Carotid space
Prevertebral muscles
Posterior cervical space
Anterior scalene muscle
Middle scalene muscle
Vertebral artery Brachial plexus root

Levator scapulae muscle First rib

Paraspinal muscles Paraspinal component,

perivertebral space
Trapezius muscle

Infrahyoid strap muscle

Internal jugular vein

Anterior scalene muscle

Subclavian artery Visceral space
Brachial plexus roots Vertebral vein
Vertebral artery
Middle scalene muscle
Second rib

Paraspinal component,
perivertebral space
Trapezius muscle

(Top) First of three axial CECT images through the lower cervical neck and cervicothoracic iunction presented from
superior to inferior shows the anterior, middle and posterior scalene muscles in the prevertebral component of the
perivertebral space. Notice the brachial plexus roots between the anterior and middle scalene muscles. (Middle) At
the level of the first thoracic vertebral hody and first rib the anterior scalene is clearly visibile anterior to the roots of
the brachial plexus. The visceral space contains the thyroid gland, parathyroid glands (not visible on CT), the cervical
esophagus and trachea. (Bottom) In this image at the level of the lung apices the visceral space is outlined by the
middle layer of deep cervical fascia. The right subclavian artery passes between the anterior and middle scalene
muscles along with the brachial plexus roots II
13
 SUPRAHYOID AND INFRAHYOID NECK OVERVIEW
~ AXIAL T1 MR
u
Q)
Z
""0 Buccinator muscle

o
>- Buccal space
....c
C\l
•.... Accessory parotid gland
'+-
C
Masseter muscle Masticator space
""0

Temporalis muscle Pharyngeal mucosal

c space/ surface
C\l
Prevertebral muscles
""0
Parapharyngeal space
o Retromandibular vein
Parotid space
>- Parotid gland
....c Carotid space
C\l
•.... Mastoid tip
0...
::l Occipital condyle
(/)

~
u
Q)
Z
""C
C Buccinator muscle
t'\l Facial vein Buccal space
""C Pharyngeal mucosal
t'\l Parotid duct
Q) space/surface
Masseter muscle
J: Masticator space

Mandibular ramus Parotid space

Medial pterygoid muscle

Retromandibular vein
External carotid artery

Vertebral artery Parapharyngeal space

Prevertebral component,
perivertebral space

Hyoglossus muscle

Mylohyoid muscle
Masseter muscle Masticator space
Pharyngeal mucosal
Medial pterygoid muscle
space/surface
Posterior belly digastric muscle
Parotid tail
Retropharyngeal space
Internal jugular vein
Posterior cervical space
Internal carotid artery

Sternocleidomastoid muscle
Prevertebral muscles

(Top) First of 6 axial Tl MR images of the suprahyoid & infrahyoid neck presented from superior to inferior. In this
image the buccal space is outlined on left. There is no fascial margin to the buccal space. The parapharyngeal space is
seen as 2 fat-filled areas surrounded by the pharyngeal mucosal, masticator, parotid & carotid spaces. (Middle) In
this image at mandibular teeth level the parotid space is seen posterior to the masticator space. Both are surrounded
by the superficial layer of deep cervical fascia. (Bottom) In this image the pharyngeal mucosal space is made up of
the anterior lingual & lateral palatine tonsils. Fat stripe behind the pharyngeal mucosal space is the retropharyngeal
space. Behind the retropharyngeal space is the prevertebral component of the perivertebral space. The posterior belly
II of digastric muscle separates carotid from parotid space.
136
 SUPRAHYOID AND INFRAHYOID NECK OVERVIEW
AXIAL T1 MR

Platysma muscle
Anterior belly, digastric muscle
Submandibular space
Infrahyoid strap muscles
Submandibular gland
Facial vein Pharyngeal mucosal space
(hypopharynx)
Carotid space
External jugular vein
Vertebral artery Retropharyngeal space
Posterior cervical space
Levator scapulae muscle
Paraspinal component,
Paraspinal muscles perivertebral space

:J
-+,
.....•
OJ
7
'<
o
0...
Platysma muscle Z
ro
n
lnfrahyoid strap muscles r:-
Anterior cervical space
Sternocleidomastoid muscle Visceral space
Common carotid artery
Carotid space
Internal jugular vein
External jugular vein Retropharyngeal space
Vertebral artery
Posterior cervical space

Levator scapulae muscle Paraspinal component,

perivertebral space
Trapezius muscle

Platysma muscle
Trachea in visceral space
lnfrahyoid strap muscles
Sternocleidomastoid muscle
Thyroid gland in visceral space
Common carotid artery
Internal jugular vein Carotid space
Esophagus
Posterior cervical space
Anterior scalene muscle
Retropharyngeal space
Middle scalene muscle

Posterior scalene muscle

Paraspinal component,
Brachial plexus root perivertebral space

(Top) In this image the visceral space of the infrahyoid neck is visible. The middle layer of deep cervical fascia
circumscribes the visceral space. The visceral space at this level contains the infrahyoid strap muscles, pyriform
sinuses & epiglottis. (Middle) At the level of true vocal cords both the anterior & posterior cervical spaces are seen.
Note the anterior cervical space is a direct extension of the submandibular space into the infrahyoid neck. The
carotid space is surrounded by the carotid sheath. The common carotid artery, internal jugular vein & vagus nerve
are found in the infrahyoid carotid space. (Bottom) At the level of the upper trachea the thyroid gland is now the
largest structure in the visceral space. The parathyroid glands, cervical trachea and esophagus, paratracheal nodes and
recurrent laryngeal nerve are all in the visceral space. II
137
 SUPRAHYOID AND INFRAHYOID NECK OVERVIEW
AXIAL T2 MR

Buccinator muscle
Buccal space
Facial vein
Parotid duct Pharyngeal mucosal
space/surface
Masseter muscle Masticator space
-0 Parotid space
c Mandibular ramus
ro Medial pterygoid muscle
-0
o Retromandibular vein
>-
...r:: Internal jugular vein
ro Parapharyngeal space
"-
0... Internal carotid artery Carotid space
:J
Vl
Prevertebral component,
~ perivertebral space
U
Q)
Z
"'0

c:
~
"'0
Anterior belly, digastric muscle
~
Q) Platysma muscle
I Hyoid bone Submandibular space
Retropharyngeal space
Submandibular gland
Facial vein Prevertebral component,
perivertebral space
Carotid space
External jugular vein
Vertebral artery
Posterior cervical space

Paraspinal component,
Paraspinal muscles perivertebral space

Platysma muscle
Infrahyoid strap muscles

Sternocleidomastoid muscle Cricoid cartilage

Common carotid artery
Thyroid gland in visceral space
Internal jugular vein Carotid space
Anterior scalene muscle Prevertebral component,
Middle scalene muscle perivertebral space
Posterior cervical space
Brachial plexus root Retropharyngeal space
Paraspinal component,
Levator scapulae muscle
perivertebral space

(Top) First of three axial T2 MR images of the neck at the level of the maxillary alveolar ridge shows the 4 key spaces
surrounding the fat-filled parapharyngeal space. These important four spaces are the pharyngeal mucosal, masticator,
parotid &. carotid spaces. The parotid &. masticator spaces are circumscribed by superficial layer of deep cervical
fasCia. (Middle) In this image at the level of hyoid bone the large submandibular glands are visible in the
submandibular space deep to the platysma muscle. (Bottom) At the level of the cricoid cartilage the prevertebral &.
paraspinal components of the perivertebral space can be seen. The brachial plexus roots exit the prevertebral
component between the anterior &. middle scalene muscles to enter the posterior cervical space fat on their way to
II the axilla.
138
 SUPRAHYOID AND INFRAHYOID NECK OVERVIEW
CORONAL T1 MR

Temporalis muscles Suprazygomatic masticator

space
Zygomatic arch

Pterygoid wing, sphenoid bone lnfrazygomatic masticator

Lateral pterygoid muscle space
Adenoids
Parapharyngeal space
Masseter muscle
Medial pterygoid muscle Parotid space
Palatine tonsil
PPS communicates with SMS
Submandibular space
Submandibular gland
Pharyngeal mucosal
Platysma muscle space/surface

Epiglottis

Sphenoid sinus
Zygomatic arch
Temporalis muscle
Coronoid process of mandible - Masticator space

Nasopharyngeal airway

Masseter muscle

Medial pterygoid muscle

Uvula Inferior para pharyngeal space
Lingual tonsil
Submandibular gland Submandibular space
Facial vein Pharyngeal mucosal
Vallecula space/surface
Platysma muscle

Sphenoid sinus
Temporalis muscle Zygomatic arch

Masticator space
Nasal airway

Masseter muscle
Medial pterygoid muscle

Inferior alveolar nerve

Oral tongue
Hyoglossus muscle
Submandibular space
Facial vein
Submandibular gland
Platysma muscle

(Top) First of three coronal Tl MR images presented from posterior to anterior shows the pharyngeal mucosal space
extending from nasopharynx to hypopharynx. It is from the pharyngeal mucosal space that the most common
malignancies of the head & neck arise, squamous cell carcinoma from the mucosa, non-Hodgkin lymphoma from
the tonsils & minor salivary gland malignancy from the minor salivary glands. (Middle) In this image the masticator
space has been outlined. Remember this space has a suprazygomatic & an infrazygomatic component. Since there is
no "horizontal fascia" between the zygomatic arch, diseases may spread within the masticator space between the
suprazygomatic & infrazygomatic components. (Bottom) In this image through the posterior nose 3 of the major
muscles of mastication are visible, the masseter, medial pterygoid and temporalis muscles. II
139
..:L. PARAPHARYNGEALSPACE
U
Q)
Z o PS laterally
""0
ITerminology o CS posteriorly
Abbreviations o RPS posteromedially
o
>- • Parapharyngeal space (PPS) Internal Structures-Critical Contents
~
CI:l
•.... Synonyms • PPS has no mucosa, muscle, bone, nodes or major
'+-
C salivary gland tissue within its boundaries
• Parapharyngeal space has been called "prestyloid
""0 para pharyngeal space" o Consequently few things primarily begin in PPS
c o Carotid space called "post-styloid parapharyngeal • Critical PPS contents
CI:l space" in this alterative terminology o Fat: Key constituent making PPS easily identifiable
""0
o Carotid space preferred terminology even with larger SHN mass lesions
o o Minor salivary glands (ectopic, rare)
>- Definitions o Internal maxillary artery
~ o Ascending pharyngeal artery
CI:l • Parapharyngeal space: Central, fat-filled spaces in
•.... lateral suprahyoid neck (SHN) around which most of o Pterygoid venous plexus (small portion, mostly MS)
0...
:J important spaces are located
Cf) o These surrounding important spaces are pharyngeal
Fascial of Parapharyngeal Space
mucosal space (PMS), masticator space (MS), parotid • Fascial margins of PPS are complex; made up of
~
U space (PS) and carotid space (CS) different layers of deep cervical fascia
IQ) o Medial fascial margin of PPS
Z • Made up of middle layer, deep cervical fascia as it
"0
Ilmaging Anatomy curves around lateral margin of PMS
c o Lateral fascial margin of PPS
~
"0 Overview • Formed by medial slip of superficial layer of deep
~ • PPS contents are limited, therefore few lesions actually cervical fascia along deep border of MS & PS
Q) o Posterior fascial margin of PPS
begin in this location
J: o Diseases of PPS usually arise in adjacent spaces (PMS, • Formed by deep layer of deep cervical fascia on
MS, PS, CS), spreading secondarily into PPS anterolateral margin of retropharyngeal space and
• Importance of PPS is its conspicuity on CT and MR as anterior part of carotid sheath (made up of
well as its direction of displacement by mass lesions of components of all 3 layers of deep cervical fascia)
surrounding spaces
o PPS displacement pattern helps define actua~
space of origin ' IAnatomy-Based Imaging Issues
• PMS mass lesion pushes PPS laterally
• MS mass lesion pushes PPS posteriorly
Key Concepts or Questions
• PS mass lesion pushes PPS medially • Because of limited normal anatomic contents of PPS
• CS mass lesion pushes PPS anteriorly few lesions primarily arise in PPS '
• Lateral retropharyngeal space mass (nodal) pushes o Rare lesions found in PPS include benign mixed
PPS anterolaterally tumor (from minor salivary gland rests in PPS),
o Combining center of mass lesion with displacement lipoma and atypical second branchial cleft cyst
direction of PPS yields strong impression of "space of o To say lesion is primary to PPS, it must be
origin" of SHN mass lesion completely surrounded by PPS fat
o In most cases where lesion is thought to be primary
Extent to PPS, careful observation will find connection to
• Crescent-shaped fat-filled space in craniocaudal one of surrounding spaces (usually PS)
dimension extends from skull base above to superior • PPS fat displacement is key imaging relationship
cornu of hyoid bone inferiorly used in evaluation of SHN mass lesions
Anatomy Relationships Imaging Recommendations
• As fatty tube separating other SHN spaces from one • MR better delineates skull base, meningeal &
another, PPS functions as "elevator shaft" through perineural lesions
which infection and tumor from these adjacent spaces o Fat-saturated contrast-enhanced T1 MR may make
may travel from skull base to hyoid bone PPS fat difficult to see
• Inferiorly there is no fascia separating inferior PPS
from submandibular space (SMS)
Imaging Pitfalls
o Open communication between inferior PPS and • Remember most lesions of PPS arise from adjacent
posterior SMS therefore exists SHN spaces
• Superiorly PPS interacts with skull base in bland
triangular area on inferior surface of petrous apex
o No exiting skull base foramina are found in this I Clinical Implications
area of attachment Clinical Importance
• Surrounding spaces include
• Since PPS empties inferiorly into SMS, PPS lesion may
o PMS medially
present as "angle of mandible" mass
o MS anterolaterally

II
140
II
141
...::L
U
Q)
Z
""'0
o
>--
...c
~
'+-
"-
C

""'0
c
~
""'0
o
>--
...c
~
"-
Q..
:J
(.f)

...::L
U
Q)
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-0
c:
~
-0
~
Q)
:::c

II
142
 PARAPHARYNGEAL SPACE
AXIAL CECT :r:
(t)
~
0..
~
Medial pterygoid plate ::J
0..
Retromaxillary fat pad (buccal Z
Lateral pterygoid plate
space) (t)
Coronoid process, mandible t"'l
';\
Masseter muscle Masticator space
(j)
Lateral pterygoid muscle
""0
c
.,
Mandibular condyle Parapharyngeal space' OJ
Parotid gland Parotid space ::r-
--<
Styloid process Carotid space o
Eustachian tube opening a...
Pharyngeal mucosal OJ
Torus tubarius space/surface :J
a...
:J
-+,
.,
OJ
::r-
--<
Medial pterygoid plate
o
a...
Lateral pterygoid plate Z
Retromaxillary fat pad (buccal (0
Masseter muscle space) n
7'
Masticator space
Medial pterygoid muscle
Prevertebral muscle Parapharyngeal space

Deep lobe, parotid gland Parotid space

Styloid process Carotid space
Internal jugular vein
Internal carotid artery Pharyngeal mucosal
space/surface

Buccinator muscle
Buccal space
Palatine tonsil
Mandibular ramus

Masseter muscle Masticator space

Medial pterygoid muscle
Parapharyngeal space
Retromandibular vein Parotid space
Deep lobe, parotid gland
Carotid space
Styloid process
Internal jugular vein Pharyngeal mucosal
space/surface
Internal carotid artery

(Top) First of six contrast-enhanced axial CT images of the suprahyoid neck presented from superior to inferior
shows the superior end of the para pharyngeal space just before it abuts the skull base, Notice the 4 major spaces
surrounding the parapharyngeal space, the pharyngeal mucosal, masticator, parotid and carotid spaces, (Middle) In
this image at the level of the inferior maxillary sinus the complex shape of the parapharyngeal space is visible. Notice
the lateral margin of the parapharyngeal space is the deep lobe of the parotid gland. (Bottom) In this
mid-oropharynx image the parapharyngeal space has the palatine tonsil on its entire medial border., It is easy to see
that a squamous cell carcinoma of the palatine tonsil that is deeply invasive would immediately enter the
parapharyngeal space fat, pushing it from medial to lateral. II
143
 PARAPHARYNGEAL SPACE
....::::L AXIAL CECT
U
Q)
Z
-0
o
>-
.J:: Palatine tonsil
ro l- Mandibular ramus
'-+--
C
Masseter muscle
Masticator space
-0
c Styloglossus muscle
ro Parapharyngeal space
-0 Stylopharyngeus muscle
Parotid space
o Posterior belly digastric muscle
>- Carotid space
.J:: Styloid process
ro
l- Pharyngeal mucosal
Internal jugular vein
0... space/surface
:J Internal carotid artery
V)

~
u
Q)
Z
""0

c:
~
""0

~ Mylohyoid muscle posterior

Q) Palatine tonsil
margin
:c Masseter muscle Masticator space
Medial pterygoid muscle Parotid space
Posterior belly digastric muscle Parapharyngeal space
Internal jugular vein
Posterior belly digastric muscle
Sternocleidomastoid muscle
Carotid space
Constrictor muscle
Posterior cervical space
Prevertebral muscle

Mylohyoid muscle

Submandibular gland
Submandibular space
Internal carotid artery
Parapharyngeal space
Internal jugular vein Pharyngeal mucosal space
Carotid space
Sternocleidomastoid muscle

Posterior cervical space

(Top) In this image the parapharyngeal space points anteriorly toward the submandibular space. On more inferior
images it will communicate with the posterosuperior submandibular space in this area. Notice the stylopharyngeus
and styloglossus muscle on the posterior margin of the parapharyngeal space. (Middle) At the level of the
mandibular body the para pharyngeal space is seen entering the superior submandibular space just anterior to the
posterior belly ot the digastric muscles and just posterior to the mylohyoid muscle. (Bottom) In this image through
the superior submandibular space it is possible to see the most inferior parapharyngeal space merging with the
submandibular space. Remember there is no fascia separating the inferior para pharyngeal, posterior submandibular
II and sublingual spaces at the posterior margin of the mylohyoid muscle.
144
 PARAPHARYNGEAL SPACE
AXIAL T1 MR

Temporalis muscle Pharyngeal mucosal space

Masseter muscle Masticator space

Lateral pterygoid muscle
Pterygoid venous plexus
Prevertebral muscle Parotid space
Parotid deep lobe Parapharyngeal space
Styloid process Carotid space
Lateral retropharyngeal space

Hard palate

Medial pterygoid muscle

Buccal space
Masseter muscle
Temporalis muscle
Masticator space
Lateral pterygoid muscle
Pharyngeal mucosal space
Tensor palatini muscle
Levator palatini muscle Para pharyngeal space
Parotid deep lobe Parotid space
Internal jugular vein Carotid space
Internal carotid artery Lateral retropharyngeal space
Prevertebral muscles

Maxillary ridge
Pharyngeal mucosal space

Buccal space
Temporalis muscle
Masseter muscle Masticator space
Medial pterygoid muscle
Soft palate
Parapharyngeal space
Superficial lobe parotid Parotid space

Deep lobe parotid Carotid space

Lateral retropharyngeal space

(Top) First of six axial Tl MR images of the suprahyoid neck presented from superior to inferior shows the
parapharyngeal space at the level of the nasopharynx. Here the surrounding spaces include the pharyngeal mucosal,
masticator, parotid and carotid spaces. Notice the lateral retropharyngeal space is on the posteromedial aspect of the
parapharyngeal space. (Middle) In this image at the level of the hard palate the posterior margins of the tensor and
levator palatini muscles are visible along the anteromedial margin of the para pharyngeal space on the right.
(Bottom) At the level of the maxillary ridge the para pharyngeal space on the left is surrounded in clockwise order by
the medial pterygoid muscle, deep lobe of parotid, internal carotid artery, lateral pharynx and tqe soft palate.
II
145
 PARAPHARYNGEAL SPACE
~ AXIAL T1 MR
u
Q)
Z
""0

o
>-
....c Buccinator muscle
ro
•... Buccal space
'+-
C Masseter muscle
""0 Pharyngeal mucosal space
Pterygomandibular raphe
c
ro Medial pterygoid muscle
Masticator space
""0

Parapharyngeal space
o Parotid deep lobe Parotid space
>-
....c
ro Styloglossus muscle Carotid space
•...
0... Stylopharyngeus muscle Lateral retropharyngeal space
:J
r../)

~
u
Q)
Z
""0

c
('tl
""0
Buccinator muscle
('tl
Q) Buccal space
:r: Masseter muscle
Pharyngeal mucosal space

Medial pterygoid muscle Masticator space

Constrictor muscle Para pharyngeal space

Parotid space
Posterior belly digastric muscle
Carotid space

Retropharyngeal space

Buccal space

Pharyngeal mucosal space

Masseter muscle
Masticator space
Medial pterygoid muscle Parapharyngeal space
Posterior belly digastric muscle Parotid space

Carotid space
Internal jugular vein
Retropharyngeal space
Internal carotid artery

(Top) In this image at the level of the maxillary teeth the PPS takes on a crescentic shape as it bends around th.e
pledial pterygoid muscle of the masticator space. The pharyngeal mucosal space makes up the medial border of the
PPS. Posteromedially the lateral retropharyngeal space is found while the carotid space makes up the PPS
posterolateral border. The deep lobe of the parotid gland makes up the lateral margin of the PPS. (Middle) In this
image at the level of the mid-oropharynx the parapharyngeal space becomes smaller along its inferior margin.
(Bottom) In this image at the level of the mandibular teeth the parapharyngeal space is visible "pointing" anteriorly
where it joins the posterosuperior margin of the submandibular space. Parapharyngeal abscess and tumor may access
II the submandibular space via this route.
146
 PARAPHARYNGEAL SPACE
CORONAL T1 MR

Mandibular condyle Masticator space

Para pharyngeal spacli
Deep lobe parotid glanq
Superficial lobe parotid gland Parotid space

Posterior belly digastric muscle Carotid space

Internal carotid artery

Pharyngeal mucosal space

Lateral pterygoid muscle

Para pharyngeal space

Levator veli palatini muscle

Masseter muscle
Masticator space
Medial pterygoid muscle
Superior constrictor muscle
Submandibular space

Submandibular gland
Platysma muscle

Temporalis muscle

Lateral pterygoid muscle Pharyngeal mucosal space

Masseter muscle

Medial pterygoid muscle

Masticator space
Uvula

Palatine tonsil Para pharyngeal space

Submandibular gland Submandibular space

Platysma muscle

(Top) First of three coronal Tl MR images of the suprahyoid neck presented from posterior to anterior. In this image
through the mandibular condyles the posterior parapharyngeal space is seen medial to the deep lobe of the paroti~
gland. (Middle) In this image the PPS is visible from its superior area of skull base abutment to its inferior merging
with the submandibular space. Note the site of abutment with the skull base contains no vital structures. Remember
there is no fascia present between the inferior PPS and the posterior submandibular space. (Bottom) In this image
through the anterior para pharyngeal space the connection between the parapharyngeal space and submandibular
space is seen. S.!1.!?!!1.i!Qdibular
space disease, especially abscess, may at times spread superiorly into th~
parapharyngeal space via this connectio~. II
147
 PHARYNGEAL MUCOSAL SPACE
ITerminology Fascia of Pharyngeal Mucosal Space
• Middle layer, deep cervical fascia (ML-DCF)
Abbreviations
represents deep margin of PMS "
• Pharyngeal mucosal space (PMS) o In nasopharynx ML-DCF encircles lateral & posterIor
Definitions margins of pharyngobasilar fascia
• PMS: Nasopharyngeal, oropharyngeal & o In oropharynx ML-DCF on deep margin of superior
hypopharyngeal surface structures on airway side of & middle constrictor muscles
""D
c middle layer of deep cervical fascia o In hypopharynx ML-DCF on deep margin of inferior
ru constrictor muscle
""D
o I Imaging Anatomy
>-
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IAnatomy-Based Imaging Issues
ru Overview
"- • PMS is conceptual construct to complete map of
Key Concepts or Questions
0...
:J spaces of suprahyoid neck • What imaging findings define a lesion as primary to
(.f)
o PMS alternative term: Pharyngeal mucosal surfac~ pharyngeal mucosal space? .
~ • There is no fascia on surface of PMS, so it is not a o Lesion is designated primary to PMS under followmg
u true fascia-enclosed space circumstances
Q)
• Lesion center is medial to parapharyngeal space
Z Extent • PMS mass pushes PPS fat from medial to lateral
""C • PMS is a continuous mucosal sheet defined from • PMS mass disrupts normal PMS mucosal &
c submucosal architecture
ro nasopharynx to hypopharynx (includes soft palate)
""C • Nasopharyngeal, oropharyngeal & hypopharyngeal
ro mucosal space components Imaging Recommendations
Q) • CECT or MR can both successfully image PMS
o See larynx anatomy for hypopharynx anatomy
J: • If skull base invasion or perineural tumor suspected,
Anatomy Relationships T1 C+ fat-saturated MR best
• Airway side of PMS has no fascial border • Bone CT may then be added to delineate skull base
• Posterior to PMS is retropharyngeal space (RPS) bone changes & tumor matrix
• Lateral to PMS is para pharyngeal space (PI'S)
• Skull base relationship to PMS
Imaging Approaches
o Broad area of attachment to skull base present • If malignant tumor of PMS suspected, remember to
o Attachment area includes posterior basisphenoid stage primary tumor & nodes in cervical neck
(sphenoid sinus floor), anterior basiocciput (anterior Imaging Pitfalls .
clivus)
• Most common error in interpreting images of PMS IS
o Also includes foramen lacerum
labeling normal asymmetry as tumor .
• Foramen lacerum: Cartilaginous floor of anterior • Lateral pharyngeal recess is notoriously asymmetrIc &
horizontal petrous internal carotid artery may have fluid within it
• Represents perivascular route for nasopharyngeal
• Variable amounts of lymphoid tissue can also create
carcinoma to access intracranial structures misimpression of tumor
Internal Structures-Critical Contents
• Mucosal surface of pharynx
• PMS lymphatic ring: Lymphatic ring of tissue of PMS I Clinical Implications
that declines in size with advancing age
Clinical Importance
o Synonym: Waldeyer ring
o Nasopharynx: Adenoids • Referring MD can see PMS surface well
o Oropharynx, lateral wall: Palatine (faucial) tonsil o Use clinical impressions as part of imaging report
o Oropharynx, base of tongue: Lingual tonsil • Most common lesion of PMS is squamous cell
carcinoma (SCCa)
• Minor salivary glands
o Become familiar with routes of spread of SCCa by
o Soft palate mucosa has highest concentration
specific primary tumor site
• Pharyngobasilar fascia
o Tough aponeurosis that connects superior o Become familiar with staging criteria for each
specific primary tumor site
constrictor muscle to skull base
o Posterosuperior margin notch = sinus of Morgagni • If not obviously SCCa, differential diagnosis of PMS
mass relies heavily on normal PMS contents
• Levator palatini muscle & eustachian tube pass
o From mucosa: Squamous cell carcinoma
through this notch on way from skull base to PMS
o From lymphoid tissue: Non-Hodgkin lymphoma
• Pharyngeal mucosal space muscles
o From minor salivary glands: Minor salivary gland
o Superior, middle & inferior constrictor muscles
malignancies (uncommon)
o Salpingopharyngeus muscle
o From constrictor or levator palatini muscles:
o Levator palatini muscle, distal end .
Rhabdomyosarcoma (rare)
• Torus tubarius: Cartilaginous end of eustachIan tube

II
148
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151
 PHARYNGEAL MUCOSAL SPACE
GENERIC PMS MASS

Levator veli palatini muscle

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C Torus tubarius
(ij
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Para pharyngeal space
o Superior constrictor muscle
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Invasion of prevertebral
component, perivertebral space

PMS tumor invades

basisphenoid

PMS tumor pushing from

medial to lateral
Parapharyngeal space

Palatine tonsil
Uvula

(Top) Axial graphic of a generic pharyngeal mucosal space mass demonstrates the disruption of the normal
architecture of the surface of the pharynx with bulging of the mass into the pharyngeal airway. Also notice the deep
margin of the mass is displacing the parapharyngeal space fat from medial to lateral. (Middle) In this illustrative case
of squamous cell carcinoma of the nasopharyngeal aspect of the pharyngeal mucosal space the tumor can be seen
disrupting the mucosal surface of the nasopharynx while pushing into the parapharyngeal space from medial to
lateral. The parapharyngeal space is more difficult to see because this is a fat-saturated Tf'enhanced MR image.
(Bottom) In this coronal fat-saturated Tl enhanced MR image of nasopharyngeal carcinoma the area of abutment &
II invasion of the skull base by this PMS tumor are clearly visible.
152
 PHARYNGEAL MUCOSAL SPACE
BARIUM SWALLOW

Oropharynx
Glossoepiglottic fold
Vallecula

Free margin epiglottis

Aryepiglottic fold Hypopharynx

Arytenoid cartilage

Pyriform sinus

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Posterior wall hypopharynx

Post-cricoid hypopharynx

Cricopharyngeus muscle
True vocal cord level indentation

Trachea

Lingual tonsil

Vallecula
Epiglottis, free margin
Hyoid bone

Posterior wall hypopharynx

Cricopharyngeus muscle
Pyriform sinus indentation

(Top) Anteroposterior barium swallow image focused on the low oropharyngeal and hypopharyngeal mucosal space
surfaces. NoJjcg the hypopharynx extends from the level of the vallecula and glossoepiglottic fold superiorly to the
iI*rior margin of the pyriform sinus, (Middle) In this lateral view of a barium swallow the irregular surface of the.
lingual tons.il is recognized along the posterior margin of the tongu~. The post-cricoid area and the posterior wall of
the hypopharynx make up two of the three major sub sites within the hypopharynx. The third sub site is the pyriform
sinus. (Bottom) In this lateral barium swallow image the indentation of the cricopharyngeus muscle is particularly
well seen. Remember the inferior margin of the vallecula marks the transition from oropharynx to hypopharynx ..
II
153
 PHARYNGEAL MUCOSAL SPACE
~ AXIAL T1 MR
u
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I Eustachian tube opening Pharyngeal mucosal space

Torus tubarius Masticator space

Tensor veti palatini muscle

Levator veti palatini muscle Parapharyngeal space

Collapsed lateral pharyngeal recess Carotid space
Adenoids
Prevertebral component,
perivertebral space

Lateral pterygoid muscle

Tensor veti palatini muscle

Prevertebral muscle Pharyngeal mucosal space

(Top) First of six axial Tl unenhanced MR images presented from superior to inferior shows the pharyngeal mucosal
space at the level of the nasopharynx. Notice the torus tubarius (distal cartilaginous eustachian tube) & the
nasopharyngeal adenoids. The lateral pharyngeal recess is collapsed & therefore not visible on imaging. (Middle) In
this image the levator veli palatini muscle is seen transitioning to the pharyngeal side of the middle layer of deep
cervical fascia (not seen). It does so over the superior margin of the pharyngobasilar fascia in the sinus of Morgagni.
The tensor veli palatini muscle does not enter the pharyngeal mucosal space. (Bottom) In this image through the
inferior maxillary sinuses the area of the pharyngeal mucosal space is outlined. Remember the middle layer of deep
II cervical fascia forms the lateral & posterior deep margins of the PMS.
154
 PHARYNGEAL MUCOSAL SPACE
AXIAL T1 MR :r:
rtl
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rtl
Pharyngeal mucosal space n
7'
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tl.l
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Buccinator muscle

Pterygomandibular raphe
Pharyngeal mucosal space

Para pharyngeal space

Superior pharyngeal constrictor

muscle

Oral tongue

Lingual tonsil
Pharyngeal mucosal space

Masticator space
Palatine tonsil
Parapharyngeal space

Retropharyngeal space

(Top) At the level of the maxillary alveolar ridge the tensor veli palatini muscle is seen turning around the hamulus
of the medial pterygoid plate to enter the anterolateral soft palate. Notice that posterior to the pharyngeal mucosal
space the thin fat stripe of the retropharyngeal space is just visible in front of the prevertebral component of the
perivertebral space. (Middle) At the level of the maxillary teeth the pharyngeal mucosal space of the superior
oropharynx is seen. Note the superior margin of the palatine tonsil along with the soft palate itself. The superior
pharyngeal constrictor muscle is present along the margins of the PMS just inside the middle layer of deep cervical
fascia which cannot be seen with imaging. (Bottom) In the mid-oropharynx the lingual and palatine tonsils of the
PMS lymphatic ring fill the pharyngeal mucosal space. II
155
 PHARYNGEAL MUCOSAL SPACE
...:::t:. AXIAL T2 MR
u
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'+- Eustachian tube opening
C

\:) Torus tubarius Masticator space

C
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Levator veli palatini muscle
0
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Q.. perivertebral space
:J Clivus
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Q)
J: Eustachian tube opening Masticator space
Torus tubarius
Tensor veli palatini muscle
Parapharyngeal space

Collapsed lateral pharyngeal recess

Carotid space
Adenoids
Prevertebral component,
Clivus perivertebral space

Hamulus of medial pterygoid plate

Medial pterygoid muscle

Masticator space
Lateral pterygoid muscle
Tensor veli palatini muscle
Levator veli palatini muscle Pharyngeal mucosal space
Prevertebral muscle
Carotid space

Prevertebral component,
perivertebral space

(Top) First of nine axial T2 unenhanced MR images presented from superior to inferior shows the pharyngeal
mucosal space at the level of the nasopharynx. Notice the torus tubarius (distal cartilaginous eustachian tube) & the
nasopharyngeal adenoids. The lateral pharyngeal recess is collapsed & therefore not visible on imaging. (Middle) In
this image the levator veli palatini muscle is seen transitioning to the pharyngeal side of the middle layer of deep
cervical fascia (not seen). It does so over the superior margin of the pharyngobasilar fascia in the sinus of Morgagni.
The tensor veli palatini muscle does not enter the pharyngeal mucosal space. (Bottom) In this image through the
inferior maxillary sinuses the area of the pharyngeal mucosal space is outlined.
II
156
 PHARYNGEAL MUCOSAL SPACE
AXIAL T2 MR

Hamulus of medial pterygoid plate

Pharyngeal mucosal space
Soft palate Masticator space

Superior pharyngeal constrictor Parapharyngeal space

muscle Retropharyngeal space
Prevertebral component,
perivertebral space

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o
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Palatine tonsil Z
CD
n
Pharyngeal mucosal space 7'
Pterygomandibular raphe

Parapharyngeal space

Superior pharyngeal constrictor

muscle

Palatine tonsil

Superior pharyngeal constrictor Parapharyngeal space

Retropharyngeal space
Palatopharyngeus muscle
Prevertebral component,
perivertebral space

(Top) At the level of the soft palate the pharyngeal mucosal space is seen with the parapharyngeal space along its
lateral borders. The retropharyngeal space is very thin at this level but it is present between the posterior pharyngeal
mucosal space and the prevertebral component of the perivertebral space. (Middle) At the level of the maxillary
teeth the pharyngeal mucosal space of the superior oropharynx is visible. Note the superior margin of the palatine
tonsil. The superior pharyngeal constrictor muscle is present along the margins of the PMS just inside the middle
layer of deep cervical fascia which cannot be seen with imaging. (Bottom) In this image through the
mid-oropharynx the palatine tonsil is the main occupant of the pharyngeal mucosal space. The retropharyngeal
space fat stripe is seen posteriorly while the parapharyngeal spaces are lateral. II
157
 PHARYNGEAL MUCOSAL SPACE
..::::L. AXIAL T2 MR
U
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Parapharyngeal space

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Lingual tonsil

Palatine tonsil Pharyngeal mucosal space

Middle pharyngeal constrictor

muscle Carotid space

Retropharyngeal space

Lingual tonsil

Oral tongue

Palatine tonsil
Pharyngeal mucosal space
Middle pharyngeal constrictor
muscle Carotid space

Retropharyngeal space
Prevertebral muscles
Prevertebral component,
perivertebral space

(Top) At the level of the mandibular teeth the pharyngeal mucosal space contains the lingual and palatine tonsils.
Anterior to the lingual tonsil is the oral tongue of the oral cavity. (Middle) In this image the retropharyngeal space
fat stripe is clearly seen posterior to the pharyngeal mucosal space. Behind the retropharyngeal space is the
prevertebral component of the perivertebral space. A posterior pharyngeal wall squamous cell carcinoma may directly
invade the retropharyngeal space or spread via lymphatics to the retropharyngeal nodes. (Bottom) Low in the
oropharynx thicker lingual tonsillar tissue can be seen along with an attenuated palatine tonsil. Remember the
lingual tonsil is located in the oropharynx, not the oral cavity.
II
158
 PHARYNGEAL MUCOSAL SPACE
GRAPHIC & CORONAL T1 C+ MR

Foramen lacerum
PMSabuts basisphenoid
Adenoids

Torus tubarius
Nasopharyngeal mucosal space
Eustachian tube opening

Soft palate Parapharyngeal space

Palatine tonsil Oropharyngeal mucosal space

Superficial layer, deep cervical

fascia
Middle layer, deep cervical fascia

Basisphenoid

Adenoids

Pharyngeal mucosal space

Mucosa

Uvula

Palatine tonsil

Torus tubarius
Nasopharyngeal mucosal space

Lateral pharyngeal recess

Palatine tonsil Oropharyngeal mucosal space

Soft palate
Oral cavity

(Top) Coronal graphic of nasopharyngeal and oropharyngeal mucosal space. Notice the middle layer of deep cervical
fascia defining the lateral margin of the pharyngeal mucosal space. The parapharyngeal spaces are paired fatty spaces
lateral to the pharyngeal mucosal space. (Middle) Coronal enhanced fat-saturated Tl MR image shows the
pharyngeal mucosal space surface enhances. Notice that the roof of the nasopharyngeal mucosal space abuts the
basisphenoid. Remember that a nasopharyngeal carcinoma that begins in the roof of the nasopharynx will often
have invaded the sphenoid sinus at the time of presentation. (Bottom) Coronal enhanced fat-saturated Tl MR image
reveals the enhancing sheet of mucosa with the torus tubarius (cartilaginous eustachian tube) and lateral pharyngeal
recess. II
159
...:::£ MASTICATOR SPACE
U
Q)
Z o Condylar process: Mandibular condyle neck & head
""0
ITerminology o Temporomandibular joint is within MS but
o Abbreviations considered separately
>.. • Masticator space (MS) • Pterygoid venous plexus along posterior border of
...!: lateral pterygoid muscle & para pharyngeal space
rcl
~
'-+-
Definitions
C • Large, paired anterolateral spaces of suprahyoid neck
Fasciaof Masticator Space
""0 (SHN) containing muscles of mastication, posterior • Superficial layer, deep cervical fascia (SL-DCF) splits
C body & ramus of mandible & of CNV3 along inferior mandible, creating "sling" enclosing MS
rcl • Surgical terms o Medial fascial slip runs along deep surface of
""0
o Infratemporal fossa: MS area deep to zygomatic arch, pterygoid muscles
o
>..
superficial to pterygomaxillary fissure • This slip of SL-DCF inserts on undersurface of
o Temporal fossa: Suprazygomatic MS skull base just medial to foramen ovale
...!: o Lateral slip SL-DCF covers surface of masseter
rcl
~
Q..
muscle, attaching to zygomatic arch
::l I Imaging Anatomy • Slip continues cephalad over surface of temporalis
(j)
muscle to top of suprazygomatic MS
~ Overview o No horizontal fascia exists deep to zygomatic arch
U
• MS is large SHN space spanning area from high • MS lesions pass freely in cranial-caudal directions
Q)
parietal calvarium (suprazygomatic MS) above to under zygomatic arch
Z
"C mandibular angle below
C • Suprazygomatic MS: Contains only belly of
ctI temporalis muscle IAnatomy-Based Imaging Issues
"C
• Infrazygomatic MS: MS "proper"; containing
ctI masseter, medial & lateral pterygoids, CNV3 &
Key Concepts or Questions
Q)
ramus/posterior body of mandible • What imaging features define a lesion as primary to
J: the masticator space?
Extent o Center of MS lesion must be in muscles of
• Craniocaudal extent of MS is more extensive than mastication-mandibular ramus
commonly recognized o MS lesions displace para pharyngeal space from
• On its cephalad margin MS reaches high on parietal anterior to posterior
calvarium at top of suprazygomatic MS
Imaging Recommendations
Anatomy Relationships • CECT or MR can both easily image MS
• Abuts skull base with foramen ovale & foramen • Enhanced multi planar MR better for perineural V3
spinosum included spread and intracranial disease manifestations
• If lesion affects skull base or mandible, add bone CT to
Internal Structures-Critical Contents delineate bony involvement and tumor matrix
• Muscles of mastication
o Masseter: Originates from zygomatic arch; inserts Imaging Approaches
lateral surface of ramus/angle of mandible • When MS tumor is identified, imaging must include
o Temporalis: Originates from suprazygomatic MS; entire course of CNV3 in search of perineural tumor
inserts on medial surface of coronoid process & • Image distal to mental foramen of mandible and
anterior surface of mandibular ramus proximal to lateral pons, including mandibular
o Medial pterygoid: Originates from medial surface foramen, foramen ovale and Meckel cave
lateral pterygoid plate & palatine bone pyramidal
process; inserts medial surface mandibular ramus
Imaging Pitfalls
o Lateral pterygoid: Originates from greater wing of • MS pseudolesions
sphenoid (superior head) & lateral surface of lateral o Pterygoid venous plexus asymmetry may appear as
pterygoid plate (inferior head); inserts capsule & infiltrating, enhancing "lesion"
articular disk of TM] (superior head) & neck of o V3 motor atrophy of muscles of mastication makes
mandible (inferior head) normal contralateral MS look like "lesion"
• Mandibular division, trigeminal nerve (V3) o Asymmetric accessory parotid gland may appear as
o Masticator nerve branch (proximal V3 motor to unilateral "mass" over surface of masseter muscle
muscles of mastication)
o Mylohyoid nerve branch (motor to anterior belly
of digastric and mylohyoid muscles) I Clinical Implications
o Inferior alveolar nerve branch (V3 sensory to
Clinical Importance
mandible & chin)
• Trismus (jaw spasm from masticator muscle spasm) is
o Lingual nerve (V3 sensory to anterior 2/3 tongue,
primary symptom of MS tumor or infection
floor of mouth)
• Primary MS tumor is sarcoma
o Auriculotemporal nerve (V3 sensory to EAC/TM])
• Remember to look for perineural V3 tumor whenever
• Ramus and posterior body of mandible
MS mass is identified!
o Coronoid process: Temporalis muscle inserts here

II
160
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 MASTICATOR SPACE
AXIAL CECT

Pterygopalatine fossa

Internal maxillary artery Buccal space (retromaxillary fat

pad)
Zygomatic arch
Masticator space
Masseter muscle

Temporalis tendon Pterygomaxillary fissure

Temporalis muscle

Lateral pterygoid muscle

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Mandibular condyle

Medial pterygoid muscle

Medial pterygoid plate

Buccal space (retromaxillary fat

Lateral pterygoid plate pad)
Masseter muscle

Temporalis muscle
Masticator space
Lateral pterygoid muscle
Mandibular ramus
Pterygoid venous plexus Parotid space

Medial pterygoid muscle Parapharyngeal space

Medial pterygoid plate

(Top) First of six axial CECT images presented from superior to inferior shows the masticator space medial to the
zygomatic arch. Notice the masseter muscle arising from the inferior margin of the zygomatic arch. Also note the
superior head of the lateral pterygoid muscle. (Middle) At the level of the mandibular condyles the MS contains the
muscles of mastication & temporomandibular joint. Note the inferior head of the lateral pterygoid muscle arising
from the lateral surface of the lateral pterygoid plate. The medial pterygoid muscle arises from the pterygoid fossa.
(Bottom) In this image through the low maxillary sinuses the masticator space is seen between the more anterior
buccal space and the more posterior parapharyngeal and parotid spaces. Notice the pterygoid venous plexus as the
enhancing area along the posterolateral margin of the MS. II
16')
 MASTICATOR SPACE
AXIAL CECT

Medial pterygoid muscle

Buccal space
Temporalis tendon
Accessory parotid gland

Masseter muscle
Masticator space
Mandibular foramen

Medial pterygoid plate hamulus Parotid space

Parapharyngeal space

Buccinator muscle

Buccal space
Pterygomandibular raphe

Masseter muscle
Masticator space
Mandibular ramus
Parotid space
Medial pterygoid musc!e
Para pharyngeal space

Buccal space

Retromolar trigo~e

Masseter muscle Masticator space

Medial pterygoid muscle
Parotid gland
Retromandibular vein
Para pharyngeal space

(Top) In this image through the maxillary ridge the mandibular foramen is seen. The inferior alveolar nerve enters
the mandible in this location. Note the hamulus of the medial pterygoid plate which acts as a pulley for the tendon
of the tensor veli palatini muscle & is site of superior attachment of pterygomandibular raphe. (Middle) In this
image the attachment of the medial pterygoid is visible along the medial ramus. Remember the pterygomandibular
raphe is the tendinous point of junction between the buccinator muscle and the superior constrictor muscle.
(Bottom) In this image the retromolar triangle is seen. Notice the retromolar trigone sits on the anterior surface of.
the masticator space. If a squamous cell carcinoma arises in the retromolar trigone the masticator space may be
II directly invaded. From there, perineural tumor spread on CNV3 may occur.,
166
 MASTICATOR SPACE
AXIAL T1 MR

Maxillary sinus
Inferior orbital fissure

Temporalis muscle

Sphenoid bone

Suprazygomatic masticator
space

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Masticator space
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Lateral pterygoid muscle

Mandibular nerve in foramen ovale
Mandibular condyle
Middle meningeal artery in
foramen spinosum

Pterygopalatine fossa
Buccal space (retromaxillary fat
Pterygomaxillary fissure pad)
Temporalis muscle
Zygomatic arch
Masticator space
Temporalis tendon

Masseter muscle
Lateral pterygoid muscle

Mandibular condyle
Mandibular nerve
Mandibular nerve

(Top) First of six axial Tl MR images presented from superior to inferior. In this image above the zygomatic arch the
suprazygomatic masticator space is seen. Notice that the temporalis muscle & fat are the only occupants of this
portion of the masticator space. (Middle) In this image the mandibular nerve (CNV3) can be visualized within the
foramen ovale. The middle meningeal artery can be seen posterolateral to foramen ovale within the foramen
spinosum. The pterygopalatine fossa opens laterally through the pterygomaxillary fissure into the MS. (Bottom) In
this image the mandibular nerve is visible along the posteromedial border of the lateral pterygoid muscle. The
temporalis muscle & its hypointense tendon fill the anterolateral masticator space. The lateral pterygoid muscle
inferior head originates from the lateral surface of lateral pterygoid plate. II
167
 MASTICATOR SPACE
AXIAL T1 MR

Buccal space (retromaxillary fat

pad)
Temporalis muscle
Zygomatic arch
Masticator space
Temporalis tendon

Masseter muscle

Lateral pterygoid muscle

Mandibular condyle

Hamulus of medial pterygoid plate Buccal space (retromaxillary fat

pad)
Temporalis muscle

Mandibular coronoid process

Masseter muscle Masticator space

Lateral pterygoid muscle

Medial pterygoid muscle
Mandibular ramus Parotid space
Tensor veli palatini muscle
Para pharyngeal space

Buccinator muscle
Buccal space

Retromolar triangle
Masseter muscle Masticator space
Mandibular foramen
Inferior alveolar nerve

Medial pterygoid muscle Parotid gland

Parapharyngeal space
Pharyngeal mucosal space

(Top) In this image the masseter muscle is seen arising from the inferior surface of the zygomatic arch. The
retromaxillary fat pad (superior buccal space) is visible anterior to the masticator space. (Middle) Image at the level
of the maxillary ridge the temporalis muscle is seen inserting on the medial surface of the coronoid process of the
mandible. The tensor veli palatini muscle approaches the hamulus of the medial pterygoid plate where it will turn
medially to the soft palate. (Bottom) Image at the level of the mandibular teeth, the inferior alveolar nerve can be
seen entering the mandibular foramen. The retromolar triangle represents the mucosal surface behind the 3rd
mandibular molar and in front of the anterior mandibular ramus. Squamous cell carcinoma of the retromolar
II triangle when invasive readily involves the masticator space.
168
 MASTICATOR SPACE
CORONAL T1 MR

Meckel cave

Trigeminal ganglion
Suprazygomatic masticator
Temporalis muscle space
Foramen ovale Zygomatic arch
Mandibular nerve

Lateral pterygoid muscle Infrazygomatic masticator

space
Pterygoid venous plexus
Mandibular foramen
Masseter muscle
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Angle of mandible

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Suprazygomatic masticator
Temporalis tendon space
Zygomatic arch

Masseter muscle
- Infrazygomatic masticator
Medial pterygoid muscle
space
Mandibular ramus
Inferior alveolar nerve
Angle of mandible
Submandibular gland
Para pharyngeal space

(Top) Coronal T1 enhanced fat-saturated MR image shows the mandibular nerve (main trunk CNV3) descending
through foramen ovate. Although not visible, the masticator nerve (motor to muscles of mastication) branches off
the mandibular nerve shortly after it exits the foramen ovale. (Middle) Coronal Tl unenhanced MR image reveals
the superior and inferior heads of the lateral pterygoid muscles. Also note the medial pterygoid muscle arises from
the pterygoid fossa above and inserts on the medial ramus and angle of the mandible. (Bottom) Coronal T1
unenhanced MR image through the posterior nose shows masseter muscle arising from the inferior surface of the
zygomatic arch and inserting on the lateral ramus and angle of the mandible. Notice the inferior alveolar nerve as a
focal low signal focus within the high signal fatty marrow of the mandible. II
169
~ PAROTID SPACE
u
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Z ITerminology IAnatomy-Based Imaging Issues

-0
o Abbreviations Key Concepts or Questions
>- • Parotid space (PS) • What imaging features define a primary parotid
....c
('ij space lesion?
~ Definitions
'-+- o Center of lesion is within parotid gland
C • PS: Paired lateral suprahyoid neck spaces enclosed by o If larger mass lesion of deep lobe, mass displaces PI'S
-0 superficial layer deep cervical fascia containing parotid from lateral to medial with widening of
c glands, nodes & extracranial facial nerve branches stylomandibular gap
('ij
-0 Imaging Recommendations
o Ilmaging Anatomy • CECT or MR can both readily image PS
>- • T1 C+ fat-saturated axial & coronal MR better for
....c
('ij Extent perineural CN7 spread
~
0.. • PS extends from external auditory canal (EAC) &
::J mastoid tip superiorly to below angle of mandible Imaging Approaches
C/)
(parotid tail) • Small, superficial lobe PS lesions need no imaging
~ o Parotid tail inserts inferiorly between platysma & o Needle aspiration to confirm benign mixed tumor
u sternocleidomastoid muscle in area of posterior with superficial parotidectomy sufficient
(J,)

Z submandibular space • If inflammation-infection of PS suspected, CECT best

""0
o Angle gantry to avoid dental amalgam & visualize
Anatomy Relationships parotid duct looking for cause of obstruction
c:: • Para pharyngeal space (PI'S) is directly medial to PS
('j o 2-3 mm CT slice thickness recommended
""0 • Masticator space (MS) is anterior to PS • If tumor suspected, T1 C+ fat-saturated MR best
('j • Carotid space (CS) is separated from upper PS by o Look for perineural facial nerve tumor along
Q)
posterior belly digastric muscle intratemporal segments CN7
J: o T-bone CT helps define associated bony changes
Internal Structures-Critical Contents
• Parotid gland Imaging Pitfalls
o Superficial lobe represents - 2/3 of parotid space • Parotid gland becomes progressively more fatty with
o Deep lobe projects into lateral PPS advancing age
• Extracranial facial nerve (CN7) o Parotid glands appear similar to soft tissue in
o Exits stylomastoid foramen as single trunk; ramifies children
within PS lateral to retromandibular vein • Parotid tail mass must be identified as intra parotid or
o Ramifying intra parotid facial nerve creates surgical excision may injure facial nerve
plane between superficial & deep lobes o Parotid tail area defined by superficial platysma,
o Intra parotid facial nerve not visible with CT or MR deep sternocleidomastoid & carotid space
except proximally with high-resolution 3T MR • Facial nerve plane in parotid can only be estimated
• External carotid artery
o Medial, smaller vessel of 2 seen just behind
mandibular ramus in PS I Clinical Implications
• Retromandibular vein
o Lateral, larger of 2 vessels seen just behind Clinical Importance
mandibular ramus in parotid • Intra parotid facial nerve although invisible to imager
o Intraparotid facial nerve branches course just lateral is key PS structure
to retromandibular vein • Try to assess relationship of mass lesion to estimated
• Intraparotid lymph nodes facial nerve plane (lateral to retromandibular vein)
o - 20 lymph nodes found in each parotid gland o Superficial, deep or in plane of intraparotid CN7?
o Parotid nodes are 1st order drainage for EAC, pinna o Evidence of perineural tumor affecting CN??
& surrounding scalp • Parotid tumors: Benign mixed tumor (75%), Warthin
• Parotid duct tumor (5'},,), adenoid cystic carcinoma (5%),
o Emerges from anterior PS, runs along surface of mucoepidermoid carcinoma (5%), other (10%)
masseter muscle
o Duct then arches through buccal space to pierce
buccinator muscle at level of upper 2nd molar I Embryology
• Accessory parotid glands
o Project over surface of masseter muscles Embryologic Events
o Present in - 20'V., of normal anatomic dissections • Parotid space undergoes late encapsulation in
embryogenesis
Fascia of Parotid Space
• Superficial layer of deep cervical fascia (SL-DCF) Practical Implications
surrounds parotid space • Late encapsulation results in intraparotid lymph nodes
• Parotid nodes are 1st-order drainage for malignancies
of adjacent scalp, EAC & deep face

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Medial pterygoid muscles

(Top) Axial graphic of generic deep lobe of parotid gland mass demonstrates medial displacement of the
parapharyngeal space fat. Notice also the slight enlargement of the stylomandibular gap. Smaller lesions of the
superficial lobe of the parotid gland are easily identified as intraparotid. Larger deep lobe lesions may be more
difficult to identify as PS in origin. (Middle) Axial T1 MR through the maxillary ridge reveals a pear-shaped mass
arising from the deep lobe of the parotid gland. This benign mixed tumor enlarges medially, displacing the
parapharyngeal space from lateral to medial. (Bottom) Coronal T1 MR of a large benign mixed tumor enlarging
medially from its origin in the deep lobe of the parotid gland. Note the crescent of parapharyngeal space fat arching
medially and still visible despite the large size of this deep lobe tumor. II
173
 PAROTID SPACE
PERINEURAL PAROTID SPACE MALIGNANCY

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External auditory canal

Jugular bulb
Mastoid segment, CN?

Mastoid air cells

Sigmoid sinus

(Top) Sagittal graphic of a generic parotid malignancy affecting intra parotid facial nerve. The tumor spreading along
CN? through the stylomastoid foramen to the proximal mastoid segment within the temporal bone. If left untreated,
such perineural malignant tumor will eventually access the intracranial compartment via the internal auditory canal.
(Middle) Coronal T1 enhanced fat-saturated MR of the left temporal bone shows an enhancing adenoid cystic
carcinoma of the parotid gland spreading into the lower flared portion of the stylomastoid foramen. This malignant
tumor then spreads in a perineural fashion up the mastoid segment of the facial nerve to the posterior genu.
(Bottom) Axial enhanced Tl fat-saturated MR image reveals an enlarged enhancing mastoid segment of CN? as a
II result of perineural spread of adenoid cystic carcinoma from the parotid space.
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 PAROTID SPACE
AXIAL CECT

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Parotid duct
Parapharyngeal space
Masseter muscle
Projected CN? course
Medial pterygoid muscle
Retromandibular vein Superficial lobe, parotid gland

Posterior belly digastric muscle Deep lobe, parotid gland

Sternocleidomastoid muscle

(Top) First of six axial CECT images presented superior to inferior. This image shows the right stylomastoid foramen
with low attenuation fat contained within. The facial nerve is not visualized on CT images. If perineural tumor is
present, stylomastoid foramen fat will be replaced by tumor. (Middle) In this image the deep lobe of the parotid
gland can be seen projecting through the stylomandibular gap to abut the para pharyngeal space. Note the medial
external carotid artery and more lateral retromandibular vein. (Bottom) In this image, the parotid duct is seen
piecing the buccinator muscle just lateral to the 2nd maxillary molar. The projected course of the extracranial CN7
lateral to the retromandibular vein &: over the surface of the masseter muscle is drawn. Note the large size of the
superficial lobe compared to the deep lobe of the parotid. II
175
 PAROTID SPACE
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Internal carotid artery

Mylohyoid muscle

Platysma muscle
Submandibular space
Submandibular gland

Parotid tail Parotid space

Sternocleidomastoid muscle
Posterior cervical space

(Top) In this image at the level of the mid-oropharynx the larger laterally placed retromandibular vein can be
distinguished from the more medial external carotid artery. Remember that the intraparotid facial nerve. cannot be
seen on CECT but its path can be projected along a line just lateral to the retromandibular vein and out over the
surface of the masseter muscle. (Middle) At the level of the mandibular angle the parotid space is now separated
from the carotid space by the posterior belly of the digastric muscle. Note the platysma muscle is now visible over the
surface of the parotid gland. (Bottom)Just below the mandible the parotid tail is visible projecting into the posterior
aspect of the submandibular space. Excisional biopsy of a low lying mass, unrecognized as being in the parotid tail,
II may result in facial nerve injury ..
J 76
 PAROTID SPACE
AXIAL T1 MR

Internal carotid artery Parapharyngeal space

Internal jugular vein Masticator space

Parotid space
Mandibular condyle

External ear
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Masticator space
.Masseter muscle

Parotid space

Retromandibular vein

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Carotid s]'>ce
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digastric muscle

(Top) First of six axial Tl MR images presented superior to inferior shows the right facial nerve exiting the
stylomandibular foramen. There is fat in the lower flared aspect of the stylomastoid foramen so the main trunk of
the facial nerve is visible. (Middle) In this image the proximal intraparotid facial nerve is seen on the right. Note the
accessory parotid gland overlying the right masseter muscle bilaterally. (Bottom) At the level of the maxillary ridge a
branch of the intraparotid facial nerve is seen projecting anterolaterally around the lateral margin of the
retromandibular vein. Usually not visible on routine imaging, the intraparotid facial nerve and its branches follow a
predictable course anterolaterally around the lateral margin of the retromandibular vein, from there anteriorly along
the lateral surface of the masseter muscle. II
177
 PAROTID SPACE
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Posterior belly of digastric muscle Carotid space

Posterior cervical space
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(Top) At the level of the maxillary teeth the parotid space is visible posterolateral to the masticator space. Remember
that both the masticator & parotid spaces are circumscribed by superficial layer of deep cervical fascia. Note the
projected intra parotid facial nerve course drawn on the right. (Middle) In this image the posterior belly of the
digastric muscle is seen on the posteromedial boundary of the parotid space, separating the PS from the carotid
space. The posterior belly of the digastric muscle is innervated by a branch of the facial nerve. (Bottom) In this image
the parotid gland is seen at the mandibular angle. The posterior belly of the digastric muscle is seen between the
parotid tail & the carotid space on the left. When a parotid space mass is present, the medial displacement of the
II posterior belly of the digastric muscle helps define its location.
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 PAROTID SPACE
AXIAL T2 FS MR :I
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muscle

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(Top) First of three axial T2 fat-saturated MR images presented superior to inferior shows the adult parotid gland is
higher signal than the surrounding muscles of the suprahyoid neck. A few sporadic high signal intraparotid nodes are
present at this level. The parapharyngeal space fat is low signal because of the fat-saturation MR sequence. (Middle)
The parotid space often abuts the accessory parotid gland that may be seen over the surface of the masseter muscle.
Both are within the superficial layer of deep cervical fascia. (Bottom) In this image at the level of the maxillary teeth
the high signal linear parotid duct is easily visualized extending anteriorly from the parotid gland along the surface
of the masseter muscle to penetrate the buccinator muscle.
II
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 .:L. CAROTID SPACE
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Z I Terminology o Suprahyoid carotid space: Carotid sheath
-0 incomplete or less substantial
o Abbreviations o Infrahyoid carotid space: Carotid sheath
>-- • Carotid space (CS) well-defined, tenacious fascia
...c
("Ij • Suprahyoid neck (SHN) and infrahyoid neck (IHN)
'-+-
"-
C Definitions IAnatomy-Based Imaging Issues
-0 • Paired, tubular spaces surrounded by carotid sheath
C that contain carotid arteries, internal jugular veins, Key Concepts or Questions
("Ij
cranial nerves (CN) 9-12 (SHN) & CNIO (IHN) • What imaging features define a lesion as primary to
-0 carotid space?
o o Lesion in SHN carotid space
>-- I Imaging Anatomy • Center of lesion is within area of ICA-IJV,
...c
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"-
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:J • Carotid space travels from inferior margins of jugular • Pushes posterior belly of digastric muscle laterally
(f)
foramen-carotid canal above to aortic arch below • If in nasopharyngeal CS, pushes styloid process
~ • SHN carotid space contains CN9-12, internal carotid anterolaterally
u artery and internal jugular vein • When mass begins in posterior SHN CS (vagal
Q)
Z • IHN carotid space contains CNIO only, common schwannoma, neurofibroma, paraganglioma), ICA
"'0 carotid artery, internal jugular vein; internal jugular is pushed anteriorly as mass enlarges
c nodal chain is closely associated with its outer surface o Lesion in IHN carotid space
('lj
• May engulf CCA and IJV or push them apart
"'0 Extent • May splay external carotid artery (ECA) and ICA
('lj
• CS defined from skull base (carotid canal and jugular (carotid body paraganglioma)
Q)
foramen) to aortic arch below
J: • CS can be divided into its major segments
• What are statistically common lesions found in the
carotid space?
o Nasopharyngeal, oropharyngeal, cervical and o Paraganglioma, schwan noma, IJV thrombosis &
mediastinal segments carotid artery dissection-pseuctoaneurysm
Anatomy Relationships Imaging Recommendations
• SHN carotid space adjacent spaces • CECT or MR both can easily identify normal CS
o Retropharyngeal space (RPS) medial anatomy and CS lesions
o Perivertebral space posterior • If using MR, remember to acquire unenhanced T1 (to
o Parotid space lateral look for high velocity flow voids of paraganglioma)
o Para pharyngeal space (PPS) anterior • MRA and MRV may be helpful in defining the normal
• lHN carotid space adjacent spaces and diseased vessels of CS (ICA dissection;
o Visceral space and RPS medial pseudoaneurysm; IJV thrombosis)
o Perivertebral space posterior
o Anterior cervical space anterior Imaging Approaches
o Posterior cervical space lateral • Remember that CS runs from jugular foramen-carotid
canal of skull base above to aortic arch below
Internal Structures-Critical Contents • If imaging CS because of left vagal neuropathy, must
• SHN carotid space reach aortopulmonic window inferiorly
o Internal carotid artery (ICA)
o Internal jugular vein (IJV) Imaging Pitfalls
o Cranial nerves 9-12 in nasopharyngeal CS • Normal vascular flow phenomenon of IJV may mimic
o Only CNIO remains in CS from oropharyngeal CS schwannoma or thrombosis
inferiorly
o CNIO located in posterior notch formed by ICA and
IJV I Clinical Implications
o Sympathetic plexus between medial CS and lateral
RPS Clinical Importance
• IHN carotid space • CN9-12 and carotid artery are vital structures in
o Common carotid artery (CCA) carotid space
o Internal jugular vein
o Vagus nerve
Function- Dysfunction
o Internal jugular nodal chain closely associated but • Injury to nasopharyngeal CS may result in complex
not in infrahyoid neck carotid space cranial neuropathy involving some combination of
CN9-12
Fasciaof Carotid Space • Vagus nerve injury: Vocal cord paralysis
• Carotid sheath made from components of all 3 layers • Carotid artery proximity to internal jugular nodal
of deep cervical fascia chain makes injury from squamous cell carcinoma
extra nodal tumor likely

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 CAROTID SPACE
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(Top) Lateral view 3D-VRT CECT reconstruction of major vessels of the neck. The hyoid bone is apQroximatelx at the
level of the carotid bifurcatioq with the internal carotid artery found in the suprahyoid carotid space and the
common carotid artery found within the infrahyoid carotid space. (Middle) Lateral view of extracranial MRA shows
the carotid artery from the arch below to the supraclinoid area above. Remember that the carotid artery extends in
the carotid space throughout this entire distance. (Bottom) Sagittal reformation of CECT of the extracranial head
and neck shows the internal jugular vein from its emergence from the jugular foramen above to the clavicle level
below. Thrombosis of this vessel can mimic infection (acute thrombophlebitis) or tumor (chronic thrombosis).
II
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 CAROTID SPACE
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muscle
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Submandibular gland
External carotid artery

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Carotid space
Internal jugular vein
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(Top) First of six axial CECT images presented from superior to inferior. In this image at the level of Cl vertebral
body the nasQphALYJ2R.eilJ carotid space contains the internal carotid artery, internal jugular vein and CN9-12. Notice
a
that the CS is posteiior to the· styloid ·process ..~t the level of the nasopharynx carotid space mass will push from
posterior to anterior into the para pharyngeal space and displace the styloid process anterolaterally. (Middle) In this
image at the level of the,.mid-oropharynx. the posterior belly of the digastric muscle is visible anterolateral to the
carotid space. A CS mass here would push this muscle anterolaterally and the parapharyngeal space anteriorly.
(Bottom) At th~ level of the hYoid bone the carotid bifurcation can be seen. At this level only the vagus nerve is left
II within the CS..
184
 CAROTID SPACE
AXIAL CECT I
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Thyroid cartilage

Thyroid gland
Sternocleidomastoid muscle

Internal jugular vein

Carotid space
Area of vagus nerve

Common carotid artery

Cricoid cartilage

(Top) At the level of the hyoid bone the carotid space has only the common carotid artery, internal jugular vein and
vagus nerve within it. Notice that despite the high resolution nature of this CT image, it is not possible to see the
vagus nerve or the carotid sheath. (Middle) In this image through the infrahyoid aspect of the carotid space the
surrounding deep tissue anatomy can be seen. Posterolateral to the carotid space the large fat-filled posterior cervical
space is visible. Posteromedial the perivertebral space is found. Medial to the CS is the visceral space and the
retropharyngeal space. Anteriorly resides the sternocleidomastoid muscle. (Bottom) At th~ lev_elof the criCQid
cartilage the infrahyoid carotid space contains the common carotid artery, internal jugular vein and vagus nerve.
Despite its large size the vagal trunk cannot be seen. II
185
~ RETROPHARYNGEALSPACE
u
Q)
Z I Terminology !Anatomy-Based Imaging Issues
u
o Abbreviations Key Concepts or Questions
>- • Retropharyngeal space (RPS) • What radiologic findings define a lesion as primary to
..c
~ retropharyngeal space?
'"-
'+-
Definitions o Unilateral-nodal SHN mass
C • RPS: Midline space just posterior to pharynx & cervical • Centered posteromedial to para pharyngeal space
U esophagus running from skull base to T3 vertebral (PI'S) & directly medial to carotid space
c level in mediastinum • Encroaches on PI'S from posteromedial to
~
anterolateral (mimics carotid space mass)
U
o "Extranodal" mass in SHN or IHN (pus or tumor
o I Imaging Anatomy filling RPS)
>-
..c Overview • Rectangular-shaped mass centered behind PMS
~ • Mass anterior to prevertebral muscles
'"-
0- • RPS is fat-filled space in posterior midline of neck that
• Mass flattens & remains anterior to prevertebral
:J can be identified on imaging from skull base to upper
muscles as it enlarges
(f)
mediastinum
• Contrast with perivertebral space mass which
~ • Upper-most RPS (nasopharyngeal portion) is "tight" elevates prevertebral muscles as it enlarges
u o In RPS abscess path of least resistance is inferiorly
Q) • SHN RPS lesion imaging appearances
Z • RPS nodes only found in suprahyoid neck RPS o Lesion begins most commonly in RPS nodes
"'0
Extent o Seen on CT or MR as unilateral RPS mass
c: o If extranodal disease (edema, infection or tumor).
ro • Skull base to T3 vertebral body level in upper
will fill RPS from side to side
"'0 mediastinum
ro • IHN RPS lesion imaging appearances
Q) Anatomy Relationships o Originates in SHN RPS, spreads inferiorly into IHN
:::c • Suprahyoid neck (SHN) RPS o Fills entire IHN RPS from side to side
o Pharyngeal mucosal space (PMS) is anterior o Remember to look at SHN RPS if you find IHN RPS
o Danger space (DS) is directly posterior to RPS disease
o Carotid space is lateral to RPS
• Infrahyoid neck (IHN) RPS Imaging Approaches
o Hypopharynx & cervical esophagus are anterior • CECT best imaging tool in evaluation of RPS
o Danger space is directly posterior to RPS infection
• RPS empties via "fascial trap door" into DS • MR imaging far more sensitive to presence of RPS
inferiorly at - T3 level tumor adenopathy
o Carotid space is lateral to RPS Imaging Pitfalls
Internal Structures-Critical Contents • RPS & DS are indistinguishable on CT or MR imaging
• Suprahyoid neck RPS (skull base to hyoid bone) o Best to consider DS as conduit for RPS disease into
o Fat is primary occupant of SHN RPS mediastinum only
o RPS lymph nodes • Otherwise, describe lesions in RPS only & ignore
• Lateral group: Also called nodes of Rouviere DS from imaging perspective
• Medial group: Less often visible on imaging • Lateral RPS nodal mass may mimic carotid space mass
• Infrahyoid neck RPS (hyoid bone to T3 vertebral o Look for mass medial to carotid space (CS)
body in mediastinum) o Mass displacement of CS is posterolaterally
o Fat only in IHN RPS o Both RPS & CS displace para pharyngeal space
o No RPS nodes below hyoid bone! anteriorly
• Not all fluid in RPS is abscess
Fasciaof Retropharyngeal Space o Internal jugular vein thrombosis & longus colli
• RPS has complex fascial margins tendonitis can both cause RPS edema
• Anterior wall fascia: Middle layer, deep cervical fascia o Non-abscess fluid: No enhancement of wall;
o Fascia is just behind constrictor muscle of minimal mass effect
pharyngeal mucosal space
• Posterior wall fascia: Deep layer, deep cervical fascia
o Fascia is just anterior to prevertebral muscles of I Clinical Implications
perivertebral space
o Two slips present with danger space between Clinical Importance
• Lateral fascial wall: Slip of deep layer, deep cervical • RPS nodes are seeded by pharyngitis
fascial called alar fascia o Once seeded they react, suppurate & eventually
• Median raphe divides RPS into two halves rupture to create RPS abscess
o Relatively weak fascial slip that is present more • Squamous cell carcinoma of nasopharynx and
consistently in superior RPS posterior wall of oropharynx & hypopharynx drain
into RPS nodal chain

II
186
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 RETROPHARYNCEAl SPACE
AXIAL CECT

Pharyngeal mucosal space

Lingual tonsil

Carotid space
Palatine tonsil

Prevertebral component,
Prevertebral III uscles perivertebral space •
Retropharyngeal space

Hypopharynx
Carotid space

Common carotid artery Prevertebral component,

Internal jugular vein perivertebral space

Prevertebralmuscles
Retropharyngeal space

Trachea Visceral space

Hypop h aryngea I-eso p h agea I

junction Carotid space
Thyroid gland

Retropharyngeal space
Anterior scalene muscle
Prevertebral muscle
Prevertebral componellt,
perivertebral space

(Top) First of three axial CECT images of the neck. This image at the level of the low oropharynx shows the stripe of
fat behind the pharyngeal mucosal space that represents the retropharyngeal space. Posterior to the retropharyngeal
space is the prevertebral portion of the perivertebral space. Lateral to it are the carotid spaces. (Middle) In this image
at tile level of the.S1lpraglottis.the stripe of fat behind the larynx & hypopharynx is the retropharyngeal space. The
carotid spaces are at the lateral margin of the RPS bilaterally. (Bottom) At the level of the mid-infrahyoid neck. the
retropharyngeal space is larger and more obvious than in the suprahyoid neck. Anterior is the visceral space with the
hypopharyngeal-esophageal junction abutting the RPS. The prevertebral component of the perivertebral space is
posterior to the RPS. II
191
 RETROPHARYNGEAL SPACE
-6 AXIAL T1 MR
(l)

Z
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o
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Epiglottic free margin

Palatine tonsil
Pharyngeal mucosal space
Internal carotid artery
Carotid space

Internal jugular vein Prevertebral component,

perivertebral space
Prevertebral muscles
Retropharyngeal space

Subglottis

Thyroid gland Visceral space

Common carotid artery Carotid space

Internal jugular vein

Retropharyngeal space

Anterior scalene muscle

Prevertebral component,
Prevertebral muscle perivertebral space

(Top) First of three axial Tl MR images of the extracranial head and neck. This image at the level of the oropharynx
shows a thin stripe of high signal fat behind the pharyngeal mucosal space that represents the retropharyngeal space.
Posterior to the retropharyngeal space is the prevertebral portion of the perivertebral space. (Middle) In this image at
the level of the low oropharynx, the high signal stripe of fat behind the oropharyngeal mucosal space is the
retropharyngeal space. The carotid spaces are at the lateral margin of the RPSbilaterally. The prevertebral muscles in
the perivertebral space are directly posterior to the RPS. (Bottom) In this image at the level of the mid-infrahyoid
neck the RPSis easily seen between the carotid spaces. The visceral space is anterior and the prevertebral component
II of the perivertebral space posterior to the RPS.
192
 RETROPHARYNCEAL SPACE
AXIAL BONE CT & T2 MR I
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Pharyngeal mucosal space

Para pharyngeal space

Lateral retropharyngeal nodes Lateral retropharyngeal node

Internal carotid artery

Carotid space
Prevertebral muscle
Prevertebral component,
perivertebral space

(Top) Axial bone CT through mid-oropharynx in a trauma patient shows air has collected in the retropharyngeal
space, allowing the median raphe to be seen. The median raphe functions as an attachment of the constrictor
muscles. In addition it provides an initial barrier to spread of disease from side to side in the retropharyngeal space.
(Middle) Axial bone CT at level of the supraglottis in trauma patient shows air in the retropharyngeal and danger
spaces. Air allows identification of the lateral alar fascia and the anterior slip of deep layer of deep cervical fascia that
separates these 2 spaces. (Bottom) Axial fat-saturated T2 MR through the low nasopharynx in a young adolescent
reveals normal lateral RPS nodes bilaterally. Notice these nodes are positioned just medial to the internal carotid
artery and posteromedial to the fat-saturated parapharyngeal space. II
193
 ~
u
PERIVERTEBRAL SPACE
a;
Z ITerminology o Anterior portion arches from cervical spine
-0 transverse process across prevertebral muscles to
o Abbreviations opposite transverse process
>- • Perivertebral space (PVS) • Anterior DL-DCF called "the carpet" by surgeons
..J:: • Pharynx slides up & down on this smooth,
~
~
'-+- Synonyms "carpet-like" surface
C • Perivertebral space: Prevertebral space • "Carpet" is tenacious, with infection or tumor of
-0 o Historic prevertebral space term include soft tissues PVS redirected into epidural space by this fascia
C behind vertebral column • Pharyngeal malignancy blocked from accessing
~ o Perivertebral space term adopted to include all PVS by this tough fascia
-0
tissues under deep layer of deep cervical fascia o Posterior portion DL-DCF arches over surface of
o (DL-DCF), both in front of & behind vertebral paraspinal muscles to attach to nuchal ligament of
>- column spinous process of vertebral body
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Definitions
:J • PVS: Cylindrical space surrounding vertebral column IAnatomy-Based Imaging Issues
..
V')

.:¥
extending from skull base to upper mediastinum
bounded by deep layer, deep cervical fascia subdivided Key Concepts or Questions
U into prevertebral & paraspinal components
Q.I • What imaging findings define a mass lesion as primary
• Perivertebral space: Peri (Gr. for around) the vertebra to prevertebral-PVS?
Z
"'C o Mass is centered within prevertebral muscles or
c: corpus of vertebral body
I Imaging Anatomy
"'
"'C
Extent
o Mass lifts prevertebral muscles anteriorly (RPS mass
pushes them posteriorly)
"'
Q.I
J: • PVS extends from skull base above to T4 in posterior Imaging Approaches
mediastinum • Lateral plain film
• Some anatomists describe PVS as discrete anatomic o Quick check on prevertebral soft tissue swelling &
space to level of coccyx on integrity of cervical vertebral bodies
• CECT with soft tissue & bone algorithm & sagittal
Anatomy Relationships reformation
• PVS consists of 2 major components o Best exam to look at cervical soft tissue & bones
o Prevertebral portion or space • Cervical spine MR best to assess epidural disease
o Paraspinal portion or space
• Prevertebral-PVS sits directly behind retropharyngeal Imaging Pitfalls
throughout extracranial H&N • Hypertrophic levator scapulae muscle (LSM):
o Anterolateral to prevertebral-PVS is carotid space Mistaken for enhancing mass or recurrent tumor
o Lateral to prevertebral-PVS is anterior aspect of o Secondary to CNl! injury (during neck dissection)
posterior cervical space • Sternocleidomastoid (SCM) & trapezius atrophy
• Paraspinal-PVS is deep to posterior cervical space & • LSM hypertrophies to help lift arm
posterior to transverse processes of cervical spine o Imaging findings
• LSM enlarges, may enhance .,
Internal Structures-Critical Contents • SCM & trapezius small, fatty infiltrated
• Prevertebral-PVS or prevertebral space
o Prevertebral muscles (longus colli & capitis)
o Scalene muscles (anterior, middle & posterior)
o Brachial plexus roots
I Clinical Implications
o Phrenic nerve (C3-CS) Clinical Importance
o Vertebral artery & vein • Prevertebral-PVS contains important structures
o Vertebral body o Proximal brachial plexus, phrenic nerve, vertebral.
• Paraspinal-PVS or prevertebral space arteries
o Paraspinal muscles • Most PVS lesions originate in vertebral body (infection
o Posterior elements, vertebral column or metastatic tumor)
• Brachial plexus (BP), proximal aspect o Vertebral body is usually diseased when PVS lesion is
o Brachial plexus has complex spatial anatomy found
o CS-Tl roots leave cervical neural foramina, pass • Prevertebral-PVS disease may involve epidural space
between anterior & middle scalene of o If infection or malignancy breaks out of cervical
prevertebral-PVS vertebral body into prevertebra-PVS, 1st obstruction
o BP roots pass through opening in DL-DCF, pass into to spread is deep layer of deep cervical fascia
posterior cervical space on their way to axilla o Path of least resistance of spreading pus or tumor is
Fasciaof Perivertebral Space deep through neural foramen into epidural space
o When prevertebral PVS disease is found on imaging,
• DL-DCF completely circumscribes PVS
always check for epidural space extension!

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 PERIVERTEBRAL SPACE
AXIAL CECT

Masseter muscle Retropharyngeal space

Medial pterygoid muscle Prevertebral component,
Prevertebral muscles perivertebral space
Carotid space
Sternocleidomastoid muscle
Vertebral artery
Posterior cervical space

Paraspinal muscles Paraspinal component,

perivertebral space

Trapezius muscle

Submandibular gland

Hyoid bone
Retropharyngeal space
Prevertebral muscles
Carotid space

Prevertebral component,
Vertebral artery perivertebral space
Posterior cervical space
Levator scapulae muscle
Paraspinal component,
Paraspinal muscles
perivertebral space
Trapezius muscle

Visceral space

Retropharyngeal space
Sternocleidomastoid muscle
Thyroid gland
Carotid space
Prevertebral muscles
Phrenic nerve location
Anterior scalene muscle
Middle scalene muscle Posterior cervical space

Levator scapulae muscle

Paraspinal muscles Paras pinal component,
perivertebral space

Trapezius muscle

(Top) First of six axial CECT images through the extra cranial head and neck chosen to highlight the normal features
of the perivertebral space. This image at the level of the C2 vertebral body shows the prevertebral component of the
perivertebral space contains the prevertebral muscles, vertebral body and vertebral artery only. The retropharyngeal
space fat stripe is visible anteriorly. (Middle) In this image at the level of the hyoid bone the levator scapulae muscles
and the paraspinal muscles along with the posterior elements of the vertebral body are the principal occupants of the
paraspinal component of the perivertebral space. (Bottom) At the level of the cricoid cartilage the s£alene muscles
are visible. The phrenic nerve location is marked on the left to remind the imager of its presence even though it is
not visible on imaging. II
199
 PERIVERTEBRAL SPACE
~ AXIAL CECT
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Levator scapulae muscle
Paraspinal component,
perivertebral space

Esophagus Retropharyngeal space

Prevertebral muscles
Vertebral artery/vein
Anterior scalene muscle
Middle scalene muscle

Brachial plexus roots

Levator scapulae muscle

Paraspinal component,
perivertebral space

(Top) At the level of the upper thyroid bed the scalene muscles are seen in the prevertebral component of the
perivertebral space. The anterior band of deep layer of deep cervical fascia is referred to as the "carpet". (Middle) In
this image at the level of the mid-thyroid bed the low density ovoid brachial plexus roots can be seen emerging from
the cervical neural foramina to pass anterolaterally between the anterior and middle scalene muscles in the
prevertebral component of the perivertebral space. (Bottom) At the level of the low-thyroid bed the low density
brachial plexus roots are visible passing anterolaterally between the anterior and middle scalene muscles in the
prevertebral component of the perivertebral space. These roots continue through openings in the deep layer of deep
II cervical fascia into the posterior cervical space on their way to the axillary apex.
200
 PERIVERTEBRAL SPACE
AXIAL T2 FS & CORONAL STIR MR :c
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Brachial plexus roots

Vertebral artery

Brachial plexus trunks

(Top) Axial T2 fat-saturated MR image at level of thyroid gland shows the normal high signal brachial plexus roots
between anterior & middle scalene muscles. Notice a single root passes through the neural foramen bilaterally.
Brachial plexus arises from ventral rami of C5 through Tl. (Middle) In this axial T2 fat-saturated MR image the
anterior & middle scalene muscles can be seen on the anterior & posterior sides of the high signal brachial plexus
roots. Distally the 5 roots become 3 trunks (upper, middle & lower) as they emerge from their interscalene muscle
location. (Bottom) Coronal STIRMR through the lower cervical vertebral bodies shows both the 5 brachial plexus
roots & the 3 trunks in the same plane. The pneumonic "Robert Taylor Drinks Cold Beer" reminds us that the
brachial plexus transitions from Roots to Trunks to Divisions to Cords to end in Branches. II
201
 ~ POSTERIOR CERVICAL SPACE
u
CJ.)
Z ITerminology o Subdivided by inferior belly of omohyoid muscle
'"'0 into occipital & subclavian triangles
o Abbreviations • Occipital triangle
>- • Posterior cervical space (PCS) o Boundaries: Anteromedial sternomastoid muscle;
-C posterolateral trapezius muscle; inferior is inferior

--
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C • PCS: Posterolateral fat-containing space in neck with
'"'0 complex fascial boundaries that extends from
C posterior mastoid tip to clavicle
(\j
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o I Imaging Anatomy
>-
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Q..
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• Lesions of PCS arise from spinal accessory nodal chain
~ o Infection, inflammation & tumor involving these
U
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Z Extent
"'C • PCS extends from small superior component near
C • What are criteria for defining a cervical neck mass
~ mastoid tip to broader base at level of clavicle
"'C • When viewed from side, appears as "tilting tent"
~ o Lesion displaces carotid space anteromedially
Q) Anatomy Relationships
:r: • Superficial space lies superficial to pcs
• Deep to pcs is perivertebral space
o Anterior PCS is superficial to prevertebral
component of perivertebral space
o Posterior PCS is superficial to paraspinal component
of perivertebral space
• Anteromedial to PCS is carotid space
Internal Structures-Critical Contents
• Fat is primary occupant of PCS
• Accessory nerve (CNII)
• Spinal accessory lymph node chain
o In node level numbering system this is levelS
o LevelS spinal accessory nodes (SAN) further
subdivided into A & B levels at hyoid bone
• Level SA: SAN above cricoid cartilage level
• Level 58: SAN below cricoid cartilage level
• Pre-axillary brachial plexus
o Segment of brachial plexus emerging from anterior
& middle scalene gap passes through PCS
o Leaves PCS with axillary artery into axillary fat
• Dorsal scapular nerve
o Arises from brachial plexus (spinal nerves C4 & C5)
o Motor innervation to rhomboid & levator scapulae
muscles
Fasciaof Posterior Cervical Space
• Complex fascial boundaries surround PCS
o Superficial: Superficial layer of deep cervical fascia
o Deep: Deep layer of deep cervical fascia
o Anteromedial: Carotid sheath (all 3 layers, deep
cervical fascia)
Other Related Anatomic Information
• Posterior triangle
o Definition: Region of cervical neck posterolateral to
sternomastoid muscle & anteromedial to trapezius
muscle
belly of omohyoid muscle
o Contents: Fat, accessory nerve (CNII), dorsal
scapular nerves & spinal accessory nodes
o Occipital triangle is majority of PCS
• Subclavian triangle
o Boundaries: Superior inferior belly of omohyoid
muscle; anteromedial sternocleidomastoid muscle;
posterolateral trapezium muscle
o Contents: 3rd portion of subclavian artery, cervical
brachial plexus
o Subclavian triangle is lower, smaller portion of PCS
IAnatomy-Based Imaging Issues
Key Concepts or Questions
lesion as primary to PCS?
o Lesion must be centered within fat of pcs
o Lesion elevates sternocleidomastoid muscle
o Lesion flattens deeper perivertebral space structures
• How can you tell a internal jugular from SAN?
o Within infrahyoid PCS
• Spinal accessory nodes are in fat of PCS with slip
of fat separating them from carotid space
• Internal jugular nodes abut carotid space
o Within suprahyoid PCS
• Internal jugular & spinal accessory nodal chain
converge cephalad toward jugulodigastric group
• Differentiating internal jugular from spinal
accessory adenopathy tougher in suprahyoid area
• Nodes that abut anterior, lateral or posterior to
carotid space, consider internal jugular nodes
• If node has fat slip separating it from carotid
space, consider spinal accessory nodes
I Clinical Implications
Clinical Importance
• CN 11 runs in floor of PCS
• Spinal accessory nodes are main normal occupants of
posterior cervical space
Function-Dysfunctio'n
• Accessory cranial neuropathy results when CNII
injured
o Most commonly injured during neck dissection for
malignant SCCa nodes
o Less commonly injured by extranodal spread of
squamous cell carcinoma
o Dysfunction: Sternomastoid & trapezius muscle
paresis
• Acute denervation: Muscles may swell & enhance
• Chronic denervation: Muscles atrophy & fatty
infiltrate
• Levator scapulae muscle hypertrophies
• Patient has difficulty lifting arm

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202
 POSTERIOR CERVICAL SPACE
GRAPHICS ::I:
I'C
~
c..
~
:::::l
c..
Z
I'C
Mastoid tip t"l
'7\
(j)
C
""0
....,
~
::r
'<
o
Sternocleidomastoid
muscle
Accessory nerve (CNll) c:L
~
:J
Spinal accessory nodal c:L
External jugular vein
chain

Dorsal scapular nerve

Trapezius muscle

Inferior belly
Clavicle
omohyoid muscle

Tri-color carotid sheath

Carotid space
Sternocleidomastoid
muscle
Prevertebral
component,
perivertebral space
Brachial plexus root

Omohyoid muscle Posterior cervical space

Paraspinal muscles Paraspinal component,

perivertebral space

Superficial layer, deep

Trapezius muscle cervical fascia

Deep layer, deep

cervical fascia

(Top) Lateral graphic if extracranial head & neck shows the posterior cervical space as a "tilting tent" with its superior
margin at the level of the mastoid tip and its inferior border at the clavicle. Notice it has two main nerves in its floor,
the accessory nerve (CN!!) and the dorsal scapular nerve. The spinal accessory nodal chain is its key occupant with
regards to the kind of lesions found in the PCS. (Bottom) Axial graphic through the thyroid bed of the infrahyoid
neck depicts the posterior cervical space with its complex fascial borders. The superficial layer of deep cervical fascia
is its superficial border while the deep layer of deep cervical fascia is its deep border. Note the tri-color carotid sheath
is its anteromedial border. The brachial plexus roots travel through the PCS on their way to the axillary apex.
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203
 POSTERIOR CERVICAL SPACE
.::£
U
pes NODAL STATIONS/DISEASES
Q)
Z
-0
o
>-
....c

--
-0
ro
•....
C
Spinal accessory nodal chain
above cricoid level

Accessory nerve (CNll)

C
ro
-0 Cricoid cartilage
o Spinal accessory nodal chain
>- below cricoid level
....c
ro
•....
Q..
::J
Vl

~
U
Q)
Z
-0
c
~
-0
~
OJ
Posterior cervical space
J: Posterior cervical space

Spinal accessory node (level VA) Spinal accessory node (level

VA)

Levator scapulae muscle

Carotid space
Internal jugular nodes (level 3)
Internal jugular node (level 3)

Spinal accessory nodes (level SA)

Spinal accessory node (level SA)

Paraspinal component,
perivertebral space

(Top) Oblique graphic of the extracranial head and neck depicting the principal nodal chains and their assigned
levels. The spinal accessory chain (level S) is divided at axial level of the cricoid cartilage into upper level SB and
lower level SA groups. Level 2, 3 & 4 nodes are in the internal jugular chain. (Middle) Axial CECT image of the
cervical neck at the level of the supraglottis shows bilateral level SA nodes in the posterior cervical space of the neck.
They are considered SA because they are in the posterior cervical space above the cricoid cartilage. (Bottom) In this
image in a patient with non-Hodgkin lymphoma nodes can be seen both in the internal jugular and spinal accessory
nodal chains. Notice that there is fat and internal jugular nodes between the spinal accessory chain and the carotid
II space.
204
 POSTERIOR CERVICAL SPACE
GENERIC MASS IN PCS

Carotid space

Generic posterior cervical space

mass
Posterior cervical space

Prevertebral component,
perivertebral space
Paraspinal component,
perivertebral space

Carotid space Sternocleidomastoid muscle

Prevertebral component,
perivertebral space External jugular vein

Posterior cervical space PCS lymphatic malformation

Trapezius muscle
Paraspinal component,
perivertebral space

Mastoid tip

Sternocleidomastoid muscle

PCS lymphatic malformation

External jugular vein Trapezius muscle

Clavicle

(Top) Axial graphic in the infrahyoid neck showing a generic mass in the posterior cervical space on the left. Notice
the lesion is centered within fat of PCS. A PCS mass typically displaces the carotid space anteromedially, elevates the
sternocleidomastoid muscle and flattens the deeper perivertebral space structures. (Middle) In this axial CECT image
at the level of the thyroid bed a lymphatic malformation is seen filling the left posterior cervical space. (Bottom)
CECT sagittal reformation reveals a posterior cervical space lymphatic malformation. The image is presented to show
the "tilted tent" shape of the posterior cervical space from its superior margin at the mastoid tip to its inferior margin
at the clavicle.
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205
 POSTERIOR CERVICAL SPACE
-Q AXIAL CECT
Q.)
Z
""0

o
>-
...r:
Ci3
~
'+-
C
""0

c Carotid space
Ci3
""0 Sternocleidomastoid muscle Parotid space
o Spinal accessory node (level SA)
>- Posterior cervical space
...r:
Ci3 Paraspinal muscles
~
Q.. Ligamentum nuchae
:J
(f)
Trapezius muscle
~
u
Q)
Z
"'C
c:
~
"'C
~ Common carotid artery Prevertebral component,
Q)
:r: perivertebral space
Internal jugular vein Paraspinal component,
perivertebral space
Sternocleidomastoid muscle Carotid space

Levator scapulae muscle

Trapezius muscle Posterior cervical space

Ligamentum nuchae

Retropharyngeal space
Carotid space
Sternocleidomastoid muscle

Anterior scalene muscle Posterior cervical space

Brachial plexus roots
Middle scalene muscle
Posterior scalene muscle
Prevertebral component,
Levator scapulae muscle
perivertebral space

Paraspinal component,
perivertebral space

(Top) First of three axial CECT at the level of the mid-oropharynx shows the fat-filled posterior cervical space. Notice
the posteromedial extension of the posterior cervical space between the paraspinal muscles and the trapezius where it
reaches as far as the ligamentum nuchae. (Middle) In this CECT image at the level of the hyoid bone the
anteromedial border of the posterior cervical space abuts the carotid space. Deep to the posterior cervical space is the
paraspinal component of the perivertebral space. The lateral-most muscle in the paraspinal muscle group is the
levator scapulae muscle. (Bottom) At the level of the clavicle the posterior cervical space is visible enlarging in the
inferolateral direction to meet the axillary apex. Notice the brachial plexus roots must traverse the PCS as they
II emerge from between the anterior and middle scalene muscles.
206
 POSTERIOR CERVICAL SPACE
CORONAL T1 MR

Mastoid tip

Sternocleidomastoid muscle

Paraspinal muscles
Sternocleidomastoid muscle
Levator scapulae muscle

Clavicle
Middle scalene muscle
Posterior cervical space

Cervical spinal cord

Sternocleidomastoid muscle

Anterior scalene muscle

Clavicle
Vertebral artery
Brachial plexus root in perivertebral
space Posterior cervical space
Subclavian artery
Axillary apex
Brachial plexus in posterior cervical Brachial plexus in axillary apex
space

Common carotid artery

Sternocleidomastoid muscle
Carotid space

Internal jugular vein

Posterior cervical space

Trachea

Clavicle

(Top) First of three coronal Tl MR images presented from posterior to anterior of the extra cranial head and neck
emphasizing the anatomy of the posterior cervical space. In this image the pes is seen spanning the distance
between the mastoid tip superiorly and the axillary apex inferolaterally. A few scattered levelS spinal accessory
lymph nodes are seen in the high signal fat of the pes. (Middle) In this image through the cervical spinal cord the
brachial plexus roots are visible exiting the perivertebral space into the pes on their way to the axillary apex. Lymph
node disease of the lower spinal accessory chain in the pes can affect the brachial plexus. (Bottom) In this image
through the carotid space the most anteroinferior aspect of the posterior cervical space is seen.
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207
~ VISCERAL SPACE
u
Q)
Z • Lesion may originate in thyroid, parathyroid
ITerminology (tracheoesophageal groove), trachea or esophageus
u
Abbreviations o Thyroid mass lesion
o • Mass surrounded at least in part by thyroid tissue
~ • Visceral space (VS)
....c • CS displaced laterally with trachea & esophagus
~
•...
4-
Definitions displaced to opposite side of neck
C • VS: Cylindrical space in midline infrahyoid neck (lHN) o Parathyroid (tracheoesophageal groove) mass
-0 enclosed by middle layer, deep cervical fascia lesion
C • Mass centered between thyroid lobe anteriorly &
~ longus colli muscle posteriorly
-0
Ilmaging Anatomy • Displaces thyroid lobe anteriorly & CS
o anterolaterally
~ Overview • Mass may originate from parathyroid gland,
....c
~ • Cylindrical space in core of IHN extending from hyoid paratracheal node or recurrent laryngeal nerve
•... bone to upper mediastinum o Cervical tracheal mass lesion
0..
::J • Contains IHN viscera (larynx, trachea, hypopharynx, • Mass centered in tracheal wall
Cfl
esophagus, thyroid & parathyroid glands) • Displaces thyroid laterally & esophagus posteriorly
~ o Cervical esophageal mass lesion
U Extent • Mass centered in midline, posterior VS
Q)
• VS stretches length of IHN from hyoid bone above to immediately posterior to trachea
Z superior mediastinum below
"'0 • Displaces trachea & thyroid gland anteriorly
s::: Anatomy Relationships Imaging Approaches
~
• VS is largest space of IHN • Ultrasound ± needle aspiration biopsy is first best
"'0
~ • Lateral to VS are paired anterior cervical spaces single approach to lesions of VS
OJ • Posterolateral to VS are paired carotid spaces (CS)
:c • Posterior to VS is retropharyngeal space (RPS)
• If differentiated thyroid carcinoma, nuclear medicine
(1-131) diagnostic study is then done
Internal Structures-Critical Contents o If suspected nodes from clinical examination or
1-131 study, cross-sectional imaging usually done in
• Thyroid gland
o Two lobes connected by isthmus presurgical period
• Parathyroid glands o MR is preferred imaging tool to stage superior
o 4 glands, 2 pairs behind upper & lower poles of mediastinum as it prevents iodine load delaying
thyroid gland iodine-based nuclear medicine therapy
o Superior 2 glands consistent in location o If suspect VS malignancy, image to carina to include
o Inferior 2 glands less reliable in location level VI (paratracheal, prelaryngeal & pretracheal)
• May be normally found in cervicothoracic nodes & superior mediastinal nodes (level VII)
junction or superior mediastinum • All other lesions of VS that require cross-sectional
• Cervical trachea & esophagus imaging, easier to cover neck to carina with CECT
• Recurrent laryngeal nerve Imaging Pitfalls
o Left: Recurs at level of arch where it passes through • Patulous esophagus may project from behind left
aortopulmonic window tracheal margin, mimicking parathyroid adenoma
o Right: Recurs in most inferior IHN around right • Ending VS cross-sectional imaging at cervicothoracic
subclavian artery junction is significant imaging mistake
o In tracheoesophageal groove on way up to larynx o Multiple VS lesions require imaging to carina
• VS lymph nodes (level VI group) • When staging VS tumor, especially differentiated
o Paratracheallympn node group thyroid carcinoma, must evaluate upper
• First order drainage for thyroid malignancy mediastinal nodes (level VII)
• Serves as primary conduit for nodal spread into • Distal vagal neuropathy requires continuing to
superior mediastinum carina if on left
o Prelaryngeallymph node group • Searching for "ectopic parathyroid adenoma"
o Pretracheallymph node group includes upper mediastinal search
Fascia
• Middle layer, deep cervical fascia (ML-DCF)
completely encloses visceral space IClinical Implications
• ML-DCF also referred to as "visceral fascia" Clinical Importance
• vs mass symptoms depend of structures involved
o Recurrent laryngeal nerve: Distal vagal neuropathy
IAnatomy-Based Imaging Issues with isolated vocal cord paralysis; hoarseness
Key Concepts or Questions o Cervical esophagus: Dysphagia; solid food
intolerance
• What imaging clues define a mass lesion as primary to
visceral space? o Cervical trachea: Stridor, shortness of breath

II
208
 VISCERAL SPACE
GRAPHICS

Sternohyoid muscle

Superficial layer, deep

cervical fascia
Sternothyroid muscle
Middle layer, deep
cervical fascia
Thyroid gland
Anterior cervical space
Recurrent laryngeal
nerve
Visceral space
Parathyroid gland

Paratracheallymph
node
Carotid space

Retropharyngeal space
-
:J
....,
(l.l
::J
'<
Deep layer, deep o
cervical fascia 0....

Danger space Z
(!)
n
A

Deep layer, deep

cervical fascia
Hyoid bone
Larynx

Hypopharynx

Retropharyngeal space
Middle layer, deep
cervical fascia

Prevertebral portion,
Superficial layer, deep perivertebral space
cervical fascia

Esophagus
Danger space

Trachea

(Top) Axial graphic shows visceral space defined by middle layer of deep cervical fascia (pink). Middle layer of deep
cervical fascia, also called "visceral fascia," runs along deep surface of strap muscles, merges anteriorly with superficial
layer of deep cervical fascia (yellow) & splits to encapsulate thyroid gland. Middle layer of deep cervical fascia also
forms anterior margin of retropharyngeal space & contributes to carotid sheath. Recurrent laryngeal nerve lies in
tracheoesophageal groove & injury results in vocal cord paralysis & hoarseness. (Bottom) Sagittal graphic shows
longitudinal relationships of infrahyoid neck. Note visceral space (orange) is the only space unique to infrahyoid
neck extending from hyoid bone to superior mediastinum. Visceral space is cylindrical space in anterior midline neck
surrounded by middle layer of deep cervical fascia (pink).
II
209
 VISCERAL SPACE
AXIAL CECT

Superficial space
Hyoid bone

Submandibular gland Submandibular space

Supraglottic larynx Visceral space

""D

c Pyriform sinus, hypopharynx

ro Internal jugular vein
Carotid space
""D

Retropharyngeal space
o Prevertebral muscles
>- Prevertebral portion,
...c perivertebral space
ro
~
0....
::J
t/)

~
u
Q)
Z
""C
c:
(\l Superficial space
""C Infrahyoid strap muscles
(\l Submandibular space
Q) Thyroid cartilage
J: Supraglottic larynx Visceral space

Pyriform sinus, hypopharynx

Internal jugular vein Carotid space
Retropharyngeal space
Prevertebral muscles
Prevertebral portion,
perivertebral space

Superficial space
Thyroid cartilage Anterior cervical space
Supraglottic larynx

Pyriform sinus, hypopharynx

Common carotid artery Visceral space
Internal jugular vein
Prevertebral muscles
Prevertebral portion,
perivertebral space
Retropharyngeal space

(Top) First of six axial CECT images presented from superior to inferior of visceral space shows hyoid bone which
represents superior extent of visceral space. This cylindrical space in midline infrahyoid neck is enclosed by middle
layer of deep cervical fascia & extends to superior mediastinum. Submandibular space is continuous with anterior
cervical space. (Middle) This image shows visceral space contains larynx & hypopharynx at this level. It is bordered
posteriorly by retropharyngeal space & posterolaterally by carotid spaces. (Bottom) This image shows visceral space is
completely enclosed by middle layer of deep cervical fascia, represented by line drawing. Paired anterior cervical
spaces are lateral to visceral space & are continuous with submandibular spaces superiorly. Retropharyngeal space is
II seen as stripe of fat between posterior hypopharynx & prevertebral muscles.
210
 VISCERAL SPACE
AXIAL CECT :r:
ro
~
c..
~
:J
c..
Superficial space
Strap muscles Z
Anterior cervical space ro
("')
Thyroid cartilage
7'
True vocal cord Visceral space
Vl
c
Common carotid artery
Internal jugular vein
Carotid space
Retropharyngeal space
-.
-0
OJ
::J
Prevertebral muscles
Prevertebral portion, '<
o
perivertebral space
0...
OJ
:J
0...

-.
:J
-+..
OJ
::J
'<
o
0...
Subglottis Superficial space Z
(D
Cricoid cartilage Anterior cervical space ("')
A
Inferior cornu thyroid cartilage
Visceral space
Common carotid artery
Carotid space
Internal jugular vein
Retropharyngeal space

Thyroid gland Prevertebral portion,

perivertebral space
Prevertebral muscles

Trachea
Common carotid artery Carotid space
Internal jugular vein Visceral space
Thyroid gland Retropharyngeal space
Prevertebral portion,
Tracheoesophageal groove
perivertebral space
Esophagus

(Top) Image at level of glottis shows visceral space in anterior midline surrounded by anterior cervical space, carotid
space & retropharyngeal space. Recurrent laryngeal nerve is located in tracheoesophageal groove but cannot be seen
on conventional imaging. Injury of this nerve results in vocal cord paralysis & imaging should extend to carina in
patients with left-sided injury. (Middle) Image at subglottic larynx level shows upper thyroid lobes. (Bottom) Image
at thyroid gland level shows inferior visceral space which includes esophagus & trachea. Thyroid disease is one of
most common lesions of visceral space & is often best evaluated by ultrasound. If differentiated thyroid disease is
present, nuclear medicine 1-131 study is next best study. CECT may delay therapy in patients planned for
iodine-based nuclear medicine therapy. II
211
 VISCERAL SPACE
CORONAL CECT & THYROID MASS GRAPHIC

""0

c
~ Thyroid cartilage
""0

o Thyroid neoplasm
>-
..c
~
"- Low internal jugular
Q..
:J lymph node (level IV)
Vl
Spinal accessory lymph
~ node (level V)
U
Q)
Z Trachea Paratracheallymph
""0

node (level VI)

c:
(\j
""0

(\j
Q)
:c
Superior mediastinal
lymph node (level VII)

Internal carotid artery

Pyriform sinus,
hypopharynx

Trachea

Thyroid gland
Visceral space
Internal jugular vein

Clavicle

Aortic arch

(Top) Coronal graphic shows a typical VS mass, differentiated thyroid carcinoma, within left lobe of thyroid gland.
Several metastatic lymph nodes are seen including paratracheallymph nodes (within visceral space), superior
mediastinal, low internal jugular & spinal accessory chain lymph nodes. Paratracheallymph node group is first order
drainage for thyroid malignancy &. serves as main conduit for nodal spread into superior mediastinum. (Bottom)
Coronal CECT image shows chevron shape of thyroid gland to best advantage. Visceral space contents includes
larynx, hypopharynx, trachea, esophagus, thyroid & parathyroid glands. Recurrent laryngeal nerves & para tracheal
(level VI) lymph nodes are other important visceral space structures. Ending imaging at cervicothoracic junction is an
II important imaging mistake. Many VS lesions require imaging to carina.
212
 VISCERAL SPACE
SAGITTAL ANATOMY & GENERIC VS MASS GRAPHIC

Thyroid mass

Tracheal wall mas

Tracheoesophageal
groove mass
Esophageal mas
::J
.,
-+.
~
:J"'"
'<
o
0..
Z
(D
n
A

Epiglotti

Hyoid bon
Hypopharynx

Laryn

Thyroid cartilag
Visceral space
Retropharyngeal space

Esophagus

Trache

(Top) Axial graphic shows four distinct generic visceral space mass locations. Thyroid mass is defined by mass at least
partially surrounded by thyroid tissue. A mass involving tracheoesophageal groove typically results in recurrent
laryngeal nerve injury. Differential considerations for tracheoesophageal groove lesion include a malignant
paratracheallymph node (often from differentiated thyroid carcinoma), parathyroid adenoma, traumatic dislocation
of cricothyroid joint, recurrent laryngeal nerve schwan noma or patulous esophagus. Tracheal wall mass is centered in
tracheal wall & displaces thyroid gland laterally & esophagus posteriorly. An esophageal mass is typically midline &
displaces trachea & thyroid anteriorly. (Bottom) Sagittal NECT reformation shows visceral space in midline
infrahyoid neck, anterior to retropharyngeal space. II
213
~ HYPOPHARYN~LARYNX
u
Q.)
Z • Vocal processes: Anterior projections of arytenoids
ITerminology where posterior margins of TVC attach
-0
o Corniculate cartilage: Rests on top of superior
o Abbreviations
>- process of arytenoid cartilage, within AE folds
• Aryepiglottic fold (AE fold)
...c • Supraglottis of endolarynx
• True vocal cord (TVC); false vocal cord (FVC)
--
-0
~
L..

C Synonyms
• Hypopharynx = laryngopharynx
o Extends from tip of epiglottis above to laryngeal
ventricle below
o Contains vestibule, epiglottis, pre-epiglottic fat, AE
C folds, FVC, paraglottic space, arytenoid cartilages
~ Definitions o Epiglottis: Leaf-shaped cartilage, larynx lid with free
-0 • Hypopharynx: Caudal continuation of pharyngeal margin (suprahyoid), fixed portion (infrahyoid)
o mucosal space, between oropharynx & esophagus • Petiole is "stem" of leaf which attaches epiglottis
>- • Larynx: Junction of upper & lower airway to thyroid lamina via thyroepiglottic ligament
...c
~ • Hyoepiglottic ligament attaches epiglottis to
L..
Q..
hyoid; glossoepiglottic fold is midline mucous
::J I Imaging Anatomy membrane covering hyoepiglottic ligament
<J)

~
.. Extent
o Pre-epiglottic space: Fat-filled space between hyoid
bone anteriorly & epiglottis posteriorly
u • Hypopharynx: Extends from level of glossoepiglottic & o AE folds: Projects from cephalad tip of arytenoid
(1)
pharyngoepiglottic folds superiorly to inferior cricoid cartilages to inferolateral margin of epiglottis
Z cartilage (cricopharyngeus muscle) • Represents superolateral margin of supraglottis,
""0
o Oropharynx above, cervical esophagus below dividing it from pyriform sinus (hypopharynx)
c • Larynx: Cranial margin at level of glossoepiglottic &
~ o False vocal cords: Mucosal surfaces of laryngeal
""0 pharyngoepiglottic folds with caudal margin defined vestibule of supraglottis
~ by lower edge of cricoid • Beneath FVC are paired paraglottic spaces
(1)
o Oropharynx above, trachea below o Paraglottic spaces: Paired fatty regions beneath
J: false & true vocal cords
Internal Structures-Critical Contents
• Superiorly they merge into pre-epiglottic space
• Hypopharynx consists of 3 regions
• Terminates inferiorly at under surface of TVC
o Pyriform sinus: Anterolateral recess of HP
• Glottis of endolarynx
• Between inner surface of thyrohyoid membrane
o TVC & anterior & posterior commissures
(above), thyroid cartilage (below) & lateral AE fold
• lVC: Only soft tissue structures of glottic region
• Pyriform sinus apex (inferior tip) at level of TVC
• Comprised of thyroarytenoid muscle (medial
• Anteromedial margin of pyriform sinus is
fibers are "vocalis muscle")
posterolateral wall of AE fold ("marginal
• Anterior commissure: Midline, anterior meeting
supraglottis")
point ofTVC
o Posterior wall: Inferior continuation of posterior
• Subglottis of endolarynx
oropharynx wall
o Subglottis extends from under surface of TVC to
o Post-cricoid region: Anterior wall of lower
inferior surface of cricoid cartilage
hypopharynx
o Mucosal surface of subglottic area is closely applied
• Interface between hypopharynx & larynx
to cricoid cartilage
• Extends from cricoarytenoid joints to lower edge
o Conus elasticus: Fibroelastic membrane extends
of cricoid cartilage
from medial margin of TVC above to cricoid below
o Pharyngeal plexus (CN9-10 branches) provides all
o Quadrangular membrane: Fibrous membrane
motor & most sensory to hypopharynx
extends from upper arytenoid & corniculate
• Laryngeal cartilages cartilages (posteriorly) to lateral margin epiglottis
o Thyroid cartilage: Largest laryngeal cartilage;
(anteriorly); medial margin of paraglottic space
"shields" larynx
• Two anterior laminae meet anteriorly at acute
angle
• Superior thyroid notch at anterior superior aspect
I Embryology
• Superior cornua are elongated & narrow, attach to Embryologic Events
thyrohyoid ligament • Larynx has two embryologically distinct portions
• Inferior cornua are short & thick, articulating separated at laryngeal ventricle
medially with sides of cricoid cartilage • Supraglottic larynx forms from primitive
o Cricoid cartilage: Only complete ring in buccopharyngeal anlage & has rich lymphatics
endolarynx, provides structural integrity • Glottic & subglottic larynx forms from
• Two portions, posterior lamina & anterior arch tracheobronchial buds & has few lymphatics
• "Signet ring" band anterior & "signet" posterior
• Lower border of cricoid cartilage is junction Practical Implications
between larynx above & trachea below • Supraglottic SCCa have a much higher incidence of
o Arytenoid cartilage: Paired pyramidal cartilages nodal metastases at presentation compared to glottic
that sit atop posterior cricoid cartilage & subglottic SCCa
• Vocal & muscular processes are at level of TVC

II
214
 HYPOPHARYNX-LARYNX
GRAPHICS :r:
ro
~
c..
~
::::l
c..
Hyoid bone
Z
Pre-epiglottic space ro
("\

Vallecula Glossoepiglottic fold '"

(fJ

Pharyngoepiglottic fold c
U
....•
Epiglottis, free edge
~
::J"'"
'<
Pharyngeal constrictor muscle Posterior pharyngeal wall o
0..
OJ
:J
0..

Thyroid cartilage Pre-epiglottic space

Hyoepiglottic ligament

Paraglottic space
Epiglottis, fixed portion

Aryepiglottic fold Pyriform sinus

Pharyngeal constrictor muscle Posterior pharyngeal wall

Thyroid cartilage

False vocal cord Paraglottic space

True vocal cord

Arytenoid superior process

Aryepiglottic fold Pyriform sinus
Posterior pharyngeal wall
Pharyngeal constrictor muscle

(Top) First of six axial graphics of larynx & hypopharynx from superior to inferior shows roof of hypopharynx at
hyoid bone level & high supraglottic structures. Free edge of epiglottis is attached to hyoid bone via hyoepiglottic
ligament which is covered by glossoepiglottic fold, a ridge of mucous membrane. (Middle) Graphic at
mid-supraglottic level shows hyoepiglottic ligament dividing lower pre-epiglottic space. No fascia separates
pre-epiglottic space from paraglottic space. These two endolaryngeal spaces are submucosal locations where tumors
hide from clinical detection. Aryepiglottic fold represents junction between larynx & hypopharynx. (Bottom)
Graphic at low supraglottic level shows false vocal cords (FVCl formed by mucosal surfaces of laryngeal vestibule.
Paraglottic space is beneath FVC, a common location for submucosal tumor spread. II
215
 HYPOPHARYNX-LARYNX
...::L. GRAPHICS
U
Q)
Z Anterior commissure
u
o Vocal ligament
>- Thyroid cartilage
...!::
ro Vocalis muscle
"-
'-+-
C Vocal process, arytenoid cartilage
Thyroarytenoid muscle
u
c Pyriform sinus apex Arytenoid cartilage
ro
Thyroarytenoid gap
U
Cricoid cartilage Posterior cricoarytenoid muscle
o
>- Post-cricoid hypopharynx
...!::
ro
"-
Q..
:J
V)

~
u
Q.)
Z
u
c:
ro
"'0 Thyroid cartilage
ro
Q.) Undersurface of true vocal cord
I

Cricoid cartilage
Cricothyroid space
Posterior cricoarytenoid muscle
Post-cricoid hypopharynx
Pharyngeal constrictor muscle
Posterior wall, hypopharynx
Longus capitis muscle

Cricothyroid membrane

Cricoid cartilage

Thyroid gland
Cricothyroid joint
Inferior cornu, thyroid cartilage
Recurrent laryngeal nerve

Cervical esophagus

(Top) Graphic at glottic, true vocal cord level shows thyroarytenoid muscle which makes up bulk of true vocal cord.
Medial fibers of thyroarytenoid muscle are known as vocalis muscle. Pyriform sinus apex is seen at glottic level.
Thyroarytenoid gap is location where tumors may spread between larynx & hypopharynx. (Middle) Graphic at level
of undersurface of true vocal cord shows posterior lamina of cricoid cartilage. Post-cricoid hypopharynx represents
anterior wall of lower hypopharynx & extends from cricoarytenoid joints to lower edge of cricoid cartilage at
cricopharyngeus muscle. Posterior wall of hypopharynx represents inferior continuation of posterior oropharyngeal
wall & extends to cervical esophagus. (Bottom) Graphic at subglottic level shows cricothyroid joint immediately
II adjacent to recurrent laryngeal nerve, located in tracheoesophageal groove.
216
 HYPOPHARYNX-LARYNX

Epiglottis, free margin

----------- Hyoid bone

Aperture for internal

branch superior Thyr~id cartilage,
laryngeal nerve supenor cornu
Thyrohyoid membrane

Thyroid notch

-
Thyroid cartilage,
anterior lamina :J
""""

CJ
:::J
'<
o
Cricothyroid __ Thyroid cartilage,
0....
om _n_

membrane inferior cornu

Z
(D
nn -- Cricoid cartilage, n
anterior ring r::-
First tracheal ring

Epiglottis, free margin u _

--- Hyoid bone

Thyrohyoid ligament ------------

Thyroid cartilage,
superior cornu
Thyrohyoid membrane------

----- - Aperture for internal

branch superior
Corniculate cartilage un_un laryngeal nerve

Arytenoid cartilage

Thyroid cartilage,
inferior cornu

Cricoid cartilage,
posterior ring

(Top) Anterior view of laryngeal cartilage which provides structural framework for soft tissues of larynx to drape
over. Note two large anterior laminae of thyroid cartilage "shield" the larynx. Thyrohyoid membrane contains an
aperture through which internal branch of superior laryngeal nerve & associated vessels course. Mixed (external)
laryngoceles herniate through thyrohyoid membrane to extend into submandibular space. (Bottom) Posterior view
shows arytenoid cartilage sitting on top of posterior cricoid cartilage. True vocal cord attaches to vocal process of
arytenoid cartilage & forms glottis. Epiglottis is a leaf-shaped cartilage which forms lid of larynx & contains fixed &
free margins. Cricoid cartilage is only complete ring in endolarynx & provides structural integrity. Lower border of
cricoid represents junction between larynx above & trachea below.
II
217
 HYPOPHARYNX-LARYNX
...:::£ GRAPHICS
U
Cl.)
Z
""0

o
>- Epiglottis, free edge
....c
Ci:l
•....
'-l-
C
Thyrohyoid membrane
""0
Hyoid bone
c
Ci:l Hyoepiglottic ligament Aperture for internal
""0 branch superior
laryngeal nerve
o
>-
....c I'r\!-epiglottic space Aryepiglottic fold
Ci:l
•....
0..
::l Arytenoid cartilage
C.f)
False vocal cord
~ Laryngeal ventricle
u True vocal cord
Cl.)
Z Vocal ligament
"'C
C
ro
"'C Cricoid cartilage
ro
Cl.)
:r:

Epiglottis

Paraglottic space

Hyoid bone Thyrohyoid membrane

- Quadrangular
Thyroid cartilage membrane

False vocal cord - Laryng\!alventricle

Tnt\! vocal cord

Vocalis muscle

Thyroaryt\!llOid muscle Conus elasticus

Cricoid cartilage

(Top) Sagittal graphic of midline larynx shows laryngeal ventricle, air-space which separates false vocal cords above
with true vocal cords below. Aryepiglottic folds project from tip of arytenoid cartilage to inferolateral margin of
epiglottis. Aryepiglottic folds represent junction between supraglottis & hypopharynx. Medial wall of aryepiglottic
fold is endolaryngeal while posterolateral wall is anteromedial margin of pyriform sinus. (Bottom) Coronal graphic
posterior view shows false & true vocal cords separated by laryngeal ventricle. Quadrangular membrane is a fibrous
membrane which extends from upper arytenoid & corniculate cartilages to lateral epiglottis. Conus elasticus is a
fibroelastic membrane which extends from vocal ligament of true vocal cord to cricoid. There membranes represent a
II relative barrier to tumor spread but are not seen on conventional imaging.
218
II
219
 HYPOPHARYNX-LARYNX
..:::£ AXIAL CECT CORDS ABDUCTED (APART)
U
Q)
Z
"'D
o
>-.
...r::
ro Hyoid bone
'-
'-+-
C Pre-epiglottic space
"'D Vallecula
c Glossoepiglottic fold
ro Epiglottis, free edge
"'D
Hypopharynx, posterior wallj
o
>-.
...r::
ro
'-
0...
:J
(/)

~
u
Q)
Z
"'0

c:
ro
"'0 Hyoepiglottic ligament
ro
Q) Inferior hyoid bone
:c Pre-epiglottic space
Glossoepiglottic fold Vallecula
Epiglottis

Hypopharynx, posterior wall t

Thyroid notch

Thyroid cartilage Pre-epiglottic space

Epiglottis Paraglottic space

Pyriform sinus Aryepiglottic fold

.Hypopharynx, posterior wall?

(Top) First of nine axial CECT images presented from superior to inferior of larynx & hypopharynx with patient in
quiet respiration. Hyoid bone represents the level of the roof of larynx & hypopharynx Glossoepiglottic &
pharyngoepiglottic folds represent transition from oropharynx above to larynx & hypopharynx below. (Middle)
Image of high supraglottic level of larynx shows C-shaped pre-epiglottic space, a common location for tumors to
hide. If supraglottic tumor extends to pre-epiglottic space, it becomes a T3 tumor. (Bottom) Image of high
supraglottic level shows pre-epiglottic & paraglottic spaces are continuous, with no intervening fascia. This allows
tumors to spread submucosally in these locations. Aryepiglottic fold, part of larynx, represents transition betwee(f
II larynx & hypopharynx<'Posterolateral wall of aryepiglottic fold is anteromedial margin of pyriform sinus.
220
 HYPOPHARYNX-LARYNX
AXIAL CECT CORDS ABDUCTED (APART)

Thyroid notch

Thyroid cartilage Thyroepiglottic ligament

Paraglottic space

Aryepiglottic fold
Pyriform sinus
Hypopharynx, posterior wall

:J
--+,
....,
Q)
::J
'<
o
Q...

Z
ro
n
7\
Paraglottic space
Thyroid cartilage
False vocal cord
Strap muscles
Hypopharynx, posterior wall

Anterior commissure
True vocal cord
Thyroid cartilage
Vocal process, arytenoid
Posterior commissure Arytenoid cartilage
Thyroarytenoid gap
Cricoid cartilage
Hypopharynx

(Top) Image of mid-supraglottic level shows thyroepiglottic ligament dividing the pre-epiglottic space. Aryepiglottic
folds are at margin of pyriform sinus & larynx & a tumor primary to aryepiglottic fold is considered a "marginal
supraglottic" tumor. (Middle) Image of low supraglottic level shows false vocal cord level. Paraglottic space represents
deep fatty space beneath false vocal cords. Tumors that cross laryngeal ventricle & involve false & true vocal cords are
considered transglottic. (Bottom) Image at glottic level shows true vocal cords in abduction in quiet respiration. True
..,Yocalcord level is identified on CT when arytenoid & cricoid cartilages are seen &-musde fills inferior paraglottic
space> Anterior & posterior commissures of true vocal cords should be less than 1 mm in normal patients.
Post-cricoid hypopharynx is typically collapsed. II
221
 HYPOPHARYNX-LARYNX
ij AXIAL CECT CORDS ABDUCTED (APART)
OJ
Z
""D
o
>--
..r:
(Ij

'-I-
"-

C Anterior commissure

Undersurface of true cord

Thyroid cartilage

Cricoid cartilage Cricothyroid space

Post-cricoid hypopharyngeal wall

Cricothyroid membrane

Thyroid cartilage

Cricoid cartilage Cricothyroid joint

Posterior cricoarytenoid muscle Location of recurrent laryngeal
Hypopharynx nerve

Thyroid gland
Cricoid cartilage
Inferior cornu, thyroid cartilage
Posterior cricoarytenoid muscle Location of recurrent laryngeal
Hypopharynx/esophagus junction nerve

(Top) In this image through the undersurface of true cord level the cricothyroid space is seen. Lack of arytenoid
cartilage identifies undersurface of true cord level. (Middle) Image more inferior shows subglottic level with cricoid
ring nearly complete. Cricoid is only complete cartilage ring in larynx & provides structural integrity. Dislocations of
cricothyroid joint may result in vocal cord paralysis secondary to recurrent laryngeal nerve injury. There may be
associated atrophy of posterior cricoarytenoid muscle on involved side of vocal cord paralysis. (Bottom) At the level
of the inferior cricoid cartilage the inferior margin of larynx & hypopharynx are transitioning to the trachea &
cervical esophagus. Mucosa along subglottis should be no more than Imm in normal patients. If thickened mucosa,
II raises concern for tumor.
222
 HYPOPHARYNX-LARYNX
AXIAL CECT CORDS ADDUCTED (TOGETHER) :r:
('0
~
0..
~
:::J
0..
Thyroid notch Z
ro
n
Thyroepiglottic ligament ;:::-
Thyroid cartilage Paraglottic space V'l
C
-0
Aryepiglottic fold ....,
Pyriform sinus OJ
Posterior wall, hypopharynx :::J
--<
o
Q..
OJ
::J
Q..

:J
-+-.
....,
OJ
:::J
--<
o
Q..

Z
ro
n
A

Thyroid cartilage Paraglottic space

Aryepiglottic fold
Pyriform sinus
Posterior wall, hypopharynx

Strap muscles
True vocal cord
Thyroid cartilage
Arytenoid cartilage
Pyriform sinus
Cricoid cartilage

(Top) First of three axial CECT images from superior to inferior in patient with breath holding shows adduction of
false & true vocal cords as well as aryepiglottic folds. (Middle) Image at low supraglottic level shows level of false
vocal cords in adduction. Note mucosa of aryepiglottic folds contacts posterior hypopharyngeal wall. (Bottom)
Image at glottic level shows adduction of true vocal cords. With breath holding, true vocal cords oppose in midline.
A cord that remains paramedian is either paralyzed or mechanically fixed. Vocal cord paralysis typically results in a
paramedian true vocal cords with associated abnormal location of arytenoid cartilage which is fixed in an
anterior-medial position. With breath holding, paralyzed cord remains fixed while opposite normal cord crosses
midline in attempt to close glottis. There may be an associated patulous pyriform sinus. II
 HYPOPHARYNX-LARYNX
...::::t:. CORONAL NECT
U
OJ
Z
""D
o
>-
..c
(\j
•.... Aryepiglottic fold
'+- Hyoid bone
C
Thyrohyoid membrane Pyriform sinus
""D
c
(\j

""D
o Thyroid cartilage
>-
..c
(\j
•....
Q..
::l
Vl Thyroid gland
~
U
Q)
Z
"'C
c:
~
"'C Epiglottis
~
Q)
:r: Hyoid bone
Aryepiglottic fold
Pyriform sinus

Thyroid cartilage Apex, pyriform sinus

Arytenoid cartilage

Cricoid cartilage

Thyroid gland Trachea

Epiglottis
Hyoid bone
Aryepiglottic fold

Pyriform sinus
Thyroid cartilage
Arytenoid cartilage

Cricoid cartilage

Thyroid gland

(Top) First of six NECT coronal reformation images of larynx & hypopharynx presented from posterior to anterior
shows hyoid bone which represents the level of the roof of larynx & hypopharynx. CT is particularly good for
evaluation of patients with diseases of larynx & hypopharynx as these patients often have difficulty with secretions,
coughing & swallowing making a short exam time vital. (Middle) Image more anterior shows laryngeal cartilages.
These cartilages are variably ossified in adults which makes pathologic conditions such as cartilage invasion difficult
to diagnose with certainty. Apex of pyriform sinus extends inferiorly to level of true vocal cord. (Bottom) In this
Image aryepiglottic folds are well seen as they extend from lateral epiglottis to arytenoid cartilage. Pyriform sinus is
II most common location for tumors of hypopharynx.
22--1
 HYPOPHARYNX-LARYNX
CORONAL NECT :::c
~
l:IJ
a..
l:IJ
:J
a..
Z
Vallecula ~
Hyoid bone n
7'
Epiglottis
Aryepiglottic fold Vl
C
Pyriform sinus ""D

Thyroid cartilage ....,

Laryngeal ventricle OJ
Arytenoid cartilage 7
'<
o
Cricoid cartilage 0....
OJ
:J
0....
Thyroid gland
:J
•...•...•
....,
OJ
7
'<
o
0....
Z
(I)
n
Hyoid bone 7'\

Thyroid cartilage Paraglottic space

False vocal cord
Laryngeal ventricle
True vocal cord

Cricoid cartilage

Hyoid bone
Pre-epiglottic space
Paraglottic space

Thyroid cartilage Laryngeal ventricle

Cricoid cartilage

(Top) This image shows the fixed portion of epiglottis in midline. Aryepiglottic fold which represents junction
between larynx anteriorly & hypopharynx posteriorly is noted. (Middle) In this image the laryngeal ventricle is
visible as an air space between false vocal cords above & true vocal cords below. When a tumor crosses laryngeal
ventricle to involve true & false cords it is transglottic, which has important treatment implications. Coronal imaging
is particularly useful for evaluation of transglottic disease. (Bottom) This image reveals pre-epiglottic fat to be
continuous with paraglottic fat. These are the most important spaces of endolarynx as they allow submucosal spread
of tumors which is undetectable by clinical exam.
II
ns
 HYPOPHARYNX-LARYNX
...::::t:. SAGITTAL NECT
U
Q.)
Z
-0 Lingual thyroid
o Epiglottis, free margin
>-
....c Vallecula
(\j
'-
'+- Hyoid bone
C Epiglottis, fixed portion
-0 Pre-epiglottic space Posterior wall, hypopharynx
c
(\j Thyroid cartilage
-0
o
>- Cricoid cartilage
....c
(\j
'-
0...
Cricoid cartilage
:J
(j)
Trachea
~
u
Q.)
Z
""0

C
~ Epiglottis
""0
Vallecula
~
Q)
Hyoid bone
:I: Posterior wall, hypopharynx
Pre-epiglottic space

Thyroid cartilage
Laryngeal ventricle

Cricoid cartilage

Cricoid cartilage

Vallecula Epiglottis

Hyoid bone
Posterior wall, hypopharynx
Pre-epiglottic space

Thyroid cartilage

Cricoid cartilage
Cricoid cartilage

(Top) First of three sagittal NECT images from medial to lateral shows midline larynx & hypopharynx. Pre-epiglottic
fat is seen at midline posterior & inferior to hyoid bone. Diseases of posterior hypopharyngeal wall are well seen on
sagittal imaging. Sagittal imaging also helps define cranial to caudal extent of lesions. (Middle) Image more lateral
shows laryngeal ventricle, the air space that separates false vocal cords above from true vocal cords below. (Bottom)
Image more lateral shows laryngeal cartilages. Laryngeal cartilage is variably ossified in adults which makes disease of
the cartilage difficult to evaluate, particularly cartilage invasion from tumors & traumatic injury. Cricoid cartilage is
only complete ring in larynx & provides structural integrity. It has a signet ring shape with the larger signet portion
II projecting posteriorly.
226
 HYPOPHARYNX-LARYNX
AXIAL T1 MR :r:
(t)
~
a..
~
:::::l
a..
Z
(t)
Hyoid bone r"'l
7'
Glossoepiglottic fold Vallecula
CJ)
Epiglottis, free margin
""0
c
Pharyngoepiglottic fold
Aryepiglottic fold """"

Pyriform sinus ~
:J
Posterior wall, hypopharynx
--<
o
a..
~
:J
a..
:J
-+,
""""

~
:J
--<
o
0....
Z
(t)
n
Pre-epiglottic space 7\
Strap muscles
Epiglottis

Aryepiglottic fold
Pyriform sinus

Posterior wall, hypopharynx

Thyroid notch

Pre-epiglottic space

Paraglottic space Epiglottis

Thyroid cartilage
Aryepiglottic fold
Pyriform sinus

Posterior wall, hypopharynx

(Top) First of six axial Tl MR images from superior to inferior of larynx & hypopharynx with patient in quiet
respiration shows roof of larynx which is defined by epiglottis, glossoepiglottic & pharyngoepiglottic folds. MR is
typically reserved for answering specific questions such as cartilage invasion rather than as a first imaging study of a
patient with larynx or hypopharynx disease. (Middle) Image at level of high supraglottis shows C-shaped fat filled
pre-epiglottic space & fixed portion of epiglottis. Cartilage is variably ossified which make it somewhat difficult to
visualize on Tl MR images. (Bottom) Image at mid-supraglottic level shows fat of pre-epiglottic space continuous
with fat of paraglottic space. Lack of fascia between these two submucosal spaces allows tumor to travel from one to
the other & hide from clinical detection. II
227
 HYPOPHARYNX-LARYNX
AXIAL T1 MR

Paraglottic space
'"D
c Thyroid cartilage
r\l False vocal cord
'"D Aryepiglottic fold
Pyriform sinus
o
>--
..£:
r\l Posterior wall, hypopharynx
'-
0....
:J
t/)

~
u
Q)
Z
"'0

C
~
"'0

~
Q) Anterior commissure
:r:
Thyroid cartilage True vocal cord

Arytenoid cartilage Thyroarytenoid gap

Posterior cricoarytenoid muscle
Cricoid cartilage
Post-cricoid, hypopharynx

Cricothyroid membrane

Cricoid cartilage
Cricothyroid joint

Inferior cornu, thyroid cartilage

Post-cricoid hypopharynx

(Top) Image at level of low supraglottis demonstrates false vocal cords & aryepiglottic folds. Paraglottic space beneath
false vocal cords is primarily fat filled. Aryepiglottic folds often contact posterior wall of hypopharynx in normal
patients. (Middle) Image at glottic level shows muscle in paraglottic space beneath true vocal cords. Both cricoid &
arytenoid cartilage are seen at true vocal cords level. Thyroarytenoid muscle makes up bulk of true vocal cords.
Posterior cricoarytenoid muscle is often atrophied in patients with vocal cord paralysis. (Bottom) Image at subglottic
level shows large, broad posterior cricoid cartilage. Cricothyroid joint is where recurrent laryngeal nerve is located.
Dislocation of this joint is associated with recurrent laryngeal nerve injury. Post-cricoid hypopharynx extends from
II cricoarytenoid joints to lower cricoid cartilage.
228
 HYPOPHARYNX-LARYNX
SAGITTAL T1 MR I
~
CJ
0..
CJ
:::::l
0..
Z
Lingual tonsil, tongue base ~
n
7'"
Vallecula
Epiglottis, free margin Vl
c
Hyoid bone

Pre-epiglottic space Epiglottis, fixed portion

-.
-0
C>
:J"'"
Posterior wall, hypopharynx --<
o
Thyroid cartilage
Q...
Arytenoid prominence
Laryngeal ventricle C>
:::l
Q...

:J
-.
...•...
C>
:J"'"
--<
o
Q...

Z
(t)
Lingual tonsil, tongue base n
A

Vallecula Epiglottis, free margin

Hyoid bone

Epiglottis, fixed portion

Pre-epiglottic space Posterior wall, hypopharynx

Laryngeal ventricle

Cricoid cartilage

Vallecula
Epiglottis, free margin
Hyoid bone
Epiglottis, fixed portion
Pre-epiglottic space Posterior wall, hypopharynx
Thyroid cartilage
Laryngeal ventricle Arytenoid cartilage
Cricoid cartilage

(Top) First of three sagittal Tl MR images from medial to lateral of larynx & hypopharynx shows midline structures.
Pre-epiglottic space is T1 hyperintense as it is primarily fat-filled. Free margin (suprahyoid) & fixed portion
(infrahyoid) of epiglottis is well visualized making sagittal imaging useful for evaluation of epiglottic lesions.
(Middle) Image just lateral to midline shows laryngeal ventricle which is important as it is the air-space that
separates false vocal cords above from true vocal cords below. Knowing if a tumor crosses the laryngeal ventricle is
vital for surgical planning. (Bottom) Paramedial image through the cricoarytenoid joint shows arytenoid cartilage
sitting on top of posterior cricoid cartilage. Traumatic dislocation of arytenoid cartilage may mimic vocal cord
paralysis clinically & on imaging. II
229
 ..:L THYROID GLAND
U
Q.)
Z I Imaging Anatomy o Image-based nodal classification: Level 6
-0 o Initial lymphatic drainage courses to periglandular
o Overview nodes
>-
...c • "H" or "U" shaped gland in anterior cervical neck • Prelaryngeal, pretracheal & paratracheal nodes
~ formed from 2 elongated lateral lobes with superior & along recurrent laryngeal nerve
•... inferior poles connected by median isthmus • Paratracheal nodes drain along recurrent laryngeal
'+-
C nerve into mediastinum
• 40% of people have pyramidal lobe ascending from
-0 isthmus area toward hyoid bone • Regional drainage occurs laterally into internal
C jugular chain (level 2-4) & spinal accessory chain
~ Extent (level 5), higher in the neck along internal jugular
-0 vein
• Extends from level of 5th cervical vertebra to 1st
o thoracic vertebra
>- Fascia
...c Anatomy Relationships
~ • Middle layer of deep cervical fascia surrounds
•... • Thyroid gland lies anterior & lateral to trachea in visceral space & ensheathes thyroid gland
0..
:J visceral space of infrahyoid neck • Thyroid gland has inner true capsule
CJ)
• Posteromedially is tracheoesophageal groove o True capsule is thin & adheres closely to gland
~ (paratracheal nodes, recurrent laryngeal nerve, o Extension of capsule into gland forms numerous
u parathyroid glands) septae, dividing gland into lobes & lobules
Q)
• Posterolaterally are carotid spaces
Z • Anteriorly are infra hyoid strap muscles
"'0

l:: • Anterolaterally are sternocleidomastoid muscles I Embryology

~ • Parathyroid glands lie close to deep surface of thyroid
"'0 gland; may be intracapsular
~ • Thyroid is first endocrine gland in body to develop (-
Q) Internal Structures-Critical Contents
J: • Thyroid gland
o Two lateral lobes each"" 4 cm in height
• Each lobe has upper & lower pole
• Lateral lobes are commonly asymmetric
o Lateral lobes joined by midline isthmus
• Arterial supply to thyroid gland
o Superior thyroid arteries
• Superior thyroid artery is 1st anterior branch of
external carotid artery
• Runs superficially on anterior border of lateral
lobe, sending a branch deep into gland before
curving toward isthmus where it anastomoses
with contralateral artery
• Proximal course closely associated with superior
laryngeal nerve
o Inferior thyroid arteries
• Arises from thyrocervical trunk, a branch of
subclavian artery
• Ascends vertically, then curves medially to enter
tracheoesophageal groove in plane posterior to
carotid space
• Most of its branches penetrate posterior aspect of
lateral thyroid lobe
• Closely associated with recurrent laryngeal nerve
o Thyroidea ima occasionally present (3%)
• Single vessel originating from aortic arch or
innominate artery
• Enters thyroid gland at inferior border of isthmus
• Venous drainage of thyroid gland
o 3 pairs of veins arise from venous plexus on surface
of thyroid gland
o Superior & middle thyroid veins drain into internal
jugular vein
o Inferior thyroid veins end in left brachiocephalic
vein
• Lymphatic drainage from thyroid gland
o Lymphatic drainage is extensive & multidirectional
Embryologic Events
24th gestational day)
• Thyroid gland originates from 1st & 2nd pharyngeal
pouches (medial anlage)
• Originates as proliferation of endodermal epithelial
cells on median surface of developing pharyngeal floor
termed foramen cecum
• Bilobed thyroid gland descends anterior to pharyngeal
gut along thyroglossal duct
o Tubular duct later solidifies then obliterates entirely
(gestational weeks 7-10)
• Inferior descent of thyroid gland carries it anterior to
hyoid bone & laryngeal cartilages
• As it descends it takes on its mature shape, with a
median isthmus connecting 2 lateral lobes
• Lateral thyroid lobes may form from 4th & 6th
branchial pouches (lateral anlagen)
Practical Implications
• Thyroglossal duct cyst results from failure of
involution of portion of thyroglossal duct
o Occurs anywhere along course of thyroglossal duct
from foramen cecum at tongue base to just anterior
to thyroid lobes
o Most occur in midline in vicinity of hyoid bone
o When infrahyoid, most commonly paramedian, just
dorsal to lateral thyroid lobe
o Often have thyroid tissue in wall
• Thyroid tissue remnants from sequestration of
thyroid tissue along thyroglossal duct
o Seen anywhere along course of thyroglossal duct
from foramen cecum to superior mediastinum
o Pyramidal lobe of thyroid is midline normal variant
remnant of this process
o Ectopic thyroid gland from incomplete descent of
thyroid into low neck
• Seen anywhere along course from foramen cecum
in tongue base to superior mediastinum
• Most common location in neck is just deep to
foramen cecum in tongue base = lingual thyroid

II
230
 THYROID GLAND
GRAPHICS :c
ro
~
c..
~
::J
c..
Lingual tonsils
Z
ro
n
7\
Foramen cecum Vl
""'0
c
.....•
~
Epiglottis ::J
'<
o
Hyoid bone 0....
~
:J
0....
:J
.....•..•
Thyroid cartilage .....•
Thyroglossal duct tract ~
::J
'<
o
0....
Z
Thyroid gland lobe (1)

Thyroid gland isthmus

n
A

External carotid artery

Superior thyroid artery

Superior pole, left

thyroid lobe

Common carotid artery

Thyroid gland isthmus

Trachea

(Top) Sagittal oblique graphic displays thyroglossal duct tract as it traverses the cervical neck from its origin at the
foramen cecum to its termination in the anterior & lateral visceral space of the infrahyoid neck. The medial thyroid
anlage arises from the paramedian aspect of the 1st & 2nd branchial pouches (foramen cecum area), then descends
inferiorly through the tongue base, floor of mouth, around and in front of the hyoid bone, through the area of the
infrahyoid strap muscles to a final position in the thyroid bed of the visceral space. Thyroglossal duct cyst (failure of
involution of duct) or thyroid tissue remnants may be found anywhere along this tract. (Bottom) Oblique graphic of
the infrahyoid neck shows the superior thyroid artery as the first branch of the external carotid artery. Its proximal
course closely associated with superior laryngeal nerve.
II
231
 THYROID GLAND
~ GRAPHICS
u
Q)
Z
u
o
>-
....c
ro Infrahyoid strap
"-
'-+-
C Thyroid gland isthmu muscles

u
c
ro
U Middle layer, deep
Thyroid gland lob
o cervical fascia
>-
....c
ro Trache Thyroid capsule
"-
0...
:J
V) Trachcocsophagea Parathyroid gland
groov
..::c:
u
Q)
Paratracheallymph
node (level 6)
Z Esophagu
"'0 Recurrent laryngeal
C nerve
~
"'0
~
Q)
J:

Superior thyroid artery

Hypopharynx
Vagus nerve

Superior parathyroid
gland

Thyroid gland lobe Right recurrent

laryngeal nerve
Inferior parathyroid
gland
Inferior thyroid artery

Common carotid artery

Inferior thyroid vein

Cervical esophagus
Thyrocervical trunk

(Top) Axial graphic at thyroid level, depicts the thyroid lobes & isthmus in the anterior visceral space wrapping
around the trachea. Notice that there are three key structures found in the area of the tracheoesophageal groove, the
recurrent laryngeal nerve, the paratracheallymph node chain and the parathyroid gland. The parathyroid glands
may be inside or outside of the thyroid capsule. (Bottom) Coronal graphic views the thyroid and parathyroid glands
from behind. The drawing depicts the typical anatomic relationships of the paired superior and inferior parathyroid
glands closely applied to the posterior lobes of the thyroid gland. Note the arterial supply to superior and inferior
thyroid lobes, the superior and inferior thyroid arteries respectively.
II
232
 THYROID GLAND
AXIAL CECT

Pyramidal lobe thyroid gland

Infrahyoid strap muscles

Sternocleidomastoid muscle

Common carotid artery -r Trachea

Thyroid gland lobe

Internal jugular vein
Esophagus

Retropharyngeal space

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Internal jugular vein

Tracheoesophageal groove
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Thyroid gland isthmus

Sternocleidomastoid muscle Infrahyoid strap muscles

Trachea
Common carotid artery
Thyroid gland lobe
Internal jugular vein

Tracheoesophageal groove
Esophagus

(Top) First of three axial CECT images presented from superior to inferior shows a small superiorly projecting
pyramidal lobe in the anterior midline just beneath the infrahyoid strap muscles. Notice the retropharyngeal space
fat stripe extends posterior to the thyroid lobes and esophagus. (Middle) In this image the thyroid gland isthmus is
visible arching from thyroid lobe to thyroid lobe across the anterior surface of the trachea beneath the infra hyoid
strap muscles. The thyroid lobes are found along the lateral margin of the trachea. (Bottom) The thyroid gland
isthmus is prominent on this image. The tracheoesophageal groove has been circled. Remember that the recurrent
laryngeal nerve, paratracheal nodes and parathyroid glands can all be normally found in this location. None of these
structures are normally visible on routine enhanced CT images. II
2H
 THYROID GLAND
CORONAL CECT

Internal jugular vein

Thyroid cartilage
Common carotid artery
""'0 Undersurface of true vocal cord
c
ro
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Carotid space
o Trachea
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Common carotid artery

Right subclavian artery

Superior mediastinum

Sternocleidomastoid muscle
Trachea
Thyroid gland lobe, right
Thyroid gland isthmus

(Top) First of three coronal CECT reformations presented from posterior to anterior demonstrates the two lobes of
the thyroid gland with the trachea on their medial borders. Lateral to each of the thyroid lobes are the carotid spaces
containing the vagus nerve, common carotid artery and internal jugular vein. (Middle) In this image the
chevron-shaped lobes of the thyroid gland are particularly well seen. Notice the intimate relationship between the
superomedial thyroid gland and the larynx. Remember that thyroid gland malignancy first order nodes are the
para tracheal nodes. The para tracheal nodes drain inferiorly into the superior mediastinum. Consequently it is
important for the radiologist to image to the aortic arch in cases of thyroid gland malignancy. (Bottom) The isthmus
II of the thyroid gland is visible just anterior to the trachea in this image.
214
 THYROID GLAND
ULTRASOUND

Thyroid gland isthmus

Infrahyoid strap muscles

Trachea

Thyroid gland lobe

Common carotid artery

Prevertebral muscle

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lnfrahyoid strap muscle

Infrahyoid strap muscle

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Common carotid artery

Common carotid artery

Trachea
Flow within thyroid lobe

(Top) In this transverse grayscale ultrasound image the thyroid gland isthmus is visible arching from thyroid lobe to
thyroid lobe across the anterior surface of the trachea beneath the infrahyoid strap muscles. Notice that the
tracheoesophageal grooves & cervical esophagus are not seen due to shadowing from air in the trachea. (Middle)
Higher resolution transverse grayscale ultrasound image constructed from individual scans of both sides of the neck
shows the tracheoesophageal grooves as a result of angling of the transducer at the time of scan acquisition.
(Bottom) Power Doppler images of both sides of the neck at the level of the thyroid lobes shows flow in both
common carotid arteries. The normal power Doppler image of the thyroid demonstrates sporadic flow within the
thyroid lobes secondary to branches of intra thyroid vessels. II
23')
 THYROID GLAND
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Common carotid artery

(Top) In this transverse power Doppler ultrasound image through the right thyroid lobe the, high flow within the
common carotid is visible along the lateral margin of the right thyroid lobe. The focal sporadic areas of high flow
within the thyroid lobe and isthmus represent normal intrathyroidal vessels. (Middle) Transverse color Doppler
ultrasound image of the left thyroid lobe shows high flow in the common carotid artery and internal jugular vein.
Color Doppler provides directional and flow information. The colored areas within the thyroid lobe represent
intrathyroidal vessels. (Bottom) In this transverse grayscale sonographic image of the right neck shows a
well-circumscribed hypoechoic right superior parathyroid gland medial to common carotid artery and posterior to
II superior right thyroid lobe.
236
 THYROID GLAND
GRAPHICS OF THYROID LESIONS

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Differentiated thyroid carcinoma

primary tumor

Internal jugular nodal chain Internal jugular node (level 4 )

Spinal accessor~' node (le\'el S)

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Paratracheal node ne\'e! 6)

, Anterior mediastinal node newl 7)

(Top) Oblique sagittal graphic of a thyroglossal duct cyst that occurs at the level of the hyoid bone along the
thyroglossal duct tract. Thyroglossal duct cysts and thyroid remnants can be found anywhere along the tract of the
thyroglossal duct from the level of the foramen cecum to the superior mediastinum, (Middle) Axial graphic through
the thyroid bed shows a generic intrathyroid mass. The lesion appears to arise out of the left thyroid lobe, lifting the
infrahyoid strap muscles, (Bottom) Coronal graphic of the infrahyoid neck and superior mediastinum shows a left
thyroid lobe and isthmus differentiated thyroid carcinoma primary, Notice that in addition to nodal metastases in
the internal jugular and spinal accessory chains there are also nodal metastases in the para tracheal and superior
mediastinal nodal groups, II
237
~ PARATHYROID GLANDS
u
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o Abbreviations Imaging Approaches

>- • Parathyroid gland (PTG) • Imaging for pre-operative localization of parathyroid
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Definitions
• PTG: Posterior visceral space (VS) endocrine glands
that control calcium metabolism by producing
o Ultrasonography
• Best 1st examination for localizing most PTA
• Use high-resolution linear array transducer (7.5-10
C parathormone MHz)
~ • Identifies 95% of PTA weighing> 1 gram
""'0
o Cross-sectional imaging (CT or MR)
o IImaging Anatomy • Used for anatomic localization of ectopic PTA
>- discovered with radionuclide exam
..!:
~ Anatomy Relationships
•... • PTG closely applied to posterior surface of thyroid
o Nuclear scintigraphy
Q.. • Tc-99m sestamibi concentrates in PTA
~ lobes within visceral space • Very useful study when ectopic PTA is suspected
V'l
• JYTGextracapsular (outside thyroid capsule) in most from negative surgical exploration
~ cases
U • PTG in vicinity of tracheoesophageal groove
Q)
Z Internal Structures-Critical Contents I Clinical Implications
-0
• Parathyroid glands Clinical Importance
r::: o Small lentiform glands posterior to thyroid glands in
~ • Primary hyperparathyroidism with hypercalcemia is
-0 visceral space
most commonly secondary to PTA
ttl o Normal measurements
Q) o Less common cause is parathyroid hyperplasia
• Approximately 6 mm length, 3-4 mm transverse &
J: 1-2 mm in anteroposterior diameter
• Imaging of PTG is primarily to find PTA
• Imaging & surgical challenges arise when PTG affected
o Normal number = 4, two superior & two inferior
is ectopic
• May be as many as 12 total PTGs
o Superior PTG normal locations
• Lie on posterior border of middle 1/3 of thyroid
75% of time I Embryology
• 25% found behind upper or lower 1/3 of thyroid Embryologic Events
• 7% found below inferior thyroidal artery • Superior PTG develop from 4th branchial pouch
• Rarely found behind pharynx or esophagus along with primordium of thyroid gland
o Inferior PTG normal locations o Less than 2% of superior PTG are ectopic
• Inferior glands lie lateral to lower pole of thyroid • Inferior PTG develop from 3rd branchial pouch
gland (50%) along with anlage of thymus
• 15% lie within 1 cm of inferior thyroid poles o Descend variable distance with thymic anlage in
• 35% position is variable residing anywhere from thymopharyngeal duct tract
angle of mandible to lower anterior mediastinum o May descend into anterior mediastinum as far as
• Intrathyroidal PTG are rare pericardium
o PTG arterial supply
• Superior PTG supplied by superior thyroid artery Practical Implications
• Inferior PTG supplied by inferior thyroid artery • Abnormal PTG descent may cause inferior PTG to
occupy "ectopic" sites
Fascia o May be of critical importance when searching for
• Visceral space & its contents including PTGs are parathyroid adenoma
surrounded by middle layer of deep cervical fascia • In cases where surgical exploration for PTA is done
Parathyroid Gland Microscopic Anatomy without imaging, no PTA may be found if PTG is
• JYTGare composed of chief cells & oxyphil cells ectopic
• Cells are embedded within fibrous capsule & mixed o Most frequent ectopic site is just below inferior
with adipose tissue thyroid pole
• Oxyphil cell function unknown o Less commonly PT may migrate into superior
• Chief cells manufacture parathormone (PTH) mediastinum with thymus creating ectopic
o PTH regulates concentration of calcium in mediastinal PTA
interstitial fluids o Rarely PTG does not descend significantly which
o Serum calcium levels regulate secretion of PTH creates ectopic in upper cervical neck PTA
o Rarest reported locations include retropharyngeal,
retro-esophageal & posterior mediastinal PTA

II
238
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240
 PARATHYROID GLANDS
ULTRASOUND

Sternocleidomastoid muscle lnfrahyoid strap muscle

Right lobe thyroid gland Trachea

Internal jugular vein Parathyroid gland

Common carotid artery

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Sternocleidomastoid muscle lnfrahyoid strap muscle

Common carotid artery Parathyroid gland

Trachea

(Top) First of three transverse, grayscale sonographic image of right neck shows a well-circumscribed hypoechoic
right superior parathyroid gland:medial to common carotid artery and posterior to superior right thyroid lobe.
(Middle) Image of left neck at the level of the thyroid gland shows the left inferior parathyroid gland as a
hypoechoic ovoid lesion closely applied to posterior right thyroid lobe. The esophagus is not seen due to shadowing
from the trachea, however the parathyroid gland is positioned within the tracheoesophageal groove. (Bottom) Image
of right neck, demonstrates a rightfuferior parathyroid gland medial to common carotid artery, lateral to cervical
trachea and inferior to right thyroid lobe.
II
241
 PARATHYROID GLANDS
GENERIC TRACHEOESOPHAGEAL GROOVE MASS

Isthmus of thyroid gland

Thyroid gland Trachea

Parathyroid gland Generic mass of

tracheoesophageal groove
Recurrent laryngeal nerve
Esophagus

Sternocleidomastoid muscle
Trachea
Infrahyoid strap muscle

Common carotid artery Thyroid gland

Internal jugular vein

Cervical esophagus Parathyroid adenoma

Trachea
Internal jugular vein

Common carotid artery

Cervical esophagus Parathyroid adenoma

(Top) Axial graphic shows a well-circumscribed generic mass in the left tracheoesophageal groove, causing mass
effect on recurrent laryngeal nerve, esophagus, trachea and left thyroid lobe. Parathyroid adenoma, recurrent
laryngeal nerve schwan noma and nodal disease in the paratracheal nodal chain all could cause such an appearance.
(Middle) Axial CECT image at the level of thyroid gland shows an enhancing parathyroid adenoma in the left
tracheoesophageal groove, posterior to left thyroid lobe. In a patient with hypercalcemia and elevated parathormone,
this location and appearance is diagnostic. (Bottom) Axial Tl contrast-enhanced fat-saturated MR image at the level
of the thyroid bed demonstrates an enhancing parathyroid adenoma posterior to the left lobe of the thyroid in the
II left tracheoesophageal groove.
242
 PARATHYROID GLANDS
ECTOPIC PARATHYROID ADENOMA

Submandibular gland

Right thyroid lobe Left thyroid lobe

Ectopic parathyroid adenoma

Ectopic parathyroid adenoma

Anterior mediastinum with
thymic remnant
Ascending aorta

Ectopic parathyroid adenoma

(Top) Hypercalcemic patient with elevated parathormone underwent Tc-99m Sestamibi nuclear medicine scan. In
this 120 minute delayed scan an area of persistent concentration of isotope is visible in the mediastinum. In this
clinical setting an ectopic parathyroid adenoma can be diagnosed. Persistent activity is also visualized in thyroid and
submandibular salivary glands. CECT is ordered for presurgical localization. (Middle) Axial CECT image at the level
of main pulmonary artery demonstrates an enhancing parathyroid adenoma in the anterior mediastinum, anterior to
ascending aorta. (Bottom) Axial fusion image of CECT and Tc-99m Sestamibi nuclear medicine scan at the level of
left atrium, shows ectopic radiotracer activity in an anterior mediastinal parathyroid adenoma.
II
24l
~ CERVICAL TRACHEA AND ESOPHAGUS I
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I Terminology • Continuous sheet from larynx above
• Layer of pseudostratified ciliated columnar
epithelium interspersed with goblet cells with
o Definitions
both lying on basal lamina
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...r:: • Cilia propel mucus towards laryngeal inlet (1,000
~ cartilage & fibromuscular membrane connecting

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larynx to lungs
• Cervical esophagus: Muscular food & fluid-conveying
tube connecting pharynx to stomach
beats per minute)
• Minor salivary glands sporadically distributed in
tracheal mucosa
o Blood supply: Inferior thyroid arteries & veins
C
~ o Lymphatic drainage: Level VI pretracheal &
""0

o IImaging Anatomy para tracheal nodes

• Cervical esophagus
>- Overview o Begins at lower border of cricoid cartilage as
...r::
~ • Trachea continuation of hypopharynx
I.-

0- o 10-13 cm tube extending in midline from inferior • Upper limit is defined by cricopharyngeus muscle,
:J larynx at "" 6th cervical vertebral body to carina at which encircles it from front to back
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• Non-keratinized stratified squamous epithelium
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Z hypopharynx at "" 6th cervical vertebral body to o Lymphatic drainage: Level VI paratracheal nodes
""0 11th thoracic vertebral body Fascia
l:: o Descends behind trachea & thyroid, lying in front of
• Middle layer, deep cervical fascia surrounds visceral
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lower cervical vertebrae
• Inclines slightly to left in lower cervical neck &
space with trachea & esophagus inside

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vertebral body level
Anatomy Relationships
• Cervical trachea
o Anterior structures: Infrahyoid strap muscles;
isthmus of thyroid gland (2nd-4th tracheal
cartilages)
o Lateral structures: Lobes of thyroid gland
• Tracheoesophageal groove structures: Recurrent
laryngeal nerve, paratracheal nodes, parathyroid
glands
o Posterior structure: Cervical esophagus
• Cervical esophagus
o Anterior structure: Cervical trachea
o Anterolateral structures: Tracheoesophageal groove
structures
o Lateral structures: Carotid spaces
o Posterior structures: Retropharyngeal/danger spaces
Internal Structures-Critical Contents
• Cervical trachea
o Cartilage anatomy
• Each cartilage is "imperfect ring" of cartilage
surrounding anterior two-thirds of trachea
• Flat deficient posterior portion is completed with
fibromuscular membrane
• Cross-sectional shape of trachea is that of letter D,
with flat side posterior
• Smooth muscle fibers in posterior membrane
(trachealis muscle) attach to free ends of tracheal
cartilages & provide alteration in tracheal
cross-sectional area
• Hyaline cartilage calcifies with age
o First tracheal cartilage
• Broadest of all tracheal cartilages
• Often bifurcates at one end & is connected by
cricotrachealligament to inferior cricoid cartilage
o Cervical tracheal mucosa
IAnatomy-Based Imaging Issues
Imaging Approaches
• Cervical trachea
o Multislice CT with sagittal & coronal reformations
exam of choice for trachea
• Cervical esophagus
o Air-contrast barium swallow is primary
diagnostic tool in esophageal evaluation
o Multislice CECT for esophageal tumor staging
I Clinical Implications
Clinical Importance
• Cervical tracheal lesions present with shortness of
breath & stridor
o May be treated for asthma prior to diagnosis
• Cervical esophageal lesions present with dysphagia
o Aspiration pneumonia may occur prior to diagnosis
I Embryology
Embryologic Events
• During 4th gestational week respiratory primordium
begins with formation of laryngotracheal groove that
extends lengthwise in floor of gut just caudal to
pharyngeal pouches
• Groove then deepens into laryngotracheal
diverticulum whose ventral ectoderm become larynx
& trachea
• Lateral furrows develop on either side of
laryngotracheal diverticulum, then deepen to form
laryngotracheal tube
• Tracheoesophageal septum then develops caudally to
cranially, separating respiratory system from
esophagus

II
244
 CERVICAL TRACHEA AND ESOPHAGUS
BARIUM SWALLOW

Larynx

Hypopharynx

Junction of hypopharynx &

esophagus

Cervical esophagus

Oropharynx
Lingual tonsil

Hyoid bone
Vallecula
Epiglottis Hypopharynx

Cricopharyngeus muscle
Larynx indentation

Trachea Esophagus

Oropharynx

Hyoid bone
Vallecula
Hypopharynx
Epiglottis

Posterior wall hypopharynx

Post-cricoid hypopharynx
Cricopharyngeus muscle
indentation

Trachea Esophagus

(Top) Frontal view of a normal barium swallow shows barium deflected around the larynx which appears as a filling
defect. Inferior cricoid cartilage delineates inferior larynx & hypopharynx on CT studies as well as junction of
hypopharynx with cervical esophagus. (Middle) Lateral view of barium swallow of upper pharynx shows junction of
oropharynx & hypopharynx at hyoid bone. Lingual tonsil (base of tongue) causes a lobulated impression upon
anterior oropharynx. Epiglottis closes during swallowing to protect larynx from aspiration. Valleculae are recesses
between tongue & epiglottis. (Bottom) Lateral view of barium swallow shows hypopharynx & cervical esophagus
posterior to larynx & trachea. Hypopharynx extends from hyoid bone to cricopharyngeus muscle. Cricopharyngeus
muscle demarcates hypopharynx from cervical esophagus on barium studies & is typically located at C5/6 level. II
245
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I esophageal muscle

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Hypopharynx

Laryngeal ventricle Cricopharyngeus

muscle location

Superficial layer, deep Cervical esophagus

cervical fascia

Trachea
Middle layer, deep
Middle layer, deep cervical fascia
cervical fascia

Danger space

(Top) Lateral graphic shows junction of larynx & hypopharynx with trachea & esophagus. Cricopharyngeus muscle,
which separates hypopharynx from cervical esophagus is part of the inferior constrictor muscle. Esophagus is
composed of outer longitudinal muscles & an inner circular muscle layer (not shown). First tracheal ring is broadest
of all tracheal cartilages & is often merged to cricoid cartilage or second tracheal ring. Mucosal portions of posterior
trachea are separated from esophagus by a thin layer of connective tissue, often called the "party wall" as it separates
trachea anteriorly from esophagus posteriorly. (Bottom) Sagittal graphic shows longitudinal relationships of
infra hyoid neck. Note middle layer of deep cervical fascia (pink) encircles trachea & esophagus as part of visceral
II space. Trachea & esophagus are inferior continuation of airway & pharynx.
246
II
247
 CERVICAL TRACHEA AND ESOPHAGUS
AXIAL CECT

Strap muscles

Inferior cricoid cartilage. Visceral space

""0

c Superior thyroid gland

ro Thyro'id cartilage, inferior cornu
Carotid space
""0

Cricothyroid joint Retropharyngeal space

o Hypopharynx
>-
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I
Inferior cricoid cartilage Visceral space
Superior thyroid gland
Carotid space
Hypopharynx/esophagus junction
Retropharyngeal space
Prevertebral muscles

Strap muscles

Visceral space
Trachea
Thyroid gland
Carotid space
Esophagus
Tracheoesophageal groove Retropharyngeal space

(Top) First of six axial CECT images from superior to inferior shows inferior larynx & hypopharynx & transition to
cervical trachea & esophagus. Inferior larynx & hypopharynx are defined by inferior cricoid cartilage on
cross-sectional imaging. This image shows subglottic larynx, area from undersurface of true vocal cords to inferior
surface of cricoid cartilage. Cricothyroid joint lies adjacent to recurrent laryngeal nerve & dislocation of this joint
may result in vocal cord paralysis. (Middle) This image shows junction of hypopharynx & larynx which is defined by
cricopharyngeus muscle on barium swallow studies. This muscle is an inferior portion of inferior pharyngeal
constrictor muscle & is typically present at CS/6. (Bottom) Image more inferior shows cervical trachea & esophagus.
II The upper second through fourth tracheal rings are surrounded by thyroid gland.
248
 CERVICAL TRACHEA AND ESOPHAGUS
AXIAL CECT

Strap muscles
Visceral space
Trachea
Thyroid gland
Carotid space
Esophagus
Retropharyngeal space
Tracheoesophageal groove

Strap muscles

Internal jugular vein Middle layer, deep cervical

Thyroid gland fascia
Esophagus Carotid space
Retropharyngeal space
Prevertebral muscles

Thyroid gland isthmus

Trachea Visceral space

Common carotid artery
Thyroid gland Carotid space
Esophagus
Party wall
Tracheoesophageal groove

(Top) Image more inferior shows cervical trachea & esophagus within inferior visceral space. Cervical trachea is
bordered anteriorly by infrahyoid strap muscles, anteriorly & laterally by thyroid gland & tracheoesophageal groove
structures & posteriorly by esophagus. Esophagus is bordered anteriorly by cervical trachea, anterolaterally by
tracheoesophageal groove structures, laterally by carotid spaces & posteriorly by retropharyngeal space. (Middle) This
image shows middle layer of deep cervical fascia encircling the visceral space. (Bottom) This image shows'the "party
wall", the thin layer of connective tissue that separates mucosal portions of posterior trachea from anterior
esophagus. Tracheoesophageal groove structures include recurrent laryngeal nerve, paratracheallymph nodes &
parathyroid glands: II
249
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malignancy

Tumor in
tracheoesophageal
groove

(Top) Axial graphic shows a generic tracheal wall mass. A mass within the tracheal wall typically displaces thyroid
gland laterally & esophagus posteriorly. Primary tumors of the trachea are rare, representing 2% of upper airway
tumors. Most common primary malignant tumors include squamous cell carcinomas (SCCa) & adenoid cystic
carcinomas. SCCa usually arise in lower trachea & carina. Adenoid cystic carcinomas are usually located on
posterolateral tracheal wall. (Bottom) Axial CECT image demonstrates a right tracheal wall adenoid cystic carcinoma
that has spread posteriorly to involve the right tracheoesophageal groove and anterior wall of the cervical esophagus.
Such lesions can be relatively asymptomatic until stridor supervenes.
II
250
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251
..:::£ CERVICAL LYMPH NODES
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ITerminology extraglandular
Abbreviations • Both intraglandular & extraglandular nodes are
o within fascia circumscribing parotid space
>- • Internal jugular chain (I]C)
..c • Drains into upper I]C nodes (level II)
Cij
•... Synonyms • Most common tumors to involve this group are
'+-
C • Internal jugular chain: Deep cervical chain skin SCCa, melanoma & parotid malignancy
""0 • Spinal accessory chain (SAC): Posterior triangle chain o Retropharyngeal (RPS) nodal group: 2 subgroups
C • Medial RPS nodes: Found in paramedian RPS in
Cij Definitions suprahyoid neck (SHN)
""0
• Jugulodigastric node: "Sentinel" (highest) node, • Lateral RPS nodes: Found in lateral RPS in SHN,
o found at apex of I]C at angle of mandible lateral to prevertebral muscles, medial to ICA
>- • "Signal" (Virchow) node: Node found at bottom of • Drainage pattern: Receive drainage from posterior
..c I]C in supraclavicular fossa
Cij pharynx; drains into high I]C
•... o Facial nodal group
Cl..
::J • Mandibular nodes: Found along external
(j)
Ilmaging Anatomy mandibular surface
.::6! • Buccinator nodes: In buccal space
U Overview • Infraorbital nodes: In nasolabial fold
Q)
• Differentiation between benign or "reactive" nodes vs • Malar nodes: On malar eminence
Z pathological nodes • Retrozygomatic nodes: Deep to zygomatic arch
"'C o Morphology: Oval nodes with central fatty hila
C
~ o Size criteria
"'C • < 1.5 cm for I]C nodes near the angle of the IAnatomy-Based Imaging Issues
~ mandible
Q)
:::c • < .8 mm for retropharyngeal nodes Imaging Approaches
• < 1 cm for all other nodal groups • SCCa nodal staging: CECT or Tl C+ MR
o Scan extent: Skull base to clavicles
Internal Structures-Critical Contents • PET-CT utility in H & N SCCa nodal work-up
• Imaging-based nodal classification o Small active malignant node identification &
o Level I: Submental & submandibular nodes
treatment planning
• Level IA: Submental nodes: Found between
• Differentiated thyroid carcinoma: MR preferred
anterior bellies of digastric muscles o Scan extent: Skull base to carina
• Level IB: Submandibular nodes: Found around
submandibular glands in submandibular space
o Level II: Upper IJC nodes from posterior belly of
digastric muscle to hyoid bone
I Clinical Implications
• Level IIA: Level II node anterior, medial, lateral or Clinical Importance
posterior to internal jugular vein (JJV); if posterior • Presence of malignant SCCa nodes in staging
to I]V, node must be inseparable from I]V associated with SO<VI, ! in long term survival
• Level IIA contains jugulodigastric nodal group o If extranodal spread present, further 50% !
• Level lIB: Level II node posterior to I]V with fat • I]C is final common pathway for all lymphatics of
plane visible between node & I]V upper aerodigestive tract & neck
o Level III: Mid-IJC nodes from hyoid bone to o Since I]C empties into subclavian vein, I]V or
inferior margin of cricoid cartilage thoracic duct, SCCa does not normally drain directly
o Level IV: Low IJC nodes from inferior cricoid into mediastinum
margin to clavicle o Neck imaging to stage SCCa: Skull base to clavicles
o Level V: Nodes of posterior cervical space (SAC) • Retropharyngeal space nodal group
• SAC nodes lie posterior to back margin of o Reactive appearing RPS nodes commonly seen in
sternocleidomastoid muscle younger patients on brain MR exam
• Level VA: Upper SAC nodes from skull base to o Important when identified on imaging in SCCa
bottom of cricoid cartilage setting, as often clinically silent
• Level VB: Lower SAC nodes from cricoid to • When "signal" node (lowest I]C) found on imaging
clavicle without upper neck nodes, primary is not in neck
o Level VI: Nodes of visceral space found from hyoid • Parotid nodal group
bone above to top of manubrium below o Receives lymph drainage from external auditory
• Includes prelaryngeal, pretracheal and canal, eustachian tube, skin of lateral forehead &
paratracheal subgroups temporal region, posterior cheek, gums & buccal
o Level VII: Superior mediastinal nodes found mucous membrane (especially due to skin squamous
between carotid arteries from top of manubrium cell carcinoma & melanoma)
above to innominate vein below o Parotidectomy & nodal dissection of neck are
• Other nodal groups not included in standard necessary if malignancy of superficial ear area
imaging-based nodal classification presents as cervical neck malignant adenopathy

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 Vl
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 CERVICAL LYMPH NODES
....Y ULTRASOUND
Q)
Z
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o
>-
-C Lymph node cortex
ro
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c
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c Lymph node capsule

ro
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o
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~
u
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C
ro
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Q) Hilar vascularity
::r:

Nodal vasculature entering hilum

(Top) Grayscale ultrasound image shows the normal sonographic features of lymph nodes, which are typically oval
in shape, with un sharp borders and a prominent echogenic hilus. Large round nodes with effacement of the
echogenic hilus and sharpening of the borders, are findings typical of pathologic nodes. These findings however,
should not be used individually as sole diagnostic criteria. Ancillary findings of soft tissue edema or matting of
lymph nodes may also be seen with infection, malignancy or radiation changes. (Middle) Ultrasound image with
power Doppler, demonstrates power Doppler signal at the lymph node hilum. Vascularity of the hilum is a normal
sonographic finding. (Bottom) Ultrasound image with power Doppler, demonstrates linear power Doppler signal in
II the central hilum of the node, which represents the nodal artery and vein which enter at the hilum.
 CERVICAL LYMPH NODES
AXIAL CECT I
ro
~
a..
~
:J
a..
Z
ro
n
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External carotid artery
Vl
Internal carotid artery c
-0
]ugulodigastric node (level II) ] ugulodigastric node (level II) """"

~
Internal jugular vein :J
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o
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Q)
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Spinal accessory node (level VA) 0....
:J
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o
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Submandibular node (level lA) Submandibular node (level IA) Z

(t)
n
Submandibular gland A
High internal jugular nodes (level
II) High internal jugular nodes
(level II)
Internal jugular vein
Parotid nodes (tail area)
Sternocleidomastoid muscle

Spinal accessory nodes (level

VA)

Submental node (level IA)

Anterior belly digastric muscle Submandibular node (level IB)

Submandibular gland

Sternocleidomastoid muscle
High internal jugular nodes
High internal jugular node (level (levelllA)
liB)

Spinal accessory node (level VA)

(Top) First of three axial CECT images of the suprahyoid neck presented from superior to inferior demonstrates
lymph nodes in the internal jugular (level II) and spinal accessory chains (level V). The jugulodigastric node is the
highest or "sentinel" node of the internal jugular chain. (Middle) In this image the internal jugular & spinal
accessory lymph nodes are seen along with submandibular nodes (level IA) anterolateral to the submandibular glands
in submandibular space. Note the internal jugular nodes are closely applied to the carotid space while the spinal
accessory nodes are in the posterior cervical space. (Bottom) In this image just above the hyoid bone a submental
(level IA) node is seen between the anterior bellies of digastric muscles. Note also the submandibular (level IE), high
internal jugular (level IIA & IIB) & spinal accessory (level VA)nodes. II
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 CERVICAL LYMPH NODES
AXIAL T1 & T2 MR

Submandibular node (levelIB)

""0

c
(Ij Submandibular gland
""0
Lingual tonsil

o High internal jugular node

>-. High internal jugular node (level (level IlA)
....c IlA)
•...
(Ij

Q..
:J
V)

~
u
OJ
Z
""C
c:
(Ij
""C
~
OJ
Submandibular node (levelIB)
J:
Submandibular gland

Lingual tonsil

Internal jugular chain node

Internal jugular chain node
Oropharynx

Submandibular node (leveIIB)

Submandibular gland
Lingual tonsil

High internal jugular nodes

High internal jugular nodes (level (level IlA)
IlA)

(Top) Axial T1 MR image through low oropharynx shows characteristic low T1 signal of lymph nodes. A prominent
submandibular node with a fatty hilum is seen on the left. Level IIA internal jugular nodes are observed bilaterally.
(Middle) Axial T2 MR image at level of low oropharynx bilateral high internal jugular nodes as intermediate signal
intensity. (Bottom) Axial T2 MR image with fat saturation creates increased conspicuity of lymph nodes. The smaller
high internal jugular nodes surrounding the carotid space are easily identified on this fat-saturated T2 image. STIR
MR sequences create the same level of nodal conspicuity. Lingual tonsil tissue is also made more conspicuous with
the fat-saturation T2 sequence.
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 CERVICAL LYMPH NODES
RETROPHARYNGEAL NODES ::r:
('D
~
c..
Middle layer, deep cervical
~
fascia :::::l
Alar fascia
c..
Z
('D
Deep layer, deep cervical fascia n
7'
Medial retropharyngeal node
Vl
Lateral retropharyngeal node C
-0
Parapharyngeal space .....•
CJ
Prevertebral muscles ::r-
'<
C 1 vertebral body
Carotid space o
Danger space a...
Retropharyngeal space CJ
:J
a...

Oral tongue

Prevertebral muscles
Medial retropharyngeal nodes
Lateral retropharyngeal nodes
Lateral retropharyngeal node

Internal carotid artery

Internal jugular vein
Lateral mass of CI
Right vertebral artery flow void Vertebral artery

Retropharyngeal space

Malignant retropharyngeal
Internal carotid artery
node
Internal jugular vein

Prevertebral muscles

(Top) Axial graphic at the base of skull, demonstrates the typical location of medial and lateral retropharyngeal
nodes. Medial retropharyngeal nodes are found in the paramedian retropharyngeal space of the suprahyoid neck.
Lateral retropharyngeal nodes are lateral to the prevertebral muscles, and medial to the internal carotid artery.
(Middle) Axial T2 MR image with fat-saturation shows the location of both medial & lateral retropharyngeallymph
nodes. Note the lateral group is located on the anterolateral surface of the prevertebral muscles, just medial to the
carotid space. (Bottom) Axial CECT at the level of the low oropharynx reveals a small medial retropharyngeal node
in a patient with a posterior wall hypopharynx squamous cell carcinoma (not shown). Central low density allows
diagnosis of malignant node despite small size. II
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 SECTION 4: Oral Cavity

Oral Cavity Overview 11-260

Oral Mucosal Space 11-268
Sublingual Space 11-270
Submandibular Space 11-276
Tongue 11-282
Retromolar Trigone 11-288
Mandible and Maxilla 11-292
 ORAL CAVITY OVERVIEW
I Terminology
~
•.... Abbreviations
o • Oral cavity (OC)
Definitions
• OC: Area of suprahyoid neck below sinonasal region
and anterior to oropharynx
I Imaging Anatomy
Overview
• OC is separated from oropharynx by soft palate,
anterior tonsillar pillars and circumvallate papillae
• Suggested approach to OC imaging anatomy is to
consider 4 distinct regions
o Oral mucosal space/surface (OMS)
o Sublingual space (SLS): Non-fascial lined area
superomedial to mylohyoid muscle
o Submandibular space (SMS): SMS is located
inferolateral to mylohyoid muscle
o Root of tongue (ROT): Made up of
genioglossus-geniohyoid complex & lingual septum
Anatomy Relationships
• Oral cavity regional relationships
o Superior: Hard palate, maxillary alveolar ridge
o Lateral: Cheek-buccal space
o Inferior: Mylohyoid muscle (floor of mouth),
mandibular alveolar ridge and teeth
o Posterior: Soft palate, anterior tonsillar pillars &
lingual tonsil (tongue base)
• Sublingual space relationships
o SLS in oral tongue between mylohyoid muscle
inferolaterally and genioglossus medially
o Both SLS communicate anteriorly beneath frenulum
• Form "horizontal horseshoe" in deep oral tongue
o Posteriorly SLS empties into posterosuperior aspect
of SMS and inferior parapharyngeal space (PPS)
o No fascia separates posterior SLS from SMS and
inferior PPS
• Direct communication allows spread of disease
among these 3 spaces
• Submandibular space relationships
o SMS is a "vertical horseshoe" space between hyoid
bone below and mylohyoid muscle sling above
o SMS communicates posteriorly with inferior PPS and
posterior SLS
o SMS continues inferiorly as anterior cervical space
• Root of tongue relationships
o Inferiorly ROT ends at mylohyoid sling
o Anteriorly ends at mandibular symphysis
Internal Structures-Critical Contents
• Oral tongue
o Oral tongue: Anterior 2/3 of tongue
• Base of tongue: Posterior 1/3 of tongue (lingual
tonsil of oropharynx)
o Root of tongue: Deep muscles of oral tongue
(genioglossus and geniohyoid) + lingual septum
o Extrinsic tongue muscles
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260
• Genioglossus: Large, fan-shaped muscle arising
anteriorly from superior mental spine on inner
surface of symphysis menti of mandible; inserts
along entire length of under surface of tongue
• Hyoglossus: Thin & quadrilateral shaped arising
from body & greater cornu of hyoid bone; passes
vertically upward to insert into side of tongue
• Styloglossus and palatoglossus
• Mylohyoid muscle
o Forms floor of mouth
o Separates lower OC into SMS and SLS except along
posterior margin
o Arises from mylohyoid line of mandible
o Mylohyoid cleft at junction of anterior 1/3 and
posterior 2/3 of mylohyoid muscle
• May be prominent with fat ± vessels ± accessory
salivary tissue
• Oral mucosal space/surface
o Lines entire OC including buccal (cheeks), gingival
(gums), palatal and lingual surfaces
o Subepithelial collections of minor salivary glands
found all over OC
• Most common locations are inner surface of lip,
buccal mucosa and palate
o Retromolar trigone: Small triangular shaped region
of mucosa behind last molar on mandibular ramus
• Anatomical crossroads of OC, oropharynx, soft
palate, buccal space, floor of mouth, masticator
space and PPS
• Sublingual space
o Lingual nerve: V3 sensory combined with CN?
chorda tympani nerve (anterior 2/3 of tongue taste)
o Distal CN9 and CN12 (motor to tongue)
o Lingual artery and vein
o Sublingual glands and ducts
o Hyoglossus muscle anterior margin projects into
posterior SLS
o Deep portion of submandibular gland and
submandibular gland duct
• Submandibular space
o Large superficial portion of submandibular gland
o Submental (level IA) and submandibular (level IE)
lymph node groups
o Facial vein and artery
o Inferior loop of CN12
o Anterior belly of digastric muscles
• Pterygomandibular raphe
o Fibrous band extending from posterior mandibular
mylohyoid line to medial pterygoid plate hamulus
o Buccinator and superior pharyngeal constrictor meet
at pterygomandibular raphe
o Lies beneath mucosa of retromolar trigone
o Perifascial route of spread for SCCa
Fascia
• SLS is not lined by fascia
• SMS is lined by superficial layer of deep cervical fascia
o Deeper slip of fascia runs along external surface of
mylohyoid muscle and more shallow slip parallels
deep margin of platysma
o No fascia separates posterior SMS and SLS from
inferior para pharyngeal space
o
....•
~

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 >
~
u
~
•...
o

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 ORAL CAVITY OVERVIEW
AXIAL CECT

Sublingual space isthmus

Sublingual space

Lingual septum

Transverse intrinsic muscle

"shadow" Pterygomandibular gap
Lingual tonsil (oropharynx) Anterior tonsillar pillar
Parapharyngeal space

Sublingual space

Genioglossus muscle

Mylohyoid muscle Submandibular space

Lingual septum Para pharyngeal space

Genioglossus muscle

Mylohyoid muscle
Hyoglossus muscle

Sublingual space
Facial vein
Submandibular gland
Lingual tonsil

(Top) First of six axial CECT images of oral cavity are presented from superior to inferior. On the most cephalad
image the parapharyngeal space can be seen emptying anteriorly into the submandibular space via the
pterygomandibular gap. (Middle) The large paired genioglossus muscles are seen on either side of the lingual septum.
The cephalad submandibular space fat is just coming into view. (Bottom) The sublingual space is lateral to the
genioglossus muscle, superomedial to the mylohyoid muscle and anterior to the lingual tonsil. On the patient's right
the facial vein curves around the lateral margin of the submandibular gland.

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 ORAL CAVITY OVERVIEW
C AXIAL CECT
>
(Ij

Sublingual gland

~ Mylohyoid muscle cleft

u Genioglossus muscle
Q)
Z
"'0 Submandibular node
c: Mylohyoid muscle
Submandibular space
C':l
"'0 Hyoglossus muscle
C':l
Q) Submandibular gland
J:

Anterior belly of digastric muscle

Mylohyoid muscle

Platysma

Submandibular gland
Submandibular space

Platysma
Vallecula
Submandibular gland
Hyoid bone Facial vein

(Top) The complex shape of the submandibular space is outlined on the patient's left. Notice the mylohyoid muscle
gap anteriorly on the right. This is a normal variant and can be large and fat-filled as in this image. (Middle) The left
half of the more inferior submandibular space is outlined. The submandibular gland and anterior belly of the
digastric muscles are seen as normal occupants of the this space. Remember there is nO vertical fascia dividing the
two sides of the submandibular space. (Bottom) The platysma muscle represents the superficial border of the
submandibular space. The anterior cervical space connects to the submandibular space in the infrahyoid neck.

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 ORAL CAVITY OVERVIEW
AXIAL T2 MR

Buccinator muscle
Lingual septum, cephalad aspect

Intrinsic tongue muscles

Masseter muscle

Medial pterygoid muscle

n
OJ
Palatine tonsil Superior pharyngeal constrictor
muscle
<

Parapharyngeal space

Subfrenular sublingual space

isthmus

Sublingual gland
Genioglossus muscle
Mylohyoid muscle attaching to
mylohyoid ridge Hyoglossus muscle

Lingual tonsil

Palatine tonsil

Sublingual gland
Mylohyoid muscle
Genioglossus muscle

Lingual septum

Hyoglossus muscle Lingual tonsil

Medial pterygoid muscle

Palatine tonsil

Posterior belly of digastric muscle

(Top) First of six axial T2 MR images through the oral cavity presented from superior to inferior. This first image
reveals the cephalad surface of the oral tongue. (Middle) In this image the mylohyoid muscle can be seen attaching
to the mylohyoid ridge bilaterally. The sublingual space communicates anteriorly in the subfrenular isthmus.
(Bottom) In this image the hyoglossus muscle is seen projecting into the posterior aspect of the sublingual space.

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 ORAL CAVITY OVERVIEW
C AXIAL T2 MR
>
~
U

Genioglossus muscle
Lingual septum
Mylohyoid muscle
Hyoglossus muscle

Deep portion of submandibular Superficial portion of

gland in posterior sublingual space submandibular gland
Posterior belly of digastric
muscle
Jugulodigastric node

Inner cortical table of mandible

Mylohyoid cleft
Mylohyoid cleft
Mylohyoid muscle
Submandibular nodes
Hyoglossus muscle
Submandibular gland
Facial vein

Anterior belly of digastric muscle

Hyoid bone
Mylohyoid muscle
Platysma muscle

Submandibular gland

Submandibular node

(Top) In lower oral cavity the submandibular gland becomes visible. Notice the deep portion "plugs" the back of the
sublingual space (visible on left). The larger superficial submandibular gland is in the submandibular space proper.
(Middle) At the level of the inferior body of mandible the fatty gap in the mylohyoid muscle is visible. Also notice
the multiple reactive submandibular nodes on the left. (Bottom) At the level of the hyoid bone the bulk of the
anterior bellies of the digastric muscles are visible. The platysma is seen as the superficial margin of the
submandibular space.

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 ORAL CAVITY OVERVIEW
CORONAL T1 MR

Parapharyngeal space

Medial pterygoid muscle Palatine tonsil

Parapharyngeal space empties

Angle of mandible
into submandibular space o
Submandibular gland

Facial vein

Hyoglossus muscle

Mylohyoid ridge
Mylohyoid muscle
Inferior alveolar nerve

"Vertical horseshoe" of
submandibular space

Platysma muscle

Mylohyoid ridge
Sublingual space
Inferior alveolar nerve Mylohyoid muscle

Genioglossus muscle
Anterior belly of digastric muscle
Root of tongue
Platysma muscle

(Top) First of three coronal Tl MR images through oral cavity presented from posterior to anterior. In this most
posterior image the para pharyngeal space can be seen "emptying" inferiorly into the posterior submandibular space
on the right. (Middle) This more anterior view delineates the "vertical horseshoe" of the submandibular space
bounded superficially by the platysma and superomedially by the mylohyoid muscle. (Bottom) The sublingual space
becomes more obvious in the anterior oral cavity. Notice it is a potential space drawn in on the right lateral to the
genioglossus muscle and superomedial to the mylohyoid muscle.

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 ORAL MUCOSAL SPACE
• Extends from line of attachment of mucosa in
ITerminology buccal gutter to line of free mucosa of floor of
Abbreviations mouth
• Oral mucosal space/surface (OMS) • Posteriorly extends to ascending ramus of
• Oral cavity (OC) mandible
~ o Retromolar trigone mucosal surface
u Definitions • Attached mucosa overlying ascending ramus of
OJ
Z • OMS: Mucosal surface of oral cavity extending from mandible
""C
skin-vermilion junction of lips to junction of hard and • Extends from level of posterior surface of last
C soft palate above and to line of circumvallate papillae molar tooth to apex superiorly, adjacent to
t'd below tuberosity of maxilla
""C o Buccal mucosa
t'd
OJ
• Includes all membranes that line inner surface of
::r: I Imaging Anatomy cheeks and lips
• Extends from line of contact of opposing lips to
Overview line of attachment of mucosa of alveolar ridge
• OMS is constructed to complete radiologist's thinking (upper and lower) and pterygomandibular raphe
regarding OC locations where specific lesions o Floor of mouth, mucosal surface
primarily occur • Semilunar mucosal surface overlying mylohyoid
• Since OMS describes mucosal surface of entire oral and hyoglossus muscles
cavity, it represents continuous sheet of mucosa where • Extends from inner surface of lower alveolar ridge
squamous cell carcinoma (SCCa) may originate to undersurface of tongue
• Posterior boundary is base of anterior pillar of
Extent
tonsil
• Anterior extent of OMS: Skin-vermilion junction of • Divided into two sides by tongue frenulum
upper and lower lips • Contains ostia of submandibular and sublingual
• Posterior extent of OMS salivary glands
o Posterosuperior extent: Junction of hard and soft o Hard palate mucosal surface
palate • Semilunar mucosal area between upper alveolar
o Posteroinferior extent: Junction of anterior 2/3 of ridge and mucous membrane covering palatine
tongue and posterior 1/3 of tongue at circumvallate process of maxillary palatine bones
papillae • Extends from inner surface of superior alveolar
• Anterior 2/3 of tongue is oral tongue ridge to posterior edge of palatine bone
• Posterior 1/3 of tongue is lingual tonsil; part of o Anterior 2/3 of tongue (oral tongue) mucosal
oropharynx surface
Anatomy Relationships • Mucosal surface overlying oral tongue
• OMS represents continuous mucosal surface of OC • Extends anteriorly from line of circumvallate
which sits anterior to mucosal surface of oropharynx papillae (anterior edge of lingual tonsil) to
• Superior OMS overlies hard palate undersurface of tongue at junction of mucosal
o Floor of nose and maxlllary sinuses (palatine process surface of floor of mouth
of maxillary palatine bones) lie deep to this mucosa • Composed of 4 areas including tongue tip, lateral
• Inferior OMS overlies sublingual spaces and borders, dorsum and undersurface (nonvillous oral
mylohyoid muscles tongue ventral surface)
• Contents of OMS
Internal Structures-Critical Contents o Mucosal surface of OC
• Oral mucosal space/surface is divided into eight o Minor salivary glands (MSG)
specific areas • Lie within submucosa of OC, paranasal sinuses,
o Mucosal lip pharynx, larynx, trachea, and bronchi
• Lip begins at vermilion border junction with skin • Particularly concentrated in buccal, palatal and
• Includes only vermilion surface or portion of lip lingual submucosal regions
that makes contact with opposing lip • Mucinous or seromucinous in nature
o Upper alveolar ridge mucosal surface
Fascia
• Refers to mucosa overlying alveolar process of
maxilla • No fascia exists to define OMS
• Extends from line of attachment of mucosa in
upper gingival buccal gutter to junction of hard
palate I Clinical Implications
• Posterior margin is upper end of pterygopalatine Clinical Importance
arch
• Primary malignancies arising from OMS include SCCa
o Lower alveolar ridge mucosal surface
and MSG malignancy
• Refers to mucosa overlying alveolar process of
• Vast majority of malignancies of OMS are SCCa while
mandible
MSG malignancy is relatively rare

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 >-
.•....
SUBLINGUAL SPACE
>
('!j
u ITerminology
('!j
Abbreviations
•...
o • Sublingual space (SLS)
• Submandibular space (SMS)
• Oral mucosal space/surface (OMS)
Definitions
• SLS: Paired non-fascial lined spaces of oral cavity in
deep oral tongue above floor of mouth superomedial
to mylohyoid muscle
I Imaging Anatomy
Overview
• SLS contains key neurovascular structures of oral
cavity
o Includes glossopharyngeal nerve (CN9), hypoglossal
nerve (CNI2), lingual nerve (branch of V3), lingual
artery and vein
• When a lesion involves both SLSs across anterior
isthmus, it appears as a "horizontal horseshoe"
parallel to line of inferior mandibular surface
Anatomy Relationships
• Sublingual space relationships
o SLS in deep oral tongue superomedial to
mylohyoid muscle and lateral to
genioglossus-geniohyoid muscles
o Communication between sublingual spaces occurs
in midline anteriorly as a narrow isthmus beneath
frenulum
o SLS communicates with SMS and inferior
para pharyngeal space (PPS) at posterior margin of
mylohyoid muscle
• There is no fascia dividing posterior SLS from
adjacent SMS
• Therefore there is direct communication with SMS
and PPS in this location
Internal Structures-Critical Contents
• Posterior aspect of SLS is divided into medial and
lateral compartments by hypoglossal muscle
• Lateral compartment contents
o Hypoglossal nerve: Motor to intrinsic and extrinsic
muscles of tongue
• Intrinsic muscles of tongue include inferior
lingual, vertical and transverse muscles
• Extrinsic muscles of tongue include genioglossus,
hyoglossus, styloglossus & palatoglossus muscles
o Lingual nerve: Branch of mandibular division of
trigeminal nerve (CNV3) combined with chorda
tympani branch of facial nerve
• Lingual nerve branch of CNV3: Sensation to
anterior 2/3 of oral tongue
• Chorda tympani branch of facial nerve: Anterior
2/3 of tongue taste and parasympathetic
secreto-motor fibers to submandibular
ganglion/gland
o Sublingual glands and ducts
• Lie in anterior SLS bilaterally
• About 5 small ducts open under oral tongue into
oral cavity
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• With age sublingual glands atrophy, becoming
difficult to see on imaging
o Submandibular gland deep portion and
submandibular duct
• Submandibular gland deep margin extends into
posterior opening of SLS
• Enlarging lesions of SLS in effect push this deep
margin of submandibular gland out of the way as
they emerge from SLS into SMS
• Submandibular duct runs anteriorly to papillae in
anteromedial subfrenular mucosa
• Medial compartment contents
o Glossopharyngeal nerve (CN9)
• Provides sensation to posterior 1/3 of tongue
• Carries taste input from posterior 1/3 of tongue
• Located more cephalad in medial compartment
compared to lingual artery and vein
o Lingual artery and vein
• Vascular supply to oral tongue
• Seen running just lateral to genioglossus muscle
Fascia
• SLS is not fascia-lined space but instead is potential
space only
IAnatomy-Based Imaging Issues
Key Concepts or Questions
• What defines a mass as primary to SLS?
o Center of lesion is superomedial to mylohyoid
muscle and lateral to genioglossus muscle
• Besides spilling out back of SLS into posterior SMS,
how can a lesion of SLS access SMS?
o Mylohyoid muscle has a variably sized cleft
between its anterior 1/3 and posterior 2/3 area
o Lesions may "escape" SLS into SMS through this cleft
o When this occurs, lesion is found in anterior SMS in
front of submandibular gland
Imaging Recommendations
• CECT or TI C+ MR with fat-saturation are both
excellent imaging tools to evaluate SLS lesions
• MR better in cooperative patient
o MR less affected by dental amalgam artifact
compared to CT
o MR permits direct coronal imaging to assess
relationship of lesion to mylohyoid muscle
Imaging Pitfalls
• Extension of oral cavity squamous cell carcinoma
(SCCa) into floor of mouth or root of tongue can be
obscured by dental amalgam on CECT
I Clinical Implications
Clinical Importance
• Since neurovascular bundle to tongue travels in SLS,
oral cavity SCCa involving posterior SLS is challenging
to treat
• If SCCa crosses lingual septum to contralateral SLS,
lesion becomes unresectable for cure
II
271
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272
 SUBLINGUAL SPACE
AXIAL CECT

Sublingual gland

Genioglossus muscle

Lingua I artery
Mylohyoid muscle Hyoglossus muscle

Submandibular gland Lingual tonsil (oropharynx)

n
OJ
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Low palatine tonsil

Sublingual gland
Lingual vein
Genioglossus muscle

Mylohyoid muscle Lingual artery

Posterior margin, mylohyoid
Hyoglossus muscle muscle
Superficial portion
submandibular gland
Deep portion of submandibular
gland

Genioglossus muscle

Mylohyoid cleft with vessel

Lingual septum

Mylohyoid cleft with vessel

Hyoglossus muscle

Submandibular gland Lingual tonsil

]ugulodigastric node

(Top) First of three axial CECT images of the sublingual space within the oral cavity. This most superior image shows
the medial border of the sublingual space is the genioglossus muscle. The hyoglossus muscles are seen projecting into
the posterior sublingual spaces. (Middle) More inferiorly a larger portion of the mylohyoid muscle can be seen
forming the inferolateral border of the sublingual space. Notice the submandibular gland wrapping around the
posterior margin of this muscle on the patient's left. The deep portion of the submandibular gland is found in the
posterior sublingual space. (Bottom) Inferiorly the sublingual spaces becomes smaller with the hyoglossus muscle
filling most of this space. Both mylohyoid muscles demonstrate small clefts with a vessel present bilaterally.
II
273
 SUBLINGUAL SPACE
AXIAL T2 FS MR

Isthmus connecting sublingual

<i:l
•... spaces
o

Mylohyoid muscle

Sublingual space
Hyoglossus muscle
Medial pterygoid muscle Palatine tonsil

Posterior belly of digastric muscle

Sublingual gland

Lingual artery

Mylohyoid muscle

Medial compartment,
Hyoglossus muscle sublingual space
Medial pterygoid muscle

Posterior belly of digastric muscle

Genioglossus muscle

Sublingual glanc;l

Mylohyoid muscle
Hyoglossus muscle
Submandibular gland, superficial
Lateral compartment,
portion
sublingual space
Submandibular gland, deep portion

(Top) First of three axial T2 FS MR images are presented from superior to inferior through the oral cavity. In this
most superior image the two sublingual spaces are outlined to highlight the anterior connecting isthmus that is
present under the frenulum of the oral tongue. (Middle) Slightly inferior the medial compartment of the SLSis
outlined on the patient's left. The medial compartment is defined as the SLSarea medial to the hyoglossus muscle
containing the lingual artery and vein as well as the glossopharyngeal nerve (CN9). (Bottom) Continuing inferiorly
the submandibular gland deep portion is seen projecting into posterior margin of sublingual space. The lateral
compartment of SLSis outlined. It is defined as SLScomponent lateral to hyoglossus muscle. It contains the
II sublingual gland, lingual nerve, hypoglossal nerve and submandibular gland duct.
274
 SUBLINGUAL SPACE
CORONAL T1 MR

Mylohyoid ridge of mandible

Sublingual space
Hyoglossus muscle

Lingual artery
o
Mylohyoid muscle

Geniohyoid muscle

Platysma muscle

Mylohyoid ridge of mandible

Sublingual space

Mylohyoid muscle
Anterior belly of digastric muscle
Platysma muscle

Genioglossus muscle/lingual
septum

Sublingual gland

Inferior alveolar nerve

Sublingual space
Mylohyoid muscle
Anterior belly of digastric muscle

Platysma muscle

(Top) First of three coronal Tl MR images of normal oral cavity/sublingual space presented from posterior to
anterior. In this most posterior image the mylohyoid sling is slung from side to side between mylohyoid ridges of
inner mandibular cortex. The sublingual space is superomedial to mylohyoid muscle & lateral to genioglossus &
geniohyoid muscles. (Middle) Anteriorly in oral cavity the true size of sublingual space is visible as delineated on
patient's left. Although it is possible to see the low signal lingual artery, the remaining normal sublingual space
structures are blended into the fibrofatty space itself. (Bottom) In the very anterior floor of mouth the anterior belly
of digastric muscles are the most prominent occupants of the submandibular space. The sublingual gland is mostly
found within the anterior sublingual space where it takes up much of the space's volume. II
275
 SUBMANDIBULAR SPACE
• Caudal loop of CN12 passes through SMS on way
ITerminology before looping anteriorly and cephalad into tongue
(ij Abbreviations muscles
'-- • Anterior belly of digastric muscles
o.. • Submandibular space (SMS)
• Tail of parotid may "hang down" into posterior
~ Synonyms submandibular space
u • Term submaxillary space used by surgeons
Q) Fascia
Z Definitions • SMS is lined by SL-DCF
"'0
• SMS: Fascial-lined space inferolateral to mylohyoid o Superficial surface of mylohyoid muscle is covered
l:: by SL-DCF
(ij muscle containing submandibular gland, nodes and
"'0 anterior belly of digastric muscles o Deep surface of platysma covered by SL-DCF
~ • There is no midline fascia separating two sides of SMS
Q)
o Consequently lesion growth from side to side in
J: I Imaging Anatomy SMS is unobstructed

Overview
• SMS is one of four distinct locations within oral cavity
(OC) that may be used to develop location specific
differential diagnoses
o Other 3 locations include oral mucosal
space/surface, sublingual space and root of tongue
Extent
• SMS is defined as a superficial space above hyoid bone
deep to platysma and superficial to mylohyoid sling
Anatomy Relationships
• Inferolateral to mylohyoid muscle of floor of mouth
• Deep to platysma muscle
• Cephalad to hyoid bone
• "Vertical horseshoe-shaped" space between hyoid
bone below and mylohyoid sling above
• Communicates posteriorly with sublingual space and
inferior para pharyngeal space at posterior margin of
mylohyoid muscle
• Continues inferiorly into infrahyoid neck as anterior
cervical space
Internal Structures-Critical Contents
• Submandibular gland
o Superficial portion is larger and in SMS itself
• Superficial layer, deep cervical fascia (SL-DCF)
forms submandibular gland capsule
• Crossed by facial vein and cervical branches of
facial nerve (marginal mandibular branch)
o Smaller deep portion often called deep "process"
• Deep process is tongue-like extension of gland
• Wraps around posterior margin of mylohyoid
muscle
• Projects into posterior aspect of sublingual space
• Submandibular duct projects off deep process into
sublingual space
o Submandibular gland innervation
• Parasympathetic secretomotor supply from chorda
tympani branch of facial nerve
• Comes via lingual branch of cranial nerve V3
• Submental (level IA) and submandibular (level 18)
nodal groups
o Receives lymph drainage from anterior facial region
• Including oral cavity, anterior sinonasal and
orbital areas
• Facial vein and artery pass through SMS
IAnatomy-Based Imaging Issues
Key Concepts or Questions
• Major clinical-imaging question when mass present in
SMS: Is lesion nodal or submandibular gland in origin?
o Fatty cleavage plane between mass & submandibular
gland identifies lesion as nodal in origin
• If facial vein separates lesion from submandibular
gland, then lesion is from a node
o "Beaking" of submandibular gland tissue around
lesion margin identifies lesion as submandibular
gland in origin
• What are major diagnoses in the SMS differential
diagnoses list?
o Congenital: Epidermoid, cystic hygroma
o Inflammatory: Submandibular gland sialoadenitis
with ductal calculus; diving ranula; reactive or
suppurative adenopathy
o Benign tumor: Benign mixed tumor of
submandibular gland, lipoma
o Malignant tumor: Salivary gland carcinomas; nodal
squamous cell carcinoma and non-Hodgkin
lymphoma
Imaging Recommendations
• CECT or T1 C+ fat-saturated MR both effective in SMS
• Ultrasound with needle aspiration of lesion also used
Imaging Pitfalls
• Do not mistake obstructed, enlarged submandibular
gland for malignant node in setting of anterior floor of
mouth primary squamous cell carcinoma
IClinical Implications
Clinical Importance
• Majority of lesion of SMS are either from
submandibular gland or nodes
o Sorting lesions into these two categories helps work
through imaging differential diagnosis
• Remember clinicians can see and feel area of SMS
o Fine needle cytopathology may have already been
done at time of imaging
• Lesions of parotid tail may appear in posterior
submandibular space clinically

II
276
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~.

II
277
 II
278
 SUBMANDIBULAR SPACE
AXIAL CECT

Hyoglossus muscle

High submandibular node Mylohyoid muscle

o
Facial artery
Submandibular gland
Facial vein
Parotid gland tail

Jugulodigastric reactive node

Hyoglossus muscle
Mylohyoid muscle cleft with vessel Submandibular node (level I)

Platysma muscle
Mylohyoid muscle
Facial vein
Submandibular gland
Submandibular gland, deep
Jugulodigastric reactive node portion

Sternocleidomastoid muscle

Anterior bellies of digastric

muscles

Platysma muscle
Submandibular node (level I)

Submandibular gland

Submandibular space
Facial vein

(Top) First of three axial CECT images presented from superior to inferior. This most superior image reveals the upper
most portion of the SMS. Notice the parotid gland tail projecting into the posterior SMS on the patient's left.
(Middle) More inferiorly this image shows the enlarging SMS filled with the submandibular gland, nodes and facial
vein. The submandibular gland deep portion extends to fill the posterior margin of the sublingual space on the
patient's left. (Bottom) Low SMS axial CECT image highlights the full extent of these spaces. Notice how large the
submandibular glands become inferiorly. Also note that the anterior bellies of the digastric muscles fill the
anteromedial SMS.
II
279
 SUBMANDIBULAR SPACE
AXIAL T2 MR
>
ro
U Mental foramen

Inferior alveolar nerve

Sublingual gland
Mylohyoid muscle

Submandibular duct
Hyoglossus muscle

Submandibular gland, superficial

portion Medial pterygoid muscle

Submandibular gland, deep portion

Posterior belly of digastric
muscle

Mylohyoid cleft
Genioglossus muscles

Mylohyoid muscle

Hyoglossus muscle

Submandibular gland hilum

Facial vein Posterior belly of digastric
muscle
Jugulodigastric node

Anterior bellies of digastric

muscles

Platysma

Facial vein

Submandibular gland

Submandibular space

(Top) First of three axial T2 MR images of the oral cavity presented from superior to inferior. In this most superior
image the upper SMS is evident, filled with fat and the upper submandibular glands. Notice the high signal
submandibular ducts entering the posterior sublingual spaces bilaterally. (Middle) Moving inferiorly more fat is seen
in the SMS bilaterally surrounding the submandibular glands. Both submandibular glands can be seen wrapping
around the posterior margins of the mylohyoid muscles. Remember that the neurovascular pedicle to each side of the
tongue enters closely approximated to the hyoglossus muscles. (Bottom) Low in the SMS the full extend of both
SMSs is visible. Notice that the anterior bellies of the digastric muscles fill the anteromedial SMS. Remember there is
II no midline fascia so diseases can move across midline from side-to-side.
280
 SUBMANDIBULAR SPACE
CORONAL T1 MR

Parapharyngeal space

Palatine tonsil
Masticator space

Parapharyngeal space emptying

into submandibular space
Platysma muscle
Submandibular space
Submandibular gland
n
~
Facial vein <

Masseter muscle

Medial pterygoid muscle Parapharyngeal space

Hyoglossus muscle
Submandibular gland

Facial vein Lingual artery

Facial artery
Platysma muscle

Mylohyoid ridge Masseter muscle

Inferior alveolar nerve Mylohyoid muscle sling

Mandibular cortex
Submandibular space

Platysma muscle Anterior margin of

submandibular gland
Anterior belly of digastric muscle

(Top) First of three coronal Tl MR images are presented from posterior to anterior. This most posterior image shows
the area of the submandibular space (SMS) outlined on the patient's left. Notice the para pharyngeal space empties
inferiorly into the posterior SMS. (Middle) More anteriorly the connection between the parapharyngeal space and
the SMS is still visible. The facial vein is visible snaking along the inferolateral margin of the submandibular gland.
Remember that if the facial vein is seen between a mass and the gland, it is most likely nodal in origin. (Bottom) In
this image through the mid-oral cavity the full extent of the SMS is clearly visible from side-to-side. The location of
the superficial layer of deep cervical fascia is outlined. The mylohyoid sling forms the superomedial border of the
SMS. The superficial margin of the SMS is the platysma muscle. II
281
 TONGUE
>
(1j
u I Terminology
(1j Abbreviations
•...
o •
•
Oral mucosal space/surface (OMS)
Root of tongue (ROT)
• Floor of mouth (FOM)
• For muscles: Origin (0), insertion (I), function (F),
innervation (N)
Definitions
• Oral tongue: Anterior 2/3 of tongue not including
tongue base
o By imaging includes freely mobile portion of tongue
that is anterior to the lingual tonsil
• Root of tongue: Undersurface of oral tongue at its
junction with anterior floor of mouth and mandible
o By imaging includes lingual septum, inferior portion
of genioglossus muscles and geniohyoid muscles
• Floor of mouth: Crescent-shaped region of mucosa
overlying mylohyoid and hyoglossus muscles,
extending from inner aspect of lower alveolar ridge to
undersurface of anterior oral tongue
o By imaging includes mylohyoid muscle as it hangs
from side-to-side from medial mandible (mylohyoid
ridge) to medial mandible and hyoglossus muscle
• Base of tongue: Posterior 1/3 of tongue in oropharynx
o By imaging includes lingual tonsil
I Imaging Anatomy
Overview
• Oral tongue sits centrally within oral cavity
o Mucosal covering of oral tongue part of OMS
o SLS is non-fascia lined space within oral tongue
• Surfaces of oral tongue is covered with mucosa
Anatomy Relationships
• Sublingual space
o Part of oral tongue between mylohyoid muscle
inferolaterally and genioglossus medially
o Communicates with contralateral SLS beneath
frenulum anteriorly
o Empties posteriorly into posterosuperior aspect of
submandibular space (SMS) and inferior
para pharyngeal space (PPS)
• Root of tongue
o Inferiorly ROT ends at mylohyoid sling
o Superiorly ends at intrinsic tongue muscles
o Anteriorly ends at mandibular symphysis
Internal Structures-Critical Contents
• Oral tongue consists of four anatomic regions
o Tip of oral tongue
o Lateral borders of oral tongue
o Dorsum of oral tongue
o Undersurface (nonvillous surface) of oral tongue
• Sublingual space
o Anterior hyoglossus muscle
o Lingual nerve; CN9 and 12
o Lingual artery and vein
o Sublingual glands and ducts
o Submandibular gland duct
II
282
• Extrinsic tongue muscles: Move tongue body and
alter its shape
o Genioglossus: Large, fan-shaped muscle lying
parallel to median plane in sagittal plane
• 0: Upper genial tubercle and internal surface of
symphysis menti of mandible
• I: Along entire length of under surface of tongue
• F: Protrudes tongue
• N: CN12
o Hyoglossus: Thin and quadrilateral-shaped muscle;
"arms reaching up from posteroinferior floor of
mouth into posterior sublingual space"
• 0: Body and greater cornu of hyoid bone
• I: Passes vertically upward to insert into side of
tongue
• F: Depresses tongue
• N: CN12
o Styloglossus
• 0: Arises from styloid process and
stylomandibular ligament
• I: Passes anteroinferiorly between internal and
external carotid arteries to insert into side of
tongue, merging with hyoglossus muscle
• F: Retracts tongue upward and backward
• N: CN12
o Palatoglossus
• 0: Undersurface of palatine aponeurosis
• I: Side and dorsum of tongue
• F: Forms palatoglossal arch (anterior tonsillar
pillar)
• N: CNlO, pharyngeal plexus branch
• Intrinsic tongue muscles: Alters shape of tongue
during deglutition and speech
o Complicated bundles of interlacing fibers innervated
by CN12
o Superior and inferior longitudinal
o Transverse and vertical
• Innervation of tongue
o Sensory supply (touch, pain, temperature and taste)
• Anterior 2/3: Lingual nerve (taste fibers are from
chorda tympani branch of CN?)
• Posterior 1/3: CN9
o Hypoglossal nerve (CN12)
• Emerges from nasopharyngeal carotid space
• Receives fibers from 1st and 2nd cervical nerves
• Loops inferiorly to level of hyoid bone
• Rises anteriorly to enter posterior sublingual space
just lateral to hyoglossus muscle
• Runs in sublingual space on lateral surface of
genioglossus muscle
• Innervates extrinsic and intrinsic tongue muscles
• Vasculature of tongue
o Lingual artery: 2nd branch of external carotid artery
• Divides in sublingual space into sublingual and
deep lingual branches
o Lingual vein: Parallels lingual artery; drains into
internal jugular or facial veins
• Oral tongue lymph vessels
o Two systems: Superficial mucosa and deep collecting
o Superficial system: Crossing vessels in anterior FOM
drain bilaterally into anterior submandibular nodes
o Deep collecting system: Drain into ipsilateral
anterior submandibular nodal chain only
 II
283
 ~
•....
o

II
284
 TONGUE
SAGITTAL & CORONAL T1 MR

Intrinsic tongue muscles Soft palate

Uvula

Genioglossus muscle
Lingual tonsil
Geniohyoid muscle
Epiglottis
Mylohyoid muscle
Hyoid bone
Platysma muscle

Buccinator muscle
Intrinsic tongue muscles
Masseter muscle
Hyoglossus muscle
Sublingual space Genioglossus muscle

Mylohyoid muscle
Geniohyoid muscle
Platysma

Lingual septum

Buccinator muscle
Intrinsic tongue muscles

Sublingual space
Genioglossus muscle
Mylohyoid muscle
Geniohyoid muscle
Anterior belly of digastric muscle

Platysma muscle Root of tongue

(Top) In this sagittal T1 MR image the full extent of the genioglossus muscle can be seen extending cephalad in a fan
shape from its attachment to the posteroinferior mandible. Notice that it is difficult to distinguish the mylohyoid,
geniohyoid and inferior genioglossus muscles. (Middle) More posterior coronal Tl MR reveals the oral tongue
superomedial to mylohyoid muscle. Again the 3 stacked muscles (mylohyoid, geniohyoid and genioglossus) are
difficult to distinguish. Remember that the sublingual spaces lie lateral to the genioglossus muscles and superolateral
to the mylohyoid muscle. (Bottom) In this more anterior coronal Tl MR image, 4 muscles can be identified from
inferior to superior, namely the anterior belly of digastric, mylohyoid, geniohyoid and genioglossus muscles. Notice
also the root of tongue area. II
28'>
 TONGUE
.c AXIAL T2 MR
>
Ci3
U
~ Lingual septum
o
Genioglossus muscle
Buccinator muscle

Intrinsic tongue muscles

Lingual tonsil

Medial pterygoid muscle Palatine tonsil

Styloglossus muscle Pharyngeal constrictor muscle

Stylopharyngeus muscle Posterior belly of digastric

muscle

Lingual septum

Genioglossus muscle
Mylohyoid muscle
Hyoglossus muscle

Intrinsic tongue muscles

Palatoglossus muscle

Styloglossus muscle
Stylopharyngeus muscle Pharyngeal constrictor muscle

Posterior belly of digastric muscle

Lingual septum

Genioglossus muscle
Mylohyoid muscle

Hyoglossus muscle
Hyoglossus-styloglossus muscles
merging Palatoglossus muscle
Styloglossus muscle

Stylopharyngeus muscle
Pharyngeal constrictor muscle
Posterior belly digastric muscle

(Top) First of six axial T2 MR images of the oral tongue are presented from superior to inferior. In this first most
superior MR image the superior aspect of the oral tongue is seen. The intrinsic muscles, especially the transverse
group is well seen with just the top of the genioglossus muscle visible. The stylopharyngeus muscle is seen in its
expected location just medial to the medial pterygoid muscle. The styloglossus is identified melding with the
pharyngeal constrictor muscle. (Middle) On this inferior image the hyoglossus upper margin is seen rising into the
posterior sublingual space. The genioglossus is now readily apparent on either side of the fibrofatty lingual septum.
(Bottom) In this image the styloglossus can be seen merging with the hyoglossus (labeled on patient's right). The
II palatoglossus is now visible along anterior margin of palatine tonsil.
286
 TONGUE
AXIAL T2 MR

Lingual septum

Genioglossus muscle

Mylohyoid muscle
Hyoglossus muscle
o
Palatoglossus muscle
Medial pterygoid muscle CJ
<
Posterior belly digastric muscle Pharyngeal constrictor muscle

Root of tongue
Mylohyoid muscle cleft Genioglossus muscle

Mylohyoid muscle
Hyoglossus muscle

Submandibular gland

Posterior belly digastric muscle

Pharyngeal constrictor

Anterior belly digastric muscle

Root of tongue
Platysma muscle

Mylohyoid muscle Hyoglossus muscle

Submandibular gland
Epiglottis

(Top) At the level of the mandibular teeth roots the posterior belly of the digastric muscle is seen passing deep to the
most inferior aspect of the medial pterygoid muscle on the patient's right. The posterior belly of digastric muscle is
larger and more inferior than the styloglossus muscle. (Middle) In this image the mylohyoid muscle has left the
mylohyoid ridge of the mandible. A prominent mylohyoid muscle cleft is present on the patient's right. The area of
the root of tongue is labeled. (Bottom) This most inferior image shows the convergence of the anteroinferior
genioglossus muscle with the geniohyoid muscle to form the area of the root of the tongue. The origins of the
hyoglossus muscles are also seen rising off the hyoid bone. The free margin of the epiglottis is visible within the
pharyngeal airway. II
287
 RETROMOLAR TRIGONE
o Fascia made up of focally thickened middle layer of
ITerminology deep cervical fascia
~ Abbreviations o Middle layer of deep cervical fascia runs along
superficial margin of buccinator muscle and along
o
"-
• Retromolar trigone (RMT)
• Pterygomandibular raphe (PMR) deep and lateral margins of superior constrictor
• Oral mucosal space/surface (OMS) muscle

Definitions
• RMT: Triangle-shaped area of mucosa posterior to last IAnatomy-Based Imaging Issues
mandibular molar that covers anterior surface of lower
ascending ramus of mandible Key Concepts or Questions
• PMR: Thick fascial band that extends between • Retromolar trigone SCCa can spread in multiple
posterior border of mandibular mylohyoid ridge and directions
hamulus of medial pterygoid plate o Posterior spread of SCCa: May involve mandibular
o Fascial band represents thickening of middle layer of ramus, masticator space and perineural CNV3
deep cervical fascia condensed between posterior o Anterior spread of SCCa: Along alveolar ridge
margin of buccinator muscle and anterior margin of o Inferior spread of SCCa
superior constrictor muscle • If directly into mandible may extend anteriorly
via perineural spread along inferior alveolar nerve
• If along caudal spread along PMR, reaches
I Imaging Anatomy posterior mylohyoid line of mandible and thereby
posterior margin of mylohyoid muscle
Overview o Superior spread of SCCa: Cephalad spread along
• Pterygomandibular raphe lies beneath mucosa of PMR to inferior margin of medial pterygoid plate at
retromolar trigone hamulus
• If retromolar trigone is affected by squamous cell
carcinoma (SCCa), PMR is involved early Imaging Recommendations
• PMR provides both inferior and superior routes of • CECT provides both soft tissue and bone information
spread for SCCa o May be severely degraded by dental amalgam
artifact
Extent • MR less affected by dental amalgam artifact in most
• RMT extent cases
o Cephalad tip is at level of base of pterygoid plate o Reserve for invasive retromolar trigone SCCa
o Base of mucosal triangle is posterior margin of last o Axial T2 and Tl fat-saturated enhanced MR
mandibular molar tooth sequences best for evaluation of cephalad PMR
• PMR extent
o Fascial band extends from posterior border of Imaging Pitfalls
mylohyoid ridge of mandible to hamulus of • Dental amalgam artifact on CECT may obscure RMT
medial pterygoid plate primary SCCa primary site ± spread along PMR in
cephalad direction
Anatomy Relationships o Key CT observation
• Retromolar trigone relationships • Always check above CT artifact in oral cavity in
o Deep to RMT mucosa & posterior mandibular body area of cephalad PMR (inferior margin of
o Also covers anterior surface of inferior mandibular pterygoid plate) for evidence of tumor spread if
ramus primary RMT SCCa is known to be present
• PMR can be located at line of junction between
buccinator (posterior margin) muscle and superior
constrictor muscle (anterior margin) I Clinical Implications
Internal Structures-Critical Contents Clinical Importance
• Retromolar trigone • SCCa of RMT may spread along PMR
o Paired triangle-shaped mucosal surface in o Cephalad spread along PMR takes tumor up to
posterolateral oral cavity inferolateral pterygoid plate-anteromedial
• Pterygomandibular raphe masticator space
o PMR forms line of attachment for buccinator and • Tumor is seen at level of inferior pterygoid plate
superior constrictor muscles involving posterior buccinator muscle and
o Represents junction of oropharynx posteriorly and anterior superior constrictor muscle
oral cavity anteriorly • Enlarging tumor involves maxillary sinus, buccal
o Lies between anterior tonsillar pillar & retromolar and masticator spaces
trigone o Caudal spread along PMR takes tumor inferiorly to
posterior margin of mylohyoid muscle
Fascia
• Enlarging tumor in this location involves floor of
• PMR: Thick fascial band formed at junction of mouth of oral cavity
buccinator and superior constrictor muscles

II
288
o

II
289
 RETROMOLAR TRIGONE
C AXIAL T2 MR
>
C\l
U

Maxillary alveolar ridge

Buccinator muscle
Masseter muscle
Pterygomandibular raphe,
Temporalis muscle cephalad attachment

Medial pterygoid muscle

Hamulus of medial pterygoid

plate

Maxillary alveolar ridge Buccinator muscle

Pterygomandibular raphe

Medial pterygoid muscle Superior pharyngeal constrictor

muscle

Longus colli/capitis muscle

Buccinator muscle
3rd mandibular molar
Retromolar trigone

Ramus of mandible

Superior pharyngeal constrictor

Medial pterygoid muscle

(Top) First of three axial T2 MR images presented from superior to inferior. This most superior image shows the point
of attachment of the pterygomandibular raphe to the hamulus of the medial pterygoid plate. (Middle) On this more
inferior image the buccinator can be seen meeting the superior pharyngeal constrictor muscle at the
pterygomandibular raphe. The raphe itself is difficult to visualize. (Bottom) At the level of the mandibular alveolar
ridge the area of the retromolar trigone can be outlined. Notice it is found directly behind the mandibular 3rd molar
tooth. The buccinator is seen along its lateral margin while the superior pharyngeal constrictor can be seen
approaching its medial margin. Just above this slice these two muscles meet at the pterygomandibular raphe.
II Squamous cell carcinoma of the retromolar trigone often spread cephalad along this raphe.
290
 RETROMOLAR TRIGONE
AXIAL T1 MR

Maxillary alveolar ridge

Buccinator muscle

Pterygomandibular raphe,
o
Temporalis muscle tendon
cephalad attachment

Medial pterygoid muscle

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Hamulus of medial pterygoid
plate

Mandibular teeth

Buccinator muscle
Oral tongue

Pterygomandibular raphe

Ramus of mandible

Mandibular foramen Superior constrictor muscle

Medial pterygoid muscle Palatine tonsil

Mandibular alveolar ridge

Buccinator muscle

3rd mandibular molar tooth

Retromolar trigone
Mandibular ramus

Inferior alveolar nerve Superior pharyngeal constrictor

muscle

Palatine tonsil

(Top) First of three axial Tl MR images through oropharynx-oral cavity presented from superior to inferior. On this
most superior image the buccinator can be seen inserting at the inferolateral margin of the pterygoid plate with the
most superior aspect of the pterygomandibular raphe. (Middle) Inferiorly at the level of the mandibular teeth the
buccinator and the superior constrictor muscle meet at the pterygomandibular raphe. The superior constrictor
muscle cannot be differentiated from the palatine tonsil on Tl images. (Bottom) On this most inferior image at the
level of the mandibular alveolar ridge the area of the retromolar trigone is outlined on the patient's left. Note that
the retromolar trigone is found directly behind the 3rd mandibular molar tooth. Squamous cell carcinoma can spread
up the pterygomandibular raphe from this location. II
291
 MANDIBLE AND MAXILLA
I Terminology
Abbreviations
• Mandible (Md)
• Maxilla (Mx)
Definitions
• Angle of mandible: Obtuse angle of Md where inferior
segment of ramus becomes contiguous with posterior
mandibular body
Ilmaging Anatomy
Internal Structures-Critical Contents
• Mandible anatomy: Bony
o 2 vertical rami attached to horizontal,
horseshoe-shaped body
o Each ramus has 2 upwardly directed processes
• Condylar process: Condylar head and neck
contains articular surface of TMJ
• Coronoid process: Temporalis muscle inserts here
• Mandibular notch separates these 2 processes
• Mandibular ramus divides masticator space into
lateral and medial compartments
o Mandibular foramen
• Location: Center, medial surface of Md ramus
• Nerve transmitted: Inferior alveolar nerve
• Lingula: Small, osseous lip extending from
anterior aspect of mandibular foramen
o Mandibular body
• U-shaped, horizontal body composed of 2 halves;
fuses in anterior midline at symphysis menti
• Alveolar process consists of external buccal &
internal lingual plates, covered by periosteum
• Mental foramen: Paired external openings of
mandibular canal that transmits mental nerve
• Mylohyoid ridge: Bony ridge on lingual Md body;
site of attachment of mylohyoid muscle
o Mandibular canal
• Lies within distal ramus and proximal body of Md
• Extends from mandibular to mental foramen
• Contains inferior alveolar nerve and vessels
• Mandible anatomy: Nerves
o Inferior alveolar nerve
• Extends from mandibular foramen, through
mandibular canal to mental foramen
• Innervates ipsilateral premolars and molars
• Divides into mental and incisive branches
o Mental nerve
• Exits mental foramen
• Provides sensory innervation to skin and mucosa
of lower lip and labial gingiva
o Incisive nerve
• Innervates ipsilateral canine and incisors
• Maxillary alveolar and palatine processes: Bony
o Represents inferior aspect of maxillary bone
o Maxillary alveolar ridge (arch)
• Adult version contains 16 teeth
o Premaxilla: Anterior hard palate and alveolar ridge
• Contains incisive foramen (nasopalatine nerve)
• Paired nasopalatine canals terminates as single
incisive foramen
II
292
o Palatine process of maxillary bone
• Forms anterior 2/3 of hard palate
o Posterior 1/3 hard palate formed by horizontal plate
of palatine bone
• Maxillary alveolar and palatine processes: Nerves
o Nasopalatine nerve (V2 sensory branch) travels
through incisive foramen
• Supplies sensory fibers to anterior hard palate
o Greater palatine nerve comes down greater
palatine canal in palatine bone
• Supplies sensation to posterior 2/3 of hard palate
• Exits greater palatine foramen anteriorly to hard
palate mucosa
o Lesser palatine nerve also comes down lesser
palatine canal in palatine bone
• Exits lesser palatine foramen posterior to greater
palatine foramen
• Supplies sensory fibers to palatine tonsil
• Dental anatomy, mandible and maxilla
o 32 total permanent teeth in Md (16) and Mx (16)
• Each tooth has crown, root and pulp
o 16 adult teeth in each "dental arch"
• Each arch consists of 2 quadrants
• Each quadrant contains 3 molars, 2 premolars, 1
canine, 1 lateral incisor, and 1 medial incisor
o Teeth numbering convention
• Maxillary alveolar ridge: Begin with right 3rd
molar, 1-16 across to left 3rd molar
• Mandibular alveolar ridge: Begin with left 3rd
molar, 17-32 across to right 3rd molar
o Each tooth crown has 3 rings: Outer enamel
surrounding dentin; pulp in center
• Enamel: Densest material in body
• Dentin: Encases pulp
• Pulp: Nourishes the dentin
o Tooth root covered by cementum
• Cementum acts as a medium for attaching fibers
of periodontal ligament to tooth
• Periodontal ligament located in periodontal space
• Periodontal space is radiolucency surrounding
tooth root
IAnatomy-Based Imaging Issues
Key Concepts or Questions
• V2 perineural malignant tumor
o If malignancy affects skin of upper lip, hard palate,
soft palate, check for V2 perineural tumor (PNT)
o Major locations to identify V2 PNT extend from
incisive canal-greater palatine foramen to root entry
zone of V in lateral pons
o If imaging for V2 PNT, check incisive canal, greater
and lesser palatine foramen, pterygopalatine canal
and fossa, foramen rotundum, Meckel cave,
preganglionic segment of CNS, and root entry zone
• V3 perineural malignant tumor
o If malignant tumor of skin of chin, mandibular
alveolar ridge or masticator space, check for V3 PNT
o If imaging for V3 PNT check entire length of V3 to
root entry zone
• Pay special attention to inferior alveolar canal,
mandibular foramen, masticator space
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 MANDIBLE AND MAXILLA
GRAPHIC & BONE CT
Medial incisor
Lateral incisor
Canine tooth
Anterior premolar
Posterior premolar Nasopalatine nerve in incisive
foramen

3 maxillary molar teeth

Tooth # 16, left maxillary molar

o
Tooth #1, right maxillary molar
tooth tooth
Soft palate Greater palatine nerve &
foramen

Lesser palatine nerve &

foramen

Paired incisive canals

Greater palatine foramen

Greater palatine foramen

Lesser palatine foramen

Lesser palatine foramen

Optic canal

Foramen rotundum
Pterygopalatine fossa
Pterygopalatine fossa

Greater palatine canal Greater palatine canal

Greater palatine foramen Greater palatine foramen

Hamulus of medial pterygoid plate

(Top) Axial graphic of hard palate viewed from below with mucosa removed on right side of drawing. Hard palate
sensory innervation is shown on right with anterior 1/3 of hard palate supplied by the nasopalatine nerve, the
posterior 2/3 of the hard palate supplied by the greater palatine nerve. Notice there are 16 adult teeth, numbered
beginning at the right 3rd molar from 1 to 16. (Middle) Axial bone CT image depicts foramina carrying nerves to
hard palate. Anterior paired incisive canals lead to more inferior incisive foramen (not seen). Greater & lesser palatine
foramina transmit greater & lesser palatine nerves respectively. (Bottom) Coronal bone CT through vertical aspect of
greater palatine canal shows this canal connecting pterygopalatine fossa above with greater palatine foramen below.
Greater palatine nerve uses the greater palatine canal to access the palate. II
295
 MANDIBLE AND MAXILLA
C AXIAL BONE CT
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Medial incisor

Lateral incisor Canine tooth

Anterior premolar

Posterior premolar

3 molar teeth

Tooth #1, right 3rd Tooth #16, left 3rd

maxillary molar tooth maxillary molar tooth

Ramus of mandible

Mandibular foramen

Medial incisor

Lateral incisor
Canine tooth

Anterior & posterior

premolar teeth

3 molar teeth,
mandible

Tooth #32, right Tooth #17, left

mandibular 3rd molar mandibular 3rd molar

Inferior mandibular
Inferior alveolar canal ramus

(Top) Axial bone CT at the level of the maxillary ridge delineates the 16 upper teeth. Numbering convention begins
with tooth #1 (upper posterior right molar tooth) extending from there across to the opposite left posterior maxillary
molar which is designated tooth #16. Note there are two each of medial and lateral incisors, canine, anterior and
posterior premolars and three molar teeth. (Bottom) Axial bone CT of the 16 mandibular teeth is shown. Continuing
the numbering convention for the mandibular teeth, the left 3rd molar is considered tooth #17 with numbering
moving across to the opposite right 3rd mandibular molar designated tooth #32. Note again there are paired medial
II and lateral incisors, canines, anterior and posterior premolars and three molar teeth in the mandible.

296
II
297
 PART III
Spine

Vertebral Column, Discs & Paraspinal Muscle

Cord, Meninges and Spaces

Vascular

Plexus
Peripheral Nerves
SECTION 1: Vertebral Column, Discs & Paraspinal Muscle

Vertebral Column Overview 11I-2

Ossification 11I-10
Vertebral Body and Ligaments 11I-26
Intervertebral Disc & Facet Joints 11I-42
Paraspinal Muscles III-SO
Craniocervical Junction III-56
Cervical Spine 11I-74
Thoracic Spine 11I-92
Lumbar Spine 11I-104
Sacrum and Coccyx 1II-118
 VERTEBRAL COLUMN OVERVIEW
• Meninges
ITerminology o Single (meningeal) layer of dura
Abbreviations o Arachnoid (continuous with cranial arachnoid,
loosely adherent to dura)
• C1 (atlas), C2 (axis)
o Pia (covers spinal cord, nerves)
• Atlanto-occipital (AO)
• Anterior, posterior longitudinal ligaments (ALL, PLL) • Vasculature
o Arteries: Segmental arteries arise as dorsal rami from
vertebral, subclavian, intercostal arteries
o Veins: V-shaped basivertebral veins connect with
I Gross Anatomy valveless epidural venous plexus; extensive
<J)
Overview anastomoses with cavae, azygos/hemiazygos systems
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• Normally 33 spinal vertebrae (varies from 32-35)
o, o 7 cervical (most constant); 12 thoracic; 5 lumbar
I Imaging Anatomy
o 5 sacral elements fuse -+ sacrum
c
o 4-5 coccygeal elements -+ coccyx (most variable)
E • Classic anatomic division into anterior (vertebral
Overview
::J
body), posterior elements (neural arch) • MR
o • "Three columns" concept (used by spine surgeons)
o Body: Signal intensity of marrow varies with age
U • Hemopoietic ("red") marrow is hypointense on
o Anterior column
riJ 1'1WI, becomes hyperintense with conversion
•... • Anterior half of vertebral body/disc/annulus
from red -+ yellow (age 8-12 years)
..D. • ALL
Q) • End-plate, reactive marrow changes normally with
......,
•...
Q)
o Middle column
aging (can be fibrovascular, fatty, or sclerotic)
• Posterior half of vertebral body/disc/annulus
> • PLL
o Intervertebral disc: Signal intensity varies with age
• Hyperintense on T2WI in children, young adults;
Q) o Posterior column
c progressive! water -+ hypointense on T2WI
a.
• Posterior elements (pedicles, facet joints, laminae,
spinous processes) • Disc degeneration, dessication, shape change ..
rJ)
• Ligamentum flavum (bulge) normal after second decade
• Interconnecting ligaments (interspinous, etc.) o Ligaments: Hypointense on both 1'1 & T2WI
o Nerves: No enhancement until reach dorsal root
Components ganglia, where they loose blood-nerve barrier
• Bones o Meninges: Dura, basi-/epidural veins enhance
o Body: Cylindrical ventral bone mass
o Arch: Composed of 2 pedicles, 2 laminae, 7
processes (1 spinous, 2 transverse, 4 articular) IAnatomy-Based Imaging Issues
• Pedicles: Extend from dorsolateral body to unite
with pair of arched, flat laminae Imaging Recommendations
• Laminae: Arch over canal, join at midline to • CT: Use both bone, soft tissue algorithms; sagittal,
dorsal projection (spinous process) coronal reconstructions helpful
• Transverse processes: Arise from sides of arch • MR: Use STIR, fat-sat 1'1 C+ scans for marrow disorders
• Articular processes: Each has superior process o Standard planes = axial/sagittal but coronal useful in
(with facet directed dorsally), inferior process elderly, scoliotic patients
(facet directed ventrally), pars interarticularis o Obtain axial scans through discs using coronal
(between facets) localizer for scoliotic patients
• Intervertebral disc
Imaging Pitfalls
o Composed of inner nucleus pulposus, outer annulus
fibrosus • Classic number (7-12-5-5-4) found in only 20%
o Adhere to hyaline cartilage of vertebral endplates • Foc.i of 1'1 hyperintensity (focal fatty marrow deposits,
o Avascular (except in young children and peripheral InCIdental hemangiomas) are common & normal
annular fibers in adults) • Vertebral marrow in middle-aged, elderly patients may
• Ligaments appear very inhomogeneous
o ALL
• Fibrous band along entire ventral surface of spine
• Skull to sacrum I Embryology
o PLL
Embryologic Events
• Dorsal surface of vertebral bodies
• Skull to sacrum • Cranial half of C1, occipital sclerotomes combine -+
occiput
o Craniocervicalligaments
o Interspinous ligaments o C1 exits below occiput, above C1 ring
• Nerves (31 pairs) • Lower half of upper, upper half of lower sclerotomes
o 8 cervical, 12 thoracic combine -+ vertebral bodies
o 5 lumbar (exit above disc, below pedicle) o C8 exits below lowest cervical vertebra (C7)
o 5 sacral, 1 coccygeal o All thoracic and lumbar nerves arise below their
respective pedicles

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 VERTEBRALCOLUMN OVERVIEW
CORONAL NECT CJl
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Lumbar inferior process
articular process Lumbar facet joint

Iliac wing

(Top) First of four coronal reformatted CT images shows the dorsal aspects of the spinal column. Spinous processes
are seen as ovoid bony corticated densities, with the symmetrical costovertebral joints surrounding each posterior
element. The more anterior section through the lumbar regions shows the junction of the spinous process with the
lamina, and the lumbar facet joints. (Bottom) Section more anteriorly shows the appearance of the laminae and
costotransverse joints that lie superolateral to the laminae. Inferiorly the lumbar region demonstrates the facet joints
and the opposed superior and inferior articular processes.
III
7
 VERTEBRAL COLUMN OVERVIEW
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Thoracic vertebral
Thoracic intervertebral bodies
disc

Lumbar intervertebral
disc
Lumbar vertebral
bodies
Sacroiliac joint

Sacral ala
Sacral foramen

(Top) Image through the pedicles shows the width of the bony spinal canal in the thoracic and lumbar segments.
The medial rib heads and pedicles are seen as paired ovoid bony densities on either side of midline. The transition to
the lumbar spine is defined by the lack of medial rib component, and a large horizontally directed transverse process.
(Bottom) Image through the mid-vertebral body level shows the rectangular shaped bodies of the thoracic and
lumbar segments. The costovertebral joints are present in the thoracic spine centered at the disc levels since they
attach to two adjacent vertebral bodies with demifacets. The thick and stout lumbar bodies are seen atop the
III triangular shaped sacrum with the ventral directed sacral neural foramina.

8
 VERTEBRAL COLUMN OVERVIEW
SAGITTAL T2 MR & CT MYELOGRAM "'0
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bodies
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(Top) Sagittal T2 MR image of the entire spine shows the general morphology of the spinal canal and spinal cord.
The cord follows the gentle undulating course of the two upper spinal curves to end at the conus medullaris around
the 11 level. The multiple roots of the cauda equina descend from the distal cord to their exiting foramen in the
lumbar and sacral spines. (Bottom) Sagittal midline CT myelogram is shown for comparison with the overview T2
MR "myelogram". Both provide excellent visualization of the spinal cord and subarachnoid space. Normal filling
defects seen on myelography are typically due to denticulate ligaments and septum posticum whereas on MR they
are artifacts caused by inhomogeneous cerebrospinal fluid flow and spin dephasing. III
9
 OSSIFICATION
• Plus 1° ossification centers for two costal processes
I Gross Anatomy • These appear by 6 months of age
Overview • Fuse with transverse process, vertebral body by 5-6
• Primary (1°) ossification center years
o Primary focus of spinal ossification • If remain unfused --. cervical ribs (1 %)
o At site of blood vessel invasion of future vertebrae • Thoracic (Tl-12)
cartilaginous model o Three 1° ossification centers per vertebra
o Present at birth • Centrum (1), posterior vertebral neural arch (2)
• Secondary (2°) ossification center o Five 2° ossification centers per vertebra
o Secondary focus of spinal ossification • Spinous process apex (1), transverse process apex
<Jl
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• Ring (annular) apophysis • Lumbar (Ll-5)
o o 2° ossification of superior/inferior centrum edges o Three 1° ossification centers per vertebra
~ o Separated from remainder of vertebral body by thin • Centrum (1), posterior vertebral neural arch (2)
c o Seven 2° ossification centers per vertebra,
E hyaline cartilage rim
• Spinous process apex (1), transverse process apex
::J o Appears between 6-8 years (girls) to 7-9 years (boys)
(2), annular epiphysis (2), base of mamillary
o o Coalesces by ~ 21 years into single ring
o Fusion with vertebral body (age 14-21 years) --. processes (2)
U
longitudinal growth stops • Sacrum (Sl-5)
Ci:l o Five 1° ossification centers per vertebra
'- • Synchondrosis
..D o Cartilaginous junction between nonmobile vertebral • Centrum (1), posterior neural arch (2), costal
...-(J)'- articulating surfaces element remnants (2)
(J) o Neurocentral suture = synchondrosis between o Four 2° ossification centers
> vertebral centrum, neural arches • Sacroiliac (SI) joint epiphyseal plates (fuse ~ 25
years)
Q)
c: • Coccyx (Co1-Co4)
o Col has three 1° ossification centers: Centrum (1),
C.
trJ
I Imaging Anatomy cornua (2)
Overview o C02-C04 have one 1° ossification center each
• General ossification patterns o Col ossifies shortly following birth; remaining
o Centrum ossification coccygeal vertebra ossify into 3rd decade
• Starts at lower thoracic/upper lumbar spine of o No 2° ossification centers
fetus
• Moves in both cranial, caudal directions
o Neural arch ossification IAnatomy-Based Imaging Issues
• Begins at cervicothoracic level --. upper cervical --.
Key Concepts or Questions
thoracolumbar
o At birth most vertebrae have three 1° and five 2° • Centrum smaller than adult vertebral body
ossification centers connected by hyaline o Centrum --. central vertebral body
synchondroses o Anterior extent of neural arch --. posterolateral
o Exceptions to typical ossification occur at Cl, C2, vertebral body
C7, lumbar vertebra, sacrum, coccyx • Progression of synchondrosis closure important for
imaging interpretation
• Atlas (C1)
o Cl
o Two to five (3 most common) 1° ossification centers
• Anterior arch (I), posterior arch (1) + lateral • Anterior Cl arch: 8-12 months
masses (2) • Posterior Cl arch: 1-7 years
o No 2° ossification centers • Cllateral masses: 7-9 years
o C2
• Axis (C2)
o Five 1° ossification centers • Odontoid: C2 body: 3-7 years
• Centrum (1), posterior vertebral neural arch (2), • Superior odontoid center appears ~ 2-6 years,
odontoid process (2) fuses ~ 11-12 years
• Dens separated from C2 centrum by remnant of • Posterior C2 synchondrosis: 4-7 years
embryonic CI-2 disc o Below C2
o Two 2° ossification centers • Neurocentral synchondrosis closes ~ 3-7 years,
• Inferior annular epiphysis, apex of odontoid posterior synchondrosis ~ 4-7 years
• C3-6 Imaging Pitfalls
o Three 1° ossification centers per each vertebra • Symmetry, location, corticated margins, patient age
• Centrum (1), posterior vertebral neural arch (2) help distinguish open synchondrosis from fracture
o Five 2° ossification centers per each vertebra • Cervical vs. thoracic ribs: Transverse processes oriented
• Spinous process apex (1), transverse process apex inferiorly in cervical, superiorly in thoracic spine
(2), annular epiphysis (2)
• C7
o Same 1°/2° ossification centers as C3-6

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 OSSIFICATION
Q) AXIAL BONE CT, ATLAS (C1) VERTEBRA
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Odontoid processes (C2)

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Neural arch/lateral mass

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c:
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Neural arch Neural arch

Synchondrosis

Odontoid process (C2)

Fused odontoid synchondrosis

Transverse foramen

(Top) Axial bone CT of a 2 week old female demonstrates the three atlas 1 ossification centers. Much of the atlas is
0

unossified cartilage at this age. The odontoid process ossification centers (C2) are identified posterior to the C1
anterior arch. (Middle) Composite image from two contiguous axial bone CT images of C1 of a 14 month old male
shows further development of the three 1 ossification centers. The synchondroses between the centrum and
0

posterior neural arches are smaller. (Bottom) Axial bone CT of the atlas of a 6 year old female shows fusion of the
anterior and posterior neural arch 1 ossification centers to form a complete C1 ring. Note that the two C2 odontoid
0

process 1 ossification centers show residual sclerotic line at the synchondrosis.

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III
14
 OSSIFICATION
AXIAL BONE CT, AXIS (C2) VERTEBRA

Neurocentral synchondroses

Centrum
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Neural arch Neural arch

Cl-2 disc remnant

Transverse foramen

Spinous process

(Top) Axial bone CT of a 2 week old female demonstrates the three axis 1 ossification centers separated by
0

synchondroses. (Middle) Axial bone CT of a 4 year old male demonstrates progressive ossification of the three axis 10

ossification centers. Note that the centrum comprises only the central vertebral body, while the anterior portion of
the neural arches form the lateral vertebral body. The posterior arch synchondrosis is fused. (Bottom) Axial bone CT
of a 10 year old male shows fusion of the 1 ossification centers by closure of the neurocentral synchondroses.
0

Sclerosis at the dens base indicates ossification within the rudimentary Cl-2 intervertebral disc remnant joining the
odontoid process to the C2 centrum.
III
15
 OSSIFICATION
Q.) CORONAL BONE CT, AXIS (C2) VERTEBRA
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Centrum

Occipital condyle

Odontoid process Cllateral mass

Cl·2 intervertebral disc remnant

(Top) Coronal bone CT of the upper cervical spine of a 2 week old female shows the three cervical vertebra 1 0

ossification centers and two 1 odontoid ossification centers. The dens tip is cartilaginous at this developmental
0

stage. (Middle) Coronal bone CT of the cervical spine of a 4 year old male shows progressive ossification of the
centrum and neural arches connected by thin synchondroses. The characteristic location, symmetry, and well
corticated margins of the synchondroses helps distinguish them from fracture. Note that the ossified odontoid tip 2 0

ossification center is now visible. (Bottom) Coronal bone CT of a 10 year old male shows fusion of the
synchondroses. The Cl·2 intervertebral disc remnant separating the dens from the C2 centrum remains visible as a
III sclerotic line.
16
 OSSIFICATION
AXIAL & SAGITTAL BONE CT, CERVICAL (C3-6) VERTEBRA

Centrum

Neurocentral synchondrosis Neural arch

Neural foramen n
o
c
3
:J

o
(fl
(")
Synchondrosis (fl

Spheno-occipital synchondrosis

Basisphenoid
~
Basiocciput Odontoid tip 2° ossification C
(fl
center (")

CD
Spinous process

Fused neurocentral synchondrosis Fused neurocentral

synchondrosis

Transverse foramen

(Top) Axial bone CT of CS of a 2 week old female demonstrates neurocentral synchondroses and synchondrosis
junction of the neural arches. Note that the lateral vertebral body arises from the neural arches. (Middle) Sagittal
bone CT of a 6 year old male demonstrates the normal appearance of the mid-cervical vertebra. The wide
intervertebral distance between the ossified centrums represents the intervertebral discs and nonossified annular
epiphysis 2° ossification centers. There is normal sclerosis at the fusion of the odontoid process to the C2 centrum.
The odontoid tip persists as a separate 2° ossification center. (Bottom) Axial bone CT of a mid-cervical vertebra of a 6
year old female shows complete synchondrosis fusion, with only a faint sclerotic line visible at the site of the fused
neurocentra I synchondroses. III
17
 OSSIFICATION
Q) AXIAL BONE CT, C7 VERTEBRA
U
Vl
::J
~

Neurocentra! synchondrosis

Centrum
Posterior neural arch

Transverse process
Vl
U
Vl

o,
c
E
::J
o
U

Neurocentra! synchondrosis
Neurocentra! synchondrosis

Neura! foramen

Transverse process 2° ossification

center

Transverse process 2°
ossification center

(Top) Axial bone CT of a 7 week old female demonstrates the normal appearance of C7. The transverse processes are
characteristically longer than the other cervical vertebra, assisting identification of C7. (Middle) Axial bone CT of a 4
year old male demonstrates posterior fusion of the neural arches. The neurocentra I synchondrosis is faintly apparent.
The transverse process tip 2° ossification centers are visible. (Bottom) Axial bone CT of a 6 year old female shows
synchondrosis fusion between the centrum and posterior neural arches. The synchondrosis between the transverse
process tip 2° ossification center and neural arch transverse process remains open (normally closes at puberty).

III
18
 OSSIFICATION
AXIAL BONE CT, THORACIC VERTEBRA

Centrum

Neurocentral synchondrosis Neurocentral synchondrosis n

o
c
Posterior neural arch Posterior neural arch
3
,:J

o
V'l
Synchondrosis n
V'l

~
C
V'l
n
([)
Centrum
Neurocentral synchondrosis Neurocentral synchondrosis

Neural arch Neural arch

Rib head 2° ossification center Rib head 2° ossification center

(Top) Axial bone CT of a 3 day old male demonstrates the three 1° ossification centers + synchondroses seen in a
typical thoracic vertebra. (Middle) Axial bone CT of a 2 year old female shows narrowing of the neurocentra I
synchondroses and enlargement of the ossified centrum. The rib 2° ossification centers have not yet appeared.
(Bottom) Axial bone CT of a 13 year old male shows fusion of the neurocentral and transverse process 2° ossification
center synchondroses. The rib head 2° ossification centers are now ossified.

III
19
 OSSIFICATION
Q) AXIAL BONE CT, LUMBAR VERTEBRA
u
l/)
:J
~

Centrum
Neurocentra! synchondrosis Neurocentra! synchondrosis
l/)
U
l/)
Neural arch Neural arch
o,
c
E
:J Synchondrosis
o
U
(1j
•....
..D
Q)
+-'
•....
Q)

>
Q)
c: Centrum
0.. Neurocentral synchondrosis
lJ) Neurocentra! synchondrosis

Posterior neural arch Posterior neural arch

Transverse process Transverse process

Transverse process 2°
ossification center
Transverse process 2° ossification
center

(Top) Axial bone CT of a 4 day old male demonstrates the three 1 vertebral ossification centers and synchondroses
0

in a typical lumbar vertebra. (Middle) Axial bone CT of L1 of a 2 year old male shows maturational development of
the 1 ossification centers and neurocentra I synchondroses. The transverse process 2° centers are not yet ossified.
0

(Bottom) Axial bone CT of L2 of a 13 year old male shows completed fusion of the 1° synchondroses. The transverse
process 2° ossification centers are ossified but not yet fused to the transverse processes.

III
20
 OSSIFICATION
AXIAL BONE CT, SACRUM

Centrum (Sl)
Costal element remnant n
Costal element remnant o
c
Iliac wing Iliac wing :3
::J
Centrum (S2)
o
V">
n
Neural arch Neural arch V">

~
C
Centrum V">
n
(!)
Costal element remnant Costal element remnant

Neural arch Neural arch

Fused synchondrosis
Fused synchondrosis
S1 joint

Synchondrosis

(Top) Axial bone CT of 52 of a 3 day old female shows the five 1 ossification centers (centrum, costal element
0

remnants, neural arches) present at birth, separated by synchondroses. Both the 51 and 52 centrums are visible in
this single slice because of the oblique angulation of the sacrum relative to the axial CT slice. (Middle) Axial bone CT
of the sacrum of a 2 year old male shows typical configuration of the five 1 sacral ossification centers. The 51 joints
0

appear widened because the 51 joint epiphyseal plates are not yet ossified. (Bottom) Axial bone CT of the sacrum of a
16 year old female demonstrates closure of the synchondroses and completed ossification of the 1 and 2
0 0

ossification centers. The site of the synchondroses persist as faint sclerotic lines.
III
21
 OSSIFICATION
Q) SAGITTAL BONE CT, COCCYX
u
<fl
:J
~

<fl
U
Sl
<fl

o
c
E
:J
o
U
<i:l
~
...0
Q) S5
.•....
~
Q)

>
Q)
Co1-Co3
c:
Cl.
IJl

Sl

Sacral hiatus

S5

Co1-Co3

(Top) Sagittal bone CT of the sacrum and coccyx of a 24 month old female demonstrates ossification of the five
sacral vertebra. The first three coccygeal vertebra show ossification in the primary ossification centers only. The
underlying cartilaginous model is visible as soft tissue density containing the ossified centrums. (Bottom) Sagittal
bone CT of the sacrum and coccyx of a 16 year old female. Note the more mature appearance of the five sacral
vertebra and first three coccygeal vertebra.

III
22
n
o
c
:3
,:J
o
tr>
n
tr>

~
C
tr>
n
(D

III
23
 OSSIFICATION
Q) SAGITTAL T1 MR
u
<Jl
:J
~

Basivertebral venous plexus Central vertebral ossification

center

Intervertebral disc Cartilage end plates from

adjacent vertebrae
<Jl
U
<Jl

o, Complete vertebral body

c
E
:J
o
U
Ci3
•....
...0
Q)
.•.....
•....
Q)

>
Q) Basivertebral venous plexus
C Central vertebral ossification
c.. Intervertebral disc center
lJ)

Cartilage endplates from

adjacent vertebrae
Complete vertebral body

Central vertebral ossification

center
Intervertebral disc

Cartilage endplates from

adjacent vertebrae

Complete vertebral body

(Top) Sagittal Tl MR in 4 day old infant shows characteristic appearance of vertebrae & intervening disc. The central
vertebral ossification center is markedly hypointense & contains a linear horizontal hyperintense cleft from the
developing basivertebral venous plexus. The very prominent cartilaginous endplates are hyperintense & separated by
hypointense disc. (Middle) Sagittal T1 MR in 5 month old infant showing gradual increasing signal within the ovoid
vertebral ossification center, and decreasing prominence of the hyperintense cartilage endplates. (Bottom) Sagittal Tl
MR in 1 year old infant shows continued increasing signal within the vertebral ossification center which now has a
more rectangular shape. The cartilage end plates are less prominent & have continued decreased signal relative to the
III vertebral ossification center.
24
 OSSIFICATION
SAGITTAL T2 MR ""0
fJ)

:::l
ro
<
CD
....•
r-+
CD
cr-
....•
cu
n
Intervertebral disc o
Cartilage endplates c
3
,:J
Vertebral ossification center o

Basivertebral vein

~
Intervertebral disc C
(J)
n
CD
Vertebral body

Basivertebral vein

Vertebral body

Intervertebral disc

(Top) Corresponding sagittal T2 MR in same 4 day old infant shows very hypointense central ossification centers,
mildly hyperintense cartilage endplates & hyperintense intervertebral discs. (Middle) Corresponding sagittal T2 MR
in same 5 month old infant shows increasing signal within the central vertebral body which are now isointense with
the endplates. (Bottom) Corresponding sagittal T2 MR in same 1 year old infant shows similar increasing signal
within the central vertebral body with corticated hypointense margins. The intervertebral disc remains hyperintense.

III
25
 VERTEBRAL BODY AND LIGAMENTS
ITerminology
Abbreviations
• Anterior, posterior longitudinal ligaments (ALL, PLL)
I Gross Anatomy
Overview
• Vertebral body
<Jl
U o Varies in size, shape depending on region
<Jl
o Generally t size from cervical to lumbar, then t
o from sacrum to coccyx
c • Cervical: Upper 7 vertebrae
o C1 (atlas): No body, spinous process; circular shape
E • Anterior, posterior arches; 2 lateral masses;
::J
transverse processes
o o C2 (axis): Body with bony peg (dens/odontoid
U
process)
(Ij
•.... • Large, flat ovoid articular facets
..0 • Broad pedicles, thick laminae
(l)
.•....• • Transverse processes contain L-shaped foramina
•....
(l) for vertebral artery
> o C3-6 similar in size, shape
Q) • Bodies small, thin relative to size of arch
c: • Transverse diameter> AP; triangular central canal
0.. • Lateral edges of superior surface turn upward,
fJ)
form uncinate processes
• Pedicles short, small, directed posterolaterally
• Lateral masses rhomboid-shaped with slanted
superior/inferior articular surfaces
• Transverse processes contain transverse foramina
for VAs
• C3-5 spinous processes usually short, bifid
o C7 marked by longest spinous process
• Thoracic
o Bodies heart-shaped, central canal round
o Pedicles short, directed posteriorly
o Laminae broad/thick
o Spinous processes point caudally, dorsally
o Superior articular processes vertical, flat, face
posteriorly
o T12 resembles upper lumbar bodies with inferior
facet directed more laterally
o Costal articular facets on body/transverse processes
• Articulate with heads of ribs
• T1 has complete facet for first rib, inferior
demifacet for second rib
• Lumbar
o Body large, wide, thick
o Pedicles strong, thick, directed posteriorly
o Laminae strong, broad
o Superior articular processes face dorsomedial
o Inferior articular processes face anterolateral
• Sacrum: Fusion of 5 segments
o Large triangular shaped bone with base, apex, 3
surfaces (pelvic, dorsal, lateral), 2 alae
o Base: Round/ovoid; articulates with L5
o Pelvic surface
• Anterior sacral foramina at lateral ends of ridges
• Concave, crossed by 4 transverse ridges
o Posterior surface
• Median sacral crest in midline
III
26
• Sacral groove on either side of crest
• Intermediate crest lateral to sacral groove
• Posterior sacral foramina lateral to crest
• Lateral crest is lateral to sacral foramina
o Lateral surface: Formed by costal, transverse
processes
• Alae on sides articulate with iliac bone
o Apex: Inferior aspect of S5, articulates with coccyx
• Coccyx: Fusion of 3-5 segments
o Anterior surface concave with transverse ridges
o Posterior surface convex with transverse ridges
o Apex round, directed caudally, may be bifid
• Ligaments
o ALL: Fibrous band on ventral surface of spine from
skull to sacrum
• Firmly attached at ends of each vertebral body
• Loosely attached at midsection of disc
• 3 sets of fibers: Deep span 1 disc; intermediate 2-3
discs; superficial 4-5 levels
o PLL: Dorsal surface of bodies from skull to sacrum
• Attached at discs, margins of vertebral bodies
• Cervical/thoracic: Broad, uniform
• Lumbar: Narrow at body, broad at disc level
o Ligamentum flavum
• Largest elastic ligament in body
• Connects adjacent lamina from C2 to lumbosacral
junction
• Extends from capsule of apophyseal joint to
junction of lamina with spinous process
• Thin, broad in cervical region, thicker in lumbar
o Intertransverse ligaments: Extend between
transverse processes
• Cervical: Sparse or absent
• Thoracic: Stronger associated with muscles
o Interspinous ligaments: Connect adjoining spinous
processes
• Between ligamentum flavum, supraspinous
ligaments
• Strongest in lumbar spine
o Supraspinous ligaments: Extend from tips of
spinous processes from C7 to sacrum
• Fused with dorsal margin of interspinous ligament
• Broader, thicker in lumbar spine
• Merges with ligamentum nuchae in cervical spine
• Ligamentum nuchae extends from external
occipital protuberance to C7
Ilmaging Anatomy
Overview
• Transitional lumbosacral bodies (up to 25% in normal)
o Sacralization of lumbar body: Spectrum extending
from expanded transverse processes of L5
articulating with top of sacrum to incorporation of
L5 into sacrum
o Lumbarization of sacrum: Elevation of Sl above
sacral fusion mass assuming lumbar body shape
o Sacralization and lumbarization may be similar in
appearance, requiring evaluation of entire spinal
axis to define anatomy and correct level
nomenclature
n
o
c
3
:J

o
(Jl
n
(Jl

~
c
(Jl
n
ro

III
27
 OJ
u
lJ)
:J
~

lJ)
u
lJ)

o,
c
E
:J
o
U

III
28
 VERTEBRAL BODY AND LIGAMENTS
CERVICAL RADIOGRAPHY ""0
CJl

::::l
ro

Lateral columns or
"pillars" n
o
c
Uncovertebral joint 3
::J
Uncinate process o
Superior endplate CJl
n
Vertebral body Pedicle CJl

Inferior endplate

Spinous process

~
C
CJl
n
ro

C1 posterior arch

C2 spinous process
C2-3 disc space
Superior end plate Superior articular facet

C3 vertebral body
Inferior articular facet
Inferior end plate

Transverse process

Anterior vertebral body Posterior vertebral

cortical margin body cortical margin

(Top) AP view of the cervical spine. The vertebral bodies show a distinctive shape with their curved lateral margins
with uncinate processes forming the uncovertebral ("Luschka") joints. The pedicles are poorly seen due to their
obliquity to the plane, as are the facet joints. The lateral masses assume a flowing or undulating contour to the lateral
aspects of the spine. The superior and inferior endplates are well-defined. The bifid spinous processes project through
the vertebra body. (Bottom) Lateral view of cervical spine. The superior and inferior vertebral endplates are
well-defined in this projection. The pedicles are poorly seen due to obliquity. The transverse processes overlap the
vertebra bodies and are not well-defined. With proper positioning, the facet joints of each side overlap to merge into III
what appears to be one joint with a well-defined joint space.
29
 VERTEBRAL BODY AND LIGAMENTS
Q)
THORACIC RADIOGRAPHY
U
IJl
:J
~

Intervertebral disc
space

IJl
U Superior endplate
IJl

o, Lateral vertebral body

c Pedicle cortical margin
E Thoracic vertebral body
:J
o Transverse process
U Inferior end plate

~
•....
..D
Q)
+-'
Rib
•....
Q)
Spinous process
>
Q) Lamina
C
0-
CJ')

Inferior cortical margin

of pedicle

Neural foramen

Costovertebral joint

Superior end plate

Anterior vertebral body

1- Co"o"'n'v<~' joint

cortical margin

Thoracic vertebral body Right and left ribs

overlapping
Inferior endplate
Posterior vertebral
Disc space body cortical margin

Pedicle

(Top) AP view of the thoracic spine. The vertebral bodies are square with well-defined cortical margins. The
intervertebral disc spaces are small relative to the lumbar region. The pedicles are visible end on with an oval
configuration. The spinous process are long and obliquely oriented and extend caudally, overlapping the more
inferior vertebral body on this view. (Bottom) Lateral view of the thoracic spine. The anterior and posterior thoracic
body cortical margins are well-defined and maintain a smooth alignment in the vertical direction. The bony
end plates are well-defined, separating the thin intervertebral discs. The region of the costovertebral joints is
III poorly-defined, just anterior to the inferior margin of the neural foramen. The costotransverse joints are seen end on.

30
 VERTEBRAL BODY AND LIGAMENTS
LUMBAR RADIOGRAPHY

Inferior articular
process

n
Superior cortical o
Spinous process margin c
:3
Superior articular
::J
Pedicle
process
o
<Jl
Lateral cortical margin n
Transverse process <Jl

Lamina Inferior cortical margin

Inferior articular
Facet joint
process

Inferior cortical margin

of lamina ~
C
<Jl
n
(D

Disc space

Superior vertebral body

cortical margin Spinous process

Superior articular
Anterior vertebral body process
cortical margin
Transverse process

Pars interarticularis

Inferior articular
Inferior vertebral body
process
cortical margin
Facet joint

Pedicle

(Top) AP view of the lumbar spine. The vertebral bodies assume a more rectangular appearance in this view, with
strong, large ovoid pedicles seen end on. A portion of the facet joints are visualized, being relatively oriented in the
sagittal plane and allowing flexion and extension. The posterior elements forming the "H" pattern are well-defined
with their superior and inferior articular processes and broad lamina. The spinous process is midline, pointing
slightly inferior. (Bottom) Lateral view of the lumbar spine. The broad and square shaped bodies in this view
separate the large intervertebral disc spaces. The anterior and posterior vertebral body cortical margins line up,
allowing a gentle lordotic curvature. The pedides and neural foramina are well visualized in this plane, with bony
overlap obscuring the facet joint space.
III
31
 VERTEBRAL BODY AND LIGAMENTS
Q) AXIAL NECT
u
rJl
::l
~
Anterior longitudinal ligament

Vertebral body cortical bone

Vertebral body medullary bone
Psoas muscle
Basivertebral vein
Pedicle
Spinal canal
rJl
Superior articular facet
U Transverse process
rJl
Inferior articular facet
o, Interspinous ligament Ligamentum fIavum
c Spinous process
E
::l
o Supraspinous ligament
U
ro
"'-
..D
Q)
.•....• Anterior longitudinal ligament
"'-
Q)

> Vertebral bony endplate

Q) Posterior longitudinal ligament
C
c.. Spinal canal with thecal sac
rJ)
Neural foramen
Ligamentum fIavum
Lamina

Spinous process

Intervertebral disc

Superior articular facet

Spinal canal with thecal sac
Facet joint Ligamentum fIavum
Lamina
Inferior articular facet

Spinous process
Supraspinous ligament

(Top) Axial NECT image through mid-pedicle level of lumbar vertebra shows the thick pedicles extending into the
superior articular process with the obliquely angled facet (zygapophyseal) joint. The ligamentum flavum extends to
the midline as a paired structure and laterally along the lamina and facet joint margins. The basivertebral veins are
seen as paired lucencies in the midline of the posterior portion of the vertebral body. (Middle) Axial CT image
though the end plate shows the triangular shaped junction of the lamina with the dorsally directed spinous process.
The neural foramina are large and directed laterally. (Bottom) Axial CT image through the intervertebral disc level.
The ligamentum flavum is well-defined and does not cross the midline, extending laterally towards the facet joints.
III
32
 VERTEBRAL BODY AND LIGAMENTS
LUMBAR CORONAL NECT

Vertebral body

Intervertebral disc

Basivertebral vein n
o
Psoas muscle c
3
,:J
o
Pedicle

Anterior epidural space Posterior margin vertebral body

Neural foramen

Pedicle
Spinal canal with thecal sac

Superior articular process

Transverse process
Pars interarticularis Lamina
Inferior articular process

Pedicle

Superior articular process

Lamina Transverse process

Pars interarticularis

Inferior articular process

Facet joint Superior articular process

Spinous process

(Top) First of three coronal NECT reformats of lumbar spine presented from anterior to posterior shows the
rectangular-shaped vertebral bodies. The posterior margin of the body is pierced by the basivertebral veins. The
pedicles arise dorsally from the vertebral bodies and are seen in transverse section. (Middle) Section more posteriorly
extending through three levels of the spinal canal. The slightly oblique coronal section extends from the posterior
vertebral body at top, through the pedicles in the middle, to the lamina at the bottom. The neural foramina are large
and bounded superiorly by the pedicles. (Bottom) Section more posteriorly through the articular processes. The
posterior elements in this plane assume a typicallH" configuration with the superior and inferior articular processes
forming the vertical components and the lamina forming the central bar. III
33
 IJ)
u
IJ)

o,
c
E
:J
o
U

III
34
n
o
c
3
,:J

o
Vl
n
Vl

~
c
Vl
n
(!)

III
35
 OJ
U
<Jl
:J
~

<Jl
U
<Jl

o
c
E
:J
o
U
(\:l
"-
....0
OJ
+-'
"-
OJ
>

III
36
 VERTEBRAL BODY AND LIGAMENTS
CERVICAL SAGITTAL T2 MR ""0
Vl

:::l
ro
Anterior arch Cl
Posterior arch Cl
Atlanto-axial joint Spinous process C2
C2 body

Prevertebral space Ligamentum nuchae n

C4 body
o
c
Ventral dural margin/posterior Interspinous ligament
longitudinal ligament 3
::J
Supraspinous ligament
C6-7 intervertebral disc
Anterior longitudinal ligament
Dorsal dural margin o
(Jl

Cerebrospinal fluid n
Spinal cord (Jl

Cerebellar tonsil
Occipital condyle
Cllateral mass
C2 pars interarticularis ~
C2 pedicle C
C2 inferior articular process (Jl
n
Vertebral artery (D
C3 superior articular process
CS facet

CS-6 facet joint

Vertebral artery entering
transverse foramen
First rib

Occipital condyle Posterior arch Cl

Cl lateral mass C2 pars interarticularis

Atlanto-axial joint
C2 transverse foramen Inferior articular facet C2
Superior articular facet C3
C4 neural foramen
C4-S facet joint
CS inferior articular process
C6 superior articular process
C6-7 facet joint

(Top) Midline sagittal T2 MR image shows the relationship of the cervical cord, vertebral bodies and spinous
processes with smooth straight margins and alignment. The posterior dural margin merges with the ligamentum
flavum and spinous process cortex low signal. The anterior dural margin merges with the posterior body cortex and
posterior longitudinal ligament. (Middle) Paramedian T2 MR image shows the lateral facets at each level, and the
flow void of the vertebral artery within the transverse foramen. (Bottom) Paramedian sagittal T2 MR image shows
normal alignment of the lateral cervical bodies and facet joints. The rhomboidal configuration of the cervical facets is
noted, with their complementary superior and inferior articular facets.
III
37
 VERTEBRAL BODY AND LIGAMENTS
THORACIC SAGITTAL T2 MR

Thoracic cord
Intervertebral disc
Ligamentum flavum
<i.l
C
Posterior longitudinal ligament
Q..
<.J)
<i.l Spinous process
"- Superior endplate
<i.l
CL
Thoracic vertebral body
~
<.J) Inferior end plate
U
Interspinous ligament
<.J)

o,
c Anterior longitudinal ligament
Supraspinous ligament
E Basivertebral veins Cerebrospinal fluid
:J
o
U
<i.l
"-
..D
Q)
+-' Intervertebral disc Superior articular process
"-
Q)

> Lateral aspect thoracic vertebral

body Inferior articular process
Q)
c Facet joint
Superior endplate
a. Pedicle
CJ)

Inferior endplate

Thoracic segmental nerve

Segmental artery and vein within foramen

Neural foramen

Costovertebral joint

Inferior demifacet for rib

Superior demifacet for rib

Segmental artery and vein
Lateral aspect neural foramen
Intervertebral disc

Lateral margin thoracic vertebral

body Segmental nerve within
foramen

(Top) First of three sagittal midline T2 MR images of the thoracic spine presented from medial to lateral. The
interspinous and supraspinous ligaments show typical normal low signal, attaching the adjacent spinous processes
with their well-defined cortical margins and intermediate signal fatty marrow. The anterior longitudinal ligament
low signal merges with the low signal of the anterior cortex of the vertebral body. The posterior longitudinal
ligament is not separately defined from the anterior dural margin. (Middle) More lateral image of the thoracic spine.
The lateral body marrow signal extends into the broad pedicle with the well-defined superior and inferior articular
processes. The neural foramina are oval with rostral segmental vessels and nerves (Bottom) More lateral image of
III thoracic spine show the costovertebral joints spanning the posterior intervertebral discs.
B
 VERTEBRAL BODY AND LIGAMENTS
LUMBAR SAGITTAL T2 MR

Supraspinous ligament
Anterior longitudinal ligament
Interspinous ligament

Annulus fibrosus Spinous process

Ligamentum flavum (')

Posterior longitudinal o
ligament/dura c
Nucleus pulposus
:3
Cauda equina ,:J

o
Vl
(")
Cerebrospinal fluid Vl

Nucleus pulposus

Posterior vertebral body cortical

margin

Annulus fibrosus ~
C
Superior end plate Vl
(")

(D
Anterior longitudinal ligament

Inferior end plate Ligamentum flavum

Inferior articular process

Anterior vertebral body cortical

margin

Superior articular process

Pedicle
Inferior articular process
Inferior end plate

Superior end plate

Segmental nerve within

Neural foramen foramen

Anterior vertebral body cortical

margin

(Top) First of three sagittal midline T2 MR images of the lumbar spine presented from medial to lateral. The medial
portion of the ligamentum flavum is seen as a linear low signal posterior to the dural margin. The PLL and dura are
seen as prominent linear low signal line spanning the discs and vertebral bodies. The ALLis seen as a smooth linear
low signal along the anterior cortical margin of the vertebra body. (Middle) More lateral view of the lumbar spine.
The articular processes are seen as oval bone masses posterior to the high signal cerebrospinal fluid of the thecal sac.
The ligamentum flavum is more prominent as low signal along the ventral margin of the posterior elements.
(Bottom) More lateral view of the lumbar spine. The neural foramina are key hole shaped, with larger superior
portion bounded superiorly by the inferior margin of the pedicle. III
9
 VERTEBRAL BODY AND LIGAMENTS
Q)
THORACIC AXIAL T2 MR
u
<.J)
:J
~ Anterior longitudinal ligament

Annulus fibrosus
Nucleus pulposus

Neural foramen
Spinal cord
Superior articular process
Ligamentum flavum
<.J) Inferior articular process
u
<.J)
Spinous process
o, Supraspinous ligament
c
E
:J
o
U
ru
•.... Anterior longitudinal ligament
...D
Q)
+-'
•.... Anterior cortical margin of
Q) vertebral body
>
Q) Spinal cord
c:
Costovertebral joint
a..
(J'j
Pedicle
Medial rib
Ligamentum flavum

Lamina
Interspinous ligament

Costovertebral joint Spinal cord

Medial rib Pedicle

Transverse process Costotransverse joint

Lamina
Supraspinous ligament
Spinous process

(Top) First of three axial T2 MR images of the thoracic spine through the intervertebral disc presented from superior
to inferior. The thoracic spine shows coronal orientation of the facet joints with a less distinct ligamentum flavum.
The low signal outer component of the annulus fibrosus merges with the low signal of the anterior longitudinal
ligament. The posterior longitudinal ligament is not visualized. (Middle) More inferior view of the thoracic spine
through the vertebral body level. The costovertebral joint is well-defined, with the costotransverse joint out of plane
of imaging. The pedides at this level are short, encompassing the small central bony canal. (Bottom) More inferior
image of the thoracic spine. The costovertebral and costotransverse joints are both visualized on this section, with
III rectangular shaped transverse processes.
40
 VERTEBRAL BODY AND LIGAMENTS
LUMBAR AXIAL T1 MR

Anterior longitudinal ligament

Anterior cortex of vertebral body

Thecal sac
Ligamentum flavum
Pedicle
n
Superior articular process Transverse process o
c
Facet joint
Inferior articular process
:3
Interspinous ligament ::J
Spinous process o
CJl
(")
CJl

Anterior longitudinal ligament Anterior cortex of vertebral

body

~
Thecal sac C
CJl
(")
Neural foramen Segmental ganglion
(D

Lamina
Ligamentum flavum

Spinous process

Supraspinous ligament

Intervertebral disc
Thecal sac

Neural foramen
Superior articular process
Ligamentum flavum
Facet joint
Inferior articular process
Lamina

Spinous process
Supraspinous ligament

(Top) First of three axial Tl MR images of the lumbar spine through the vertebral body presented from superior to
inferior. The low signal anterior longitudinal ligament merges with the low signal of the anterior cortical margin. The
ligamentum flavum is seen along its medial portion, extending laterally towards the facet joint. The facet joint is
obliquely oriented around 45 degrees, with a well-gefined joint space. (Middle) More inferior axial T1 weighted
image of the lumbar spine. The neural foramina are outlined by the high signal foraminal fat, with the centrally
situated ganglion. The lamina and spinous process form a "Y"shaped structure projecting dorsally. (Bottom) More
inferior axial Tl weighted image of the lumbar spine through the intervertebral disc. The facet or zygapophyseal
joints are well visualized with the facet joint space, and ventral margin bounded by the ligamentum flavum. III
41
 INTERVERTEBRAL DISC & FACET JOINTS
• Cations attract anions --+ high osmotic pressure
ITerminology enables disc to absorb water
Synonyms o Except for outer annulus, disc relies on nutrient
• Facet joint; apophyseal joint; zygapophyseal joint diffusion from endplate vessels
• Steep metabolic gradient between vessels, disc
centrum
I Gross Anatomy • Centrum has ~ glucose + oxygen, t lactic acid
• Carbohydrate utilization dominated by glycolysis
Overview
Facet Joints
• C2 --+ Sl vertebrae articulate in 3 joint complex
<Jl • Articular processes (zygapophyses)
U o Secondary cartilaginous joints (symphyses) between
<Jl o Paired posterior lateral joints
vertebral bodies
o, o Synovial joints between articular processes
• Superior facet surface directed dorsally
• Inferior facet surface directed ventrally
c (zygapophyses)
• Facets joined by pars interarticularis
• Other articulations
E o Fibrous (between laminae, transverse/spinous
o True synovial joint
:::J • Hyaline cartilage surfaces, synovial membrane,
o processes)
fibrous capsule
U o Uncinate processes (C3-7)
o Orientation
rcl
lo-
Intervertebral Discs • Obliquely sagittal in lumbar spine (protects disc
..0 • Overview from axial rotation)
a;
.•.... o Lie between thin horizontal hyaline/fibrocartilage • Coronal in cervical and thoracic spine (protects
l0-
a; end-plates on superior, inferior surfaces of vertebrae against shear)
>.. o With ALL/PLL, link vertebrae from C2 --+ sacrum o Innervation: Nociceptive fibers from medial branch
of dorsal ramus
Q)
o Comprise 1/3 of spinal column height
s::: • Thickness varies (thinnest in upper T, thickest in o Function: Load bearing in extension, rotation
lower L) • Pars interarticularis
c.. o Lies between subatlantal superior/inferior articular
CJ) • Lumbar discs 7-10 mm thick, 4 cm diameter
o Components facets
• Central nucleus pulposus o C2 unique
• Peripheral annulus fibrosus • Anterior relation of superior to posterior placed
o Major function is mechanical inferior facet
• Transmit, distribute load from weight/activity • C2 pars interarticularis unusually elongated
• Allow flexion/extension, lateral bending, torsion
• Discs loaded preferentially in flexion
• Annulus fibrosus I Imaging Anatomy
o Concentric series of 15-25 fibrous lamellae
• Surround, constrain nucleus pulposus
Overview
• Collagen fibers lie parallel within each lamina • Signal on MR related to water content
• Fibers oriented 60° to vertical o Nucleus, inner annulus high signal on T2WI
• Type I collagen predominates in outer annulus o Outer annulus hypointense on T1 & T2WI
• Type II predominates in inner annulus o t Collagen/proteoglycan cross-linking with age --+
o Inner annulus blends gradually with nucleus decreased water binding, ~ T2 signal
o Outer annulus attaches to ALL, PLL and to fused • Disc "bulge"
epiphyseal ring of vertebral bodies by Sharpey fibers o Normal age-related change (begins as early as
o Innervation: Branch of ventral primary ramus mid-teens)
o Vasculature: Outer annulus supplied by capillaries o Posterior margin convex
from spinal branches of dorsal rami o Disc extends circumferentially beyond end plates
• Nucleus pulposus • Concentric annular tear in posterior disc common
o Origin: Remnant of notochord o High signal on T2WI
o Eccentric position within annulus o Vascularized granulation tissue enhances on T1 C+
• More dorsal compared to center of vertebral body
o Components
• 85-95% water IAnatomy-Based Imaging Issues
• Loose fibrous strands of collagen, elastin with Key Concepts or Questions
gelatinous matrix
• Spondylolysis
• Scattered chondrocytes
o Pars interarticularis fracture
• Major macromolecular component =
o Superior facets displace ventrally
proteoglycans
o Inferior facets remain attached to dorsal arch
• Proteoglycans = protein core + attached
• Spondylolisthesis
glycosaminoglycan chains
o Slip of one vertebrae relative to adjacent level
• Glycosaminoglycan chains have negatively
o Many etiologies (congenital dysplasia of articular
charged sulphate, carboxyl groups
processes, trauma, degenerative instability, etc.)

III
42
n
o
c
:3
:::::l

o
Vl
n
Vl

s:
c
Vl
n
(t)

III
43
 lJ)
u
lJ)

o
c
E
::J
o
U

III
44
 INTERVERTEBRAL DISC & FACET JOINTS
CERVICAL AXIAL & SAGITTAL NECT

Intervertebral disc

Transverse process
Uncinate process
Superior articular process Neural foramen
Facet joint n
o
Inferior articular process Lamina
c
:3
,::J
o
Spinous process

Intervertebral disc
~
Vertebral artery C
Vertebral body bony end plate (fl

Superior articular process

Pedicle n
Facet joint
ro
Inferior articular process
Lamina

Atlanto-occipital joint
Occipital condyle

Lateral mass Cl

Transverse foramen Inferior articular process C2

Superior articular process C3

Course of vertebral artery
Inferior articular process C3

Facet joint

Transverse process

(Top) Axial NECT image of the cervical spine. The facet joint is viewed obliquely, with the superior to inferior
articular process forming the oval-shaped facet mass. The intervertebral disc is cup-shaped, bounded along the
posterior aspect by the upturned bony uncinate process. The anterior border of the neural foramen is shielded from
the intervertebral disc by the uncinate process. (Middle) More inferior axial NECT view of the cervical spine. The cup
shape of the intervertebral disc is also apparent on this section, with upturned bone of the posterior and lateral
end plates. The facet joint is again viewed in oblique section forming an oval facet mass. (Bottom) Sagittal NECT
reformat of cervical spine better defines the margins of the facet joints with their oblique inferior course. Just ventral
to the facets is the long course of the vertebral artery. III
45
 INTERVERTEBRAL DISC & FACET JOINTS
Q.) THORACIC AXIAL & SAGITTAL NECT
u
lJl
::J
~
ro
c
0..
lJl Vertebral body bony end plate
ro
"-
ro
0... Intervertebral disc
o(S
lJl Rib
U
lJl Facet joint Superior articular process
o Lamina Inferior articular process

c
E Spinous process
::J
o
U
ro
"-
..0
Q.)
~
"-
Q.)

>
Q.)
c:
Vertebral body
c..
CJ)
Pedicle
Costovertebral joint
Rib head
Superior articular process
Inferior articular process Facet joint

Spinous process

Pedicle

Neural foramen
Intervertebral disc Superior articular process

Inferior endplate
Inferior articular process
Superior end plate Facet joint
Lateral margin of vertebral body

(Top) Axial NECT image through the thoracic spine. The facet joints show a more coronal orientation, relative to the
oblique coronal (or horizontal) cervical joint orientation, and the oblique sagittal orientation of the lumbar joints.
The bony spinal canal containing the thoracic cord is relatively small with respect to the body and posterior
elements. (Middle) More inferior axial NECT view of the thoracic spine. The coronal oriented facet joints are again
visualized, merging into the lamina and inferiorly directed spinous process. The costovertebral joint laterally provides
additional stabilization. (Bottom) Sagittal reformat of thoracic spine NECT. The facet joint orientation is well-defined
in this view, showing the articulation of the adjacent vertebral bodies with their superior and inferior articular
III processes.
46
 INTERVERTEBRAL DISC & FACET JOINTS
LUMBAR AXIAL & SAGITTAL NECT

Vertebral bony end plate

Intervertebral disc n
Neural foramen o
Superior articular process c
Facet joint
Inferior articular process 3
:::.l
Lamina
o
CJl
Spinous process n
CJl

Anterior cortical margin of

vertebral body

~
C
CJl

Pedicle n
(t)

Transverse process Superior articular process

Facet joint
Inferior articular process

Ligamentum flavum

Spinous process

Inferior end plate

Neural foramen
Superior endplate
Superior articular process
Anterior cortical margin of
vertebral body Pars interarticularis

In tervertebral disc Inferior articular process

Facet joint
Pedicle

(Top) Axial NECT of the lumbar spine. The oblique sagittal orientation of the facet joint is evident in this section,
with the well-defined articular processes, forming the posterolateral margin of the spinal canal. The ventral margin of
the facet forms the posterior aspect of the neural foramen. (Middle) More inferior axial NECT section of the lumbar
spine through the pedicles. The oblique sagittal orientation of the facets is maintained. (Bottom) Sagittal reformat of
NECT examination of the lumbar spine. The facet joints are well-defined with their large, robust superior and inferior
articular processes. The ventral facet joint forms the posterior margin of the neural foramen. The anterior margin of
the neural foramen is composed of cortical margin of two vertebral bodies, and the intervening intervertebral disc.
III
47
 INTERVERTEBRAL DISC & FACET JOINTS
SAGITTAL T2 INTERVERTEBRAL DISC

Cerebellar tonsil

Foramen magnum
Anterior arch Cl
Cerebrospinal fluid Spinal cord

C2-3 intervertebral disc

Annulus fibrosus/posterior
Annulus fibrosus/anterior
longitudinal ligament complex
longitudinal ligament complex
Vl
U
Vl

o, Inferior endplate C6
Superior endplate C7
c Intervertebral disc
E
:J
Nucleus pulposus
o
U
ro
"-
..D
OJ
•.....
"-
OJ
> Annulus fibrosus/anterior
OJ longitudinal ligament complex
C Annulus fibrosus/posterior
Inferior endplate T6 longitudinal ligament complex
0..
CJ) Superior endplate T7
Thoracic intervertebral disc
T8 vertebral body
Thoracic spinal cord

Basivertebral vein

Conus medullaris

Superior end plate L3 Cauda equina

Inferior endplate L3
Nucleus pulposus Annulus fibrosus
Posterior longitudinal ligament

Intranuclear cleft
Cerebrospinal fluid

Ann ul us fibrosus/ an terior

longitudinal ligament complex

(Top) Sagittal midline T2 MR image through the cervical spine. The intervertebral discs are relatively small, with thin
low signal outer annular fibers and a predominate high signal central nucleus pulposus. The intranuclear cleft is not
usually visible. (Middle) Sagittal T2 MR of the thoracic spine. The vertebral bodies are square in morphology, with
slightly more pronounced intervertebral discs. The intranuclear cleft is not usually visible in the mid and upper
thoracic region, but becomes progressively more pronounced at the thoracolumbar junction. (Bottom) Sagittal T2
MR image of the lumbar spine. The intervertebral discs are large, with pronounced low signal annulus fibrosus. The
intranuclear cleft is a typical feature of the adult lumbar disc on T2 MR images.
III
48
 INTERVERTEBRAL DISC & FACET JOINTS
SAGITTAL T2 FACET JOINTS

Atlanto-occipital joint Pars interarticularis of C2

Atlantoaxial joint
Inferior articular process C2
Superior articular process C3
Inferior articular process C3
n
o
c
CS-6 facet joint 3
,:J

o
(Jl
n
(Jl

Neural foramen
~
Intervertebral disc C
(Jl

Pedicle
n
(!)
Superior articular process
Inferior articular process

Facet joint

Superior articular process L2

Intervertebral disc

Neural foramen
Facet joint

Superior articular process

Pars interarticularis

Superior articular process S1 Inferior articular process LS

(Top) Sagittal T2 MR image through the cervical spine. The cervical pillars are readily visible, composed of the
adjacent superior and inferior articular processes and the intervening joint. The C2 body is transitional with the
inferior articular process forming the rostral part of the pillar. The superior process of C2 is more ventral, and
articulates with the inferior articular facet of Cl. (Middle) Sagittal T2 MR image of the thoracic spine. The
orientation of the thoracic facets allows good visualization of the facet joints, as well as the neural foramen.
(Bottom) Sagittal T2 MR image of the lumbar spine. The facet joints are more obliquely oriented, allowing flexion
and extension. The superior articular process forms the dorsal margin of the neural foramen.
III
49
 PARASPINAL MUSCLES
• 0: LN, SP C7-T3
ITerminology • I: Occipital bone, mastoid
Abbreviations • F: Draws head back, bends head laterally
• Origin (0), insertion (I), innervation (N), function (F) o Splenius cervicis
• Ligamentum nuchae (LN) • 0: SP T3-6
• Spinous, transverse processes (SP,TP) • I: TP CI-3
o Erector spinae (iliocostalis, longissimus, spinalis)
• 0: SP Tl-LS, lower 6 ribs, iliac crest, TP Tl-S
IGross Anatomy • I: Upper border ribs 1-6, TP C2-7, lumbar and
thoracic TP
V'l
U Overview o Semispinalis (capitis, cervical, thoracic)
V'l
• Musculature of back arranged in layers • 0: TP C7-TlO
o, o Superficial (extrinsic or "immigrant") muscles • I: SP C2-T4, occipital bone
• Innervated by anterior rami of spinal nerves • F: Rotate head/column to opposite side
c o Multifidus
• Run between upper limb, axial skeleton
E o Deep (intrinsic or "true") muscles • 0: C4-7 articular processes, thoracic TP, lumbar
:::l
• Innervated by spinal nerve dorsal rami superior articular facets
o • Lie deep to thoracolumbar fascia • I: Crosses 1-4 vertebrae to reach SP C2-LS
U
• Muscles of back enclosed by fascia • F: Rotate column to opposite side
•...
C\3
o Fascia attaches medially to LN, SP, supraspinous o Rotatores
.0 ligaments, medial crest of sacrum • 0: TP
a;
.•....• • I: SP adjacent vertebrae
•... o Cervical (deep cervical fascia)
a; • Prevertebrallayer covers anterior vertebral muscles • F: Rotate column to opposite side
> o Thoracic: Thin, transparent; joins ribs o Interspinalis
a; o Thoracolumbar fascia • Connect apices of adjoining SP C2-LS
c
.- • Dense; continuous with abdominal aponeurosis o Intertransverse
c. • Connect adjacent TP
CJ) • Suboccipital
I Imaging Anatomy o Rectus capitis
• 0: SP C2, posterior arch Cl
Superficial Muscles • I: Occipital bone
• Trapezius • F: Extend, rotate head
o 0: EOP, LN, SP C7-Tl2 o Oblique capitis superior
o I: Clavicle, acromion, scapular spine • 0: TP Cl
o F: Rotation, adduction, raising, lowering scapula • I: Occipital bone
o N: CNll, C3, C4 • F: Extend, bend head same side
• Latissimus dorsi o Oblique capitis inferior
o 0: Lumbar aponeurosis to T6-12 SP,iliac crest, lower • 0: Spine of C2
4 ribs • I: TP Cl
o I: Intertubercular groove of humerus • F: Turn head same side
o F: Extends, adducts, rotates arm medially • Prevertebral
o N: Thoracodorsal o Rectus capitis
• Levator scapulae • 0: TP Cl
o 0: Posterior tubercles + TP CI-4 • I: Occipital bone
o I: Medial border scapula • F: Flexes head
o F: Elevate and rotate scapula • N: CI-2
o N: C3-S o Longus colli
• Rhomboid minor • 0: TP C3-S, vertebral bodies CS-T3
o 0: LN, SP C7-Tl • I: Anterior arch Cl, vertebral bodies C2-4
o I: Medial border scapula • F: Flexes, rotates neck
o F: Scapula medially • N: C2-7
o N: Dorsal scapular o Longus capitis
• Rhomboid major • 0: TP C3-6
o 0: SP T2-S • I: Occipital bone
o I: Medial border scapula, below spine • F: Flexes head
o F: Scapula medially • N: CI-3
o N: Dorsal scapular o Scalene (anterior, middle, posterior)
• 0: TP, vertebrae C2-7
Deep Muscles • I: Ribs 1, 2
• C/T /L general musculature • F: Lateral bending, flexing neck
o F: All extend vertebral column • N: CS-8
o N: All by posterior divisions of spinal nerves o Psoas (major, minor) functionally part of iliac
o Splenius capitis region, thigh flexors

III
50
 Vl
~.
::::l
..
I'D

n
o
c
:3
,:J

o
Vl
n
Vl

s
c
Vl
n
(!)

III
51
 PARASPINAL MUSCLES
Q) AXIAL CECT CERVICAL
u
tJl
:J
~
Longus colli muscle Carotid artery

Jugular vein Retromandibular vein

C2 body (axis) Posterior digastric muscle
Vertebral artery in transverse Levator scapulae muscle
foramen
Sternocleidomastoid muscle
Epidural veins
tJl Inferior oblique capitis muscle
U
tJl

o Splenius muscle
Semispinalis muscle
c
Trapezius muscle
E
:J
Ligamentum nuchae
o
U

Longus colli muscle

Jugular vein Sternocleidomastoid muscle

Longus capitis muscle Carotid artery

Vertebral artery
Splenius cervicis muscle

Longissimus capitis muscle

Levator scapulae muscle
Multifidus muscle

Interspinalis muscle Semispinalis muscle

Splenius capitis muscle
Ligamentum nuchae Trapezius muscle

Sternocleidomastoid muscle
Jugular vein Carotid artery
Anterior scalene muscle
Longus colli muscle Middle scalene muscle
Longus capitis muscle
Posterior scalene muscle
Levator scapulae muscle Longissimus capitis muscle
Multifidus muscle
Semispinalis muscle
Interspinalis muscle

Splenius capitis muscle Trapezius muscle

Ligamentum nuchae

(Top) First of three axial CECT image of the cervical spine presented from superior to inferior. The ligamentum
nuchae and many of the deep neck extensor muscles are attached to the spinous processes within the cervical spine,
such as the semispinalis (thoracic and cervical components), multifidus and interspinalis muscles. The vertical
segment of the longus colli is located within the shallow depression along the anterior margins of the vertebral
bodies. (Middle) Image through mid-cervical spine. The paired deep cervical musculature is identified in this view,
including the multifidus, semispinalis and splenius capitis muscles. The longus colli attaches to the anterior tubercle,
while the longus capitis is slightly more lateral. (Bottom) View of lower cervical spine. The anterior and middle
III scalene muscles insert on the first rib, with the posterior scalene inserting on the second rib.
52
 PARASPINAL MUSCLES
AXIAL CECT THORACIC ""0
CJl

~
1'0

n
Thoracic vertebral body
o
c
Spinal canal Pedicle :3
Multifidus muscle ,:J
Interspinalis muscle
Longissimus muscle o
Trapezius muscle Spinalis thoracis muscle

~
C
(f)

n
1'0
Thoracic vertebral body
Spinal canal
Multifidus muscle

Interspinalis muscle
Longissimus muscle

Trapezius muscle Spinalis thoracis muscle

Multifidus muscle

Longissimus muscle
Interspinalis muscle
Iliocostalis muscle
Latissimus dorsi muscle

(Top) First of three axial CECT images of the thoracic spine presented from superior to inferior. The posterior
margins of the transverse processes provide attachment for the deep thoracic muscles. The erector spinae muscle
group includes the medial spinalis thoracis, longissimus, and laterally positioned iliocostalis muscles. The spinous
processes provide attachment for multiple muscle groups, such as the more superficial trapezius, rhomboids,
latissimus dorsi, serratus posterior, as well as the deep muscles groups. (Middle) View of mid-thoracic spine. Many
small muscle groups are attached to the posterior elements. The transversospinalis group includes the interspinalis,
rotatores, multifidus and semispinalis muscles. (Bottom) Image at thoracolumbar junction. The erector spinae group
(e.g., medial multifidus and the lateral iliocostalis muscles) are well-defined here. III
53
 PARASPINAL MUSCLES
Q.) AXIAL CECT LUMBAR
u
<Jl
::J
~

Vertebral body
Psoas muscle

Transverse process Thoracolumbar fascia (anterior

layer)
Transverse abdominis muscle
Quadratus lumborum muscle
<Jl
U Internal oblique muscle
<Jl Thoracolumbar fascia (middle
External oblique muscle
o, Interspinalis muscle
layer)
Iliocostalis muscle
c Thoracolumbar fascia (posterior Longissimus muscle
E layer)
::J Spinous process Multifidus muscle
o
U
('1j
•....
...0
Q.)
~•....
Q.)

> Vertebral body

Q.)
c Thoracolumbar fascia (anterior Psoas muscle
a.. layer)
CJ)
Thoracolumbar fascia (middle Quadratus lumborum muscle
layer)
Iliocostalis muscle
Multifidus muscle
Longissimus muscle
Thoracolumbar fascia (posterior
layer) Spinous process

Iliacus muscle Iliac artery

Iliac vein
Psoas muscle

Ilium
Sacral ala

Gluteus maximus muscle Sacroiliac joint

Spinal canal Erector spinae muscle

Posterior iliac spine

(Top) First of three axial CECT images through the lumbar spine presented from superior to inferior. The posterior
layer of thoracolumbar fascia is adjacent to the erector spinae muscle group. The quadratus lumborum muscle
provides the landmark for the middle and anterior layers; the anterior margin of the muscle is the anterior fascial
layer, while the posterior margin of the muscle defines the middle layer. (Middle) Image through the mid-lumbar
spine. The psoas muscles are prominent on either side of the vertebral body. The psoas muscles attach to the superior
and inferior margins of all the lumbar vertebral bodies. The posterior layer of the thoracolumbar fascia is the
boundary of the dorsal spinal muscles. (Bottom) Image through the Sllevel. This level is defined by the ventral
III psoas and iliacus muscles, the dorsolateral gluteus maximus and the dorsomedial erector spinae group.
54
 PARASPINAL MUSCLES
CORONAL CECT THORACOLUMBAR

Rib Spinalis thoracis muscle

n
o
Semispinalis thoracis muscle c
Multifidus muscle
Longissimus thoracis muscle
:3
:)
Spinous process
o
CJl
n
CJl

Lamina
Interspinous ligament Intercostal muscle
s
c
CJl
n
(!)
Rib
Spinalis thoracis muscle

Rotatores muscle

Longissimus thoracis muscle

Spinous process

Costotransverse joint

Interspinous ligament

Rib
Multifidus muscle

Spinous process

Lamina Longissimus thoracis muscle

(Top) First of three coronal CECT images of the thoracolumbar junction dorsal musculature presented from posterior
to anterior. The longissimus thoracis bend the spinal column to one side, and can depress the ribs. The semispinalis
thoracis rotate the spinal column to one side, while the multifidus muscles and the small rotatores muscles rotate the
column to the opposite side. (Middle) Image of the thoracolumbar junction dorsal musculature, just ventral to
superior image. The multiple, paired small slips of erector muscles are demonstrated, with the rotatores and spinalis
thoracis shown. (Bottom) Image of the thoracolumbar junction dorsal musculature, just ventral to upper image. The
oblique angled multifidus muscles are shown, extending from transverse processes towards the spinous processes.
III
55
 CRANIOCERVICAL JUNCTION
• Transverse ligament: Strong horizontal
ITerminology component between lateral masses of Cl, passes
Definitions behind dens
• Craniocervical junction (CC]) = Cl, C2 and • Craniocaudal component: Fibrous band running
articulation with skull base from transverse ligament superiorly to foramen
magnum and inferiorly to C2
o Tectorial membrane: Continuation of posterior
I Gross Anatomy longitudinal ligament; attaches to anterior rim
foramen magnum (posterior clivus)
Overview o Posterior atlanto-occipital membrane
U)
u • Craniocervical junction comprises occiput, atlas, axis, • Posterior arch Cl to margin of foramen magnum
U)
their articulations, ligaments • Deficit laterally where vertebral artery enters on
o, Components of Craniocervical Junction
superior surface of Cl
• Biomechanics
c • Bones o Atlanto-occipital joint: 50% cervical
E o Occipital bone flexion/extension and limited lateral Illotion
:J
• Occipital condyles are paired, oval-shaped, o Atlanto-axial joint: 50% cervical rotation
o inferior prominences of lateral exoccipital portion
U
of occipital bone
co
•.... • Articular facet projects laterally I Imaging Anatomy
..0 o Cl (atlas)
Q)
.•....• • Composed of anterior and posterior arches, no Overview
•....
Q) body • Lateral assessment of CC]
> • Paired lateral masses with their superior and
inferior articular facets
o CI-2 interspinous
o Atlanto-dental
space: ::; 10 mm
interval (ADI)
Q)
C • Large transverse processes with transverse foramen • Adults < 3 mm, children < 5 mm in flexion
0.. o C2 (axis) o Pseudosubluxation
r.J) • Large body and superiorly projecting odontoid • Physiologic anterior displacement seen in 40% at
process C2-3 level and 14% at C3-4 level to age 8
• Superior articulating facet surface is convex & • Anterior displacement of C2 on C3 up to 4 mm
directed laterally o Posterior cervical line: Line is drawn from anterior
• Inferior articular process + facet surface is typical aspect of CI-3 spinous processes => anterior C2
of lower cervical vertebrae spinous process should be within 2 mm of this line
• Superior facet is positioned relatively anteriorly, o Wackenheim line
inferior facet is posterior with elongated pars • Posterior surface of clivus => posterior odontoid
in terarticula ris tip should lie immediately inferior
• Joints • Relationship does not change in flexion/extension
o Atlanto-occipital joints o Welcher basal angle
• Inferior articular facet of occipital condyle: Oval, • Angle between lines drawn along plane of
convex surface, projects laterally sphenoid bone and posterior clivus
• Superior articular facet of Cl: Oval, concave • Normal < 140°, average 132°
anteroposteriorly, projects medially o Chamberlain line
o Median atlanto-axial joints • Between hard palate and opisthion
• Pivot type joint between dens + ring formed by • Odontoid tip ~ 5 mm above line abnormal
anterior arch + transverse ligament of Cl o McGregor line
• Synovial cavities between transverse • Between hard palate to base of occipital bone
ligament/odontoid & atlas/odontoid articulations • Odontoid tip ~ 7 mm above line abnormal
o Lateral atlanto-axial joints o Clivus canal angle
• Inferior articular facet of Cl: Concave • Junction of Wackenheim line and posterior
mediolaterally, projects medially in coronal plane vertebral body line
• Superior articular facet of C2: Convex surface, • 180° extension, 150° flexion, < 150° abnormal
projects laterally o McRae line
• Ligaments (from anterior to posterior) • Drawn between basion and opisthion
o Anterior atlanto-occipital membrane: Connects • Normal 35 mm diameter
anterior arch Cl with anterior margin foramen • Frontal assessment of CC]
magnum o Lateral masses of Cl and C2 should align
o Odontoid ligaments • Overlapping lateral masses can be a normal
• Apical ligament: Small fibrous band extending variant in children
from dens tip to basion o Atlanto-occipital joint angle
• Alar ligaments: Thick, horizontally directed • Angle formed at junction of lines traversing joints
ligaments extending from lateral surface of dens • 125-130° normal, < 124° may reflect condyle
tip to anteromedial occipital condyles hypoplasia
o Cruciate ligament

III
56
n
o
c
:3
,::l
o

III
57
 Q.)
U
lJl
:J
~

lJl
U
lJl

o,
c
E
:J
o
U
ro
"--
..0
Q.)
.•....
"--
Q.)
>
Q)
c::
Cl.
CJ)

III
58
o
<Jl
n
<Jl

~
C
<Jl
n
(!)

III
59
 Q)

U
V1
:J
~

V1
U
V1

o,
c
E
:J
o
U
ro
"-
...0
Q)
.•.....
"-Q)

>
Q)
c
Cl.
rJ')

III
60
 CRANIOCERVICAL JUNCTION
BONE CT & T1 MR CRANIOMETRY ""0
[Jl

:J
rc
<
ro
.....,
,....,.
ro
c;
.....,
~
Wackenheim line
n
Chamberlain line
o
c
3
,::l
o
(fl
n
(fl

~
C
(fl
n
ro

Chamberlain line

McGregor line

(Top) Sagittal CT reformat in the midline. Chamberlain line is shown in orange extending from hard palate to
opisthion. Projection of up to 1/3 of dens (S mm) above this line normal. Wackenheim line is shown in green along
the clivus. The dens should lie immediately inferior to line, & any intersection is considered abnormal. (Bottom)
Sagittal T1 MR with Chamberlain line shown in orange. Odontoid tip S mm or more above line defines basilar
impression. McGregor line shown in yellow. This line has the same significance as Chamberlain line, with the
odontoid tip 7 mm or more above line defining basilar impression.
III
61
 CRANIOCERVICAL JUNCTION
Q) LATERAL RADIOGRAPH CRANIOMETRY
u
tJ)
::J
~
C1J
c
D-
tJ)
C1J
'--
C1J
CL Welcher basal angle
o(S
tJ)
U
tJ)

o,
c
E
::J
o Ranawat measurement
U

McCrae line

McGregor line
Redlund-johnell
measurement

(Top) In this lateral plain film the Welcher basal angle is shown in red. Platybasia exists if angle> 140° (normal <
140°). Ranawat measurement shown in blue - used to assess collapse at the CI-2 articulation. Measurement taken
from center of C2 pedicle to line connecting anterior & posterior arch of Cl. Normal 2: 14 mm in men & 2: 13 mm
in women. < 13 mm is consistent with impaction. (Bottom) In this lateral plain film, McCrae line is shown in blue.
Normal"" 35 mm diameter. The normal odontoid process does not extend above this line. Redlund-]ohnell
measurement shown in red. This measurement is from the base of C2 body to McGregor line (shown in yellow).
Normal 2: 34 mm in men, 2: 28 mm for women.
III
62
 CRANIOCERVICAL JUNCTION
LATERAL RADIOGRAPH

Cl arch n
o
c
Atlantodental interval Posterior Cl arch
3
:::l
Odontoid process o
(Jl

C2 body
n
(Jl

Normal alignment of
posterior spino-laminar
C3 body lines

C4 body

Spinous process

~
C
(Jl
n
ro

Atlantodental interval

Posterior cervical line

Pseudosubluxation of
C2 on C3, C3 on C4

(Top) Lateral plain film of the cervical spine in a child shows physiologic anterior displacement of C2 with respect to
C3, and C3 with respect to C4, the so-called pseudosubluxation. Physiologic subluxation is differentiated from
pathologic anterior displacement by the absence of prevertebral soft tissue swelling, reduction on extension &
assessment of the posterior cervical line as described below. (Bottom) Posterior cervical line is drawn along anterior
aspect of Cl-3 spinous processes. The anterior C2 spinous process should be within 2 mm of this line in flexion &
extension. Atlantodental interval < 3.5 mm in children « 3 mm in adults).
III
63
 CRANIOCERVICAl JUNCTION
Q) RADIOGRAPHY
u
rJl
:J
~

Odontoid

Atlanto-occipital joint

Lateral mass Cl
Atlanto-axial joint
rJl Transverse process Cl
U
rJl Lateral cortical margins
o aligning at Cl-2
C2 body
c
E C2 bifid spinous
:J
process
o
U
C2-3 disc space
ro
"-
...0 C3 body
Q)
.•....
"-
Q)

>
Q)
c
0..
rJl

Clivus

Basion
Opisthion
Anterior arch Cl

Posterior arch Cl
Odontoid pl"Ocess

C2 spinous process
Body C2

Posterior spino-laminar
C2-3 disc space line
Facet joint
Transverse process C4

(Top) AP open mouth view of odontoid process. With proper positioning, the odontoid process is visualized in the
midline with symmetrically placed lateral Cl masses on either side. The medial space between odontoid and Cl
lateral masses should be symmetric as well. The lateral cortical margins of the Cl & C2 lateral masses should align.
The atlanto-occipital and atlanto-axial joints are visible bilaterally, with smooth cortical margins. The bifid C2
process should not be confused for fracture. (Bottom) Lateral radiograph of craniocervical junction. There is smooth
anatomic alignment of the posterior vertebral body margins, and the posterior spino-laminar line of the posterior
elements. The anterior arch of Cl should assume a well-defined oval appearance, with sharp margination between
III the anterior Cl arch and the odontoid process.
64
 CRANIOCERVICAL JUNCTION
CORONAL BONECT ~
"'C
::::l
ro

n
o
Basion Occipital condyle c
Atlanto-occipital joint
3
:J

Cl lateral mass
Odontoid process
o
Transverse process Cl
Atlanto-axial joint
Normal alignment of
lateral cortical margins C2 body
Cl & C2

Uncinate process C2-3 intervertebral disc

~
C
Neural foramen CJl
n
(t)

Jugular foramen
Hypoglossal canal

Occipital condyle

Atlanto-occipital joint

Cl lateral mass Odontoid process

Transverse process Cl

Atlanto-axial joint

C2 body C2-3 intervertebral disc

(Top) First of two coronal bone CT reconstructions of the craniocervical junction are presented from anterior to
posterior. The odontoid process is visualized in the midline as a sharply corticated bony peg with symmetrically
placed lateral Cl masses on either side. The lateral cortical margins of the Cllateral masses, and the C2 lateral masses
should align. The atlanta-occipital and atlanto-axial joints are visible bilaterally, with even joint margins, and sharp
cortical margins. (Bottom) More posterior view of the craniocervical junction. Both atlanto-occipital joints are now
well-defined with smooth cortical margins, sloping superolateral to inferomedial. The atlanto-axial joints are
smoothly sloping inferolateral to superomedial. III
65
 CRANIOCERVICAL JUNCTION
Q) AXIAL BONE CT
u
(f)

:J
~
Superior cortex of anterior arch Cl

Atlanto-occipital joint
Styloid process

Occipital condyle
Foramen magnum
(f)

U Retrocondylar vein
(f)

o...
c
E
:J
o
U
ri.l
'-
...D
Q)
.•....
'-
Q)
Anterior arch Cl
> Anterior atlantodental joint
Q)
C Odontoid tip Cllateral mass
0-
V') Atlanto-occipital joint

Foramen magnum

Opisthion

Odontoid
Transverse process

Transverse foramen Superior articular facet Cl

Transverse ligament

Posterior arch Cl

(Top) First of six axial bone CT images through the craniocervical junction are presented from superior to inferior.
The anterolateral margin of the foramen magnum is formed by the prominent occipital condyles which articulate
with the superior articular facets of the Cllateral masses. (Middle) More inferior image of craniocervical junction.
The anterior arch of Cl is now well-defined, with the odontoid process of C2 coming into plane. The
atlanta-occipital joint is seen in oblique section and therefore has poorly-defined margins. The odontoid is tightly
applied to the posterior margin of the Cl arch, held in place by the strong transverse component of the cruciate
ligament. (Bottom) Image at level of atlas. The unique morphology of the Cl body is defined with its large transverse
III process with transverse foramen and ring shape.
66
 CRANIOCERVICAL JUNCTION
AXIAL BONE CT ""0
CJl

::J
(t)

<
...•
(!)
r-+
C2 superior articular facet
(!)
Junction base of odontoid with
body C2
Atlanto-axial joint
...•
U
~
Cl inferior articular facet n
Spinal canal o
c
Cl posterior arch :3
::J
o
(Jl
n
(Jl

Transverse process Inferior body C2 ~

C
(Jl
Pedicle Transverse foramen n
(!)

Lamina

Spinous process

C2-3 intervertebral disc

C3 uncinate process C2-3 neural foramen

C3 superior articular process

Facet joint
C21amina C2 inferior articular process

C2 bifid spinous process

(Top) Image through lateral atlanto-axial joints. This section defines the junction of the odontoid process with the
body of C2. The obliquely oriented atlanto-axial joints are partially seen, with the Cl component lateral to the joint
space, and the C2 component medial. (Middle) Image through inferior C2 body level showing large C2 vertebral
body & vertebral arch formed by gracile pedicles & laminae. (Bottom) Image through C2-3 intervertebral disc level.
The C2-3 neural foramen is well-defined, with the posterior margin formed by the superior articular process of C3.
The spinous process of C2 is large and typically bifid. The C2-3 disc assumes the characteristic cervical cup-shaped
morphology bounded by uncinate processes.
III
67
 <J)
u
<J)

o
c
E
:J
o
U
(\)
'-
...0
Q)
.j-I

'-
Q)

>
Q)
c
a.
CJ')

III
68
n
o
c
3
:J

o
<Jl
n
<Jl

~
C
<Jl
n
(t)

III
69
 Q)

u
l/)
:J
~

l/)
u
l/)

o,
c
E
:J
o
U
ro
'--
...0
Q)
"'--'
'--
Q)

>
Q)
C
0..
V')

III
70
 CRANIOCERVICAl JUNCTION
AXIAL T2 MR ""0
[Jl

::J
I'D

Anterior atlanto-occipital
membrane n
Basion
o
c
3
Vertebral artery ,::J
Cervicomedullary junction
Spinal portion of accessory o
nerve (CNll) (fl

Cerebellar tonsil n
(fl

~
C
(fl
Anterior arch Cl
Odontoid tip
n
(!)

Atlanto-occipital joint Alar ligament

Cervical cord

Anterior arch Cl Anterior atlantodental joint

Odontoid process
Transverse ligament
Transverse foramen

Cruciate ligament Cervical cord

(Top) First of three axial T2 MR images through the craniocervical junction from superior to inferior shows the
anterior margin of the foramen magnum, the cervicomedullary junction and adjacent vertebral artery flow voids.
(Middle) Image at level of Cl anterior arch. The odontoid tip is seen as rounded intermediate signal in the midline,
ventral to the cervical cord. The anterior arch of Cl is visible, with its well-defined cortical margins. The alar
ligaments are identified as low signal intensity bands extending laterally from the lateral margins of the odontoid
process towards the occipital condyles. (Bottom) More inferior image through atlantodental joint. The anterior
atlantodental joint is seen along ventral margin of odontoid process. The cruciate ligament (transverse component) is
seen as low signal bands curving over dorsal margin of odontoid. III
71
 CRANIOCERVICAL JUNCTION
Q) SAGITTAL CT & MR
u
IJl
:J
~
Basion
Anterior atlanto-occipital
membrane Tectorial membrane
Odontoid tip
Apical ligament
Cruciate ligament
Anterior arch Cl
Opisthion
Anterior atlantodental joint
IJl Cl posterior arch
U Base of odontoid process
IJl

o, C2-3 intervertebral disc

C2 spinous process

c
E
:J
o
U

Basion
Apical ligament
Anterior atlanto-occipital
membrane Tectorial membrane
Anterior arch Cl Opisthion
Cruciate ligamen t
Anterior atlantodental joint
Anterior longitudinal ligament
Cl posterior arch
Base of odontoid process

C2-3 intervertebral disc

C2 spinous process

Basion

Anterior atlanto-occipital Superior extension of cruciate

membrane ligament
Apical ligament Tectorial membrane

Anterior arch Cl Odontoid tip

Cruciate ligament

Anterior longitudinal ligament Cl posterior arch

Posterior longitudinal ligament
Base of odontoid process

C2-3 intervertebral disc

(Top) Sagittal midline CT reformat shows the ligamentous structures visible at the craniocervical junction. The apical
ligament is visible as a linear band between odontoid tip and clivus. The tectorial membrane is the superior
extension of the posterior longitudinal ligament. The anterior atlanto-occipital membrane is the extension of the
anterior longitudinal ligament. (Middle) Sagittal Tl MR midline image of craniocervical junction. The atlantodental
interval is well-defined by the adjacent low signal cortical margins of Cl anterior arch and the odontoid process. The
cruciate ligament is a low signal band dorsal to the odontoid. (Bottom) Sagittal T2 MR image of the craniocervical
junction. The tectorial membrane, superior extension of cruciate ligament, apical ligament & anterior
III atlanto-occipital membranes are evident.
72
 BASAL GANGLIA AND THALAMUS
AXIAL T2 MR Cl:'
"'"
~
::J
Vl
c
-0
Head of caudate nucleus
....•
Anterior limb, internal capsule ~
r-+
Genu, internal capsule
Putamen ro
:J
r-+
Globus pallid us
o
....•
Posterior limb, internal capsule
Thalamus

Pulvinar, thalamus

Head of caudate nucleus

Anterior limb, internal capsule
Putamen

Thalamus

Head of caudate nucleus

Body of caudate nucleus

Thalamus

(Top) Image more superior shows basal ganglia & thalamus. Occasionally, a single large thalamoperforator artery,
called artery of Percheron or paramedian thalamic artery, supplies both medial thalami & can result in bilateral
medial thalamic infarcts. This condition may mimic neoplasm such as lymphoma or glioma on imaging. (Middle)
This image shows superior thalamus & superior aspects of caudate head & putamen. Anterior limb of internal capsule
separates caudate head from putamen, while posterior limb separates thalamus from globus pallidus & putamen.
(Bottom) Image at level of centrum semiovale shows caudate nucleus as it wraps around lateral ventricles.
Huntington disease is characterized by an inability to prevent unwanted movement. Caudate head becomes
atrophied in this disease making a "box-car" appearance of frontal horns of lateral ventricles.
73
 BASAL GANGLIA AND THALAMUS
C CORONAL STIR MR
nJ
•...
CO
nJ

Body, corpus callosum

Head of caudate nucleus

Internal capsule
Putamen
External capsule
Claustrum
Extreme capsule
Insula

Body, corpus callosum

Head of caudate nucleus
Internal capsule Putamen
External capsule Globus pallidus
Extreme capsule
External medullary lamina
Anterior commissure

Body, corpus callosum

Head of caudate nucleus
Thalamus
Internal capsule
Putamen
Claustrum
External capsule
Insula
Extreme capsule Hypothalamus
External medullary lamina

(Top) First of six coronal STIR MR images from anterior to posterior shows caudate head continuous with inferior
putamen immediately above anterior perforated substance. Other connections between caudate & putamen can be
seen along course of anterior limb of internal capsule. (Middle) Image through anterior commissure shows decreased
signal of globus pallidus relative to putamen related to increased iron deposition in globus pallidus. Putamen is
separated from globus pallidus by external medullary lamina. Globus pallidus contains two segments, lateral &
medial, which are not resolved on conventional imaging. (Bottom) Image through anterior limb internal capsule.
The insula lies deep in floor of sylvian fissure & is overlapped by the operculum. Insula has many connections with
thalamus & amygdala, as well as with olfactory & limbic systems.
74
n
o
c
3
,:J

o
(Jl
(")
(Jl

~
c
(Jl
(")

([)

III
75
r.J)
u
r.J)

o
c
E
~
o
U

III
76
n
o
c
:3
,:J
o
r.r>
n
r.r>

~
C
r.r>
n
(1)

III
77
 <Jl
U
<Jl

o
c
E
:J
o
U
(Ij
"-
..0
.•...
OJ
"-OJ
>
OJ
c:
a.
rJ)

III
78
 CERVICAL SPINE
RADIOGRAPHY Vl
-c
:::l
(t)

<
ro
.....•
~
(t)
'J
.....•
~
n
C3 body o
Cervical lateral masses c
"pillars"
:3
C4 body ,:J
In tervertebral disc
space
o
CJl
n
CJl
C6 uncinate process

C7 transverse process C7 pedicle

Tl transverse process
First rib
~
Clavicle C
CJl
n
(t)

Posterior arch Cl

C2 body
Inferior articular facet
C2
Anterior cortical
margin, C3 Superior articular facet
C3

Corticated margin
Prevertebral soft tissues defining spino-laminar
line

C7 spinous process

Posterior cortical
margin, C6

(Top) AP plain film view of the cervical spine. The articular facets are viewed obliquely in this projection & therefore
not defined, giving the appearance of smoothly undulating lateral columns of bone. The superior & inferior vertebral
endplate margins are sharp, with regular spacing of the intervertebral discs. The spinous processes are midline. C7
transverse process is directed inferolaterally compared with Tl which is directed superolaterally. (Bottom) Lateral
radiograph of cervical spine. The prevertebral soft tissues should form a defined, abrupt "shelf" at approximately C4/S
where the hypopharynx/esophagus begins, hence thickening the prevertebral soft tissues. The bony cervical spine is
aligned from anteriorly to posteriorly with the anterior vertebral body margins, the posterior vertebral body margins III
& ventral margins of the spinous processes (spino-laminar line).
79
 <fl
U
<fl

o,
c
E
:J
o
U
C\l
'-
....0
C])
.•....
'-
C])

>

III
80
n
o
c
:3
:J

o
<Jl
n
<Jl

~
C
<Jl
n
CD

III
81
 CERVICAL SPINE
Q) AXIAL BONE CT
u
<Jl
::)
~

C4 inferior end plate

Uncinate process CS
C4-S intervertebral disc Neural foramen

Superior articular facet

Facet joint
<Jl Inferior articular facet
U Lamina
<Jl
Spinal cord
o,
c
E::)
o
U
ro
l-
...0
Q)
.•.....
l-
Q)
C4 inferior endplate

> Transverse process Uncinate process CS

Q)
C C4-S intervertebral disc CS pedicle
0-
CJ)
Superior articular facet
Facet joint
Spinal cord

Lamina

CS body
Anterior tubercle transverse
process
Posterior tubercle transverse process
Transverse foramen
CS pedicle

Spinal cord
Lamina

Spinous process

(Top) First of six axial bone CT images presented from superior to inferior through the cervical spine starting at the
C4-5 level. The cup-shaped intervertebral disc of the cervical region is seen centrally, bounded along the
posterolateral margin by the uncinate processes. The uncinate process defines the joint of Luschka between adjacent
vertebral segments. The neural foramina exit at around 45° in an anterolateral direction, bounded posteriorly by the
superior articular process. (Middle) Image through inferior margin of intervertebral disc. The gracile pedicles arise
obliquely from the posterolateral margins of the vertebral bodies. The bony canal is large relative to the posterior
elements, & assumes a triangular configuration. (Bottom) Image through C5 body level. The transverse process
III contains the transverse foramen for the vertebral artery.
82
 CERVICAL SPINE
AXIAL BONE CT ""0
V'l

:J
(t)

<
(t)
Anterior tubercle transverse .....•
CS body ..-T
process (!)
U
.....•
Posterior tubercle transverse process Transverse foramen OJ

Basivertebral veins CS pedicle n

o
Vertebral canal c
Lamina :3
:J

Spinous process (bifid)

o
Vl
n
Vl

CS body
Anterior tubercle transverse ~
C
process Vl
n
Neural foramen (!)
Neural foramen
Uncinate process C6
Vertebral canal
Lamina

Spinous process

Neural foramen
CS-6 intervertebral disc
Superior articular facet
Uncinate process C6
Facet "pillar" Facet joint

Lamina Inferior articular facet

Spinous process

(Top) Image through mid CS body at the pedicle level. The transverse foramina are prominent at this level, with the
round, sharply marginated transverse foramen encompassing the vertical course of the vertebral artery. The anterior
& posterior tubercles give rise to muscle attachments in the neck. The vertebral body is interrupted along the
posterior cortical margin for the passage of the basivertebral venous complex. (Middle) Image at the inferior CS body
level. The uncinate process arising off of the next inferior vertebral body is coming into view. The inferior margins of
the transverse processes are incompletely visualized. The spinous process is well seen joining with the thin lamina.
(Bottom) View at CS-6 level shows the next neural foraminallevel bounded by uncovertebral joint anteriorly, &
facet posteriorly. III
83
 CERVICAL SPINE
CORONAL CT MYELOGRAM

Occipital condyle
Vertebral artery
Atlanto-occipital joint
Posterior arch Cl

Cervical spinal cord Cervical lateral masses (pillars)

V1 Nerve rootlets
U
V1

o
c Tl transverse process
E
:J
o Second rib
U
Vertebral artery Occipital condyle

Foramen magnum
Atlanto-occipital joint

Cervical spinal cord Cervical lateral masses (pillars)

Nerve rootlets (ventral)

Anterior median sulcus of

First rib spinal cord

Atlanto-occipital joint
Cl lateral mass

Atlantoaxial joint

Intervertebral disc space C3-4 neural foramen

C4-S neural foramen C4 body
Basivertebral vein

C6 transverse process anterior

tubercle

First rib

(Top) First of three coronal reformatted images from a CT myelogram displayed from posterior to anterior. Most
posterior view shows the spinal cord with exiting nerve rootlets at each segmental level traversing in a craniocaudal
direction within the thecal sac. Tl transverse process is prominent & directed superolaterally. (Middle) More anterior
view shows the ventral margin of the cervical spinal cord with the anterior median sulcus, which would contain the
anterior spinal artery. The ventral nerve rootlets are also visible. The articular pillars of the facet joints are well
shown, giving a view similar to an AP radiograph of the undulating lateral margin of the cervical pillars. (Bottom)
More anterior view shows transverse processes with adjacent neural foramina. The posterior margins of the vertebral
III bodies show the midline basivertebral veins.
84
 CERVICAL SPINE
SAGITTAL CT MYELOGRAM Vl
"'0
::l
ro
Atlanto-occipital joint
Posterior arch Cl
<
ro
.....,
r-!"
Atlantoaxial joint C2 pars interarticularis ro
Inferior articular facet C2
u
.....,
~
Superior articular facet C3
n
o
c
C4-S facet joint
:3
,:J

o
(fl
n
(fl
C7-Tl facet joint

~
C
(fl
n
ro

Neural foramina Facet joint complex

C7 pedicle

Uncinate process

Basion

Opisthion

Anterior arch Cl Posterior arch Cl

C2 body Spinous process

Ligamentum nuchae

Interspinous ligament
Intervertebral disc
Dorsal dura margin

Prevertebral soft tissues Cerebrospinal fluid

Spinal cord

(Top) First of three sagittal reformatted images from CT myelogram. Paramedian sagittal section through the
articular pillar showing the facet joints in profile. Superior articular facets are directed posteriorly while inferior facets
are directed anteriorly. The curvilinear shape of the atlanto-occipital joint is visible, allowing for flexion/extension.
(Middle) More medial section through obliquely oriented neural foramina which are bounded above & below by
pedicles, anteriorly by uncovertebral joint, disc & vertebral body, & posteriorly by facet joint complex. (Bottom)
Midline section shows the spinal cord outlined by the high attenuation of the contrast within the cerebrospinal
fluid. Vertebral alignment is normal & prevertebral soft tissues demonstrate an abrupt "shelf" at approximately C4-S
level where esophagus begins. III
85
 CERVICAL SPINE
Q)
SAGITTAL T1 MR
u
tJ)
:J
~ Occipital condyle
Atlanto-occipital joint

Atlantoaxial joint

tJ) C4-S facet joint

u
tJ)

o, Inferior articular process C6

Superior articular process C7
c
E C7-Tl facet joint
:J
First rib
o
U
(ij
'-
..0
Q)
+-'
'-
Q)

> Posterior arch Cl

Q,)
c:
c..
CJ)

Lamina

C7-Tl neural foramen C7 inferior articular process

Tl pedicle

Basion

Anterior arch Cl
Opisthion
Posterior arch Cl
C2 body
Spinous process C2
Ligamentum nuchae
Prevertebral soft tissues
C4 body Interspinous ligament

C6-7 intervertebral disc

Spinal cord
Cerebrospinal fluid

(Top) First of three sagittal TI MR images viewed from lateral to medial. View through the articular pillar showing
the facet joints in profile. Margins of the facet joints are well corticated & seen as thin hypointense lines. (Middle)
More medial section through obliquely oriented neural foramina. (Bottom) Midline image shows the well-defined
low signal cortical margins of the vertebral bodies, which merge along their anterior & posterior margins with the
hypointense anterior & posterior longitudinal ligaments respectively. Vertebral marrow signal is hyperintense relative
to intervening discs on TI MR. Cerebrospinal fluid is hypointense.

III
86
 CERVICAL SPINE
SAGITTAL T2 MR CJl
-0
:J
ro
Occipital condyle
Posterior arch Cl <
(!)
""""'
r-+
Cl lateral mass C2 pars interarticularis (!)
U
""""'
Vertebral artery in C2 transverse Inferior articular facet C2 ~
foramen
Superior articular facet C3 n
C4-S facet joint o
CS-6 neural foramen c
3
C6-7 facet joint :J
C6 tra nsverse process
o
Vl
n
Vl

$
c
Vl
n
Vertebral artery (!)
CS facet

CS-6 facet joint

Vertebral artery entering transverse

foramen
First rib

Anterior arch Cl

Spinous process C2
C2 body

Prevertebral soft tissues Ligamentum nuchae

Ventral dural margin/posterior Interspinous ligament

longitudinal ligament

C6-7 intervertebral disc

Dorsal dura margin
Cerebrospinal fluid
Spinal cord

(Top) First of three sagittal T2 MR images viewed from lateral to medial. View through the articular pillars show
normal alignment of the facet joints. The rhomboidal configuration of the cervical facets is noted, with their
complementary superior & inferior articular facets. The exiting spinal nerves run in the groove along the superior
aspect of transverse processes. (Middle) More medial section shows the overlapping facets at each level, & the flow
void of the vertebral artery within the transverse foramen. (Bottom) Midline image shows the relationship of the
cervical cord, vertebral bodies & spinous processes with smooth straight margins & alignment. The posterior dural
margin merges with the ligamentum flavum & spinous process cortex low signal. The anterior dural margin merges
with the posterior body cortex & posterior longitudinal ligament. III
87
 CERVICAL SPINE
Q) AXIAL GRE MR
u
(J)
:J
~
Transverse process
Vertebral body C2
Vertebral artery

Transverse foramen
Anterior internal venous plexus
Nerve roots Spinal cord
(J) Lamina
U
(J)
Spinous process
o, Posterior external vein

c
E
:J
o
U
ru
•....
....Q
Q)
.•.....
•....
Q)

> Vertebral endplate

Vertebral artery
Q)
Uncinate process
c: Neural foramen
c..
CJ')
Dorsa I nerve roots

Spinal cord

Lamina

Spinous process

Vertebral endplate
Intervertebral disc
Uncinate process Vertebral artery
Neural foramen

Inferior articular facet

Lamina

Spinous process

(Top) First of six axial gradient echo MR images with large flip angle (giving dark CSF signal) shown from superior to
inferior beginning at the inferior C2 body level. The prominent transverse foramen with the vertebral artery is
apparent. Flow related enhancement is also visible in the cervical dorsal veins, as well as the epidural veins (anterior
internal venous plexus). (Middle) Image at the inferior end plate of C2. The neural foramina are directed at 45°
anterolaterally & show flow related enhancement in epidural/foramina I venous plexus, & the ascending vertebral
arteries. The spinal cord & dural margins are well-defined & smooth. The dorsal nerve rootlets are barely visible
within the dorsal thecal sac. (Bottom) Image at the C2-3 disc level. The inferior articular facet of C2 & the prominent
III C2 spinous process are visible.
88
 CERVICAL SPI N E
AXIAL GRE MR V'l
""C
:J
(tl
Intervertebral disc
<
(tl
Anterior tubercle transverse process .....•.
""""

(tl
Uncinate process Vertebral artery u""""

Neural foramen OJ
Nerve root sleeve
()
Spinal cord o
Lamina c
:3
::J
o

Vertebral artery in transverse

Vertebral body foramen
~
Superior articular facet C4 C
(f)

Neural foramen n
Facet joint (tl

Inferior facet C3
Spinal cord

Posterior external vertebral vein

Vertebral end plate Vertebra I artery

Transverse foramen
Transverse process
Pedicle
Thecal sac
Lamina

(Top) Image through C2-3 intervertebral disc. The intermediate signal, square shaped intervertebral disc is evident,
with the bounding lower signal uncinate processes. The low signal, CSF containing, triangular shaped root sleeves are
seen extending anterolaterally into the neural foramina. (Middle) Image through superior C3 vertebral body shows
the C3-4 facet joint with the anterior low signal superior facet of C4, the intermediate signal linear joint space, & the
dorsal positioned low signal inferior facet of C3. (Bottom) Jmage through C3 pedicles which project posterolaterally
from the vertebral body. The delicate laminae complete the triangular shaped vertebral foramen containing the
thecal sac & contents. The transverse foramina containing the vertebral arteries are prominent within the transverse
processes. III
89
 CERVICAL SPINE
Q) AXIAL T2 MR
u
rJl
:J
~
Anterior atlanto-axial joint Anterior arch Cl

Odontoid process
Transverse ligament
Cl lateral mass
Transverse foramen

rJl Vertebral artery flow void Spinal cord

U
rJl
Cerebrospinal fluid
o
~
c
E
:J
o
U
~
•...
...Q
Q)
.•....•
•...
Q)

> Atlanto-axial joint/superior

(]) articular facet C2
c::
.- Vertebral body C2/base of odontoid
c..
rJ) Vertebral artery Anterior internal venous
plexus/epidural fat
Spinal cord
Cerebrospinal fluid

Vertebral artery
C2 body
Neural foramen

Cerebrospinal fluid
Lamina
Spinal cord

Spinous process

(Top) First of six axial T2 MR images shown from superior to inferior beginning at the level of the anterior arch of
Cl. The anterior atlantodental joint is well-identified, bounded by the low signal cortical margins of the anterior
odontoid & anterior arch of Cl. Posterior to the odontoid is the low signal transverse ligament complex. (Middle)
Image at odontoidjC2 body level. The base of the odontoid is at the level of the lateral atlanto-axial articulation. This
joint is sloped, being more superior at the medial margin. The vertebral arteries are identified by their flow voids,
located just lateral to the lateral masses, passing superiorly toward the Cl transverse foramen. (Bottom) Image at C2
body level. The relationship of the vertically oriented vertebral artery to the neural foramen is highlighted in this
III section.
90
 CERVICAL SPINE
AXIAL T2 MR ""0
CJl

::J
(0

<
(!)
Intervertebral disc ....•
Vertebral endplate r-+
(!)
Vertebral artery flow void 0-
....•
Uncinate process p.,J

CSF flow artifact n

o
Spinal cord
c
:3
:J

o
V'l
(')
V'l

Vertebral artery
~
Transverse process C
V'l
Pedicle (')

(!)
Articular pillar
Spinal cord
Ligamentum flavum

C3 inferior endplate
Vertebral artery

Neural foramen
Facet joint Cerebrospinal fluid

Spinal cord
Lamina

Spinous process

(Top) Image at C2-3 disc level. The intervertebral disc is fully visualized as low signal, with the bounding posterior
lateral uncovertebral joints. (Middle) Image through pedic1es of C3. Pedicles are delicate & are directed
posterolaterally from the vertebral body. The articular pillars are formed by the superior & inferior articular processes
& intervening facet joints. Prominent vertebral artery flow voids are seen within the transverse foramina of the
transverse processes. (Bottom) Image through the neural foramina of C3 which are oriented approximately 45°
anterolaterally. The posterior margin of the neural foramen is the facet joint & the ventral margin the disc &
uncinate process.
III
91
 THORACIC SPINE
o Rib articulations
ITerminology • Costovertebral joint: Rib head articulates with
Abbreviations two costal demifacets; superior costal facet of same
• Costovertebral (CV) number vertebrae as rib & inferior costal facet of
next vertebral body
Synonyms • Costotransverse joint: Transverse process of
• Costal facet = demifacet vertebral body T1-10
• Muscles
o Superficial muscles include trapezius, rhomboid,
<Jl
IGross Anatomy latissimus dorsi & serratus inferior & superior
U o Deep muscles include erector spinae (sacrospinalis),
<Jl Overview iliocostalis, longissimus, spinalis & semispinalis
o, • Consists of 12 vertebrae (Tl-12) thoracis, multifidus, rotatores & interspinalis
• Thoracic kyphosis • Ligaments
c o One of two primary spinal curves (thoracic & sacral) o Anterior & posterior longitudinal, interspinous,
E present at birth, maintained throughout life supraspinous ligaments & ligamentum flavum
:J
o Cervical & lumbar lordoses are secondary curves, o Costovertebral ligaments
o more flexible & result of development • Radiate ligament connects head of rib & adjacent
U
• Considerable variability in amount of kyphosis vertebral bodies
(20-45°) • Costotransverse ligaments (lateral & superior)
• Each body contributes 3.8° of kyphosis via connect neck of rib with transverse process
wedge-shaped angulation • Biomechanics
• Apex at T7 o Intact rib cage increases axial load resistance 4x
• Increases with age o Rib cage & facets limit rotation
• M < F
• Thoracolumbar junction
o Transition from rigid thoracic spine to more mobile I Imaging Anatomy
lumbar spine
o Tl1, Tl2 ribs provide less rigidity compared to rest Radiography
of thoracic spine • Short C7 transverse process projects inferolaterally;
o No connection to sternum (free floating) long T1 transverse process projects superolaterally
o Only single rib articulation on vertebral bodies
• Thoracic spine unique features
MRI
o Articulation with rib cage • Body: Signal intensity of marrow varies with age
o Coronal facet orientation o Hemopoietic ("red") marrow is hypointense on
o Small spinal canal relative to posterior element size T1WI, becomes hyperintense with conversion from
red -+ yellow (age 8-12 years)
Components o End-plate, reactive marrow changes normally with
• Bones aging (can be fibrovascular, fatty, or sclerotic)
o Thoracic vertebrae increase in size from T1 '* T12 • Intervertebral disc: Signal intensity varies with age
o Body o Hyperintense on T2WI in children, young adults;
• Typical body contains two costal demifacets progressive ~ water -+ hypo intense on T2WI
laterally o Disc degeneration, dessication, shape change (bulge)
• T1 has complete facet superiorly and demifacet normal after second decade
inferiorly, TlO has superior demifacet only, T11 • Ligaments: Hypointense on both T1 & T2WI
and 12 have complete facet
o Arch
• Pedicle: Projects directly posteriorly IAnatomy-Based Imaging Issues
• Transverse process: T1 transverse process projects
superolaterally; T1-10 transverse process costal Key Concepts or Questions
facet articulates with costal tubercle • Thoracic spinal cord is protected & shielded from
• Articular processes: Superior & inferior articular injury by paraspinal muscles & rib cage
process with coronally oriented facet joint • Narrow spinal canal of thoracic spine allows for easy
• Lamina cord compression with malalignment or trauma
• Spinous process: Tl-9 project inferiorly; TlO-12 • Normal kyphotic posture increases risk of fracture
project more horizontally • Thoracolumbar junction at more traumatic risk due to
• Intervertebral foramen lack of rib cage stabilization
o Oriented laterally below pedicle
Imaging Pitfalls
• Joints
o Intervertebral disc • Cervicothoracic junction
o Facet (zygapophyseal) joints o Cervical ribs arising from C7 found in 0.5%
population
• Facets oriented near vertical in coronal plane
o Short C7 transverse process projects inferolaterally
• Limit flexion & extension
o Long T1 transverse process projects superolaterally

III
92
n
o
c
:3
:J

~
c
CJl
n
ro

III
93
 THORACIC SPINE
Q)
RADIOGRAPHY
u
<Jl
:J
~
First rib
Ci:l
C
n vertebral body

0..
<Jl
Ci:l Tracheal air column
'-
Ci:l
0... TS pedicle
o<l Fifth rib
<Jl TS body
U
<Jl
TS costovertebral joint
0
Lateral cortical margin
C
T8 body
E
:J
Inferior endplate T8
0 T9 transverse process
U
Ci:l Superior end plate no
'-
...n Intervertebral disc
Q)
.•..... space
'-
Q)
> T12 vertebral body
OJ
C
0..
rJ'J
T12 spinous process /

Pedicle
Tracheal air column

Costovertebral joint

Neural foramen

Superior end plate

Inferior end plate

Posterior cortical
Intervertebral disc margin of vertebral
space body

An terior cortical
margin of vertebral
Rib
body

Spinous process

(Top) AP view of the thoracic spine. The square thoracic vertebral bodies are aligned in the midline, with
symmetrical paired & sharp corticated ovals of the pedicles. The endplates are well-defined with smooth
intervertebral discs. The spinous processes also align in the midline, with the tips extending to the next inferior level.
The rib heads articulate with the two adjacent vertebra (TS rib articulates with T4 & TS bodies). (Bottom) Lateral
view of the thoracic spine. The vertebral bodies are identified with sharp cortical margins on all four sides,
well-defined intervertebral disc spaces, & a gentle thoracic kyphotic curvature. The neural foramina are well
identified on this projection. The posterior elements are ill-defined, due to considerable overlap of the right &
III left-sided ribs.
94
 THORACIC SPINE
CORONAL CT MYELOGRAM ""0
Vl

:::::l
Spinous process /"C

Lamina Inferior articular process

Superior articular process
Facet joint

Medial portion of rib

Neural foramen

Pedicle Ribs

Inferior articular process Spinal canal

Superior articular process
o
fJl
n
fJl

Transverse process

Spinous process
Lamina Inferior articular process

Superior articular process

~
Medial portion of rib Costovertebral joint C
fJl
n
Pedicle ro
Ribs
Neural foramen

Spinal cord within canal

Transverse process

Medial portion of rib

Costovertebral joint
Basivertebral veins
Inferior demifacet of costovertebral
joint
Superior demifacet of Ribs
costovertebral joint

Posterior cortex vertebral body

Spinal canal
Conus medullaris Neural foramen
Pedicle
Cauda equina

(Top) First of three coronal reformat images from CT myelogram through the thoracic spine presented from posterior
to anterior. The posterior spinal canal is identified with the intrathecal contrast, bounded laterally by the pairs of
medial ribs/pedicles seen as well-defined corticated oval bony densities. With the normal thoracic kyphosis, the
superior & inferior thoracic spine is seen in more anterior section than the mid portion. (Middle) More anterior
image through mid canal level. The relationship of the neural foramen, pedicle & adjacent medial rib is identified.
(Bottom) More anterior image through the posterior vertebral body level. The costovertebral joint articulations are
particularly well identified in this view. Note the superior & inferior costal facets (demifacets) with the rib head at
disc level. III
95
 <.J)
u
<.J)

o
c
E
:J
o
U

III
96
 SELLA, PITUITARY AND CAVERNOUS SINUS
SAGITTAL FAT-SATURATED T1 MR OJ
~
~
:J
(f)

""0
C
....•
tl)
r-+
(t)
::J
r-+
o
....•

Optic chiasm
Midbrain

Infundibulum
(pituitary stalk)
Pons
Adenohypophysis
(anterior lobe, pituitary
gland)
Neurohypophyseal
"bright spot" Clivus

Tuber cinereum
Optic chiasm

Infundibulum
(pituitary stalk)
Sphenoid sinus

Pituitary gland
Clival venous plexus

Nasopharyngeal
adenoidal tissue

(Top) Unenhanced sagittal Tl fat-saturated MR image through the midline sella turcica demonstrates Tl shortening
in the neurohypophysis (posterior pituitary "bright spot" or PPBS).The PPBSis caused by vasopressin and oxytocin,
not fat, and therefore does not suppress. Note prominent developmental sphenoid pneumatization in this case.
(Bottom) Enhanced sagittal Tl fat-saturated MR image through the midline in the same case shows normal pituitary
gland and stalk enhancement. The tuber cinereum and hypothalamus between the infundibulum and mammillary
bodies lacks a blood-brain barrier and also enhances. Note normal enhancement of the nasopharyngeal tissue and its
proximity to the central skull base.

97
 PINEAL REGION
ITerminology
Synonyms
• Pineal gland, pineal body, epiphysis cerebri
• Posterior commissure: Epithalamic commissure
Definitions
• Epithalamus: Dorsal nuclei of diencephalon
I Gross Anatomy
Overview
• Major components of pineal region
a Pineal gland
a Posterior recesses of third ventricle
a Internal cerebral veins, vein of Galen; medial
posterior choroidal artery
a Epithalamus, quadrigeminal plate (tectum), corpus
callosum
a Dura, arachnoid
• Pineal gland
a Unpaired midline endocrine organ located within
quadrigeminal cistern
a Structure
• Attached to diencephalon & posterior wall of
third ventricle by pineal stalk
• Pineal stalk consists of superior/inferior lamina
(form superior & inferior borders of pineal recess
of third ventricle)
• Superior/inferior lamina connect
habenular/posterior commissures, respectively, to
pineal gland
a Vascular supply: Primarily medial posterior
choroidal artery (lacks blood-brain barrier)
a Contents: Pineal parenchymal cells, germ cells, some
neuroglial cells (predominately astrocytes)
a Functions: Incompletely understood but include
• Secretion of melatonin, thought to regulate
sleep/wake cycle in humans
• Regulation of reproductive function, such as onset
of puberty in humans
• Pineal gland connections
a Habenular commissure: Connects habenular,
amygdaloid nuclei and hippocampi
a Posterior commissure: Connections with dorsal
thalamus, superior colliculi, pretectal nuclei and
others; medial longitudinal fasciculus fibers also
cross here
a Stria medullaris thalami: Fibers connecting both
habenular nuclei
a Habenular nuclei: Relay station for olfactory centers,
brain stem, and pineal
a Paraventricular nuclei: Connections with
hypothalamus, hippocampus, amygdala, brain stem,
septal nuclei and stria terminalis
a Superior cervical ganglia sympathetic fibers
a Dorsal tegmentum nonadrenergic tract
Anatomy Relationships
• Pineal gland boundaries
a Superior: Cistern of velum interpositum and internal
cerebral veins
98
a Inferior: Superior colliculi of midbrain tectum
a Anterior: Pineal and suprapineal recesses, third
ventricle
a Posterior and superior: Vein of Galen
a Posterior and inferior: Superior cerebellar cistern
I Imaging Anatomy
Overview
• Pineal gland lacks blood-brain
contrast administration
barrier, enhances after
• CT
a Pineal gland calcifications common, increase with
age
• Globular or concentric lamellar patterns common
• Incidence increases with age « 3% at 1 year, 7%
by 10 years, 33% by 18 years, > 50% of older
patients)
• Central calcifications normal, generally s 10 mm
• Larger, peripheral or "exploded" calcifications
abnormal, may signify underlying neoplasm
a Habenular commissure sometimes calcifies
("C-shaped" on lateral projections)
• MR
a Homogeneous enhancement is typical
a Incidental, nonneoplastic intra pineal cysts common
• Usually proteinaceous (FLAIR bright)
• Enhancement can be nodular, crescentic or
ring-like
IAnatomy-Based Imaging Issues
Imaging Recommendations
• MR: Thin-section enhanced sagittal images (1 mm)
and smaller field of view (16 cm) best
Imaging Pitfalls
• Benign, nonneoplastic pineal cysts are common
a Most appropriate management and follow-up
recommendations are controversial
a Unilocular small simple cysts most common (on
routine imaging), usually do not require follow-up
a Suggested follow-up if > 1 cm or atypical
enhancement pattern; some authors suggest
follow-up based on clinical indications
a Large cysts can become symptomatic (cause
hydrocephalus or Parinaud syndrome)
• Pineal cysts may mimic tumors (pineocytoma) and
vice versa
• Exophytic midbrain tecta I masses may mimic primary
pineal region tumors (pineal tumors usually compress
tectum and displace it inferiorly)
Clinical Implications
• Parinaud syndrome
a Dorsal midbrain or collicular syndrome caused by
mass in pineal region compressing tecta I plate
a Loss of vertical gaze; nystagmus on attempted
convergence; pseudo-Argyll-Robertson pupil
• "Pineal apoplexy"
a Sudden onset severe headache, visual problems
a Hemorrhage into pineal cyst or neoplasm
 THORACIC SPINE
AXIAL BONE CT

Aorta

Vertebral body
n
Basivertebral vein o
Spinal canal
Pedicle c
:3
Costotransverse joint ,~
Medial rib

Transverse process Spinous process

o
(Jl
()
(Jl

Aorta

~
Vertebral body C
(Jl
()

([)

Neural foramen Spinal canal

Transverse process Lamina

Right rib
Spinous process

Aorta

Vertebral end plate

Thoracic intervertebral disc

Neural foramen
Spinal canal
Superior articular facet Facet joint
Inferior articular facet Lamina

Left rib
Spinous process

(Top) Image through mid vertebral body level. The posterior vertebral body is pierced by the basivertebral veins in
the midline. The thoracic pedicles are gracile, leading to large obliquely oriented transverse processes supporting the
costotransverse joints for the ribs. (Middle) Image through the neural foraminallevel of the thoracic spine. The large
neural foramina are directed laterally. The orientation of the transverse processes is posterior & laterally as shown.
(Bottom) Image at intervertebral disc level. Neural foramina are directed laterally, & bounded anteriorly by the
posterior vertebral body margin, & dorsally by the facet joint (superior articular facet). The facet joints are oriented in
a coronal plane, & strongly resist rotation combined with the costovertebral joints.
III
99
 THORACIC SPINE
SAGITTAL CT MYELOGRAM

Spinous process

Spinal canal

Vertebral body Interspinous ligament

Anterior cortical margin

<J)
u Intervertebral disc Lamina
<J)

o,
c Neural foramen Inferior articular facet
E Superior articular facet
::J Facet joint
o Pedicle
U

Spinal canal

Vertebral body

Lamina

Anterior cortical margin

Spinous process
Intervertebral disc
Interspinous ligament

Basivertebral vein

Inferior articular facet

Superior articular facet
Neural foramen
Pedicle Facet joint

Vertebral body
Anterior cortical margin

Intervertebral disc Lamina

Spinal canal

Interspinous ligament

(Top) First of three sagittal reformat images from CT myelogram presented from medial to lateral. The slight off
midline alignment allows for visualization of the midline spinous processes of the superior thoracic spine, & the
more lateral lamina & facet joints of the inferior thoracic spine. (Middle) The oblique alignment again allows for
visualization of the lamina of the upper thoracic spine, with the midline spinous processes visible in the lower
thoracic segment. The vertebral bodies are square, with well-defined cortical margins, & relatively thin intervertebral
discs. (Bottom) The upper thoracic segment demonstrates the pedicles extending into the superior & inferior
articular facets. The laterally directed neural foramen, bounded by vertebral body, pedicle & facet are evident.
III
100
 THORACIC SPINE
SAGITTAL T1 MR "'0
(J)

::l
(i)

Spinal canal with spinal cord

Ligamentum flavum
Vertebral body
Superior end plate Lamina
Inferior endplate
Anterior cortical margin n
o
Intervertebral disc
c
Spinous process :3
:J
Anterior longitudinal ligament Interspinous ligament
o
Basivertebral vein Supraspinous ligament

Lamina

Epidural fat Ligamentum flavum

~
Pedicle C
<Jl
Facet joint n
(i)
Neural foramen Inferior articular facet
Vertebral body
Superior articular facet
Anterior cortical margin

Intervertebral disc

Inferior articular facet

Superior articular facet
Neural foramen
Pedicle

Costovertebral joint

Vertebral body
Ligamentum flavum

Intervertebral disc

(Top) First of three sagittal Tl MR images of the thoracic spine presented from medial to lateral. The posterior
supporting ligamentous structures are identified on this view, including the interspinous ligaments, ligamentum
flavum, & supraspinous ligament. The anterior & posterior longitudinal ligaments are not separately identified,
rather they merged into the low signal of the anterior & posterior vertebral body cortical margins, respectively.
(Middle) The neural foramina are highlighted by high signal foraminal fat content. The posterior, coronally oriented
facet joints are evident. (Bottom) The costovertebral joint articulations are viewed as triangular shaped areas of
intermediate signal along the posterior disc margins.
III
101
 THORACIC SPINE
SAGITTAL T2 MR

Spinal canal with spinal cord

Vertebral body
Ligamentum flavum
Superior endplate
Inferior endplate
Posterior dural margin
Anterior cortical margin
Epidural fat
lJ) Intervertebral disc
u Spinous process
lJ)

o, Anterior longitudinal ligament Interspinous ligament

c
E Basivertebral vein
Supraspinous ligament
:J Conus medullaris
o
U

Facet joint

Pedicle
Inferior articular facet

Neural foramen
Superior articular facet
Vertebral body

Anterior cortical margin

Lamina
Intervertebral disc
Epidural fat

Neural foramen
Costovertebral joint
Erector spinae muscle
Superior articular facet

Intervertebral disc Inferior articular facet

Vertebral body Pedicle

(Top) First of three sagittal T2 MR images of the thoracic spine presented from medial to lateral. The square thoracic
vertebral bodies with the small intervening intervertebral discs are identified in this midline view. The spinous
processes are large & dominate the dorsal soft tissues. The thoracic cord is seen in its entirety, with its smoothly
tapering conus medullaris. (Middle) The facet joints are identified on this sagittal image, with the coronal oriented
joints seen in lateral view. The superior & inferior articular processes & neural foramen are easily viewed in this
plane. (Bottom) The more lateral margin of the neural foramen are identified on this section, as well as the
costovertebral joints at the disc levels.
III
102
 THORACIC SPINE
AXIAL T2 MR Vl
""C
:J
(t)

Aorta <
(D
...•
r-+
(D
0-
Spinal canal Vertebral body ...•
CJ
Spinal cord
Costovertebral joint n
Pedicle o
Transverse process Costotransverse joint
c
:3
Rib Ligamentum flavum :J

Spinous process o
IJl
()
IJl

Aorta

Vertebral body (endplate)

~
C
IJl
Spinal canal ()
Spinal cord
Neural foramen (D

Superior articular facet

Inferior articular facet Lamina

Spinous process

Aorta
Annulus fibrosus
Intervertebral disc (nucleus
Spinal canal pulposus)

Neural foramen
Superior articular facet Facet joint
Inferior articular facet
Lamina
Supraspinous ligament Spinous process

(Top) First of three axial T2 MR images of the thoracic spine. The relationship of the medial rib forming the strong
costotransverse & costovertebral joints is highlighted. The transverse processes extend out dorsally, & laterally to
articulate with the medial ribs. The spinous process is large, & directed caudally. (Middle) Image through the
foraminallevel of the thoracic spine. The neural foramina are directed laterally, with their posterior margin formed
by the facet joints, & anterior margin by the vertebral body & disc. (Bottom) Image through the disc level. The
coronal orientation of the facet joints are identified in this section, forming the posterior boundary of the neural
foramen. The components of the intervertebral disc are shown in this section, with well-defined nucleus pulposus &
annulus fibrosus. III
103
 Q) LUMBAR SPINE
u
tJ)
::l • Superior facet: Concave, faces dorsomedially to
ITerminology meet inferior facet from above
~
Abbreviations • Inferior facet: Faces ventrolaterally to meet
• Anterior longitudinal ligament (ALL) superior facet from body below
• Posterior longitudinal ligament (PLL) • Ligaments
o Anterior and posterior longitudinal ligaments,
Synonyms interspinous and supraspinous ligaments
• Articular processes = facets = zygapophyses o Ligamentum flavum
• Thick in lumbar region
• Connects adjacent lamina
tJ)
u I Gross Anatomy • Extends from capsule of facet joint to junction of
tJ)
lamina with spinous process, discontinuous in
o Overview midline
• 5 discovertebral units (Ll-5) • Muscles
c o Erector spinae: Poorly differentiated muscle mass
E Components composed of iliocostalis, longissimus, spinalis
::l • Bones o Multifidi (best developed in lumbar spine)
o o Body o Deep muscles: Interspinalis, intertransversarius
U • Large oval cancellous ventral mass o Quadratus lumborum & psoas muscles
• Larger in transverse width than AP diameter • Biomechanics
o Endplates o Lumbar articulations permit ventral flexion, lateral
• Formed by superior & inferior surfaces of vertebral flexion, extension
bodies o Facets prevent rotation
• Consist of concave surfaces of 1 mm thick cortical o Lumbosacral junction motion checked by strong
bone & hyaline cartilage plates iliolumbar ligaments
• Endplates are transitional between fibrocartilage
disc & vertebral body
• Nutrients to disc diffuse via end plates I Imaging Anatomy
o Arch
• Pedicle: Project directly posteriorly Radiography
• Transverse process: Extend out laterally, long and • "Scotty dog" demonstrated on oblique view
flat on Ll-4, small at L5 o Nose = transverse process, eye = pedicle, ear =
• Articular process: Superior and inferior articular superior articular process, neck = pars
processes with pars interarticularis between; facet interarticularis, front leg = inferior articular process
joints oriented obliquely
• Lamina: Broad, thick, overlap minimally Cross-Sectional Imaging
• Spinous process • Facet joint orientation
• Intervertebral foramen o Facet joint angle is measured relative to coronal
o Aperture giving exit to segmental spinal nerves and plane
entrance to vessels o Normal facet joint angle"" 40°
o Oriented laterally below pedicle o More sagittally oriented facet joints (> 45°) at L4 &
o Boundaries L5 levels t incidence of disc herniation &
• Superior & inferior pedicles of adjacent vertebrae degenerative spondylolisthesis
• Ventral boundary is dorsal aspect vertebral body
above and intervertebral disc below
• Dorsal boundary is joint capsule of facets and IAnatomy-Based Imaging Issues
ligamentum flavum
o Vertical elliptical shape in lumbar region Imaging Pitfalls
• Vertical diameter 12-19 mm • Lumbosacral junction
• Transverse diameter from disc to ligamentum o Transitional lumbosacral vertebrae
flavum "" 7 mm, thus little room for pathologic • Congenital malformation of vertebrae, usually last
narrowing lumbar or first sacral vertebra
• Joints • Bony characteristics of both lumbar vertebrae and
o Intervertebral disc sacrum
• Outer annulus fibrosus (alternating layers of o Vertebral facet asymmetry (tropism)
collagen fibers) • Asymmetry between left & right vertebral facet
• Inner annulus fibrosus (fibrocartilaginous (zygapophyseal) joint angles
component) • Tropism defined as mild (6_10°), moderate
• Transitional region (10-16°), or severe (> 16°)
• Central nucleus pulposus (elastic mucoprotein gel • Variable relationship between facet joint tropism
with high water content) & disc herniation at L4 and L5 level
o Facet (zygapophyseal) joints
• Facet joints oriented obliquely

III
104
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106
 LUMBAR SPINE
RADIOGRAPHY

T12 ribs
Pedicle Ll body

Facet joint
L2 body
Intervertebral disc space
L3 body
Transverse process

Spinous process n
L4 body o
Lamina c
LS body :3
,::J
Sacral ala
Sacroiliac joint Sacral foramen
o
tJl
n
tJl

T12 ribs

Neural foramen Ll-2

Inferior endplate L2
Pedicle ~
C
Superior endplate L3 tJl
n
(!)
Intervertebral disc space Inferior articular process L3

Superior articular process L4

LS body Facet joint

LS-S1 intervertebr~l disc space Pars interarticularis LS

Sl body

"Scotty dog" Transverse process

Superior articular process (ear)
Transverse process (nose)

Pedicle (eye)
Pars interarticularis (neck) Inferior articular process (front
leg)
Pars interarticularis LS

(Top) AP view of the lumbar spine. The lumbar bodies are large & rectangular in shape, with relatively thick
intervertebral disc spaces. The pedicles are viewed en face, with the adjacent facet joints incompletely visualized due
to their obliquity. The large horizontal transverse processes are easily identified, at the pedicle levels. (Middle) Lateral
view of the lumbar spine. The large, strong lumbar bodies join with the stout lumbar pedicles & posterior elements.
The neural foramina are large & directed laterally. The boundary of the neural foramen includes posterior vertebral
body, inferior & superior pedicle cortex, & superior articular process. (Bottom) Oblique view of the lumbar spine.
The typical "Scotty dog" appearance of the posterior elements is visible. The neck of the dog is the pars
interarticularis. III
107
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109
 LUMBAR SPINE
Q) AXIAL BONE CT
u
<Jl
:J
~

Psoas muscle
Intervertebral disc

Neural foramen
<Jl
U Facet joint
<Jl

o, Lamina

c Spinous process
E
:J
o
U
(Ij
"-
...0
Q)
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"-
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>
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C Vertebral body
c..
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Pedicle

Superior articular process &

Facet joint facet
Inferior articular process &
Ligamentum flavum facet
Spinous process

Vertebral body

Basivertebral vein
Vertebral canal Pedicle

Transverse process

Lamina

(Top) First of six axial bone CT images through the lumbar spine presented from superior to inferior. Image at
intervertebral disc & lower neural foraminallevel. Posterior intervertebral disc forms the lower anterior border of
neural foramen which contains primarily fat. Exiting nerves are in upper neural foramen. (Middle) Image through
facet joints. Facet joint shows typical lumbar morphology, with superior facet showing a concave posterior surface &
inferior facet showing the complementary convex anterior surface. Facet joints are oriented approximately 40° from
coronal plane. An angle of> 45° from coronal plane increases incidence of disc herniation & degenerative
spondylolisthesis at L4 & L5 levels. (Bottom) Image showing triangular central vertebral canal & posteriorly oriented
III pedicles. Basivertebral veins enter vertebral body through posterior cortex.
110
 LUMBAR SPINE
AXIAL BONE CT

Vertebral body

Basivertebral vein
Pedicle n
Vertebral canal o
Transverse process c
Lamina 3
,::J
Spinous process
o
If>
n
If>

Psoas muscle
Vertebral body end plate
~
Posterior longitudinal ligament C
If>
n
Neural foramen (1)
Ligamentum flavum

Vertebral canal Lamina

Spinous process

Psoas muscle Intervertebral disc

Neural foramen
Facet joint Superior articular process
Inferior articular process
Lamina
Ligamentum flavum

Spinous process

(Top) Image at mid vertebral body level showing thick cortical vertebral body margin & midline posterior
basivertebral veins. The pedicles are strong, thick & directed posteriorly. Large transverse processes project from the
lateral margins. (Middle) Image at endplate level. The neural foramen are identified, opening laterally. The posterior
elements have a "T"pattern with the large posteriorly directed spinous process. (Bottom) Image through the
intervertebral disc level again demonstrates lower neural foramen bounded anteriorly by intervertebral disc &
posteriorly by the superior articular process & facet joint. Oblique coronal orientation of facet joints is again
appreciated. Asymmetry between left & right vertebral facet joint angles, with one joint having a more sagittal III
orientation than the other is termed "tropism".
111
 LUMBAR SPINE
SAGITTAL T1 MR

Conus medullaris

Basivertebral vein Spinous process

Supraspinous ligament
Anterior longitudinal ligament Interspinous ligament
Epidural fat
I.Jl Inferior end plate L4 Dorsal dural margin
U
I.Jl Intervertebral disc
o, Superior end plate LS
Lumbar cerebrospinal fluid

c LS body
E SI body
:::J
o
U
C\:l
~
..0
•....
Q)
~
L1 vertebral body
Q)

> Anterior longitudinal ligament

Q)
c:
a.
(J') Epidural fat
Inferior endplate L4 Facet joint
Intervertebral disc
Inferior articular process L4
Superior endplate LS
LS body
Ligamentum flavum

SI body

L1 vertebral body

Neural foramen

L3 nerve root
Superior articular process L4
Inferior endplate L4
Facet joint
Intervertebral disc
Pedicle LS
Superior endplate LS
Nerve root LS
LS body
SI nerve root

(Top) First of three sagittal Tl MR images of the lumbar spine presented from medial to lateral. The normal marrow
signal on Tl images is of increased signal compared to the adjacent intervertebral discs in the adult, due to fatty
marrow content. The basivertebral veins are seen as signal voids in the midline of the posterior vertebral bodies,
often with surrounding high signal fatty marrow. The intervertebral disc morphology is poorly identified on this
sequence, with little differentiation of annulus or nucleus. (Middle) In this image the lateral vertebral bodies are
evident, with the pronounced oblong shaped inferior articular facets dominating the posterior aspect. (Bottom) In
this image the anterior boundaries of the neural foramina are evident, as is the relationship of the disc to the exiting
III nerve.
112
 LUMBAR SPINE
AXIAL T1 MR

Aorta
Inferior vena cava

Psoas muscle

Thecal sac with cauda equina

Ligamentum flavum
Pedicle
Transverse process
Superior articular process n
o
Facet joint Inferior articular process c
Lamina
3
Multifidus muscle ..•::J

Spinous process
o

Aortic bifurcation
Anterior longitudinal ligament

Psoas muscle
Vertebral body endplate
~
C
V1

Neural foramen
Exiting nerve n
(t)
Ligamentum flavum
Spinal canal Lamina

Spinous process

Inferior vena cava Left common iliac artery

Psoas muscle Intervertebral disc L3-4

Thecal sac with cauda equina

Ligamentum flavum
Neural foramen
Superior articular process
Facet joint
Lamina Inferior articular process

Multifidus muscle

Spinous process

(Top) First of three axial Tl MR images of the lumbar spine presented from superior to inferior. This superior view
shows the thick broad pedicles extending into the posterior elements. The transverse processes are large, providing
surface area for muscle attachment. (Middle) Image though the upper neural foraminallevel. The neural foramina
are directed laterally, bounded anteriorly by the posterior vertebral body & intervertebral disc & posteriorly by the
facet complex. Exiting peripheral nerves are surrounded by hyperintense fat within neural foramen. (Bottom) Image
at intervertebral disc & lower neural foramen level. The facet joints are well-defined in this plane, & are oriented
approximately 400 from coronal plane. The spinal canal assumes a triangular configuration with the ventral disc
margin, & the dorsal ligamentum flavum. III
113
 LUMBAR SPINE
CORONAL T1 MR

L2 pedicle

Superior articular process L3 Ligamentum flavum

L3lamina
Epidural fat
Inferior articular process L3 Superior articular facet L4

Lamina L4
Inferior articular process LS
V1
Inferior articular process L4
U
V1
Sacral articular process
o,
c Sacral ala
E SI nerve
Sacroiliac joint
::J
o
U
~ L2 nerve
'-
..n
Q) Psoas muscle
.•..... Thecal sac
'-
Q)

> Dorsal ramus of L3 nerve

Q) Epidural fat
c:
0.. Dorsal ramus of L4 nerve L4 superior articular facet
tJ)

Superior articular process LS LS transverse process

L4-S facet joint SI body

SI nerve ganglion Sacral ala

SI nerve

Basivertebral vein

L2-3 intervertebral disc

Psoas muscle
L3 pedicle
Segmental lumbar artery & vein

L3 nerve ganglion
L4 transverse process
Dorsal ramus of L4 nerve

LS transverse process
Epidural fat

Sacral ala

Sacroiliac joint SI body

(Top) First of six coronal Tl MR images through the lumbar spine presented from posterior to anterior. The posterior
elements are visualized in this section, with the lateral margins of the facet joints in view. (Middle) More anterior
image of the lumbar spine. Dorsal (posterior) ramus of L4 nerve is demonstrated surrounded by fat passing
posteriorly following its exit through the neural foramen. Midline epidural fat is seen as a linear band separating the
paired ligamentum flavum. (Bottom) More anterior image of the lumbar spine. The L3 nerve is seen extending
underneath the L3 pedicle. The spinal nerve ganglia are surrounded by fat within the neural foramen. Distal to the
ganglion, the spinal nerve divides into anterior & posterior branches. Posterior branches supply motor innervation to
III deep muscles of the back & sensation to skin of the back.
114
 LUMBAR SPINE
CORONAL T1 MR

Basivertebral vein

L2-3 intervertebral disc

L3 vertebral body
Segmental lumbar artery & vein
L3 nerve
Thecal sac
L4 pedicle
Epidural fat L4 nerve n
o
L5 pedicle c
L5 nerve ganglion :3
L5 nerve ,:J
Sl body o
V"l
()
Sacroiliac joint V"l

Basivertebral vein L2-3 intervertebral disc

L3 vertebral body
Segmental lumbar artery & vein
~
C
Posterior longitudinal ligament L4 pedicle V"l
()

Psoas muscle (t)

L4-5 intervertebral disc
L5 pedicle
L5 nerve L5 inferior end plate

L5-S 1 intervertebral disc

Sl body
Sacroiliac joint

L2 vertebral body
Basivertebral vein

Segmental lumbar artery & vein 13 vertebral body

L4 inferior end plate L4 vertebral body

L4-5 intervertebral disc Psoas muscle

L5 superior end plate LS vertebral body

L5-S 1 in tervertebral disc

Sl vertebral body

(Top) More anterior image of the lumbar spine showing relationship of exiting nerves to the pedicles. Nerves exit the
foramina in an inferior lateral direction at the same numbered pedicle level (Le., LS root exits below LS pedicle).
(Middle) The junction of the vertebral bodies with the ventral epidural space is highlighted in this view. The
posterior longitudinal ligament is seen as a dark vertically oriented band in the midline. The adjacent epidural fat
shows high signal. The vertebral bodies are defined by the superior & inferior endplates. (Bottom) Most anterior
image of the lumbar spine. The vertebral body endplates are visualized for each segment, with the intervening thick
intervertebral disc.
III
115
 LUMBAR SPINE
OJ AXIAL T2 MR
u
<fl
:J
~
Aorta
Inferior vena cava

Psoas muscle Intervertebral disc L3-4

Thecal sac with cauda equina L4 transiting nerve

L3 nerve
Neural foramen
<fl
U Lamina L3-4 facet joint
<fl

o Multifidus muscle Ligamentum flavum

c Spinous process
E
:J
o
U
<i:l
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•...
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OJ Aortic bifurcation
> Inferior vena cava

Q)
L4 vertebral body
c: Epidural fat
c.. Thecal sac
CJl
L4 pedicle

L4 nerve
Ligamentum flavum

Spinous process

Inferior vena cava Left common iliac artery

Psoas muscle

Neural foramen L4 nerve ganglion

Lamina
Spinous process

Interspinous ligament
Supraspinous ligament

(Top) First of six axial T2 MR images of lumber spine presented from superior to inferior. This view through the
intervertebral disc shows increased disc signal within the central nucleus pulposus due to its high water content, &
low signal within the peripheral annulus fibrosus. The margin with the thecal sac is sharp, with the cauda equina
seen as punctate nerves within the high signal cerebrospinal fluid. L3 nerve is extraforaminal in location, L4 nerve is
transiting in lateral recess. (Middle) Image just below L4 pedicle shows exiting L4 nerve passing just below pedicle
within the upper neural foramen. (Bottom) This image shows L4 nerve ganglion & surrounding fat within mid
neural foramen. Posterior margin of neural foramen at this level is facet joint complex, & anterior margin is posterior
III vertebral body
116
 LUMBAR SPINE
AXIAL T2 MR rJl
"'C
::::l
ro
<
ro
....•
r-?
Psoas muscle (!)
Intervertebral disc L4-5 r::::r
....•
ClJ
Transiting L5 nerve
n
L4 nerve (ventral branch) o
Superior articular process of L5 c
L4 nerve (dorsal branch)
Inferior articular process of L4 3
,:J
Lamina Ligamentum flavum
o

Psoas muscle

$:
Vertebral body c
(Jl
Thecal sac with cauda equina n
(!)
Pedicle

L5 nerve

Sl nerve within thecal sac

Spinous process

Intervertebral disc L5-S1

Thecal sac with cauda equina

Neural foramen
Superior articular process of Sl
Facet joint
Inferior articular process of L5

Lamina Ligamentum flavum

(Top) Image through lower neural foramen bordered anteriorly by posterior margin of intervertebral disc &
posteriorly by facet joint. L4 nerve has divided into anterior & posterior branches. (Middle) Image through upper LS
neural foramina show exiting LS nerves just below the pedicles. (Bottom) Image through LS-Sl intervertebral disc.
The typical facet morphology is again identified. The superior articular facet is seen as a convex anterior bony mass
with low signal cortical margin. The joint space is seen as a linear focus of high signal due to joint fluid & cartilage.
The inferior articular facet is typically convex anteriorly, although can be seen as a more straight margin or even
slightly concave (as is seen on the left). Facet joints are oriented approximately 40 from coronal plane.
0

III
117
 SACRUM AND COCCYX
• Soft tissues
ITerminology o Thecal sac
Definitions • Thecal sac terminates at S2 level
• Sacrum is a large triangular bone formed from 5 fused • Extradural component of filum terminale
vertebrae at base of vertebral column continues from S2 to attach at 1st coccygeal
segment
o Nerves
I Gross Anatomy • Sacral canal contains sacral & coccygeal nerve
roots
Overview • Nerves emerge via ventral & dorsal sacral foramina
IJ)
u • Sacrum o Muscles
IJ)
o Consists of 5 fused vertebrae (Sl-5) • Piriformis: Arises from ventral sacrum, passes
o o Large, triangular shape, forms dorsal aspect of pelvis laterally through greater sciatic foramen to insert
on greater trochanter; nerves of sacral plexus pass
c o 3 surfaces: Pelvic, dorsal & lateral
o Base: Articulates superiorly with L5 along anterior surface of piriformis muscle
E o Apex: Articulates inferiorly with coccyx • Gluteus maximus, erector spinae & multifidis arise
:J
• Coccyx from dorsal sacrum
o o Consists of 3-5 rudimentary fused segments o Ligaments
U
• Anterior longitudinal ligament passes over sacral
(ij
~ Components of Sacrum promontory
..n • Bones • Posterior longitudinal ligament on dorsal surface
Q)
-+-' o Central body, lateral sacral ala, posterior triangular of lumbosacral disc forming ventral margin of
~
Q) shaped sacral canal bony canal
> o 4 paired ventral & dorsal sacral foramina extend
laterally from sacral canal to pelvic & dorsal surfaces
• Sacroiliac joint secured by broad anterior,
interosseous & posterior sacroiliac ligaments
Q)
!:: respectively • Sacrospinous ligament bridges lateral sacrum to
o Pelvic surface ischial spine
0-
(J) • Concave, forms dorsal aspect of pelvis • Sacrotuberous ligament bridges lateral sacrum to
• 4 paired anterior sacral foramina ischial tuberosity
• 4 transverse ridges between anterior sacral
foramina
o Dorsal surface I Imaging Anatomy
• Convex
• Median sacral crest in midline ;:,;fused spinous Overview
processes • Lumbosacral junction
• Sacral groove on either side of crest o Transitional vertebrae
• Intermediate sacral crest lateral to groove ;:,; • 25% of normal cases
fused remnants of articular processes • Sacralization of lumbar body: Spectrum from
• 4 paired posterior sacral foramina are lateral to expanded transverse processes of L5 articulating
intermediate crest with top of sacrum to incorporation of L5 into
• Lateral sacral crest lateral to foramina ;:,; sacrum
remnants of transverse processes • Lumbarization of sacrum: Elevation of Sl above
• Sacral hiatus: Dorsal bony opening below sacral fusion mass assuming lumbar body shape
termination of median sacral crest o Sacrum lies at 40° incline from horizontal at
o Lateral surface lumbosacral junction
• Broad upper part, tapers inferiorly • Axial load result in rotational forces at LS junction
• Ventral articular surface for sacroiliac joint & • Rotation forces checked by sacrotuberous,
dorsal roughened area for ligamentous attachment sacrospinous ligaments
• Joints
o Lumbosacral junction
• Joins with 5th lumbar vertebra by L5-S1 disc & IAnatomy-Based Imaging Issues
facet joints
• Superior base articulates with L5 Imaging Pitfalls
• Superior articular processes of Sl faces dorsally • Lumbarization & sacralization may appear similar,
o Sacrococcygeal joint require counting from C2 caudally to precisely define
• Apex of sacrum & base of coccyx anatomy
• Contains fibrocartilaginous disc
o Sacroiliac joints
• Ventral synovial joint: Between hyaline covered
articular surface of sacrum & fibrocartilage
covered surface of iliac bone
• Dorsal syndesmosis: Interosseous sacroiliac
ligament

III
118
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121
 SACRUM AND COCCYX
Q) AXIAL T2 MR
u
<Jl
:::l
~
ro
c Thecal sac
L5-S1 intervertebral disc
Q...
<Jl Ligamentum fIavum
ro
"--
ro Sacral ala
0... Superior articular facet S1
Sacroiliac joint
c(\
Facet joint
<Jl Inferior articular facet L5
U
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o
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Q) Sl body
C Sacral ala
Q... Sacroiliac joint
lJ) Caudal thecal sac

Median sacral crest

Iliac crest

Ventral sacral foramen

Pelvic surface of sacrum
Exiting ventral Sl sacral nerve
Sacral ala Remnant of Sl-2 disc
Sacroiliac joint
Caudal thecal sac

Dorsal sacral foramen Median crest of sacrum

(Top) First of six axial T2 MR images of the sacrum presented from superior to inferior. The lumbosacral facet
articulations are visible between the functioning anterior positioned superior articular process of 51 (which faces
medially & dorsally) articulating with the posterior positioned inferior articular facet of LS. (Middle) Image through
S1 body. At this level, the sacral body & sacral ala are seen as one large bony mass extending between the lateral
sacroiliac joints. Posteriorly, the median crest of the sacrum is prominent. (Bottom) Image more inferiorly through
the 51/52 junction. The exiting ventral & dorsal 51 nerves are seen passing through the ventral & dorsal foramina
respectively.
III
122
 SACRUM AND COCCYX
AXIAL T2 MR CJl
-0
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(t)
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r-r
Lumbosacral trunk & SI nerves (t)
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sacroiliac joint t:U

Sacral ala
Interosseous sacroiliac ligament n
o
Sacral canal c
Iliac crest
:3
:J
o
CJl
n
CJl

Ventral sacral foramen ~

C
CJl
n
S2 nerves (t)

Sciatic nerve

Piriformis muscle
Ventral sacral foramen

Sacral canal

(Top) Image through S2 body (incidental spina bifida is seen on this and the lower two images). At this level, the
sacral body & sacral ala are again seen as one large bony mass extending between the lateral sacroiliac joints. The
sacroiliac joints consist of a ventral synovial joint & a dorsal syndesmosis bridged by the interosseous sacroiliac
ligament. The thecal sac has terminated at this level (S2) & the sacral canal now only contains peripheral lower sacral
& coccygeal nerves, fat & extradural portion of filum terminale. (Middle) Ventral S2 nerves are seen exiting
anteriorly. (Bottom) Section through lower sacrum demonstrates piriformis muscle arising from lateral sacrum &
extending laterally through greater sciatic foramen. Note the large sciatic nerve on the anterior surface of the
piriformis muscle. III
123
 SACRUM AND COCCYX
Q) AXIAL NECT
u
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Pelvic surface
Synovial portion of sacroiliac
joint

Body
Sacral ala
Interosseous sacroiliac ligament
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Median sacral crest
c
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c::
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Median sacral crest

Dorsal sacral foramina

(Top) First of three axial NECT images through sacrum presented from superior to inferior. Bony components of
sacrum include central body, paired lateral ala & dorsal sacral canal. The different components of the sacroiliac joints
are seen. The ventral synovial & dorsal syndesmosis are evident. (Middle) More inferior image through sacrum
showing one of the 4 paired ventral sacral foramina where the 51-54 ventral sacral nerves exit into the pelvis.
(Bottom) Image through mid-sacrum showing one of the paired dorsal sacral foramina.

III
124
 SACRUM AND COCCYX
ANTERIOR RADIOGRAPH & CORONAL NECT ""0
CJl

:J
C'O

LS transverse process

Sacral ala

Body n
o
Sacroiliac joint c
4 ventral sacral foramina
3
,:J

o
fJl
n
fJl

Sacrococcygeal joint

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LS-S1 disc

Sacral ala Sl body ~

C
fJl
Sacroiliac joint n
(D

Ventral sacral foramina

LS body

Sacral ala

Sl body
Sacroiliac joint

Ventral sacral foramen

Coccyx

(Top) Anterior radiograph of sacrum showing paired sacroiliac joints on either side of the triangular sacrum,
composed of 5 fused sacral vertebrae. The ventral sacral foramina are clearly outlined by a corticated superomedial
margin & an indistinct inferior margin. (Middle) Coronal CT image through the sacrum. The paired ventral sacral
foramina are evident. The broad sacroiliac joint is identified. The fused 5 sacral segments are visible in the midline.
(Bottom) More posterior image through the sacrum. The ventral sacral foramina are seen at various degrees of
obliquity, giving a variety of appearances from circular to rectangular.

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125
 SACRUM AND COCCYX
Q)
CORONAL T1 MR
U
lJl
LS body
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~ LS-S1 disc

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lJl
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lJl

o,
c
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ro
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Sacroiliac joint

Ventral sacral foramina

Coccyx

Thecal sac

Sacral ala
Iliac wing
Sacroiliac joint
Thecal sac termination
Sacral root

Ventral sacral foramina

(Top) First of three coronal Tl MR images through the sacrum presented from anterior to posterior. The ventral
sacral foramina are readily identified by the target appearance of cortical bone, foraminal fat & central nerve. The
sacrum & coccyx are partially identified due to the sacral & coccygeal curvature. (Middle) Image through the
mid-sacrum. The paired ventral sacral foramina are evident with their rounded foci of high signal fat with central low
signal exiting roots. The broad sacroiliac joint is identified as low signal separating the ala from iliac wings. The fused
5 sacral segments are visible in the midline. (Bottom) In this image the distal thecal sac is evident terminating at 52
level.
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 SACRUM AND COCCYX
LATERAL RADIOGRAPH & SAGITTAL T2 MR CJl
"'C
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ro
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r-l-

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0-
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c
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Promontory
,:J

Sl body o
S1/S2 disc remnant Sacral canal

~
C
Vl
Sacral hiatus
n
ro

Posterior longitudinal
L5 body ligament

Thecal sac
L5-S1 intervertebral
disc

Sl body
Thecal sac termination

Pelvic surface of
sacrum S3 body

Sacral rudimentary disc

Sacrococcygeal joint
Coccyx

(Top) Lateral radiograph of sacrum & lumbosacral junction. Sacrum consists of 5 fused vertebrae with pelvic, dorsal
& lateral surfaces. It articulates at its base with L5, at its apex with the coccyx & laterally with the iliac bones
bilaterally. The anterior margin of Sl body is termed the promontory & forms the posterior margin of the pelvic
inlet. (Bottom) Sagittal midline T2 weighted image of the sacrum. The typical lumbosacral junction morphology is
present, with well-defined L5-S1 intervertebral disc, square shape of L5, & trapezoidal shape of S1. Rudimentary
sacral intervertebral discs are seen as linear low signal. Note the thecal sac termination at the S2 level.
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SECTION 2: Cord, Meninges and Spaces

Spinal Cord and Cauda Equina 11I-130

Meninges and Compartments 11I-140
 SPINAL CORD AND CAUDA EQUINA
I Terminology
Abbreviations
• Spinal cord (SC); cauda equina (CE)
• Cerebrospinal fluid (CSF); subarachnoid space (SAS)
• Dorsal root ganglion (DRG)
Definitions
• Tract: Nerve fibers with shared origin, destination or
function
~ • Root: Coalescence of rootlets into dorsal (sensory),
u
•..... ventral (motor) roots
o • Nerve: Union of dorsal, ventral roots
U • Ganglion: Aggregation of cell bodies, nerve fibers
OJ
c:
c.. I Gross Anatomy
rJ')
Overview
• Spinal cord
o Suspended within thecal sac
o Anchored to dura by denticulate ligaments
o Long tapered cylindrical conduit between medulla,
peripheral nervous system
o Two enlargements
• Cervical enlargement (C3-T2) with maximum
diameter at C6
• Lumbar enlargement at T9-12
o Cord tapers to diamond-shaped point (conus
medullaris)
o Conus normally ends between T12 to L2-3
interspace (TI2-Ll most common level)
o External landmarks
• Deep ventral (anterior) median fissure extends
along entire ventral surface
• Dorsal (posterior) median sulcus is more shallow
• Posterolateral sulcus (dorsal rootlets enter cord
here)
• Ventral rootlets emerge from ventrolateral sulci
o Internal landmarks
• In contrast to brain, gray matter is on inside with
white matter on periphery of cord
• Central gray matter formed by columns ("horns")
of neuronal cell bodies, is roughly "H"-shaped
• Anterior, posterior gray commissures connect two
near-vertical arms of "H"
• Ventral (anterior) horn of "H" is shorter, thicker,
contains multipolar motor neurons
• Dorsal (posterior) horn is longer, more narrow,
receives sensory axons from DRGs
• Small lateral horn only found between T2, Ll cord
segments
• Ependymal-lined central canal
• Three white matter columns (funiculi): Dorsal,
ventral, lateral
• Descending motor, ascending sensory tracts
mostly in lateral, ventral funiculi
• Fibers for position, discriminative touch in dorsal
funiculi
• Filum terminale
o Strand of connective tissue extending inferiorly
from conus
o Fuses distally into dura, attaches to dorsal coccyx
III
130
• Spinal nerve roots
o 8 cervical (first exits between skull base, Cl), 12
thoracic, 5 lumbar, 5 sacral, 1 coccygeal
o Paired dorsal, ventral roots exit from their respective
hemicords
o Descend separately across SAS,dura, then unite
in/near intervertebral foramina
o Ventral roots contain mostly efferent somatic, some
sympathetic fibers
o Dorsal roots mostly contain afferent axons (both
somatic, visceral)
o Lose pia at dorsal root ganglia level
• Cauda equina
o "Horse's tail" of lumbar, sacral, coccygeal nerve roots
below conus
I Imaging Ana'tomy
Overview
• Spinal cord
o "H"-shaped central gray matter hypointense
compared to myelinated (hyperintense) white
matter
o Maximal cord diameter in axial section varies with
location
• Up to 75% at cervical enlargement
• Generally 50% or less in thoracic region except for
slight t at thoracic enlargement
o Filum terminale
• Normally 2 mm or less in diameter
• Has distal branch of anterior spinal artery, which
normally enhances
• Spinal nerve roots
o Course becomes longer, more oblique at caudal
levels
o Intrathecal nerve roots have blood-nerve barrier, do
not normally enhance
o DRG has no blood-nerve barrier, enhances normally
• Cauda equina
o On axial T2WI, normally lie in a "U"-shaped
configuration within thecal sac
IAnatomy-Based Imaging Issues
Key Concepts or Questions
• Somatotopic cord organization predicates clinical
findings, pathology
• Central gray matter = cord "watershed" zone
• Conus is at normal "adult" level at birth
Imaging Recommendations
• Multiplanar T2WI best demonstrates cord, roots
• T2 FSEor CISS sequence for "MR myelogram" effect
Imaging Pitfalls
• Sagittal plane less reliable than axial for determining
conus position
• Pulsatile CSF flow, spin dephasing often causes "flow
voids" and should not be mistaken for vascular
malformation
 V'l
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132
 SPINAL CORD AND CAUDA EQUINA
CORONAL CT MYELOGRAM V'l
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Vertebral artery

Spinal cord

Ventral median fissure

Ventral median fissure

Ventral root of spinal nerve

(Top) First of three coronal CT myelograms presented from posterior to anterior demonstrates the dorsal (sensory)
roots surrounded by dense CSF. (Middle) This image depicts the spinal cord within the thecal sac. The central spinal
cord canal may imbibe myelographic contrast in some cases (especially on delayed scans), although in this case the
high density in the central cord represents partial volume averaging with the ventral median fissure. Note that CT
provides little information regarding the internal cord structure due to its limited contrast resolution. (Bottom) This
image shows the ventral spinal cord and ventral (motor) nerve roots and dense contrast opacified CSFwithin the
ventral median fissure.
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133
 SPINAL CORD AND CAUDA EQUINA
<Jl
Q) CORONALCTMYELOGRAM
u
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Q.. Spinous process
Vl
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c
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<Jl
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be
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c
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Spinal cord within canal

Upper thoracic spinal cord

Conus medullaris
Cauda equina

(Top) First of three coronal reformatted images from CT myelogram through the thoracic spine presented from
posterior to anterior. The posterior spinal canal is identified with the intrathecal contrast, bounded laterally by the
pairs of medial rib/pedicles seen as well-defined corticated oval bony densities. With the normal thoracic kyphosis,
the superior & inferior thoracic spine is seen in more anterior section than the mid portion. (Middle) More anterior
image through mid-canal level. In the thoracic spine, the cord typically occupies approximately 50% of the
subarachnoid space. (Bottom) Image through the posterior vertebral body level. The conus medullaris is well seen
here. There is a slight expansion of the distal thoracic spinal cord before it tapers into its diamond-shaped point, the
III conus.
134
 SPINAL CORD AND CAUDA EQUINA
SAGITTAL T2 & CORONAL STIR MR

Cervicomedullary junction

~
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Conus medullaris :J
0...
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OJ
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Cauda equina

L3

L4

LS

51

(Top) Sagittal T2 MR demonstrates the entire spinal cord from the cervicomedullary junction to the conus. The
cauda equina is draped dependently within the caudal thecal sac. Although the patient is imaged supine, it is typical
for the normal thoracic spinal cord to be anteriorly positioned and conus posteriorly positioned in the thecal sac
because of the normal kyphotic thoracic and lordotic lumbar curvature. (Middle) First of two coronal STIRMR
images demonstrates the cauda equina roots somatotopically organized within the caudal thecal sac. The nerve roots
are arranged with more rostral (lumbar) levels laterally and caudal (sacral, coccygeal) levels medially. (Bottom) A
more ventral image shows the lumbosacral spinal nerves exiting through their named neural foramina.
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135
 SPINAL CORD AND CAUDA EQUINA
<Jl
Q) AXIAL CISS & T2 MR
u
C'j
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,
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o
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Ventral horn Ventral median fissure

Dorsal horn

Ventral nerve root

Peripheral white matter Intermediolateral column
Central gray matter Dorsal nerve root

(Top) Axial CISS sequence provides bright, homogeneous CSF signal intensity. The hypointense bilateral denticulate
ligaments anchor the spinal cord to the dura. The dorsal and ventral roots are resolved as separate structures within
the thecal sac, and join at the neural foramen to produce the proper spinal nerve. (Middle) First of two axial T2 MR
images shows the normal cervical spinal cord gray and white matter clearly delineated. The intermediolateral gray
matter column representing the cell bodies of the sympathetic nervous system is only present in the thoracolumbar
spinal cord and not seen at the cervical level. (Bottom) Image of the conus demonstrates normal conus anatomy.
The peripheral white matter and central gray matter are easily distinguished. Note the characteristic bump of the
III intermediolateral column of the sympathetic nervous system.
136
 SPINAL CORD AND CAUDA EQUINA
AXIAL T2 MR "'0
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:J
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OJ
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Dorsal roots of cauda equina "'0

OJ
n
(t)
Vl

Ventral roots of cauda equina

Dorsal roots of cauda equina

Epidural fat Dura

Nerve roots of cauda equina

(Top) First of three axial TZ MR images at the L1 foraminallevel shows the conus tip and cauda equina. At this level,
the ventral and dorsal nerve roots of the cauda equina are separately positioned ventrally and dorsally respectively
within the thecal sac. (Middle) This image at the mid LZlevel reveals the cauda equina nerve roots moving laterally
in preparation to form the spinal nerve proper and exit through the appropriate neural foramen. Note that the
ventral roots remain ventral and dorsal roots dorsal. (Bottom) This image at the L4 level shows the nerve roots losing
their ventral/dorsal orientation in order to congregate near the lateral thecal sac in preparation to form the
appropriate spinal nerves. At this and lower levels the roots assume a "U" shaped configuration around the margins
of the thecal sac. III
137
 SPINAL CORD AND CAUDA EQUINA
<Jl
Q) LONGITUDINAL ULTRASOUND
u
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c Spinal cord
~
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Q)
bO Dorsal cauda equina
C
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,
""0

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o
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c:
CL
rJ')

Conus

Cauda equina

Dorsal cauda equina

Filum terminale
Conus tip

Ventral cauda equina

(Top) First of three longitudinal ultrasound images shows the normal hypoechoic spinal cord with hyperechoic
central echo complex. Contrary to popular misunderstanding, this central echo complex is a reflection of echoes
from the interface between the ventral white commissure and CSF within the ventral median fissure rather than from
the central canal. (Middle) Image centered more caudally best demonstrates the hypoechoic spinal cord terminating
as the conus. The hyperechoic cauda equina drapes around the conus and undulates with each CSF pulsation during
real-time observation. (Bottom) This image demonstrates the mildly hyperechoic filum terminale anchoring the
spinal cord to the terminal thecal sac. The cauda equina nerve roots drape dependently within the thecal sac.
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 SPINAL CORD AND CAUDA EQUINA
TRANSVERSE ULTRASOUND ""0
V'l

:J
I'D

n
o
.,
,0...

~
Cauda equina I'D
:::J
:::J
O'Q
I'D
t.rl

~
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Conus Central echo complex 0...
V'l
-0
~
n
([)
t.rl

Cauda equina

Cauda equina

Filum terminale

Cauda equina

(Top) First of two transverse ultrasound images demonstrates the hypoechoic conus surrounded by hyperechoic
cauda equina nerve roots. The central echo complex is well visualized. (Bottom) A more caudal image shows the
hypoechoic cauda equina suspended within cerebrospinal fluid. The filum is positioned centrally within the cauda
equina.

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139
 MENINGES AND COMPARTMENTS
o Subarachnoid space (SAS)
ITerminology • Between inner surface of arachnoid, pia
Abbreviations • Contains CSF, vessels, spinal cord ligaments,
• Dorsal root ganglia (DRG) nerves, filum terminale
• Continuous with intracranial SAS
Definitions o Subpial space (potential space only)
• Meninges = collective term for dura, arachnoid, pia • Compartments
o Pachy ("thick") meninges = dura o Extradural compartment
o Lepto ("thin") meninges = arachnoid, pia • Epidural space
• Spaces = real or potential spaces between meningeal • Vertebral bodies, neural arches, intervertebral
layers or adjacent structures discs, paraspinous muscles
• Ligaments = suspend cord within thecal sac o Intradural extramedullary compartment
• Compartments = anatomic construct for • SAS
location-based imaging differential diagnoses • Spinal cord ligaments, nerve roots, cauda equina,
filum terminale
o Intramedullary compartment
I Gross Anatomy • Spinal cord, pia

Overview
• Meninges I Imaging Anatomy
o Dura
• Dense, tough outermost layer of connective tissue Overview
• Only one dural layer in spine • Meninges
• Attached by fibrous bands to posterior o Dura
longitudinal ligament • Thin black line on T2WI
• Tubular prolongations of dura/arachnoid extend • Vessels lack endothelial tight junctions so dura
around roots/nerves through intervertebral enhances strongly, uniformly
foramina, terminate near DRG o Arachnoid
• Dura fuses with epineurium of spinal nerves distal • Normally adheres to dura; not visualized
to DRG separately
o Arachnoid • Ligaments
• Thin, delicate, continuous with cranial arachnoid o Seen as thin, linear "filling defects" on T2WI
• Two layers: Outer (loosely attached to dura), • Spaces
intermediate (attached to pia) o Spinal CSF isointense with intracranial CSF
o Pia
• Delicate, innermost layer of meninges
• Closely applied to cord, spinal nerves IAnatomy-Based Imaging Issues
• Ligaments
o Denticulate ligaments Key Concepts or Questions
• Flat, fibrous, serrated sheets that support spinal • Localization of a lesion to specific anatomic
cord compartment greatly assists differential diagnosis
• Collagenous core is continuous with pia • Position of spinal needle for lumbar puncture,
• Extend laterally from pia along each side of cord, myelography should be in SAS
between ventral/dorsal roots o Spinal needles are beveled, may "tent" arachnoid as
• Insert into dura mater they are pushed through dura
o Dorsal, dorsolateral, ventral spinal cord ligaments o May result in "split" injection (mixed subarachnoid,
• Thin irregular, fenestrated; extend from cord to subdural contrast)
arachnoid o Subdural injection usually localized
o Septum posticum o Epidural injection results in "epidurogram" with
• Incomplete longitudinal midline membrane contrast spreading freely in epidural space, along
• Connects pia/cord dorsally to dura nerve roots
• Partially divides subarachnoid space (SAS),
Imaging Recommendations
creati ng "pseudocompartments"
• T2 weighted, CISS sequences best for "MR myelogram"
• Spaces
o Epidural space (extradural compartment) • Nicely demonstrate spinal meninges, ligaments,
outline cord/roots
• Between dura & surrounding vertebral canal
• Extends from foramen magnum to posterior Imaging Pitfalls
sacrococcygeal ligament • Denticulate ligaments, septum posticum create
• Contains fat, loose connective tissue, small "pseudocompartments" where CSF may flow at
arteries, veins, lymphatics different rates, directions
o Subdural space • Spin dephasing -+ "flow vOids" in CSF, should not be
• Potential space between dura, outer surface of mistaken for vascular malformation!
arachnoid

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140
 ~
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III
141
 IJ1
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142
 MENINGES AND COMPARTMENTS
AXIAL CT MYELOGRAM

n
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Subarachnoid space compartment ro
(Jl

Dorsal nerve root Dura ~

:J
0-
Vl
-0
~
()
ro
(Jl

Ventral nerve root

Dural nerve root sleeve
outpouching

Dorsal nerve root

Dural nerve root sleeve

Neural foramen

Dorsal nerve root

(Top) First of three axial CT myelogram images through thoracic spine presented from superior to inferior in a
patient with a CSF leak. Contrast injected into the subarachnoid space has leaked into the extradural compartment
and as a result beautifully demonstrates the dura surrounded on both sides by contrast material. (Middle) The
ventral and dorsal nerve roots are seen traversing the subarachnoid space toward the dural nerve root sleeve, which is
an outpouching of dura and arachnoid. (Bottom) Here the dural nerve root sleeve containing the exiting nerve is
seen extending laterally towards the neural foramen surrounded by CSF in the extradural compartment. Dura of
nerve root sleeve is directly contiguous with the peripheral nerve epineurium lateral to the neural foramen. The
dorsal nerve root exiting at the next level down is seen within the subarachnoid space. III
14
 MENINGES AND COMPARTMENTS
Vl
Q) LONGITUDINAL & TRANSVERSE ULTRASOUND
U
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c
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Q)
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Dura
Filum terminale

Subarachnoid space (terminal

thecal sac)
Dura S2 vertebral body

Dura & arachnoid

Cauda equina
Pia on surface of cord Conus (central echo complex)

Cauda equina
Subarachnoid space
Dura

(Top) First of two longitudinal ultrasound images in a normal infant demonstrates the hypoechoic conus medullaris
surrounded by hyperechoic cauda equina nerve roots. The hyperechoic dura defines the margins of the thecal sac
filled with anechoic CSF.The arachnoid -dura mater complex of the thecal sac corresponds to the echogenic border
of the spinal canal dorsal and ventral to the subarachnoid space. (Middle) This image demonstrates the mildly
hyperechoic filum terminale anchoring the spinal cord to the terminal thecal sac at the S2 level. The cauda equina
nerve roots drape dependently within the thecal sac. (Bottom) Transverse ultrasound image shows the normal conus
and its coverings suspended within the CSF filled thecal sac.
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144
 MENINGES AND COMPARTMENTS
LONGITUDINAL & TRANSVERSE ULTRASOUND "'C
Vl

:J
(t)

n
o
.,
,a..

Dura

Dorsal epidural fat

Fluid in epidural
potential space

Pia on conus surface

Epidural fat
CSFin the epidural
Dura space

Cauda equina Conus tip

(Top) Longitudinal ultrasound image demonstrates anechoic CSF within the extradural (epidural) potential space.
The extradural effusion developed following lumbar puncture with CSF leak. The extradural fluid separates the
hyperechoic dura from normally adjacent hyperechoic dorsal extradural fat. (Bottom) Transverse ultrasound image
demonstrates CSF within the dorsal extradural (epidural) potential space. The extradural effusion developed
following lumbar puncture with CSF leak.

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145
 MENINGES AND COMPARTMENTS
l/"l
Q) SAGITTAL & AXIAL CT MYELOGRAM
u
ro
Q..
(j)

-0
c
ro
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Q)
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Q)

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~
o
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C extradural space
0..
(j)

Thecal sac termination

Extradural contrast
leaking around nerve
sheathes

Contrast leaking into

extradural fat

(Top) Sagittal CT reformat following myelography with unintentional administration of the entire contrast bolus
into the extradural space. The thecal sac terminates at around S2 in normal position. Contrast is leaking around the
dorsal extradural fat confirming its localization in the extradural space. A small LS/Sl disc protrusion is incidentally
noted. (Bottom) Axial CT image following inadvertent extradural administration of contrast demonstrates the
extradural space. Contrast surrounds the unopacified thecal sac and dural nerve root sleeves and leaks out through
the neural foramina along the nerve root sleeve. A similar appearance would be intentionally produced following
contrast injection during therapeutic extradural nerve root injection. The extradural contrast also invaginates into
III the dorsal extradural fat confirming injection into the extradural space.
146
 MENINGES AND COMPARTMENTS
SAGITTAL & AXIAL CT MYELOGRAM t.rJ
"'0
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(t)

n
o
.,
0..

~
(l)
:J
:J
OQ
(l)
CJl

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subdural space :J
0..
(f)
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s:l.l
n
(l)
CJl

Subarachnoid space
Contrast in subdural
space

(Top) Sagittal CT reformat following myelography demonstrates the subdural potential space, permitted by
inadvertent administration of intrathecal contrast into the subdural space. There is ventral displacement of the
arachnoid without disruption of the dura. (Bottom) Axial CT following myelography demonstrates the subdural
potential space, seen here because of a "split" injection of intrathecal contrast into the subdural and subarachnoid
spaces. There is slight ventral displacement of the arachnoid without disruption of the dura. The acute margins
within the thecal sac and lack of mixing with the subarachnoid contrast confirms split injection partly into the
subdural space. III
147
 MENINGES AND COMPARTMENTS
tJ'l
(]) AXIAL T2 MR
u
ro
Q..
(f)
""0

c
ro
tJ'l
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bO
c
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c
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o Denticulate ligament
U
OJ
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(f)
a.

Dura
Subarachnoid space

Spinal cord
Extradural fat

Nerve root sleeve Nerve root sleeve

(Top) Axial steady state free precession (CISS) MR image of the upper cervical spine shows the normal denticulate
ligaments anchoring the spinal cord laterally to the dura within the subarachnoid space. The denticulate ligaments
are found between the ventral and dorsal nerve roots, and are a surgical landmark. (Middle) Axial T2 MR of the
lower thoracic spine demonstrates hypointense dura delineating the thecal sac and its bright (CSF) contents. On T2
FSEMR, the CSF appears similar in signal intensity to extradural fat. (Bottom) Axial fat-saturated T2 FSEMR mostly
negates fat signal permitting visualization of the distal thecal sac (lumbar cistern) and cauda equina. The CSF-filled,
arachnoid-lined dural root sleeves are noted adjacent to the thecal sac preparing to exit through the neural foramina.
III
148
 MENINGES AND COMPARTMENTS
AXIAL T1 C+, AXIAL & CORONAL T1 MR

Ventral epidural plexus

Vertebral artery flow void ~
(1)
Extradural compartment :J
Dura :J
Spinal cord OQ
(1)
V1

OJ
:J
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(1)
V1

Dorsal root ganglion

Dura

Thecal sac

Dorsal extradural fat

Thecal sac

Nerve root sheath (sleeve)

LS pedicle
LS nerve root Dorsal root ganglion

(Top) Axial Tl C+ fat-saturated MR of the cervical spine shows intense, but normal enhancement of venous plexus
within extradural compartment outlining the isointense dura & hypointense CSF. Extradural compartment contains
primarily fat and veins. (Middle) Axial T1 MR at Lllevel shows the hypo intense dura delineating the CSF-filled
thecal sac surrounded by hyperintense fat within extradural compartment. Also note fat surrounding the dorsal root
ganglion within the neural foramina bilaterally. (Bottom) Coronal Tl MR shows the hypointense nerve root sheaths
(sleeve) which represent dural outpouchings (nerve root sheath or sleeve) exiting via the neural foramina. The nerve
roots descend in the thecal sac as the cauda equina and exit under the pedicle at their named levels. Bright signal
intensity fat defines the extradural space. III
149
 SECTION 3: Vascular

Spinal Arterial Supply 11I-152

Spinal Veins and Venous Plexus 11I-162
 SPINAL ARTERIAL SUPPLY
ITerminology
Abbreviations
·
a;. • Anterior, posterior spinal arteries (ASA,PSA)
c • Vertebral artery (VA),basilar artery (BA)
.0..
rJ) Synonyms
• Great anterior segmental medullary artery = artery of
Adamkiewicz
ICross Anatomy
Vertebral Column, Epidural Soft Tissues
• Segmental arrangement
o Arteries numbered for segments from which they
arise
o Numerous transverse, longitudinal anastomoses
extend over several segments
o Cervical
• VAs (dorsal intersegmental anastomoses)
• Thyrocervical trunk (ventral intersegmental
anastomoses)
o Thoracic
• Arise from paired intercostal arteries
• Pre-, postcentral branches to vertebral bodies
• Pre-, postlaminar, spinal branches to canal, neural
arch
o Lumbar
• Arise from paired lumbar segmental arteries
Dura, Cord, Roots, Nerves
• Spinal cord circulation derived from
o VAs (ASA, PSA)
o Segmental vessels at multiple levels
• Ascending cervical, deep cervical, intercostal,
lumbar, sacral
• Anterior spinal artery
o Arises at junction of intradural segment of VAs
o Lies in midline on ventral cord surface (in anterior
median fissure)
o Courses inferiorly from foramen magnum to filum
terminale
o Supplies anterior 2/3 of cord
• Anterior horns, spinothalamic/corticospinal
• Penetrating (central) branches have few collaterals
o Augmented by segmental feeders
• Posterior spinal arteries
o Arise from PICA or posterior rami of VA
o Paired longitudinal channels on dorsal cord medial
to dorsal roots
o Numerous plexiform anastomoses between PSAs
o Supply posterior 1/3 of cord
• Posterior columns, some corticospinal tracts
(variable)
o Augmented by medullary feeders from posterior
radicular arteries
• Segmental arteries
o Dorsal rami of segmental arteries arising from
vertebral, subclavian, thoracic intercostal, lumbar
intercostal arteries
o Enter canal through foramen, penetrate dura
o Divide into dural, radiculomedullary branches
III
152
• Dural arteries supply dura, nerve root sleeves
• Radiculomedullary branches supply roots, cord
• Radiculomedullary arteries
o Arise from dorsal segmental arteries, penetrate SAS
o Radicular branches supply anterior/posterior roots
o Medullary branches anastomose with ASA/PSA,
provide variable supply to cord
• Cervical
o Major radicular feeders between C5-7 level
o 2-3 anterior cervical cord feeders
o 3-4 posterior cervical cord feeders
• Thoracic
o Anterior thoracic cord feeders"" 2-3
• Usually left sided
• Small ventral feeders may also be present
• Inverse relationship between number, caliber of
ventral radicular vessels
• "Pauci-segmental" fewer vessels « 5) with larger
caliber
• "Pluri-segmental" more vessels with smaller caliber
o Dominant thoracic anterior radicular = artery of
Adamkiewicz
• Left side origin (73%)
• T9-12 origin (62%)
• Lumbar origin (26%)
• T6-8 (12%)
o Posterior thoracic cord feeders"" 9-12 (average 8)
• No right-left lateralization preference
• Vessel caliber 150-400 I.l
• Variable reporting of "great posterior radicular
artery"
• Lumbosacral and pelvic
o 0-1 major cord feeders
o ASA ends at conus, gives communicating branches
("rami cruciantes") to PSAs
o Posterior division of iliac artery ~ inferior &
superior lateral sacral branches ~ spinal arteries via
anterior sacral foramina
o Anterior division iliac artery ~ inferior gluteal artery
~ supplies sciatic nerve
o Posterior division internal iliac artery ~ iliolumbar
artery supplies femoral nerve at iliac wing level
• Cord nutrient vessels
o Central and peripheral systems
tracts o Central ~ ASA and flow centrifugal
o Peripheral ~ PSA, pial plexus &and flow centripetal
o Dense capillary network in gray matter of cord
IImaging Anatomy
Overview
• Artery of Adamkiewicz has characteristic "hairpin" turn
on DSA
• Vascular "watershed" of cord = central gray matter
o Hypotensive infarcts affect central gray
o ASAinfarct affects anterior 2/3 of cord
• Evaluation of vascular malformations requires
visualization of entire spinal vasculature
o VAsto iliac arteries
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 SPINAL ARTERIAL SUPPLY
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Distal intercostal artery

Muscular branches
Tll intercostal artery
Flash filling of aorta with contrast

Artery of Adamkiewicz
Anterior spinal artery
Flash filling of aorta with
contrast
Distal intercostal artery
Muscular branches

Tll intercostalartery origin

marked by catheter tip

Distal intercostal artery

TlO intercostal artery origin marked Muscular branches

by catheter tip

(Top) AP lA-DSA image from left T11 injection. The T11 intercostal artery gives rise to the major segmental feeding
vessel of the thoracic cord (artery of Adamkiewicz). The artery of Adamkiewicz shows a characteristic sharp hairpin
turn as it joins the anterior spinal artery. (Middle) AP lA-DSA later arterial phase T11 intercostal injection shows the
typical hairpin turn of the artery of Adamkiewicz. The anterior spinal artery is present in the midline as vertical
arteries both superior and inferior to the junction with Adamkiewicz. (Bottom) TI0 intercostal injection shows the
intercostal and muscular branches with no major feeding segmental vessel extending to the cord at this level.

III
157
 SPINAL ARTERIAL SUPPLY
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Branch to vertebral body l Catheter
Left T8 intercostal artery
Anterior spinal artery

Dorsal muscular branch

Vertebral body

Medial rib
Artery of Adamkiewicz
Anterior spinal artery

Neural foramen

Contrast reflux into right internal

carotid artery

Basilar artery
Distal right vertebral artery

Right vertebral coursing superior to

Cl arch Anterior spinal artery (cervical)
Distal right vertebral artery lateral
to C2

Thyrocervical trunk branches

(Top) AP view of a left T8 intercostal injection gives rise to the characteristic hairpin turn of the major segmental
feeding vessel to the thoracic cord, the artery of Adamkiewicz. Extending inferiorly from the top of the hairpin turn
is the anterior spinal artery, which supplies the anterior 2/3 of the cord. (Middle) Sagittal eTA shows the left T8
intercostal segmental artery gives rise to the characteristic hairpin turn of the major segmental feeding vessel to the
thoracic cord, the artery of Adamkiewicz. Extending inferiorly from the top of the hairpin turn is the anterior spinal
artery, supplying the anterior 2/3 of the cord. (Bottom) AP view of right vertebral injection shows the anterior spinal
artery extend\ng inferiorly from the right distal vertebral artery. The anterior spinal artery is well seen due to
III occlusion of the distal right vertebral with collateral reconstitution of the basilar.
158
 SPINAL ARTERIAL SUPPLY
AP DSA

Muscular branch
Anterior spinal artery

Artery of cervical enlargement

Right vertebral artery

Anterior spinal artery Artery of Adamkiewicz

Intercostal artery

Catheter

Anterior spinal artery

Segmental feeding artery

Catheter
L3 lumbar artery

(Top) AP view of right vertebral injection shows a dominant segmental branch (artery of cervical enlargement)
supplying the cervical anterior spinal artery and arising off of the mid cervical vertebral artery. (Middle) AP thoracic
view of left intercostal injection shows the artery of Adamkiewicz with a hairpin turn configuration, and supplying
the anterior spinal artery. (Bottom) AP view of L3 lumbar artery injection shows a dominant segmental feeding
vessel extending to L1 level.

III
159
 SPINAL ARTERIAL SUPPLY
•....
(ij AXIAL CT ANGIOGRAM
:J
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lJl
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Aorta
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C
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CJ)
Vertebral body
Basivertebral veins

Thecal sac

Aorta

Vertebral body

Lumbar segmental feeding artery

Thecal sac

Dorsal muscular branch

Aorta

Vertebral body Intervertebral disc

Lumbar segmental feeding artery

Thecal sac

Dorsal muscular branch

Dorsal muscular branch

(Top) First of three axial eTA source images show the arterial supply to the spine via lumbar segmental arteries.
Upper section through the vertebral body and transverse processes shows both right and left segmental arteries. Note
basivertebral vein, seen here as a funnel-shaped area of contrast in the middle of the vertebral body, connecting
posteriorly to the epidural venous plexus. (Middle) Scan through the middle of the vertebral body shows segmental
vessels with a dorsal muscular branch seen especially well. (Bottom) Scan at level of the intervertebral disc space
shows two dorsal muscular branches supplying the paraspinous muscles adjacent to the lamina and posterior spinous
processes.
III
160
III
161
 •....
(Ij
SPINAL VEINS AND VENOUS PLEXUS
:J
U o Cross anastomoses lie between spinous processes
Vl ITerminology o Extensive in posterior nuchal region, drain into deep
(Ij

> Abbreviations cervical veins, IJV

Q) • Vertebral venous system/plexus (VVS, VVP)
c::
• Superior, inferior vena cava (SVC, IVC)
0.. • Internal jugular vein (IJV)
(f)
Synonyms
• Epidural plexus = Batson plexus
I Gross Anatomy
Overview
• Vertebral venous system
o Large valveless network in/around vertebral column
o Part of extradural neural axis compartment (EDNAC)
o Extent: Sacral hiatus to foramen magnum
• Ends in dival plexus, suboccipital sinus
o Extensive collaterals, anastomoses
• Unites superior and inferior vena cava (like azygos
system)
• Three major external complexes: Internal VVP,
basivertebral veins, external VVP
• Smaller intradural veins
o Function
• Blood flows either direction, varies with
thoracic/abdominal pressure
• Large volume relative to arterial supply (20x
greater)
• Internal vertebral venous plexus
o Epidural venous network surrounds thecal sac
• Series of irregular, thin-walled valveless sinuses
• Arranged in ladder-like series of cross-connected
expansions up vertebral column
• Embedded in epidural fat
• Tributaries: Radicular veins, veins along posterior
elements
o Anterior/posterior epidural regions
• Anterior more prominent
• Formed from two continuous channels along
posterior surface of vertebral bodies between
pedides
• Channels expand to cross anastomose with each
other, receive basivertebral veins
• Largest at central dorsal region of vertebral body
• Thinnest at disc level
• Basivertebral veins
o Paired valveless intravertebral veins
o Extend horizontally through anterior, posterior
vertebral bodies
o Collect numerous small venous channels within
vertebral bodies
o Drain into anterior internal VVP
o Drain anteriorly into external VVP
• External vertebral venous plexus
o Anterior, posterior components in paravertebral
region
o Surround vertebral column
o Connect with: Internal VVP; azygos, lumbar veins ~
IVC, SVC
o Posterior veins form paired system, lie in
vertebrocostal grooves
• Intradural veins
o Parallel spinal arteries
o Symmetric pattern of venous drainage (compared
with highly asymmetric arterial supply)
• Minimal anterior-posterior, right-left, segmental
variations
o Central, peripheral groups of radial veins drain into
anastomoses on cord surface
o Central group provides return for anterior horns,
surrounding white matter
• ~ Drain into central veins in anterior median
fissure
• ~ Form anterior median vein
o Peripheral dorsal, lateral cord drainage via small
valveless radial vein plexus
• ~ Coronal venous plexus on cord surface
• ~ Epidural venous plexus of Batson
• Epidural plexus connects with SVC, IVC,
azygos/hemiazygos systems, intracranial dural
sinuses
o 30-70 medullary radicular veins
• No anterior or posterior dominance
• Anterior median vein continues caudally along
filum terminale to end of dural sac
o Coronal, median veins drain ~ medullary veins
• No intradural valves but medullary veins have
functional valve-like mechanism at dural margin
• Prevents epidural reflux into intradural space
• Medullary veins leave intradural space at root
sleeve ~ epidural plexus
Ilmaging Anatomy
Overview
• CT
o Normal funnel-shaped discontinuity in cortex of
posterior vertebral bodies
o Represents site at which basivertebral veins drain
into anterior internal VVP
• Spinal veins, plexi enhance strongly on Tl C+ MR
o External, internal VVPs surround vertebral column,
thecal sac
o Basivertebral vein enhances in "Y" configuration
o Thin, linear enhancement on cord surface normal,
caused by venous anastomoses
o Faint filum terminale enhancement normal
IAnatomy-Based Imaging Issues
Key Concepts or Questions
• Retrograde flow from pelvis -+ epidural plexus
o Provides natural route of spread from pelvic
neoplasms, infection to vertebral bodies
• Pharyngovertebral veins penetrate anterior
atlanto-occipital membrane ~ surround atlantoaxial
joint
o Permits inflammatory relaxation/subluxation (Grisel
syndrome)

III
162
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 SPINAL VEINS AND VENOUS PLEXUS
AXIAL T1 C+ MR

Anterior external vertebral

veins
Odontoid
Carotid artery
Internal jugular vein C2 lateral mass

Anterior interval vertebral vein Vertebral artery

Cervical spinal cord Venous plexus surrounding

vertebral artery

Posterior external vertebral

veins

Anterior external vertebral vein

C2 body

Carotid artery
Anterior internal vertebral venous
plexus
Vertebral artery Vertebral artery

Cervical spinal cord

Posterior external vertebral
veins

C2 spinous process

Anterior external vertebral veins

C2 body
Vertebral artery
Anterior internal vertebral venous Venous plexus within C2-3
plexus neural foramen
Posterior internal vertebral
venous plexus
Posterior external vertebral veins Cervical spinal cord

(Top) First of six axial fat suppressed T1 C+ MR images through cervical spine presented from superior to inferior
shows the distribution of cervical venous plexus surrounding the vertebral arteries, and joining with the anterior and
posterior internal vertebral venous plexus. The posterior external plexus forms two parallel columns of veins to either
side of the spinous processes. (Middle) Image through C2 body shows the anastomoses between the different venous
components such as anterior internal plexus and posterior external plexus dorsal to lamina, and surrounding
vertebral arteries. (Bottom) Image through the C2-3 neural foramen shows the prominent venous plexus
surrounding vertically oriented vertebral artery flow void, and anastomosing with the internal venous plexus
III circumferentially surrounding the thecal sac.
164
 SPINAL VEINS AND VENOUS PLEXUS
AXIAL T1 C+ MR fJl
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venous plexus C
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venous plexus

C2 spinous process
Posterior external vertebral
veins

Anterior external vertebral

veins
Carotid artery
C3 body
Vertebral artery
Jugular vein
Anterior internal vertebral
veins
Posterior internal vertebral
veins

Posterior external vertebral veins

Carotid artery

C3-4 intervertebral disc

Vertebral artery
Venous plexus within neural
Anterior internal vertebral
foramen
veins
Posterior internal vertebral veins

Posterior external vertebral

venous plexus

(Top) Image through more inferior aspect of the C2-3 neural foramen shows the prominent venous plexus
surrounding vertically oriented vertebral artery flow void, and anastomosing with thin crescentic internal venous
plexus circumferentially surrounding the thecal sac. The communication between the posterior external vertebral
veins and the more anterior foraminal plexus are pronounced. (Middle) Image at C3 body level shows typical pattern
of epidural enhancement due to anterior internal venous plexus, most prominent along lateral margins of anterior
canal, and thinning in the midline. The anastomoses of the plexus surrounding the vertebral artery and the more
ventral anterior external plexus are shown. (Bottom) Image through C3-4 level shows the marked enhancement of
the foraminal plexus, merging with the external plexus lateral to the facets. III
165
 SPINAL VEINS AND VENOUS PLEXUS
L-
eu CORONAL T1 C+ MR
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en
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Internal jugular'vein
Anterior internal vertebral
veins
C2 body

Anterior external vertebral

venous plexus

Internal cerebral veins

Internal jugular veins

Inferior petrosal sinus

Occipital condyle
Hypoglossal canal with venous
Odontoid process plexus

C2 body
Anterior external vertebral
veins

Internal cerebral veins

Basal vein of Rosenthal

Internal jugular veins

Hypoglossal canal with venous

plexus
Occipital condyle Anterior internal vertebral
plexus
Cllateral mass Odontoid process

Anterior external vertebral

plexus
C2 body
Venous plexus within neural
foramen

(Top) First of six coronal fat suppressed Tl C+ MR images are presented from anterior to posterior. The course of the
internal jugular veins from the jugular bulb inferiorly are shown bilaterally, and their relationship to the inferior
petrosal sinus and basisphenoid. (Middle) Image though mid-odontoid level shows inferior petrosal sinus draining
into jugular vein, and adjacent hypoglossal canal with venous plexus. Anterior external venous plexus of upper
cervical spine is defined by diffuse enhancement along course of neural foramina. (Bottom) Section towards
posterior margin of odontoid process continues to define relationship of prominent left jugular bulb with
hypoglossal canal, and inferior anterior external vertebral venous plexus.
III
166
 SPINAL VEINS AND VENOUS PLEXUS
CORONAL T1 C+ MR ""0
CJl

:J
1'0

Pons
Medulla
Jugular bulb
Hypoglossal canal with venous Posterior cortical margin
plexus odontoid process

Cllateral mass External vertebral plexus

Anterior internal vertebral

Neural foramen with venous plexus plexus

Internal cerebral veins

Choroid at foramen of Luschka

Sigmoid sinus

Vertebral artery

Venous plexus
Posterior external vertebral veins Posterior internal vertebral
veins

Vein of Galen

Transverse sinus

Sigmoid sinus
Retrocondylar vein
Venous plexus surrounding
vertebral artery

Posterior internal venous plexus

Posterior external vertebral
veins

(Top) Section through posterior margin of odontoid process shows posterior margin of the jugular bulbs and
hypoglossal canals. The anterior internal vertebral venous plexus (anterior epidural plexus) is now prominent and
merges with the plexus within each neural foramen. (Middle) Section through midportion of upper cervical canal
shows cerebral venous drainage extending to the skull base with a prominent right sigmoid sinus. The venous plexus
surrounding the vertebral artery is present cephalad to the enhancement of the internal venous plexus at CI-2.
(Bottom) Section through mid portion of upper cervical canal shows the cerebral venous drainage at skull base with
transverse and sigmoid sinuses curving along occipital bone. The retrocondylar venous system is also present,
merging with the upper cervical external plexus. III
167
 SPINAL VEINS AND VENOUS PLEXUS
•.... AXIAL, SAGITTAL & CORONAL CECT MIP
ro
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Foraminal venous plexus
Anterior internal vertebral plexus

Facet joint
Cervical lamina
Posterior external vertebral
veins

Odontoid process
Cl posterior arch
Anterior internal vertebral veins

Posterior external vertebral

veins
Basivertebral veins

C7 spinous process
Anterior external venous plexus

Cl lateral mass

C2 body
Internal jugular vein

Cervical "pillars"
Venous plexus at neural
foramen

Anterior internal vertebral veins Anterior external vertebral

veins

First rib

Drainage to superior vena cava

(Top) Axial CECT MIP image shows reflux of contrast into both external and internal venous plexus, with
opacification of left internal jugular vein. (Middle) Sagittal CECT MIP of cervical spine shows reflux opacification of
venous system, including basivertebral veins, and posterior external venous drainage surrounding spinous processes.
(Bottom) Coronal CECT MIP projection shows reflux of contrast into anterior external and internal venous systems.
The anterior internal venous plexus assumes the typical "step ladder" pattern crossing the midline at the mid
vertebral body level.

III
168
 SPINAL VEINS AND VENOUS PLEXUS
AXIAL & SAGITTAL CECT MIP

Innominate vein Left subclavian vein

Right subclavian vein

Cervical veins draining towards

Anterior external vertebral venous superior vena cava
plexus
Intravertebral venous sinuses
Foraminal plexus
Basivertebral veins Facet joint
Cervical lamina
Posterior external vertebral veins

Right subclavian vein Left subclavian vein

Innominate vein

Cervical veins draining toward

superior vena cava Anterior external vertebral
venous plexus
Basivertebral vein
First rib
Foraminal venous plexus

Anterior external vertebral

venous and foraminal venous
Carotid artery plexus
Posterior external vertebral
veins

First rib
Cervical vein draining towards
superior vena cava

Innominate vein Aortic arch

(Top) Series of CECT MIP projections of neck CT following intravenous contrast administration through left arm
vein. The first axial MIP image at cervicothoracic junction shows reflux of contrast retrograde into the cervical
vertebral veins outlining both external and internal vertebral venous plexus anatomy. The foraminal component of
the external plexus drain through multiple cervical muscular veins into the subclavian system. (Middle) Axial CECT
MIP image at the Tl level shows the anterior internal vertebral veins crossing midline with the central basivertebral
veins. The drainage of the cervical veins towards both left and right subclavian systems is demonstrated. (Bottom)
Sagittal CECT MIP image through the left cervical facet level shows the confluence of the external plexus along the
neural foramen, and the drainage towards the innominate vein. III
169
 SECTION 4: Plexus

Brachial Plexus 11I-172

Lumbar Plexus 11I-180
Sacral Plexus and Sciatic Nerve 11I-186
 BRACHIAL PLEXUS
IGross Anatomy
Overview
• Cervical plexus
o Formed from ventral rami of Cl-4 +/- minor branch
ofCS
o Has ascending superficial, descending superficial,
deep branches
o Supplies nuchal muscles, diaphragm, cutaneous
head/neck tissues
• Brachial plexus (BP)
o Formed from ventral rami of CS-Tl +/- minor
branches from C4, T2
o Has some proximal branches originating above BP
proper
• Dorsal scapular nerve; long thoracic nerve; nerves
to scalene/longus colli muscles; branch to phrenic
nerve
o Remaining minor, all major peripheral branches
arise from BP proper
o BP divided into roots/rami, trunks, divisions, cords,
terminal branches
o Roots/rami
• Originate from spinal cord levels CS to Tl
o Trunks
• Superior (CS-6), middle (C7), inferior (C8, Tl)
• Minor nerves arising directly from trunks:
Suprascapular nerve, nerve to subclavius muscle
o Divisions
• Anterior divisions innervate anterior (flexor)
muscles
• Posterior divisions innervate posterior (extensor)
muscles
• No named minor nerves arising directly from
divisions
o Cords
• Lateral cord (anterior divisions of superior, middle
trunks) innervates anterior (flexor) muscles
• Medial cord (anterior division of inferior trunk)
innervates anterior (flexor) muscles
• Posterior cord (posterior divisions of all 3 trunks)
innervates posterior (extensor) muscles
o Branches (terminal)
• Musculocutaneous nerve (CS-6) arises from lateral
cord
• Ulnar nerve (C8-Tl) arises from medial cord
• Axillary nerve (CS-6), radial nerve (CS-Tl),
thoracodorsal nerve (C6-8), upper (C6-7) and
lower (CS-6) subscapular nerves all arise from
posterior cord
Anatomy Relationships
• Cervical/thoracic
o BP enters thorax between anterior, middle scalene
muscles (scalene triangle)
o Close anatomic proximity to subclavian artery,
lymphatics
o Subclavian vein courses anterior to anterior scalene
muscle, not in direct proximity to brachial plexus
• Axilla
o Cords surround axillary artery
o In lower axilla cords divide into nerves to upper
limb
III
172
I Imaging Anatomy
Overview
• Surrounding perineural fat provides excellent
visualization of nerves, and allows them to be
distinguished from adjacent soft tissues
• Characteristics of normal nerve
o Well defined oval structure
o Discrete fascicles are uniform size, shape
• Distinct fascicular pattern distinguishes peripheral
nerves schwannoma or ganglion cyst, which also
have high intrinsic T2 signal intensity
o Isointense to adjacent muscle tissue on Tl WI
o Slightly hyperintense to adjacent muscle on
fat-saturated T2WI, STIR
IAnatomy-Based Imaging Issues
Key Concepts or Questions
• Essential to assess for anatomic integrity of plexus and
search for signs of edema or injury
• Knowledge of normal brachial plexus anatomy critical
for evaluating clinical abnormalities
Imaging Recommendations
• Multiplanar high-resolution MR peripheral nerve
imaging using surface coil
Imaging Approaches
• Preferred coil: Multipurpose flexible phase array
surface coil
• Alternative coil: Neurovascular phase array coil
• Best imaging planes: Coronal and oblique sagittal
planes from C3 (rostral) through T2 (caudal), nerve
roots (medial) through axilla (lateral)
• Best imaging sequences: Coronal Tl, coronal STIR,
oblique sagittal Tl, and oblique sagittal STIR
• Optional sequences: Oblique sagittal and coronal
contrast-enhanced fat-saturated Tl WI (for cases of
known or suspected neoplasm, scar, or infection)
Imaging Pitfalls
• Too large field of view reduces spatial resolution,
compromises visualization of internal BP architecture
• Technically simpler to evaluate the supraclavicular
plexus than infraclavicular plexus
• STIR provides more reliable fat suppression than
chemical fat-saturated T2WI
I Clinical Implications
Clinical Importance
• Complex BP anatomy predisposes to characteristic
clinical syndromes
o Erb palsy - avulsion of upper plexus elements
o Klumpke palsy - avulsion of lower plexus elements
o Thoracic outlet syndrome - neural compression at
the scalene triangle
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 BRACHIAL PLEXUS
<Jl
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X
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Vein

C8 VPR

T1 VPR

Lower trunk

Sternocleidomastoid muscle
C4 VPR
CS VPR

C6 VPR

Upper trunk C7 VPR

Middle trunk

Sternocleidomastoid muscle

Anterior scalene muscle

Cords and terminal branches

Subclavian artery

(Top) First of three coronal STIRMR images presented from posterior to anterior demonstrates the lower cervical
roots and ventral primary rami (VPR) (C8, Tl) combining into the lower trunk. (Middle) This image shows the
proximal cervical roots/VPR combining to form the upper and middle trunks of the brachial plexus. Normal nerve is
slightly hyperintense to muscle on STIR and fat-saturated T2 MR imaging. (Bottom) The distal cords and terminal
branches of the brachial plexus are depicted emerging from behind the anterior scalene muscle. The brachial plexus
normally exits the neck between the anterior and middle scalene muscles with the subclavian artery, while the
subclavian vein travels anterior to the anterior scalene muscle.
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 BRACHIAL PLEXUS
CORONAL T1 MR V'l
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T1

Sternocleidomastoid muscle

Scalene muscle
C8

C4 VPR
CS VPR
C6 VPR
Upper trunk
C7 VPR
Middle trunk
Vertebral artery

Subclavian artery

(Top) First of three coronal Tl MR images presented from posterior to anterior demonstrates the Tl root/VPR exiting
at Tl/2 and traversing over the lung apex. (Middle) The C8 root/VPR descends over the lung apex. The Tl root,
which is out of plane and not seen on this image, will combine with C8 to form the lower trunk. Note that C8 exits
from the C71Tl interspace. Since the nerves are isointense to muscle on T1 MR, it can be sometimes difficult to
distinguish nerve from slips of scalene muscle. (Bottom) Slightly more anterior image demonstrates the proximal
cervical roots/VPR combining to form the upper and middle trunks of the brachial plexus. Normal nerve is slightly
isointense to muscle on Tl MR imaging. Note the close anatomic proximity of the brachial plexus elements to the
subclavian artery. III
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 BRACHIAL PLEXUS
rJl
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CS Middle & posterior

scalene muscles
C6

First rib
Anterior scalene muscle

C7
T1

C8

Upper trunk
First rib

Middle trunk

Lower trunk

(Top) First of four oblique sagittal STIRMR images presented from medial to lateral demonstrates the ventral primary
rami of CS through Tl proximal to the trunks. C8 exits above the first rib, while Tl exits below. The BP is normally
sandwiched between the anterior and middle scalene muscles. (Bottom) Slightly more lateral slice demonstrates the
formation of the upper, middle, and lower trunks arranged in a vertical line between the scalene muscles. The CS and
C6 VPR can be still resolved as distinct elements within the upper trunk at this level.

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 BRACHIAL PLEXUS
OBLIQUE SAGITTAL STIR MR

Anterior and posterior

divisions

Clavicle

Subclavian artery
Subclavian vein

Lateral cord Posterior cord

Medial cord

Subclavian artery

(Top) Image at the division level shows mixing and matching of the trunks into anterior and posterior divisions.
Note that the divisions are retroclavicular. The posterior divisions will form the posterior cord and the anterior
divisions will form the lateral and medial cords. It is generally not possible to follow individual branches of the
divisions from trunk to cord. (Bottom) Image demonstrates the formation of the three cords (lateral, medial, and
posterior). The most important terminal branch of the lateral cord is the musculocutaneous nerve. The posterior cord
forms the axillary and radial nerve terminal branches. The medial cord terminates as the ulnar nerve.
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 BRACHIAL PLEXUS
Vl
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CS

C6
C7 transverse process

C7

Upper trunk (CS + C6)

CS

C6

C7
First rib
C8

Tl transverse process

(Top) First of four axial STIRMR images presented from rostral to caudal shows the upper brachial plexus elements
(CS-7 VPR) traveling between the anterior and middle scalene muscles in preparation to form the brachial plexus.
(Bottom) Image at the C7 IT! level depicts the linear alignment of the CS through C8 VPR. CS and C6 are closely
approximated and forming the left upper trunk.

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 BRACHIAL PLEXUS
AXIAL STIR MR V'l
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Anterior scalene muscle

Upper trunk (CS + C6)

Middle scalene muscle

First rib

C7

C6

CS
C8

First rib Tl

Second rib

(Top) Imaging more caudal at C7/TI level depicts the upper trunk on the left. Note that the brachial plexus elements
exit the neck between the anterior and middle scalene muscles. (Bottom) Image at the TI/2 level reveals the 5
roots/ventral primary rami and their relationship to the scalene muscles and ribs. They are arranged linearly on axial
imaging, and are always most easily located by finding the scalene muscles and following the roots out from the
spinal cord laterally as they exit the neck into the thorax.

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 V'l
:J
LUMBAR PLEXUS
X
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I Terminology IAnatomy-Based Imaging Issues
..
CL
QJ Abbreviations Key Concepts or Questions
c: • Lumbar plexus (LP) • MR
0.. • Lumbosacral plexus, trunk (LSP, LST) o T1WI + fat-saturated T2WI/STIR sequences
trJ
complementary
o TlWI
ICross Anatomy • Normal LP is well-defined ovoid structure
• Discrete fascicles isointense to adjacent muscle
Overview o Fat-saturated T2WI/STIR
• Lumbar plexus • LP slightly hyperintense to adjacent muscle
o Formed by • Hypointense to regional vessels
• L2-4 ventral rami • Discrete fascicles clearly-defined, separated by
• Minor branches of Ll, T12 lower intensity connective tissue
o Two major branches
• Femoral nerve (posterior divisions, L2-4) Imaging Recommendations
• Obturator nerve (anterior divisions, L2-4) • Coils
o Minor branches, constituent rami o Torso wrap-around or pelvis phase array preferred
• Iliohypogastric (Ll) o Spine phase array alternative coil
• Ilioinguinal (Ll) • Provides inferior signal to noise ratio (SNR)
• Genitofemoral (Ll, L2) • Especially notable in lateral aspects of posterior
• Lateral femoral cutaneous (L2, L3) abdomen, pelvis
• Superior gluteal nerves (L4-S1) o Body coil
• Lumbosacral trunk • Good spatial coverage
o Formed by • Poor SNR severely limits utility
• LS • Planes
• L4 ventral rami (minor branch) o Coronal, oblique sagittal
• Lumbosacral plexus o From L3 superiorly through ischial tuberosity
o Formed by inferiorly
• LST (LS, minor branch of L4) o From spine medially through greater trochanter
• Sl-4 laterally
• Sequences
Anatomy Relationships o Coronal T1 WI
• Lumbar plexus o Coronal STIR or fat-saturated T2WI
o Lies in posterior aspect of psoas major o Direct axial or oblique axial T1 WI
o Anterior to lumbar vertebral transverse processes o Direct axial or oblique axial fat-saturated T2WI/STIR
o Courses medial to psoas, ventral to quadratus o Optional: T1 C+ (if known/suspected neoplasm,
lumborum scar, infection)
• Femoral nerve • Specific recommendations
o Largest and major terminal branch of LP o For neural foramina, proximal L4-S ventral rami,
o Arises from L2-4 LST, sciatic nerve: Direct coronal, axial planes
o Courses inferiorly, medial to psoas major preferred
o Emerges between psoas, iliacus o For optimal visualization of LP internal architecture:
o Passes behind inguinal ligament into thigh Oblique axial plane preferred
o Splits into anterior, posterior divisions
o Sensory, motor fibers mixed in peripheral nerves Imaging Pitfalls
o Femoral artery lies medially • Nerves, vessels may be difficult to differentiate
o Nerves
• Round/ovoid linear structures
I Imaging Anatomy • No "flow voids"
• Branch at relatively acute angles
Overview • Enhance minimally
• General concepts • Show distinctive "fascicular" architecture (on
o Perineural fat surrounds, provides excellent axial)
visualization of LP o Vessels
o Normal nerve fascicles are uniform size, shape • Round/ovoid, linear
• MR • Have internal "flow voids"
o Intrafascicular signal intensity determined by • Branch at large angles
• Endoneurial fluid • Enhance intensely
• Axoplasmic water • Normal peripheral nerves, lesions (e.g., schwannoma)
o Interfascicular signal intensity both have high T2 signal
• Mostly fibrofatty connective tissue o Nerves have distinct fascicular pattern
• Susceptible to fat suppression

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V'l
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 LUMBAR PLEXUS
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Psoas muscle

Femoral nerve

Psoas muscle
L2

L3 Lumbar plexus (L2-4)

L4

L3

L4

L5

(Top) First of three coronal Tl MR images presented from anterior to posterior demonstrates the lumbar plexus and
ipsilateral femoral nerve traveling along the medial aspect of the psoas muscle. (Middle) This image demonstrates
the normal lumbar plexus arising from its primary neural inputs (L2-L4). Normal nerve is isointense to normal
muscle. The lumbar plexus is easily identified by locating the medial border of the psoas muscle. (Bottom) Image
more posteriorly shows the normal proximal L3, L4, and LS roots and rami exiting under the vertebral pedicle. L3
and L4 will join L2 to form the lumbar plexus and subsequently divide into anterior and posterior divisions
respectively to form the obturator and femoral nerves. LS will join a minor branch of L4 to form the lumbosacral
III trunk, a primary component of the sacral plexus.
182
 LUMBAR PLEXUS
CORONAL T2 FS MR Vl
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Lumbar plexus L3

L4

Femoral nerve

Psaos muscle

L4

Femoral nerve

Minor branch of L4

LS
Lumbosacral trunk

L3

L4

Lumbar plexus

LS

(Top) First of three coronal fat-saturated T2 MR images presented from anterior to posterior demonstrates the lumbar
plexus and its component L2-L4 roots/rami. Also seen is the proximal femoral nerve transiting along the medial
ipsilateral psoas muscle into the iliopsoas groove. Normal nerve is mildly hyperintense to muscle on fat saturated T2
or STIRMR imaging. (Middle) This image better demonstrates the L4 contribution to the lumbar plexus as well as
the proximal lumbosacral trunk, which will contribute to the sacral plexus. (Bottom) More posterior image shows
the proximal L3 and L4 roots and rami exiting under the vertebral pedicles to form the lumbar plexus along the
medial psoas border.
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 LUMBAR PLEXUS
~ AXIAL T1 MR
x
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Q..

OJ
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Psoas muscle

Lumbar plexus
Lumbar plexus

Femoral nerve

L4 + lumbar plexus

LS

(Top) First of two axial Tl MR images presented from superior to inferior depicts the lumbar plexus (composed of L2
and L3 at this level) traveling adjacent to the medial psoas muscle. A faint fascicular architecture is apparent.
Surrounding bright fat helps identification of the plexus. (Bottom) More caudal image shows the femoral nerve
along the medial psoas muscle. It is hard to identify the femoral nerve at this level on T1 MR imaging because of its
isointensity to the muscle. L4 has joined the remainder of the lumbar plexus at this level, and contributes to both
the LP and the lumbosacral trunk.
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 LUMBAR PLEXUS
AXIAL T2 FS MR ""0
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Psoas muscle

Lumbar plexus Lumbar plexus

Vein

Femoral nerve

Lumbar plexus

LS

(Top) First of two axial fat-saturated T2 MR images from superior to inferior demonstrates the lumbar plexus in its
normal location medial to the ipsilateral psoas muscle. At this level it is composed of L2 and L3, with the L4
contribution joining caudal to this slice. (Bottom) Imaging more inferiorly demonstrates the more caudal lumbar
plexus after the L4 contribution. The femoral nerve has branched off and is tracking in the iliopsoas groove in
expected location.

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 <Jl
:J
SACRAL PLEXUS AND SCIATIC NERVE
><
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o Lateral sacral artery branches accompany sacral
CL ITerminology nerves
Q) Abbreviations o Superior gluteal artery passes backward between
c: • Lumbosacral trunk, plexus (LST, LSP) L5/S1 nerves
a. • Sacroiliac (Sl), sciatic nerve (SN) o Inferior gluteal vessels lie between Sl/S2 or S2/S3
rJ)
• Sciatic nerve
o Thickest nerve in body
I Gross Anatomy o Exits pelvis
• Via greater sciatic foramen
Overview • Below piriformis muscle
• Lumbosacral trunk o Descends between greater trochanter of femur,
o Formed by L4 (minor branch), L5 ischial tuberosity
o Nerve supply to pelvis, lower limb; autonomic to o Descends along posterior thigh
pelvic viscera o Divides (usually near apex of popliteal fossa) into
o Lumbar part two branches
• Appears at medial margin of psoas major • Tibial nerve
• Courses inferiorly over pelvic rim anterior to Sl • Common peroneal nerves
joint • Pudendal nerve
• Joins Sl o Courses through greater sciatic foramen between
o Sacral part piriformis, ischiococcygeus
• S2-3 converge on LST in greater sciatic foramen -+ o Lies medial to internal pudendal vessels on spine
sciatic nerve o Accompanies internal pudendal artery through
• Sacral plexus lesser sciatic foramen into pudendal canal
o Formed by
• LST
• Ventral rami, Sl-3 IAnatomy-Based Imaging Issues
• Minor branch of S4
o Two "bands" Imaging Approaches
• Upper band: LST (L4, L5) + Sl-3 -+ sciatic nerve • Sciatic nerve
• Lower band: S2-4 -+ pudendal nerve o Coils
• Sciatic nerve • Torso wrap-around phase array coil preferred
o Major branch of sacral plexus • Flexible extremity surface coil alternative
o Coalesces from sacral plexus on ventral piriformis o Planes: Coronal, oblique or direct axial
muscle surface o Sequences
o Innervates • Coronal T1 WI, coronal STIR or fat-saturated T2WI
• Capsule of hip joint • Direct axial or oblique axial T1WI
• Posterior thigh (biceps femoris, semitendinosus, • Direct axial or oblique axial fat-saturated T2WI or
semimembranosus, adductor magnus) STIR
• All leg muscles (via common peroneal, tibial • Optional: Coronal/direct or oblique axial
nerves) fat-saturated Tl C+
• Pudendal nerve
o Formed by S2-4 ventral rami
o Exits pelvis via greater sciatic foramen between I Clinical Implications
pirifo rmi s/ ischiococcygeus
o Innervates
Clinical Importance
• Inferior rectal nerve • Compression syndromes
• Perineal nerve o Piriformis
• Penis or clitoris • Sciatic neuropathy
• Coccygeal plexus • Trapped/irritated at piriformis muscle
o Formed by (controversial)
• Minor branch of S4 (forms anococcygeal nerve) o Ischial tunnel
• S5 ventral rami • Sciatic neuropathy
• Coccygeal ventral rami • Compressed between obturator intern us/gluteus
maximus
Anatomy Relationships • At level of ischium
• Sacral plexus o Sacral plexus
o Lies against posterior pelvic wall, behind presacral • Dense presacral fascia protects sacral plexus
fascia • Sacral plexus rarely directly involved in malignant
• Anterior to piriformis pelvic tumors
• Posterior to ureter • Sacral plexus can be compressed indirectly
• Posterior to internal iliac vessels
• Behind sigmoid colon
o Iliolumbar artery accompanies L5 nerve

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III
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 SACRAL PLEXUS AND SCIATIC NERVE
~ CORONAL T1 MR
x
Q)
D...
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c:
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Sciatic nerve

Piriformis muscles

Sciatic nerve

(Top) First of two coronal Tl MR images through the pelvis presented from posterior to anterior demonstrates the 52
nerve contributing to the sacral plexus and sciatic nerve. (Bottom) Image obtained more anterior in the pelvis
demonstrates the sacral plexus coalescing into the sciatic nerve on the ventral surface of the piriformis muscle.

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 SACRAL PLEXUS AND SCIATIC NERVE
OBLIQUE AXIAL T1 MR & FS T2 MR

Sciatic nerve

Piriformis muscle
Veins

Gluteus maximus

Sciatic nerve

Veins Piriformis muscle

(Top) The sciatic nerve coalesces from the sacral plexus on the ventral surface of the piriformis muscle. On Tl MR
images, the fascicles are isointense to muscle separated by bright fibrofatty connective tissue. The fascicular
architecture permits ready distinction from vessels. (Bottom) The sciatic nerve coalesces from the sacral plexus on
the ventral surface of the piriformis muscle. On FS T2 MR images, the fascicles are mildly hyperintense to muscle
separated by dark (fat suppressed) fibrofatty connective tissue. The fascicular architecture permits ready distinction
from vessels.
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 SACRAL PLEXUS AND SCIATIC NERVE
<Jl
:J OBLIQUE AXIAL T1 MR & FS T2 MR
X
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0....
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Sciatic nerve

Piriformis muscle

Sciatic nerve

Piriformis muscle

(Top) Oblique axial Tl MR image shows the sciatic nerve on the ventral piriformis muscle. Although the nerve
(largest single nerve in the body) is enveloped by epineurium, the abundant fibrofatty epineurium gives the
impression that the individual fascicles are free in pelvic fat. (Bottom) The sciatic nerve is a more discrete structure
on fat-saturated T2 or STIRMR, with distinctive mildly hyperintense fascicles separated by interspersed dark (fat
suppressed) fibrofatty connective tissue.

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 SACRAL PLEXUS AND SCIATIC NERVE
AXIAL T1 MR AND FS T2 MR "'0
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Obturator intern us
muscle

Sciatic nerve

Gluteus maximus
muscle

Obturator intern us
muscle

Sciatic nerve

Veins

Gluteus maximus
muscle

(Top) Axial T1 MR of the sciatic nerve at the obturator internus level is readily identified between the obturator
internus and gluteus maximus muscles. The normal sciatic nerve is smaller and flatter appearing at this level than at
the piriformis level. (Bottom) Axial T2 MR of the sciatic nerve at the obturator internus level is readily identified
between the obturator intern us and gluteus maximus muscles. The normal fascicular architecture is distinctive and
permits discrimination from adjacent veins.

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SECTION 5: Peripheral Nerves

Peripheral Nerve Overview 11I-194

Radial Nerve 11I-200
Ulnar Nerve 11I-204
Median Nerve 11I-210
Femoral Nerve 11I-216
Common Peroneal/Tibial Nerves 11I-222
 rJ)
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PERIPHERAL NERVE OVERVIEW
>
L..
(]) o Functionally part of sacral plexus
I Terminology
Z • Sacral plexus
Abbreviations o Composed of
• Peripheral nervous system (PNS) • LST + Sl-3 VPRs
• Ventral, dorsal primary ramus (VPR, DPR) • Minor branch of S4
o Major branches
• Dorsal root ganglion (DRG)
• Sciatic nerve
• Common peroneal nerve
I Gross Anatomy • Tibial nerve
Anatomy Relationships
General Concepts
• Nerves usually accompanied by similarly-named
• Ramus arteries, veins
o First branch(es) of spinal nerve proper
o Supply similar target tissues
• VPR (larger branch) -+ ventral musculature, facet
o Form "neurovascular 'bundle'"
• DPR (smaller branch) -+ paraspinal muscles, facet
• Nerve
o 4-10 or more fascicles surrounded by epineurium
• Fascicle
I Imaging Anatomy
o Nerve fibers (hundreds) surrounded by connective Normal
tissue • MR findings
• Connective tissue (covers nerve fibers) o Nerves appear round/ovoid
o Epineurium o Well-defined internal fascicular architecture
• Outer layer of connective tissue o No abrupt change in caliber, course
• Longitudinally oriented o STIR/fat suppressed T2WI
• Continuous with surrounding connective tissues • Fascicles appear mildly hyperintense
• Groups fascicles into nerves, limits stretching • Interspersed with hypointense fibrofatty
o Perineurium connective tissue
• Intermediate layer of connective tissue
• Multilayered sheath that invest fascicles Abnormal
• Extends from nerve roots to nerve ends • Abnormal size (usually enlarged)
• Functions as blood-nerve barrier • +/- Loss of normal fascicular architecture
o Endoneurium • Abrupt change in caliber or course
• Innermost layer of connective tissue • STIR/fat suppressed T2WI
• Intrafascicular, surrounds individual nerve fibers o Hyperintense; approach signal of vessels
• Peripheral nerve
o Combination of one or more rami Imaging Recommendations
o +/- Schwann cell myelin sheath • High-resolution MR
o Sensory, motor fibers usually mixed o T1WI MR (relationship to adjacent structures)
• Some PNS branches purely sensory o STIR/fat suppressed T2WI (fascicular anatomy)
• Plexus o Fat-saturated T1 C+ (neuritis vs. tumor, etc.)
o Network of anastomosing nerves Imaging Pitfalls
Overview • Nerves, vessels sometimes difficult to differentiate
• Brachial plexus o Nerves
o Composed of • Round/ovoid, linear
• CS-T1 VPRs • No "flow void"
• +/- Minor C4, T2 • Branch at relatively acute angles
o Major branches • Enhance minimally
• Radial nerve • Distinctive axial fascicular architecture
• Median nerve o Vessels
• Ulnar nerve • Also round/ovoid, linear
• Musculocutaneous nerve • Have internal "flow voids"
• Axillary nerve • Branch at large angles
• Lumbar plexus • Enhance intensely
o Composed of
• L2-4 VPRs
• Minor T12, L1 branches I Clinical Implications
o Major branches
Clinical Importance
• Obturator nerve
• Femoral nerve • Neuropathy syndromes specific to abnormal nerve(s)
• Lumbosacral trunk (LST) • Imaging complimentary to clinical exam,
o Composed of electrodiagnostic testing
• LS + L4 VPR (minor)

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 PERIPHERAL NERVE OVERVIEW
r.J)
OJ CORONAL T1 & STIR MR
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Brachial plexus roots

Brachial plexus roots

(Top) Coronal T1 MR of the right brachial plexus and its roots shows the normal longitudinal T1 appearance of
peripheral nerves. Peripheral nerves are isointense to normal muscle on Tl MR images. (Bottom) Coronal STIRMR of
the right brachial plexus shows the normal longitudinal T2 appearance of peripheral nerves. Peripheral nerves are
mildly hyperintense to normal muscle on fat-saturated T2 or STIR MR images. Note that the fascicular architecture is
not always apparent on longitudinal imaging.

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 PERIPHERAL NERVE OVERVIEW
AXIAL T1 AND FS T2 MR

Z
ro
.,
<
ro
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Sciatic nerve

Sciatic nerve

(Top) Direct axial Tl MR of the sciatic nerve is coned and magnified to show characteristic transverse fascicular
appearance of peripheral nerves. The sciatic nerve is the largest single nerve in the body, and is well suited for
learning to recognize normal nerve internal architecture. The nerve fascicles are isointense to muscle and are
surrounded by higher signal intensity fibrofatty tissue. As in this instance, peripheral nerves are frequently
marginated by bright fat which assists delineation from surrounding soft tissues. (Bottom) Axial fat-saturated T2 MR
image of the left sciatic nerve reveals the normal T2 appearance of peripheral nerve. The individual fascicles are
distinct and slightly hyperintense to adjacent muscle. Low signal fibrofatty connective tissue (fat is suppressed by III
fat-saturation or STIR MR imaging) accentuates conspicuity of the individual fascicles.
19
 <Jl
CI.)
RADIAL NERVE
>
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CI.) • Supplies extensor forearm muscles, brachioradialis
Z
ITerminology • Radial nerve at wrist, hand
Abbreviations o Superficial branch of RN curves around wrist
ro
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• Brachial plexus (BP) o Passes deep to brachioradialis tendon
CI.)
...c • Radial nerve (RN) o Reaches hand
Q..
• Posterior interosseous nerve (PIN) o Divides into dorsal digital cutaneous nerves
l0-
• Radial tunnel syndrome (RTS) o Supplies skin over dorsum of wrist,
CI.)
D... • Metacarpal phalangeal joints (MCPs) thumb/index/middle/radial half of ring fingers
o Communicates with posterior, lateral cutaneous
OJ nerves of forearm (ulnar nerve)
s:::
c.. IGross Anatomy
rJ)
Overview IAnatomy-Based Imaging Issues
• RN is largest branch of BP
Imaging Recommendations
• Continuation of posterior cord of BP
• Primary nerve of forearm posterior (extensor) • Coils
compartment o Preferred: Multipurpose flexible phase array surface
• Innervates extensor muscles of arm, forearm coil
• Does NOT innervate hand muscles o Alternative: Flexible extremity surface coil
• RN divided anatomically into five segments • Best planes
o Shoulder/axilla o Direct axial
o Upper arm • Best sequences
o Elbow o TlWI
o Forearm o STIR/fat suppressed T2WI
o Wrist/hand o Optional: Fat-saturated Tl c+
• Radial nerve in shoulder/axilla Imaging Pitfalls
o Arises from BP posterior cord (CS-Tl) • Easy to image RN along spiral groove of humerus
o Descends behind third part of axillary, upper part of • Difficult to image distal RN after it bifurcates into
brachial arteries superficial, deep branches
o Passes dorsally between long/medial heads of triceps
• Radial nerve in upper arm
o Lies in spiral groove of humerus I Clinical Implications
o Accompanies profunda brachii artery, veins
o Enters posterior (extensor) compartment Clinical Importance
• Muscular branches innervate triceps, • RN most vulnerable to injury in humeral groove
brachioradialis, etc. • RN palsy
• Cutaneous branches supply skin along posterior o Following fracture of mid-numerous
surface of upper arm • Nerve laceration
o Pierces lateral intermuscular septum to re-enter • Entrapment by bone fragments
anterior compartment o "Saturday night palsy"
• Radial nerve at elbow • Prolonged pressure compressing RN in spiral
o Lies anterior to lateral epicondyle groove of humerus
o Gives off articular branches • RN sensory branch entrapment
o Divides into superficial, deep branches o Injury to superficial RN branch as it emerges below
• Radial nerve in forearm brachioradialis tendon
o Superficial branch of RN o Pain, paresthesias over radial side of dorsum of
• Direct continuation of RN wrist/hand
• Smaller of the two terminal RN branches • Radial tunnel syndrome (RTS)
• Descends lateral to radial artery o Symptoms
• Curves around lateral aspect of radius • Pain over extensors just distal to elbow
• Pierces deep fascia • No sensory disturbance, motor loss
• Entirely sensory o Entrapment neuropathy
o Deep branch of RN o Near elbow can be compressed by
• Larger of two terminal RN branches • Fibrous bands
• Largest branch is posterior interosseous nerve • Tendinous border of extensor carpi radialis brevis
• PIN is entirely muscular, articular • Supinator aponeurosis
• Enters radial tunnel proximal to radiocapitellar • Posterior interosseous nerve palsy
joint o Symptoms
• Passes between heads of supinator • Pain like RTS
• Curves around lateral side of radius • Weakness, paralysis
• Enters posterior fascial compartment of forearm • Inability to extend MCP joints of thumbs, fingers
• Terminates on dorsum of wrist • Radial deviation of wrist with extension
• Does not pass into hand o Entrapment at same anatomic sites as RTS

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z
(1)
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(1)
trl

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 RADIAL NERVE
rJl
C]) AXIAL T1 MR
>
•....
C])
z

•....
C])
D-
C])
c:::
0..
CJ)
Median nerve Radial nerve

Humerus

Brachial artery & vein

Ulnar nerve

Radial Nerve

Brachioradialis muscle

Brachialis muscle

Supracondylar
humerus

(Top) First of two axial Tl MR images in the arm presented from superior to inferior demonstrates the radial nerve
traveling in close anatomic proximity to the ulnar nerve and median nerve and brachial vessels. The nerve will move
posteriorly around the midhumeral shaft as it descends distally. It is difficult to follow the radial nerve around the
humeral shaft on T1 MR. (Bottom) Slice at the level of supracondylar humerus, the radial nerve has previously
transited around the humeral shaft and now descends anterolaterally between the brachialis and brachioradialis
muscles towards the cubital fossa.
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 RADIAL NERVE
AXIAL T1 MR ""0
V'l

:::::l
(0

\J
(0
""""

z
(0
""""

Brachialis muscle <

(0
Radial nerve <Jl
bifurcating into deep &
Median nerve superficial branches

Ulnar nerve

Biceps tendon Superficial radial nerve

branch

Brachialis muscle Deep radial nerve

branch

(Top) First of two axial Tl MR images obtained just proximal to the elbow presented from superior to inferior shows
the radial nerve bifurcation into the deep and superficial branches. (Bottom) Image obtained more distal within the
cubital fossa clearly depicts the separate superficial and deep radial nerve branches moving apart. The deep branch
forms the posterior interosseous nerve which will travel deep within the posterior compartment and provide motor
and articular innervation to the forearm, and the superficial branch which is entirely sensory and supplies sensory
fibers to dorsum of wrist, hand, and radial (lateral)1.S fingers.
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 rJl
C)
ULNAR NERVE
>
•...
C)
z ITerminology Internal Structures-Critical Contents
• Three layers of connective tissue surround nerve
Abbreviations
a From outside to inside: Epi-, peri-, endoneurium
• Brachial plexus (BP), ulnar nerve (UN) o Extrinsic arterioles/venules/capillaries lie in epi-,
perineurium
o Fascicular microvessels in endoneurium
I Gross Anatomy
Overview of Ulnar Nerve
• UN is major terminal branch of BP
Ilmaging Anatomy
o Formed from C8, Tl Overview
o Gives off no branches in arm
• Has both motor, sensory functions • MR
o TlWI
• Motor: To forearm flexors, intrinsic hand muscles • UN appears as well-defined oval
o Flexor carpi ulnaris (FCU)
• Discrete fascicles
o Flexor digitorum profundus III/IV • Isointense to adjacent muscle tissue
o Adductor pollicis, flexor pollicis brevis o Fat-saturated T2WI/STIR
o Hypothenar muscles • UN slightly hyperintense to adjacent muscle
o First palmar, dorsal interosseous muscles • Hypointense compared to adjacent vessels
o Third, fourth lumbricals • Clearly defined fascicles separated by interposed
• Sensory: Articular, cutaneous innervation lower signal intensity connective tissue
o Articular branches: Elbow, wrist, intercarpal,
carpometacarpal, intermetacarpal joints
o Cutaneous branches: Ulnar aspect of hand, 5th IAnatomy-Based Imaging Issues
finger, ulnar half of 4th finger
Key Concepts or Questions
Anatomy Relationships
• Predict where lesion resides (elbow, wrist) to place coil
• Axilla
o Courses between axillary artery, vein Imaging Recommendations
• Arm • Preferred coil: Multipurpose flexible phase array
o Runs in anterior compartment along medial surface coil
intermuscular septum o May need to use sequential stations to achieve
o Pierces medial intermuscular septum at midhumerus desired coverage
o Enters posterior compartment • Alternative coil: Flexible extremity surface coil
o Descends anterior to medial head of triceps • Best plane: Direct axial
o Lies between medial epicondyle, olecranon process • Best sequences: Tl WI, STIR/fat-saturated T2WI
of humerus • Optional sequence: Fat-saturated Tl c+
o Passes into cubital tunnel at elbow posterior to
medial epicondyle between two heads of FCU Imaging Pitfalls
• Cubital tunnel borders: Medial epicondyle • Nerves, vessels occasionally difficult to differentiate
(anterior), olecranon (lateral), Osborne fascia o Nerve
(posterior) • Round/ovoid linear structure
o UN, radial, median nerves in close approximation • No flow voids, minimal enhancement
• Forearm • Branches at relatively acute angles
a UN enters forearm • Distinct fascicular architecture on axial scans
o Descends on medial forearm, lying on flexor o Vessel
digitorum profundus • Internal flow void
o Ulnar nerve/artery/veins travel together • Branches at large angles
o Becomes superficial in distal forearm (covered by • Enhances intensely
skin, fascia)
a Transits under medial flexor retinaculum (Guyon
canal) at wrist I Clinical Implications
o Divides into superficial, deep branches
o Deep branch is muscular and articular Clinical Importance
• Muscular branches: Supply hypothenar muscles, • Clinical syndromes (compressive neuropathies)
medial two lumbricales o Cubital tunnel syndrome
• Articular branches: Supply wrist, intercarpal, • Transient paresthesias in ring, little fingers
carpometacarpal, intermetacarpal joints • +/- Clawing of digits
o Superficial branch is entirely sensory • Hypothenar atrophy
• Cutaneous fibers: Supply anterior palmar surfaces o Guyon tunnel syndrome
of medial 1.5 fingers • Hand weakness
• Dorsoulnar hand sensory deficit
• Positive Tinel over medial wrist

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z
(t)
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(t)
Vl

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 ULNAR NERVE
<Jl
Q) AXIAL T1 MR
>
"-
Q)
z

"-
Q)
0...
Q)
c:
0..
CJ) Median nerve

Brachial artery

Brachial vein Humerus

Ulnar nerve Radial nerve

Brachial artery

Brachial vein Radial nerve

Median nerve

Basilic vein
Humerus

Ulnar nerve

(Top) First of two axial Tl MR images presented from superior to inferior through the upper left arm demonstrates
the ulnar nerve traveling with the radial and median nerves and brachial artery and vein. (Bottom) Image obtained
more distally in the arm above the supracondylar humerus demonstrates the ulnar nerve moving medially in
preparation to travel under the medial epicondyle. Note the separate courses of the ulnar, radial, and median nerves
in the distal arm.

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 ULNAR NERVE
AXIAL T1 MR (J)
"'0
:J
('0

\J
ro
""""

Biceps tendon
Z
ro
""""

<
ro
(fl

Pronator teres muscle Brachialis muscle

Medial humeral
epicondyle Lateral humeral
Ulnar nerve epicondyle

Cubital tunnel
retinaculum (Osborne
fascia)

Trochlea of humerus

Pronator teres muscle Cephalic vein

Ulnar nerve

Flexor carpi ulnaris

muscle

Capitellum of humerus
Olecranon

(Top) First of two axial Tl MR images centered at the left elbow presented from superior to inferior depicts the ulnar
nerve transiting under the medial epicondyle of the humerus. The characteristic fascicular neural architecture is
distinctive, with nerve fascicles isointense to muscle and the intervening fibrofatty tissue slightly hyperintense. The
ulnar nerve normally is plumper and more conspicuous at the cubital tunnel. (Bottom) Imaging at the left elbow
distal to the medial epicondyle demonstrates the ulnar nerve entering the medial forearm. Note that the nerve
caliber is normally smaller than at the level of the medial epicondyle (cubital tunnel).
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 ULNAR NERVE
<Jl
Q) AXIAL T1 MR
>
•...
Q)
z

•...
Q) Flexor carpi ulnaris
CL muscle and tendon
Ulnar nerve
OJ
c:
0.. Ulna
rJ) Median nerve

Pronator quadratus Anterior interosseous

muscle, interosseous nerve & artery
membrane
Radius

Ulnar nerve entering

Guyon tunnel

Pisiform

Flexor tendons &

muscles

Pronator quadratus
muscle

(Top) First of two axial Tl MR images of the left forearm presented from superior to inferior shows the ulnar nerve in
the medial forearm coursing lateral to the flexor carpi ulnaris muscle. The anterior interosseous nerve branch travels
with the interosseous artery adjacent to the interosseous membrane. (Bottom) Imaging of the left forearm shows the
ulnar nerve in the medial forearm entering the medial (Guyon) tunnel at the wrist. This is a less common point of
nerve entrapment than the cubital tunnel at the elbow.

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 ULNAR NERVE
AXIAL PD FS MR "'0
Vl

::J
ro
v
(D
""""

z
(D
""""

Median nerve <

(D
CJl

Flexor carpi ulnaris

Radius
Ulnar nerve

Ulna

Ulnar nerve in Guyon

tunnel Median nerve

Pisiform

Radial nerve

(Top) First of two axial fat-saturated proton density images of the forearm and wrist presented from superior to
inferior demonstrates the ulnar nerve as mildly hyperintense to muscle with distinctive fascicular architecture that
permits distinction from adjacent tendons and vessels. (Bottom) This image depicts the ulnar nerve in Guyon tunnel
adjacent to the pisiform carpal bone. The median nerve is also distinctive with its characteristic fascicular
architecture.

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 tJl
a;
MEDIAN NERVE
>
'--
a; ITerminology o Proximal to point at which MN passes under
z tendinous arch of flexor digitorum superficialis
Abbreviations o Descends on interosseous membrane with anterior
ri:\
'-- interosseous artery (branch of ulnar artery)
a; • Brachial plexus (BP)
o Between flexor digitorum profundus, flexor pollicis
...c • Median nerve (MN)
0.. • Anterior interosseous nerve (AIN) longus muscles
o Enters palm through osseofibrous carpal tunnel
o Close to deep surface of flexor retinaculum
(transverse carpal ligament)
ICross Anatomy
• AIN can become entrapped by flexor retinaculum
Overview at wrist
• MN = principle nerve of anterior forearm fascial
compartment
• MN passes through (but has no branches in) axilla or IAnatomy-Based Imaging Issues
upper arm
Imaging Recommendations
• MN anatomically divided into six segments
o Shoulder/axilla • Coils
o Upper arm o Preferred: Multipurpose flexible phase array surface
o Cubital fossa coil (dedicated wrist coil for CTS)
o Forearm o Alternative: Flexible extremity surface coil
o Wrist o Coverage: Sequential stations needed to cover MN
o Palm course fully
• Median nerve (shoulder/axilla) • Best planes
o Infraclavicular branch of BP o Direct axial
o Two roots • Best sequences
• Lateral root from lateral cord of BP (CS-7) o TlWI
• Medial root from medial cord of BP (C8, Tl) o STIR/fat-saturated T2WI
o Roots surround, unite in front of axillary artery o Optional: Tl c+
o MN exits lower axilla Imaging Pitfalls
• Median nerve (upper arm) • Must extend axial imaging into palm for complete
o Enters upper arm lateral to brachial artery MN, AIN delineation
o In mid-arm
• MN crosses brachial artery
• Descends medially, between biceps/triceps I Clinical Implications
• MN, musculocutaneous, medial cutaneous, radial,
ulnar nerves all lie relatively superficially Clinical Importance
• MN, other nerves surround/lie adjacent to • MN can be injured during deep median cubital vein
brachial artery, basilic vein puncture
• Median nerve in cubital fossa (elbow) • MN vulnerable to wrist lacerations
o MN lies medial to brachial artery, deep to bicipital • Three major neural compression syndromes
aponeurosis, anterior to brachioradialis o Carpal tunnel syndrome (CTS)
o Courses deep to median cubital vein • Most common entrapment mononeuropathy
o Gives off articular, muscular branches to most • Caused by MN compression at wrist as it passes
superficial flexor muscles through fibro-osseous tunnel under flexor
• Median nerve in forearm retinaculum
o MN travels with ulnar artery, veins • Intermittent pain, paresthesias, numbness in
o Courses into deep forearm between heads of thumb, index/middle/medial ring fingers
pronator teres • +/- Thenar atrophy, weakness
o Gives off anterior interosseous nerve • Loss of palmar hand sensation
o Descends posterior to flexor digitorum superficialis o Anterior interosseous nerve syndrome
• Median nerve at wrist • Weakness of "pinch grip"
o MN larger, flatter at wrist than other levels • Flexor pollicis longus/digitorum profundus (index
o Becomes superficial as nears wrist finger), pronator quadratus
o Enters palm deep to flexor retinaculum • No sensory symptoms (distinguishes from
• Median nerve in palm pronator syndrome)
o Palmar cutaneous branch o Pronator syndrome
• Arises just proximal to flexor retinaculum • Caused by MN entrapment at elbow
• Therefore is spared in carpal tunnel syndrome • Uncommon
o Muscular branch to thenar muscles • Pain in proximal anterior forearm aggravated by
o Palmar digital branches flexing elbow or pronating forearm against
• Anterior interosseous nerve resistance
o Arises from MN between heads of pronator teres • Intermittent paresthesias

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z
(t)
....•
<
(t)
(fl

III
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 MEDIAN NERVE
tJl
(]) AXIAL T1 MR
>
"-(])
z
(ij
"-(])
....c
Q..

"-
(])
0...
(])
c:
0-
rJ)
Median nerve

Brachial vein Humerus

Brachial artery
Radial nerve
Ulnar nerve

Brachial artery & vein

Radial nerve

Basilic vein

Median nerve Supracondylar

humerus

Ulnar nerve

(Top) First of two axial Tl MR images presented from superior to inferior demonstrates median nerve traveling with
the radial and ulnar nerves in the arm. The neurovascular complex also includes the brachial artery and brachial
vein. (Bottom) Image lower in arm at the supracondylar humerus level depicts median nerve traveling separately
from the radial and ulnar nerves and the brachial vessels.

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 MEDIAN NERVE
AXIAL T1 MR "0
Vl

::l
ro
u
([)
....•
Brachial artery & venae
comitantes

Biceps tendon
z
([)
Median nerve ....•
<
([)
Superficial, deep
CJl
Ulnar artery branches of radial
nerve

Pronator teres muscle

Brachialis muscle

Ulnar nerve

Biceps tendon
Median nerve

Brachialis muscle
Pronator teres muscle

Trochlea Capitellum

Ulnar nerve

Olecranon

(Top) First of two axial Tl MR images at the left elbow presented from superior to inferior demonstrates median
nerve traveling with the ulnar artery between the pronator teres and brachialis muscles in the medial volar forearm.
At this level, the caliber of median nerve is smaller than the ulnar nerve. (Bottom) Image lower in the left elbow at
the level of the humeral condyles shows median nerve within the volar medial forearm. The median nerve travels
between the pronator teres and brachialis muscles at the elbow.

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 MEDIAN NERVE
(fl AXIAL T1 MR
>
"-Q)

"-Q)
Cl...
Ulnar nerve
Q)
c:
c.. Median nerve
rJ')
Ulna
AIN & anterior
interosseous artery
Interosseous membrane

Radius

Ulnar nerve

Ulna
Median nerve

Pronator quadratus
muscle & interosseous Radius
membrane

(Top) First of two axial Tl MR images of the forearm presented from superior to inferior depicts median nerve
relative to other important regional structures. Note that median nerve has divided into the AIN, which travels deep
along the volar surface of the interosseous membrane with the anterior interosseous artery, and the main median
nerve which continues into the wrist through the carpal tunnel. (Bottom) Image more distal in the forearm
demonstrates the normal course of AIN and median nerve proper in the distal forearm. At this level, the median
nerve is fairly superficial but readily identifiable.
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 MEDIAN NERVE
AXIAL PO FS MR ""0
rJl

:::::l
rtl
\J
(!)
""""

Median nerve
Ulnar nerve z
(!)
""""

<
(!)
Ulnar artery Flexor muscles & (fl

tendons

Ulna Radius

Ulnar nerve
Median nerve

Pisiform

(Top) First of two axial fat-saturated PD MR images through the wrist presented from superior to inferior shows the
median nerve well relative to adjacent important regional structures. Median nerve travels superficial to the flexor
muscles and tendons and lateral (radial) to the ulnar nerve. (Bottom) Image at the level of the Guyon and carpal
tunnels shows the normal median nerve appearance, with mildly hyperintense (to muscle) fascicles. The nerve is
normally a bit larger and flatter at the wrist than other levels, which must be remembered when imaging for
c1inicalIy suspected carpal tunnel entrapment syndrome.
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 <J)
Q)
FEMORAL NERVE
>
~
Q) o Saphenous nerve
z ITerminology • Descends in adductor canal
Abbreviations • First lateral, then medial to femoral artery
• Femoral nerve (FN) • Descends on medial side of leg
• Lumbar plexus (LP) • Supplies skin of medial thigh, knee, leg
• Ventral primary ramus (VPR)
~
Q)
I Imaging Anatomy
..
0-
Q) I Gross Anatomy Overview
r:::
Overview • MR of normal FN
c.. o T1WI: Round/ovoid shape
fJ) • Lumbar plexus
o Paraspinal nerve plexus o STIR/fat suppressed T2WI
o Lies in posterior part of psoas major • Well-defined internal fascicular architecture
o Formed by L2-4 VPRs • Uniformly mildly hyperintense fascicles +
o Branches interspersed hypointense fibrofatty connective
• Ventral branches of L2-4 VPRs form obturator tissue
nerve
• Smaller dorsal branches of L2, L3 VPRs unite to
form lateral femoral cutaneous nerve IAnatomy-Based Imaging Issues
• Larger dorsal branches of L2-4 VPRs form femoral Imaging Recommendations
nerve
• Femoral nerve • MR
o Best coils
o Largest branch of LP
o Composed of • Preferred: Torso wrap-around phase array coil
• Alternative: Flexible extremity surface coil
• Dorsal branches of L2-4 VPRs
o Best planes
• Abdominal branches supply iliacus, pectineus
muscles • Direct coronal, axial
o Best sequences
o In thigh, FN splits into anterior, posterior divisions
• Coronal Tl WI, STIR or fat-saturated T2WI
o Anterior division branches
• Axial Tl WI, STIR or fat-saturated T2WI
• Intermediate femoral cutaneous nerve
• Optional: Coronal, axial fat-saturated Tl C+
• Medial femoral cutaneous nerve
o Area to cover: Similar to sciatic nerve imaging in
• Branches to sartorius muscle
thigh
o Posterior division
• Extend scan from sacrum (posterior) to skin of
• Saphenous nerve (largest femoral cutaneous
branch) groin (anterior)
• Visualizes FN under inguinal ligament
• Muscular branches to quadriceps, rectus femoris,
vastus muscles
Anatomy Relationships I Clinical Implications
• FN descends through psoas major
• Runs caudally in iliopsoas groove, deep to iliac fascia
Clinical Importance
• Exits pelvis by passing behind inguinal ligament • FN neuropathy characterized by
• Runs inferiorly in close proximity to femoral o Quadriceps wasting/weakness
artery/vein o Pain/paresthesias anteromedial thigh, medial leg
• Courses lateral to femoral artery/vein within femoral • FN especially vulnerable to injuries at two points
canal o Within iliopsoas groove
o Acronym for femoral canal contents from lateral to o At groin
medial = NAVL(nerve, artery, vein, lymphatics) • FN generally not subject to entrapment but may be
• FN splits into anterior, posterior divisions compressed
• Anterior division branches • Compressive FN neuropathy
o Intermediate femoral cutaneous nerve o Secondary to pelvic tumor such as
• Pierces fascia lata • Lymphoma
• Descends on front of thigh • Sarcoma
• Supplies skin to knee o Secondary to psoas hematoma
o Medial femoral cutaneous nerve • Trauma
• Lateral, then anterior to femoral artery at apex of • Coagulopathy
femoral triangle • Hemophilia
• Anterior branch descends on sartorius, supplies • Noncompressive FN neuropathy
skin as low as medial aspect of knee o Diabetes
• Posterior branch anastomoses with saphenous, o Surgical (e.g., inadvertent ligation during
obturator nerve branches; supplies medial leg herniorrhaphy)
• Posterior division branches

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z
-.<
(D

(D
V1

III
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 FEMORAL NERVE
f./)
Q.) CORONAL T1 MR
>
"-Q.)

z
ru
"-
Q.)
....c
0...
L2
"-
Q.)
0...
Q.)
c: L3

0-
rJ)

L4

L5

Sacral ala

Psoas muscle

Femoral nerve

Iliacus muscle

(Top) First of two coronal Tl MR images presented from posterior to anterior demonstrates the ventral primary rami
(L2-4) which will form the lumbar plexus. LS will combine with a minor branch of L4 to form the lumbosacral trunk.
(Bottom) Image more anteriorly after formation of the lumbar plexus shows the femoral nerve in the iliopsoas
groove. The lumbar plexus is isointense to muscle signal, and often difficult to identify on coronal Tl MR images.

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 FEMORAL NERVE
CORONAL STIR MR "'0
Vl

:::::l
ro
u
(l)
....••

L2

z
(l)
....••
L3
<
(l)
(fl

L4

Femoral nerve

L5

Psoas muscle

Femoral nerve

Femoral nerve

Iliacus muscle

(Top) First of two coronal STIRMR images depicts the proximal rami contributions to the lumbar plexus. The
proximal femoral nerve travels in the iliopsoas groove, and is easily identifiable by its fascicular nature and mild
hyperintensity (to adjacent muscle). (Bottom) Image more anteriorly located shows the bilateral femoral nerves
traveling in the iliopsoas grooves. The distinct fascicular pattern is unique to normal nerves and readily permits their
distinction from vessels.

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 FEMORAL NERVE
<fl
Q.) CORONAL & AXIAL STIR MR
>
'-
Q.)
z
rI:l
'-
Q.)
....c
Q..

'-
Q.)
Cl...
(JJ
c::
a.
rJ'J
Abnormal inflamed
femoral nerve Normal femoral nerve

Suture ligature

Abnormal swollen Normal femoral nerve

femoral nerve

Iliacus muscle Iliacus muscle

Psoas muscle Psoas muscle

(Top) Coronal STIR MR shows the femoral nerves as they descend out of the pelvis into the femoral canal. The
normal left femoral nerve is mildly hyperintense to muscle. The right femoral nerve is swollen and abnormally
hyperintense to the level of a suture inadvertently ligating the femoral nerve during a herniorrhaphy. This image
reinforces the importance of continuing coronal slices anteriorly to groin skin to avoid missing lesions within the
femoral canal. (Bottom) Axial STIR MR image obtained in the pelvis contrasts the normal left femoral nerve within
the iliopsoas groove to the abnormally swollen hyperintense right femoral nerve proximal to an inadvertent surgical
ligature during herniorrhaphy. Note that both nerves clearly demonstrate the distinctive fascicular architecture of
III nerves. At this level, the iliacus and psoas muscles functionally form the iliopsoas muscle.
220
 FEMORAL NERVE
AXIAL T1 MR ""0
Vl

::l
(0

v
.,
(t)

Femoral artery z
.,
(t)

Femoral nerve <

(t)
<.r>

Femoral vein

Femoral artery Femoral nerve

muscular branches

Femoral vein

Femur

Lesser trochanter of
femur

(Top) Axial T1 MR image obtained at the level of the femoral canal demonstrates the right femoral nerve lateral to
the femoral artery, veins, and lymphatics (not seen). The acronym "NAVL" helps to remember the order of structures
within the femoral canal from lateral to medial. The left femoral nerve is not seen well. The femoral nerve is small at
this level and often difficult to identify as a discrete structure unless abnormally swollen. (Bottom) Axial Tl MR
image through the proximal thigh shows the femoral nerve branching into muscular branches that will supply the
anterior thigh quadriceps muscles. It is difficult to image femoral nerve distal to these proximal branches because of
their small size and similar signal intensity to muscles. III
221
 Vl
a;
COMMON PERONEAL/TIBIAL NERVES
>
L-
a; ITerminology o SPN supplies
Z • Peroneus longus, brevis
Abbreviations • Skin of lower leg
• Sciatic nerve (SN)
• Common peroneal nerve (CPN)
• Tibial nerve (TN) jAnatomy-Based Imaging Issues
Imaging Recommendations
• Tibial nerve
I Gross Anatomy o Coils
Overview • Preferred: Torso wrap-around phase array coil
• Sciatic nerve • Alternative: Flexible extremity surface coil
o Major continuation of sacral plexus o Best plane: Direct axial
o Passes behind, below piriformis muscle o Best sequences
• Common variation: Passes through piriformis • T1 WI, STIR/fat-saturated T2WI
o Exits pelvis through greater sciatic foramen • Optional: Fat-saturated T1 C+
o Passes between greater trochanter, ischial tuberosity • Common peroneal nerve
o Descends along posterior thigh o Coils
o Proximal to knee, divides into two major terminal • Preferred: Torso wrap-around phase array coil
branches • Alternative: Knee coil (excellent images but
• Common peroneal (fibular) nerve limited coverage) or flexible extremity surface coil
• Tibial nerve o Best plane: Direct axial
• CPN, TN divisions discrete entities within SN prior o Best sequences
to division • T1WI, STIR/fat-saturated T2WI
• TN usually larger, more medially located than • Optional: Fat-saturated T1 c+
CPN Imaging Approaches
o Supplies knee flexors + all muscles below knee
• Torso coil preferred for most suspected TN, CPN
• Tibial nerve lesions
o Larger terminal branch of SN
o Excellent signal-to-noise (SNR)
o VPR of L4-5, Sl-3
o Large coverage distance
o Descends along back of thigh, popliteal fossa o Wrap coil around both legs
o Sends articular branches to knee
o Image one leg at a time => maximizes spatial
o Branches to posterior leg muscles
resolution
• Gastrocnemius o Imaging both legs simultaneously => t FOV, ~ SNR
• Plantaris
• Knee coil
• Soleus o Optimal if specifically imaging CPN at fibular head
• Popliteus
• Tibialis posterior
• Flexor digitorum longus
• Flexor hallucis longus
I Clinical Implications
o Sural nerve (posterior!lateral skin of distal third of Clinical Importance
leg, lateral foot) • Lesions of SN, branches (CPN, TN) can occur at
o Medial calcanean branches (skin of heel, medial numerous locations
plantar surface) • Sciatic nerve
o Medial plantar nerve (main termination of tibial o Compression as components leave lumbosacral
nerve to medial sole of foot, plantar muscles) spine
o Lateral plantar nerve o Compression as SN leaves pelvis
• Lateral sole of foot o Piriformis syndrome (common anatomic variant but
• Most deep muscles of foot entrapment rare)
• Common peroneal nerve • CPN neuropathy
o Smaller terminal branch of SN o Paresis/weakness of ankle/toe dorsiflexion (foot
o Descends obliquely along lateral popliteal fossa to drop)
fibula o Most common cause = CPN compression at fibular
o Traverses lateral aspect of head of fibula head
• Especially vulnerable to injury at this point o Less common: After total knee arthroplasty,
o Two major terminal branches proximal tibial osteotomy
• Superficial peroneal nerve (SPN) • TN neuropathy
• Deep peroneal nerve (DPN) o Pain, paresthesias, paresis of plantar flexion at ankle
o DPN supplies anterior compartment leg muscles o TN can be entrapped as traverses tarsal tunnel
• Tibialis anterior
• Peroneus
• Extensor hallucis longus, brevis
• Skin on lateral aspect of ankle, dorsal foot

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 COMMON PERONEAL/TIBIAL NERVES
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Sciatic nerve

Tibial division Common peroneal

division

Femoral artery

Femoral vein Femur

Common peroneal
division
Sciatic nerve

Tibial division

(Top) First of two axial Tl MR images through the left thigh presented from superior to inferior demonstrates the left
sciatic nerve residing between the obturator internus and gluteus maximus muscles. Even at this level, the common
peroneal division and tibial division fibers are anatomically distinguishable even though the sciatic nerve proper
contains both divisions within a single epineurium layer. (Bottom) Image obtained more distally through the left
thigh shows clear separation of the common peroneal nerve and tibial nerve fibers within the sciatic nerve. This
somatotopic distribution of nerve fibers explains why some patients with sciatic nerve lesions may clinically
III demonstrate either a common peroneal or tibial neuropathy only.

224
 COMMON PERONEAL/TIBIAL NERVES
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Common peroneal
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Tibial nerve

Femur

Popliteal artery &

popliteal veins

Common peroneal
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Tibial nerve

(Top) First of two axial Tl MR images through the left mid-thigh depicts the proximal bifurcation of the sciatic nerve
into common peroneal and tibial nerve branches. The tibial nerve is normally larger than the common peroneal
nerve. (Bottom) Image more distal in the left thigh depicts the common peroneal and tibial nerves as separate nerves
with separate epineurium, but traveling adjacent to each other in the posterior thigh.

III
225
 COMMON PERONEAL/TIBIAL NERVES
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Popliteal artery

Popliteal vein
Common peroneal
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Popliteal artery

Popliteal vein

Common peroneal
Tibial nerve nerve

(Top) First of two axial Tl MR images through the distal thigh presented from superior to inferior depicts the larger
tibial nerve continuing straight distally and the smaller common peroneal nerve moving laterally in preparation to
transit around the fibular head. (Bottom) Image obtained more distally in the left thigh at the level of the
supracondylar femur clearly depicts the isointense (to muscle) tibial nerve fascicles separated by bright fibrofatty
connective tissue. The smaller common peroneal nerve is laterally positioned.

III
226
 COMMON PERONEAL/TIBIAL NERVES
AXIAL T1 MR "'0
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Popliteal artery
Popliteal vein
Common peroneal
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Fibular head
Popliteal artery

Popliteal vein

Common peroneal
Tibial nerve nerve

(Top) Axial Tl MR image obtained at the femoral condyle level confirms little change in location of the tibial nerve
as it moves distally towards the knee joint. Conversely, the common peroneal nerve is moving progressively laterally.
(Bottom) Axial Tl MR image obtained below the knee joint at the level of the proximal tibia and fibula reveals the
lateral superficial position of the common peroneal nerve at the fibular head. Because of this superficial anatomical
position adjacent to the hard fibular head, the common peroneal nerve is commonly injured in this location.

III
227
 INDEX
A Alveolar nerve, inferior, I:211, 219, II:27, 139, 162,
164,168,169,261,267,272,275,278,280,281,
Abducens nerve (CN6), 1:87, 88, 89,94, 105, 107, 291,293
121,122,124,131,175,177,181,182,210,213, Alveolar ridge mucosa, II:269
216,217,220-23,235,344, II:27, 33, 48, 91, 95 Alveus, 1:41,77,78,79,81,82,83
axial T2 and T1 C+ MR, 1:222 Ambient cistern, 1:77, 78, 79,80,82,83, 108, 116,
in cavernous sinus sinusoids, 1:93 118,119,164,165,166,183,206
in Dorello canal, 1:87, 214 Ambient segment of posterior cerebral artery, I:152,
exiting cavernous sinus, 1:87 164,166,294,312,313,314,315,316,317,320,
fibers, 1:121 321
graphics, 1:221 Ammon horn, 1:76, 78
in prepontine cistern, 1:223 Amygdala, ]:33, 36, 40, 65, 70, 76, 79, 81, 83, 84, 85,
sagittal T2 MR, 1:223 187
sulcus, 1:212 Anastomotic vein, 1:352
Abducens nucleus, 1:121, 220, 221, 223, 225, II:48, inferior. See Vein of Labbe
67 middle. See Superficial middle cerebral vein
Accessory atlanto-axialligament, III:57 superior. See Vein of Trolard
Accessory meningeal artery, 1:283 Angular artery, 1:306, 307, 308, 311
Accessory nerve (CNll), I:105, 175, 177,239,240, Angular branch of facial vein, 1:379, 380
245, 247, 2S0-S3,255,II:37, 181, 182,203,204 Angular gyrus, 1:30, 34, 35
ascending, II:37 Angu]ar vein, 1:379, 380
axial bone CT and T2 MR, 1:253 Annular epiphysis, III:11, 12
bulbar, 1:249, 251, 252, 253 Annulus fibrosus, III:27, 39, 40, 42, 43, 48, 103, 106
graphics, 1:251, 252 Annulus of Zinn, 1:191,194,199,205
motor branch, 1:252 Annulus tendineus, 1:191,194,199,205
in pars nervosa, 1:255 Ansa servicalis, 1:256
spinal, 1:130,177,180,251,252,253, III:71 Anterior arch, II:43, 131, III:11, 14,37,48,57,63,
Accessory parotid gland, II:136, 166, 177, 179 64,66,71,72,76,81,85,86,87,90
Acoustic meatus Anterior at]antodental joint, III:66, 68, 70, 71, 72
external, II:4 Anterior atlanto-occipital membrane, III:56, 57,71,
internal, 1:7, II:3, 36 72
Adamkiewicz, artery of, III:153, 157, 158, 159 Anterior brainstem, maturational changes, 1:47, 48,
Adenohypophysis, 1:86, 97 51,52
Adenoidal tissue, 1:93, 97 Anterior caudate vein, 1:337, 340, 350, 360, 361,
Adenoids, II:32, 139, 154, 156, 159 362,363,371
Aditus ad antrum, II:50 Anterior cerebral artery, 1:66, 91, 92, 93, 94,157,
Adventitia, 1:274 164,183,196,278,290,294,296,298-303,
Aerated pterygoid plate, II:123 305,310,336
Agger nasi air cells, II:109, 111, 114, 117 AP DSA,1:301
Alar fascia, II:129, 187, 188, 193,257 branches, 1:298
Alar ligament, III:57, 71 CTA,1:303
Alisphenoid, II:28 distal (A3) segment, 1:299, 300, 301, 310
Alveolar artery embryology, 1:298
inferior, 1:267, 272, II:293 graphics, 1:279, 280, 281, 299
superior, 1:267, 268, 272, 273
•
I
 INDEX
horizontal (precommunicating, AI) segment,
1:169,293,294,295,296,299,301,302,303,
309
in interhemispheric fissure, 1:157,165,169
LATDSA,1:300
MRA,l:302
normal variants and anomalies, 1:298
pericallosal branch, 1:319
splenial branch, 1:299
vascular territory, 1:278, 280, 281, 298
vertical (postcommunicating, A2) segment,
I:170,293,294,296,299,300,301,302,303,
311
Anterior cerebral vein, 1:353
Anterior cervical space, II:129, 133, 134, 137, 181,
209,210,211
Anterior chamber of globe, II:101, 102, 103
Anterior choroidal artery, 1:185, 281, 283, 286, 287,
288,289,297,307
Anterior clinoid process, 1:4,90, 92, 94, 179, 193,
196,215,217,290, 291, 295, 344, II:3, 5, 12, 13,
15,18,29,32,97
Anterior commissure, 1:19, 21, 23, 30, 34, 36, 42, 63,
65,68,70,72,74,79,85,95,117,149,152,156,
159,164,165,167,170,193, II:216, 221, 222,
228
Anterior communicating artery, 1:92, 279, 293, 294,
296,299,302,303
Anterior cranial fossa, 1:4, II:5, 106
Anterior deep temporal artery, 1:272
Anterior epidural space, Ill:33
Anterior epitympanic recess, II:78
Anterior ethmoid, II:117
Anterior ethmoid air cells, II:15, 16, 17,20,21, 105,
108,109,110, Ill, 112
Anterior ethmoid artery, II:112
Anterior ethmoid artery canal, II:6, 108
Anterior ethmoid complex, II:106, 115, 116
Anterior ethmoid nerve, 1:211, II:27
Anterior ethmoid ostia, II:115
Anterior ethmoid sinus, 1:188, II:8, 10,23
Anterior ethmoidal foramen, II:12, 13, 16
Anterior inferior cerebellar artery, 1:107, 111, 112,
122, 124, 130, 131, 144, 145, 167, 180, 181, 184,
202,207,222,235,236,243,249,279,281,324,
329,330
Anterior intercavernous sinus, 1:90, 335
Anterior interosseous artery, Ill:208, 214
Anterior interosseous nerve, Ill:196, 201, 205, 208,
211,214
Anterior longitudinal ligament, Ill:27, 32, 37, 38,
39,40,41,43,48,57,72,101,102,106,112,
113
Anterior mallear ligament, II:78
Anterior median sulcus, II1:84
II
Anterior median vein, III:163
Anterior mediastinal node, II:237
Anterior medulla, 1:128
Anterior medullary segment of posterior inferior
cerebellar artery, 1:324, 329, 330
Anterior medullary velum, 1:149, 152
Anterior medullary venous plexus, 1:373
Anterior neuropore, II:14, 20
Anterior parietal artery, 1:306
Anterior parotid space, II:127, 142, 161
Anterior perforated substance, 1:187
Anterior periorbita, II:90
Anterior pons, 1:120,184
Anterior pontine membrane, I:124
Anterior pontomesencephalic vein, 1:372, 373, 374
Anterior ponto mesencephalic venous plexus, 1:339,
368,377
Anterior radiculomedullary artery, III:153
Anterior ramus. See Ventral ramus(i)
Anterior recess, II:ll0
Anterior ring, 1:325, II:217
Anterior scalene muscle, II:134, 135, 137, 138, 191,
195,198,199,200,201,202,206,207, Ill:51,
52,174,176,179
Anterior segmental artery, Ill:153
Anterior skull base, II:12-25, 27
axial bone CT, II:15-17, 20
coronal bone CT, II:18, 19,21
coronal T2 MR, II:22, 23
development, II:12, 20-25
graphics, II:13, 14
sagittal Tl MR, II:24
sagittal T2 MR, II:25
Anterior spinal artery, 1:324, III:142, 153, 154, 157,
158, 159, 161
Anterior stapes crura, II:77, 79,80
Anterior taste fibers, II:73
Anterior temporal artery, 1:305, 306, 307, 308, 309,
313,314,315,320
Anterior thalamoperforating artery, 1:297, 314, 328
Anterior third ventricle, 1:165
Anterior tonsil, II:261
Anterior tonsillar pillar, II:150,263,269,283
Anterior tubercle, Ill:28, 34, 43, 44, 58,75,82,83,
89
Anterior vertebral line, III:78
Aorta, Ill:98, 99,103,113,116,160,161
ascending, III:153
thoracic, 1:263, Ill:154
Aortic arch, 1:262-65, II:212, 234, Ill:169
3D-VRTCECT,1:265
graphics, 1:263
LAO DSA,1:264
Aortic bifurcation, Ill:113, 116
Apical ligament, III:57, 72
 INDEX
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Q..
Apophyseal joint. See Facet joint Auditory canal. See External auditory canal; t"D

Arachnoid, 1:8, 9, 10, 16, 17, 18,87,88, 162,344, Internal auditory canal ><
353, III:140, 141, 142, 144 Auditory meatus. See Acoustic meatus
Arachnoid granulation, 1:10,11,345,346,347 Auricular artery, posterior, 1:266, 267, 268, 272
Arachnoid mater, III:142 Auricular branch of facial nerve, posterior, 1:225,
Arcuate eminence, 1:228, 229, II:47, 54, 55, 61 II:172
Arcuate fasciculus, 1:42, 43, 44, 46 Auricular vein, posterior, 1:380, 383
Arcuate fibers, short, 1:43 Auriculotemporal nerve, 1:211
Arnold nerve, II:69 Axillary apex, II:207
Arteria thyroidea ima, 1:264 Axillary nerve, III:173
Artery(ies) Axis. See C2
extracranial,I:262-75 Axon, peripheral nerve, III:197
intracranial, 1:278-331
spinal, III:152-61
Artery of Adamkiewicz, III:153, 157, 158, 159 B
Artery of cervical enlargement, III:159 Basal ganglia, 1:28, 64-75
Artery of foramen rotundum, 1:267, 283, 284 axial CECT, 1:67
Artery of Percheron, I:73 axial T1 MR, 1:68, 69
Articular disc, II:82, 83, 86, 87 axial T2 MR, 1:72, 73
Articular eminence, II:83, 84, 85, 86, 87 coronal STIR MR, 1:74, 75
Articular facet. See Inferior articular facet; coronal T1 MR, 1:70, 71
Superior articular facet graphics, 1:65, 66
Articular process. See Inferior articular process; inferior, 1:21, 23
Superior articular process PVSs,1:17, 21
Aryepiglottic fold, II:150, 15I, 153,215,218,219, Basal lamella of middle turbinate, II:111, 117
220,221,223,224,225,227,228 Basal vein (of Rosenthal), 1:99,100,101, 165, 195,
Arytenoid cartilage, II:153, 216, 217, 218, 221, 223, 207,318,321,335,336,339,340,343,345,346,
224,225,228 349,353,355,356,357,359,360,361,363,364,
Arytenoid prominence, II:229 365,366,367,368,369,371,373, III:166
Arytenoid superior process, II:215 Base of brain, 1:28
Ascending accessory nerve, I1:37 Basilar artery, 1:88, 89, 90, 95,105,107,108,109,
Ascending aorta, III:153 110,112,116,122,123,124,125,127,131,134,
Ascending cervical artery, 1:264, 265, III:153 164,180,181,195,200,202,207,210,213,278,
Ascending pharyngeal artery, 1:266, 267, 268, 269, 279,293,294,295,297,303,319,324,327,331,
271, II:49 II:123, III:158. See also Vertebrobasilar system
Association fibers, 1:42 bifurcation, 1:293, 295, 296, 309, 327, 330
Atlanto-axial joint, III:37, 49, 56, 64, 65, 68, 69,70, branches, 1:322
73,81,84,85,86,90 distal, 1:331
anterior, III:90 perforating branches, 1:281, 324, 328
lateral, III:57 in prepontine cistern, 1:151, 161, 164, 166, 167,
median, III:57 170
Atlanto-axialligament, accessory, III:57 proximal, 1:331
Atlantodental interval, III:63 trunk, III:155
Atlantodental joint, anterior, III:66, 68, 70, 71, 72 vascular territory, 1:322
Atlanto-occipital joint, 1:325, II:42, 45, III:45, 49, Basilar membrane, II:63
56,57,64,66,68,69,70,71,73,84,85,86 Basilar tip, 1:127
Atlanto-occipital joint angle, III:60, 65 Basilar venous plexus, 1:90, 222
Atlanto-occipital membrane Basilic vein, III:206, 212
anterior, III:56, 57,71,72 Basiocciput, II:8, 9, 24, 25, 28, 30, 33, 34, 35, 40, 41,
posterior, III:56, 57 43,44,45,53, III:17
Atlas. See C 1 Basion, III:57, 64, 65, 69, 70, 71, 72, 73,85,86
Atrial vein, 1:360 Basisphenoid, 1:92, II:6, 9, 30, 33, 107, 127, 142,
lateral, 1:361, 362, 363, 365, 368, 369, 371 159, III:17
medial, 1:361, 362, 365, 366, 371
Atrium, 1:149
•
I
iii
 INDEX
Basivertebral vein, III:25, 27, 32, 33, 38, 43, 45, 48, pineal region, 1:98-101
83,84,95,99,100,101,102,110,111,112,114, pons, 1:120-27
115,160,163,168,169 scalp and calvarial vault, 1:2-7
Basivertebral venous plexus, III:24 sella, pituitary and cavernous sinus, 1:86-97
Biceps tendon, III:203, 207, 213 subarachnoid spaces/cisterns, 1:160-71
Bill bar, 1:141, 237, II:48 supratentorial, 1:28-10 1
Biventral cerebellar lobule, 1:133 veins and venous sinuses, 1:334-87
Bony Eustachian tube, II:31 ventricles and choroid plexus, 1:148-59
Bony orbit and foramina, II:94-97 white matter tracts, 1:42-64
axial bone CT, II:96 Brainstem, 1:104-13. See also Medulla; Midbrain;
coronal bone CT, II:97 Pons
graphics, II:95 axial T1 MR, 1:109, 110
Bony vestibular aqueduct, II:50, 51, 54 axial T2 MR, 1:106-8
Bowman olfactory glands, I:186 coronal T2 MR, 1:111,112
Brachial artery, III:202, 206, 212 graphics, I:105
Brachial artery and venae comitantes, III:213 maturational changes, 1:47, 48, 51, 52
Brachial plexus, 1:247, III:4, 172-79,205 sagittal T2 MR, 1:113
axial STIRMR, III:178, 179 Bregma, 1:2, 3, 5, 6, 7
branches, III:173 Buccal branch of facial nerve, 1:225, II:172
cords, III:173, 177 Buccal mucosa, II:269
coronal STIRMR, III:174 Buccal space, II:128, 131, 136, 138, 143, 145, 146,
coronal T1 MR, III:175 154, 156, 161, 163, 165, 166, 167, 168
divisions, III:177 Buccinator muscle, II:131, 136, 138, 143, 146, 151,
graphics, III:173 155,157,166,168,175,178,179,261,265,269,
oblique sagittal STIRMR, III:176, 177 284,285,286,289,290,291
in posterior cervical space, II:207 Buccinator node, II:253
roots, II:134, 135, 137, 138, 195, 198,200,201, Bulbar accessory nerve, 1:249, 251, 252, 253
202,203,206,207, III:173, 198 Bulbopontine sulcus, 1:223
trunks, II:201, 202, III:173, 174, 175, 176
Brachial vein, III:202, 206, 212
Brachialis muscle, III:202, 203, 207, 213 c
Brachiocephalic artery, II:234 C1, III:4, 6, 77
Brachiocephalic trunk, 1:262, 263, 264, 265 anterior arch, II:43, 131, III:11, 14,37,48,57,
Brachiocephalic vein, 1:379, 380 63,64,66,71,72,76,81,85,86,87,90
Brachioradialis muscle, III:202 anterior ring, 1:325
Brachium conjunctivum. See Superior cerebellar exiting nerve, III:77
peduncle graphics, III:58
Brachium pontis. See Middle cerebellar peduncle inferior articular facet, III:58, 67, 73
Brain lateral mass, 1:258, 259, 386, II:42, 43, 45, 257,
basal ganglia and thalamus, I:64-75 III:14, 16,37,45,64,65,66,77,79,84,87,
brain stem and cerebellum overview, 1:104-13 90,166,167,168
cerebellopontine angle and internal auditory ossification, III:11, 14, 15
canal, I:140-47 petrous apex, III:66
cerebellum, 1:132-39 posterior arch, 1II:6, 11, 29, 63, 64, 67, 72, 73,
cerebral hemispheres overview, 1:28-41 78,79,84,85,86,87,168
cranial meninges, 1:8-15 posterior ring, 1:325
cranial nerves, I:174-259 superior articular facet, III:58, 66, 73
CSFspaces, 1:148-71 transverse foramen, 1:323, 325, III:11
extracranial arteries, 1:262-275 transverse process, 1:325, III:64, 65, 81
infratentorial,1:104-45 vertebral body, II:257
intracranial arteries, 1:278-331 Cl-2. See also Craniocervical junction
limbic system, 1:76-85 articulation, III:68
medulla, I:128-31 disc remnant, III:15, 16
midbrain, 1:114-19
pia and perivascular spaces, 1:16-25

I V
 INDEX
C2, III:4, 6,9, 77 intervertebral disc, III:76, 82
body, 1I:45, III:37, 52, 57, 63, 64, 65, 67,73,77, neural foramen, III:81, 84
79,81,85,86,87,90,166,168 C5
exiting nerve, III: 77 body, III:82, 83
graphics, III:59 exiting nerve, III:77
inferior articular facet, III:79, 81, 85, 87 facet, III:3 7, 87
inferior articular process, III:37, 45, 49, 67 inferior articular process, III: 3 7
lamina, 1:325, III:67 ossification, III: 17
lateral mass, 1:325 pedicle, III:82, 83
odontoid process. See Odontoid process transverse process, III:80, 81
ossification, III: 11, IS, 16 uncinate process, III:82
pars interarcularis, III:37, 49, 85, 87 vertebral body, 1:326, 1I:201, 202
pedicle, III:37, 67, 80 C5-6
posterior arch, III:37 facet joint, III:37, 49, 87
pseudosubluxation, III:63 intervertebral disc, III:83
spinous process, 1:325, III: 7, 15,29,37,64,67, neural foramen, III:80, 87
72,78,86,87 C6
superior articular facet, III:73, 90 exiting nerve, III:77
transverse foramen, 1:325, III: IS, 37, 67, 87 inferior articular process, III:86
transverse process, III:67 inferior end plate, III:48
vertebral body, III:76, 88 lamina, III:80
C2-3 ossification, III: 17
disc space, III:29, 64, 70 pedicle, III:80
facet joint, III:69, 77 posterior cortical margin, III:79
intervertebral disc, III:48, 65, 67, 72, 165 spinous process, III:80
neural foramen, III:67, 80 superior articular process, III:37
C3 transverse foramen, 1:270, 323
anterior cortical margin, III:79 transverse process, III:81, 84, 87
body, III:63, 64, 70, 73, 79, 80, 81 uncinate process, III: 79, 81, 83
exiting nerve, III:77 vertebral body, 1:326
inferior articular facet, III:77, 89 C6-7
inferior articular process, III:45, 49 facet joint, III:37, 87
inferior endplate, III:91 intervertebral disc, III:37, 86, 87
neural arch, III:l1 C7
ossification, III: 17 exiting nerve, III:77
superior articular facet, III:37, 79,81,85,87 inferior articular process, III:86
superior articular process, III:45, 49, 67 ossification, HI:18
transverse foramen, 1:325 pedicle, III:79, 81, 85
transverse process, 1:325 spinous process, III:3, 6,7,76,79,80,81,168
uncinate process, III:67 superior articular process, III:86
vertebral body, 1:326, III:29, 76 superior endplate, III:48
C3-4 transverse process, III: 79, 178
intervertebral disc, III: 165 uncinate process, III:80
neural foramen, III:80, 84 vertebral body, III:76, 78
C4 C7-Tl
body, III:37, 63,79,80,81,84,86 facet joint, III:85, 86
exiting nerve, III:77 neural foramen, III:86
inferior end plate, III:82 C8
neural foramen, III:37 exiting nerve, III: 77
ossification, III: 17 root exit level, III:4
superior articular facet, III:77, 89 Calcarine artery, 1:279, 313, 314, 315, 317, 318, 319,
transverse process, III:64 320,321,328
vertebral body, 1:326 Calcarine cortex, 1:190,191,329
C4-5 Calcarine segment of posterior cerebral artery,
facet joint, III:3 7, 81, 86, 87 1:312,313,314,315,316,317,318,319
•
I
v
 INDEX
Calcarine sulcus, 1:29, 30, 33, 34, 39 head, 1:31, 32, 34, 36, 40, 65, 66, 67, 68, 69,70,
Callosomarginal artery, 1:298, 299, 300, 301, 302, 71,72,73, 74, 117, 153
303 maturational changes, 1:47-62
Calvarial vault, 1:2-7 tail, 1:65, 66, 68, 69, 77,80
3D-VRTNECT,1:6,7 Caudate vein, 1:362, 366, 368
axial NECT, 1:4, 5 anterior, 1:337, 340, 350, 360, 361, 362, 363, 371
embryology, 1:2 Cavernous abducens nerve, 1:220
graphics, 1:3 Cavernous internal carotid artery, 1:91, 92, 93, 94,
sagittal T1 MR, 1:5 95,176,179,196,210,214,215,216,222,268,
"Cap" of arachnoid cells, 1:10 282,283, 331,II:10, 15,30,33,49, 112, 123
Capitellum, III:207, 213 anterior genu, 1:269, 283, 285, 286, 287, 288,
Capsule 289,291
external, 1:20, 34, 44, 63, 65, 66, 68,70,71,74 posterior genu, 1:269, 283, 284, 286, 287, 288,
extreme, 1:20, 22, 34, 63, 65, 66, 68,70,71,74 289
internal. See Internal capsule Cavernous oculomotor nerve, 1:198, 199
temporomandibular joint, II:83 Cavernous sinus, 1:13, 86-97, 157, 176, 179, 199,
thyroid gland, II:232 200,210,214,215,216,335,336,338,339,342,
Caroticotympanic artery, II:49 343,344,345,346,347,348,351,355,356,370,
Carotid artery, III:51,52, 164, 165, 168, 169. See also 377,379,380, II:33, 38
Cervical carotid arteries; Common carotid axial T1 C+ MR, 1:89, 90
artery; External carotid artery; Internal carotid coronal T1 C+ MR, 1:93, 94
artery coronal T2 MR, 1:91, 92
Carotid bifurcation, II:183 graphics, 1:87, 88
Carotid body, 1:241 lateral wall, 1:15, 344
Carotid bulb, 1:267, 274, II:49 oculomotor nerve in, 1:203
Carotid canal, 1:240, 284, 286, II:4, 9, 26, 142 sagittal fat-saturated T1 MR, 1:97
entrance, II:40 sagittal T2 MR, 1:95, 96
horizontal segment, 1:178,179, II:120 trochlear nerve in, 1:205
petrous, 1:286, 288 Cavernous trochlear nerve, 1:204
vertical segment, I:178, II:4 Cavum septi pellucidi, 1:40, 153
Carotid sheath, 1:240, 247, 274, II:129, 141, 181, Cavum veli interpositi, 1:149, 155,359
187,203 Celiac trunk, III:161
Carotid space, II:4, 127, 128, 129, 130, 131, 133, Central echo complex, III:138, 139
134, 135, 136, 137, 138, 141, 142, 143, 144, 145, Central gray matter, III:136
146,147, 149, 150, 154, 156, 158, 162, 163, 171, Central lobule, 1:133, 136, 139
173,175,176,177,178,179,180-85,187,188, Central retinal artery, 1:192, II:99
189,190,191,192,193,195,196,198,199,203, Central retinal vein, 1:192, II:99
204,205,206,207,209,210,211,234,257 Central skull base, II:13, 26-35
axial CECT,II:184, 185 axial bone CT, II:29-31
CECT and MRA of vessels, II:183 axial T1 C+ MR, II:33, 34
graphics, II:181-83 coronal bone CT, II:32
mass, II:182 development, II:26, 28, 35
superior margin, II:43 graphics, II:27, 28
Carotid sulcus, 1:285 sagittal T1 and T2 MR, II:35
Carotid vein, internal, 1:335 Central spinal cord canal, III:131
Carotid wall, 1:274 Central sulcus, 1:29, 30, 32, 38, 39, 161
Cartilage endplate, III:24, 25. See also Vertebral hand knob, 1:35
endplate maturational changes, 1:47-52
Cartilaginous anlage, III:ll Central sulcus artery, 1:306
Cauda equina, III:9, 23, 39, 48, 95,113,116,117, Centrum, III:11, 12, 13, 15, 16, 17, 18, 19,20,21
130-39, 141, 144, 145 ossification centers, III:16
dorsal, III:138 ossified disc, with red marrow, III:23
nerve roots, III:132, 137 Centrum semiovale, 1:20, 21, 22, 24, 40
ventral, III:138 Cephalad nasal cavity, I:178
Caudate nucleus, 1:35, 64, 360 Cephalic vein, III:207
body, 1:37, 69, 71, 73, 75

VI
 INDEX
Cerebellar artery
anterior inferior, 1:107, 111, 112, 122, 124, 130,
131,144,145,167,180,181,184,202,207,
222,235,236,243,249,279,281,324,329,
330
posterior inferior. See Posterior inferior cerebellar
artery
superior, 1:112,127,166,182,184,185,195,199,
200,202,205,207,210,223,279,281,296,
313,317,324,327,328,329,330
Cerebellar cistern, superior, 1:101, 105, 133, 139,
161,162,165,170,171
Cerebellar flocculus, 1:105, 107, 109, 111, 124, 126,
131,133,134,137,145,150,155,181,184,213,
230,235,236, II:61
Cerebellar folia, 1:164
Cerebellar hemisphere, 1:33, 135, 136, 143, 158,231,
329
inferior, 1:106, 107, 111, 113, 134, 138
maturational changes, 1:47-52
superio~I:108, 110, 111, 113, 135, 138
Cerebellar hemispheric vein, 1:374
Cerebellar lobes and lobules, 1:132, 133
Cerebellar nuclei, I:132
Cerebellar peduncle
decussation, I:116
inferior, 1:50,107, 109, 122, 124, 129, 131, 132,
133,134,180,181,243
middle, 1:45,46, 107, 109, 110, Ill, 113, 121,
122, 123, 124, 125, 126, 132, 133, 135, 137,
138,144,181,182,207,213,218,235,236
maturational changes, 1:51-62
superior, 1:33, 107, 110, 116, 118, 119, 121, 123,
125,132, 133, 135, 137, 151, 182, 183
Cerebellar tonsil, 1:106, 107, 109, 111, 113, 126, 133,
134,136,137,138,139,150,151,236,329,
II:44, III:37, 71
Cerebellar vein, precentral, 1:337, 349, 364, 368,
372,373,374
Cerebellar vermis, 1:32, 37, 50, 61,107,108,109,
110,125, 132, 134, 135, 136, 151, 154
components, 1:139
inferior, I:134
midline, 1:136
nodulus, 1:109,110, 137
superior, 1:110
Cerebellar white matter, 1:45, 109, 113, 135, 137,
138
Cerebellomedullary cistern, I:163
Cerebellopontine angle, 1:123, 140-45
axial bone CT, 1:142
axial T2 MR, I:144
coronal T2 MR, 1:145
graphics, 1:141
sagittal T2 MR, I:143
Cerebellopontine angle cistern, I:107, 112, 122, 123,
124, 125, 126, 127, 141, 144, 151, 164, 166, 184,
225,236,237, II:48, 58, 67
Cerebellum, 1:37, 104-13, 132-39, 159,237
anterior (petrosal) surface, 1:138
axial T1 MR, 1:109, 110, 134, 135
axial T2 MR, 1:106-8
coronal T2 MR, 1:111,112,136,137
graphics, 1:105, 133
great horizontal fissure, 1:324, 328
maturational changes, 1:53-62
sagittal T2 MR, 1:113, 138, 139
superior (tentorial) surface, 1:138
Cerebral aqueduct, 1:33, 40,105,108,110,115,117,
149,159,183,201
flow void, 1:113
with periaqueductal gray matter, I:152
Cerebral artery. See Anterior cerebral artery;
Middle cerebral artery; Posterior cerebral artery
Cerebral hemispheres, 1:28-41
axial CECT, 1:31, 32
axial T1 MR, 1:33, 34, 35
axial T2 MR, 1:40
coronal T1 MR, 1:36, 37
coronal T2 MR, 1:41
graphics, 1:29, 30
sagittal T1 MR, 1:38, 39
Cerebral peduncles, 1:44, 45, 46, 75, 105, 108, 110,
111,112,114,115,116,117,119,126,127,159,
183,184,193,201,202,206
decussation, 1:115
PVSs,I:25
Cerebral vein, 1:352-71
anterior, 1:353
deep, 1:358-61
internal. See Internal cerebral vein
middle. See Middle cerebral vein
superficial, 1:352-57
Cerebral ventricles. See Fourth ventricle;
Lateral ventricle; Third ventricle; Ventricles
Cerebrospinal fluid
in arachnoid granulation, I:10
cervical, III:37, 48, 85, 86, 87, 90, 91
epidural, III:145
flow artifact, III:91
lumbar, III:39, 48, 112
in partially fused hippocampal sulcus, 1:19
perioptic, II:99, 100, 101, 103
in quadrigeminal cistern, 1:23
thoracic, III:38
Cerebrospinal fluid spaces, 1:148-71
subarachnoid, 1:160-71
ventricles and choroid plexus, I:148-59
Cervical artery, ascending, 1:264, 265, III:153
Cervical branch of facial nerve, 1:225, II:172
•
I
VII
 INDEX
Cervical carotid arteries, 1:266-75 Cervical vein, Ill: 169
3D-VRTCECT,1:270 Cervical vertebral artery, 1:331, IIl:89, 91
AD DSA, 1:273 Cervical vertebral body, IIl:4, 5, 6, 26, 43, 44, 45,
graphics, 1:267 51,52,75,76,89,168
lateral DSA,1:268, 272 30- VRTNECT,IIl:34
MRA,I:271 anterior cortical margin, IIl:29
oblique DSA,1:269 axial T2 MR, IIl:40
ultrasound, 1:274, 275 cortical bony margin, IIl:43
Cervical dural margin, IIl:37, 85, 87 graphics, IIl:28
Cervical enlargement, artery of, IIl:159 posterior cortical margin, IIl:29
Cervical epidural venous plexus, 1:383 radiography, IIl:29
Cervical esophagus, 11:151,216, 232 sagittal T2 MR, IIl:37
Cervical facet joint, IIl:28, 34, 43, 44, 45, 48, 49, Cervical vertebral endplate, IIl:43, 45, 88, 89, 91
64,75,76,82,89,91,168,169 Cervicomedullary junction, Ill: 71, 131, 135
Cervical fascia. See Deep cervical fascia Cervicothoracic junction, 11:135
Cervical groove, Ill: 75, 77 Chamberlain line, IIl:60, 61
Cervical internal carotid artery, 1:266, 268, 331, Chiasmatic recess of third ventricle, 1:149,159,168
11:49 Chondrocranium, 11:14,24, 25
Cervical intervertebral disc, 111:34,43, 44, 45, 48, Chorda tympani nerve, 1:211, 224, 225, 11:53,67,
49,75,76,81,85,88,89,91 72,73,162, 172
Cervical intervertebral disc space, IIl:78 axial bone CT, 11:72
Cervical lamina, IIl:28, 34, 43, 44, 45, 51,75,82, canal, 11:69
83,86,88,89,90,91 coronal bone CT, 11:73
Cervical lordosis, IIl:3 origin, 11:73
Cervical lymph nodes, 11:252-57 parasympathetic fibers, 11:73
axial CECT, 11:255 Choroid, 1:192,197,300,11:103, IIl:167
axial T1 and T2 MR, 11:256 Choroid blush, 1:288
graphics, 11:253 Choroid fissure, 1:41, 77, 78,81, 148, 160
retropharyngeal, 11:257 Choroid fissure cyst, 1:22
ultrasound, 11:254 Choroid plexus, 1:141,148-59,319,336,337,359,
Cervical nerve, IIl:195 363,364,365,368,376
Cervical paraspinal muscles, IIl:51, 52 axial T2 MR, 1:150-53
Cervical "pillars," 111:34,75,77,80,91,168 blush, 1:286, 314, 374
Cervical space coronal T2 MR, 1:154-57
anterior, 11:129,133, 134, 137, 181,209,210,211 in foramen of Luschka, 1:150
posterior. See Posterior cervical space in foramen of Monro, 1:149, 170
Cervical spinal canal, IIl:28, 67, 75, 83 in fourth ventricle, 1:131,137,149,159,338
Cervical spinal cord, 1:105, 106, 163,11:207, IIl:9, glomus, 1:153, 320, 321
37,71,76,82,84,85,86,87,88,90,91,164 graphics, I:149
Cervical spine, III:74-91. See also C1 through C8 in lateral ventricle, 1:152,153,154,155,156,159,
3D-VRTNECT, Ill: 77, 80, 81 314
arterial supply, IIl:153, 155, 156, 158, 159 sagittal T2 MR, 1:158-59
axial bone CT, I1I:82, 83 in temporal horn, 1:154, 155
axial GRE MR, I1I:88, 89 in third ventricle, 1:99,149,156, 159, 170,314
axial T2 MR, IIl:90, 91 Choroidal artery, I:153
coronal CT myelogram, IIl:84 anterior, 1:185, 281, 283, 286, 287, 288, 289, 297,
graphics, I1I:75-78 307
nerve roots, 111:76,77,84,88 lateral posterior, 1:313, 314, 318, 319, 320, 321,
ossification, III:14-18 324,328,368
posterior, 11:195 medial posterior, 1:99, 162,313,314,319,321,
radiography, IIl:78-80 324,328,359
sagittal CT myelogram, IIl:85 Choroidal branches of posterior cerebral artery,
sagittal T1 MR, I1I:86 1:312
sagittal T2 MR, IIl:87 Choroidal vein, 1:153, 339, 360, 362, 363, 364, 368,
sub-axial, Ill: 74 374
veins and venous plexus, Ill: 164-69 Ciliary body, II:103

VIII
 INDEX
Ciliary ganglion, 1:199, 211 basal (first) turn, 1:145, 227, 228, 229, 231, 234,
Ciliary nerve, long, 1:211 237,11:51,52,53,55,56,57,58,60,61,63,
Cingulate gyrus, 1:29, 30, 35, 36, 37, 39, 40, 77, 79, 64,65,68,72
80,82,85,299 distal (first) turn, II:74
Cingulate sulcus, 1:30, 299 graphics, 11:63
Cingulum, 1:42,43, 44, 45, 46,77 middle turn, 1:145
Circle of Willis, 1:292-99 second turn, 11:56,57, 60, 63, 64, 65
3D-VRTCTA,1:295 structure, 11:62
CTA,I:296 Cochlear aperture, 1:141,142,234,237,11:51,52,
DSA,I:296 56,63,64,65
embryology, 1:292 Cochlear aqueduct, 1:143, 227, 258, 11:42,52, 53, 60,
graphics, 1:293 72
MRA,1:293, 294 Cochlear duct, 11:62,63
Circumvallate papilla, 11:261,269, 283 Cochlear modiolus, 1:141, 142, 144,237,11:52,60,
Cisterna magna, 1:105, 111, 113, 126, 139, 150, 159, 64,65
161,163,170,171 Cochlear nerve, 1:124, 141, 143, 144, 145, 181,230,
Cisternal segment 231,232-37,11:48,58,63,65
abducens nerve, 1:220 Cochlear nucleus, 1:129,141,237
accessory nerve, 1:250 Cochlear promontory, 11:55,64, 71
facial nerve, 1:164, 224, 11:74 Cochlear recess of vestibule, 11:63
glossopharyngeal nerve, 1:238 Cochleariform process, 1:229, 11:52,56, 57, 69,71,
hypoglossal nerve, 1:254 78,81
oculomotor nerve, 1:87, 198 Collateral sulcus, 1:29, 36, 41,77,78,79,81,83
optic nerve, 11:99 Collateral white matter, 1:77, 78, 81, 83
trigeminal nerve, 1:87,145,175,182,184,195, Colliculus
208,209,211,213,214,215,218,222,11:27, facial, 1:107,110,121,122,124,151,220,221,
61 225
trochlear nerve, 1:87,204, 205 inferior, 1:33,99, 100, 101, 108, 113, 115, 116,
vagus nerve, 1:244 183,206,207
Claustrum, 1:34, 65, 66, 68, 70, 71, 74 superior, 1:31,99, 100, 101, 108, 110, 113, 115,
Clavicle, 11:203,205, 207, 212, III:79, 177 117,119,191,193,201
Clinoid process Commissural fibers, 1:42, 43
anterior, 1:4,90, 92, 94,179,193,196,215,217, Commissure. See also Corpus callosum
290,291,295,344,11:3,5, 12, 13, 15, 18,29, anterior, 1:19, 21, 23, 30, 34, 36, 42, 63, 65, 68,
32,97 70,72,74,79,85,95,117,149,152,156,
posterior, 11:3,5, 29, 37 159,164,165,167,170,193,11:216,221,222,
Clinoid segment of internal carotid artery, 1:282, 228
283 fornix, I:77, 85
Clival occipital bone, 11:8,9, 24, 25, 28, 30, 33, 34, gray, III:131
35,40,41,43,44,45,53 habenular, 1:99,101
Clival venous plexus, 1:88,89, 97, 162,335,338, hippocampal, 1:80, 82
343,345,348,351,355,370,374,376,377,384, posterior, 1:42,99, 101, 152,11:221
386,1I:38 ventral white, III:131
Clivus, 1:4,95, 97,106,178,181,210,212,214,218, Common carotid artery, 1:247, 262, 263, 264, 265,
222,223,242,248,253,285,325,11:8,9, 10,39, 266,267,268,270,271,387,11:133, 134, 137,
41,154,156, III:57, 64,73,166 138,181,183,185,191,192,206,207,210,211,
Coccyx, III:13, 26, 119, 121, 125, 126, 127 231,232,233,234,235,236,111:153,155
body, III:4 at aortic arch, 11:183
ossification, III:22 distal, 1:274
Cochlea, 1:109,112,144,179,184,226,229,235, lateral DSA,1:268
11:6,49,56, 71, 74, 75 left, 1:262, 263, 264, 265
apical half turn, 11:59,63, 64, 65 lumen, 1:274
axial bone CT, 11:64 oblique DSA,1:269
axial T2 MR, 11:65 ultrasound, 1:274, 275
Common facial vein, 1:341, 379, 380, 387
Common iliac artery, III:113, 116 •
I
ix
 INDEX
Common peroneal nerve, III:222-27 Corticopontine tract, 1:42
axial T1 MR, III:224-27 Corticorubral tract, 1:44
graphic, III:223 Corticospinal tract, 1:41, 42,107,108,110,115,
Communicating artery 116,118, 121, 122, 123, 125
anterior, 1:92, 279, 293, 294, 296, 299, 302, 303 Corticothalamic tract, 1:42
posterior, 1:182, 200, 203, 279, 283, 286, 289, 291, Costal element remnants, III:13, 21
293,294,295,296,297,302,308,313,314, Costocervical artery, III:153
317,319,321,327,328,330 Costocervical trunk, 1:263, 264
Communicating segment of internal carotid artery. Costotransverse joint, III:5, 7,27,28,30,35,40,44,
See Supraclinoid internal carotid artery 55,93,97,98,99,103
Concha bullosa, II:114, 116, 117 Costotransverse process, III:5
Condylar canal, II:4 Costovertebral joint, III:5, 6, 8, 28, 30, 35, 38, 40,
Condylar emissary vein, 1:383 44,46,93,94,95,96,97,98,101,102,103
Condylar fossa, II:43, 53, 56, 72, 162 Cranial fossa
Condylar occipital bone, II:40, 41, 42, 53 anterior, 1:4, II:5, 106
Constrictor muscle. See Pharyngeal constrictor middle, 1:4,295, 309, II:5, 6, 16,29, 106, 120
muscle posterior, 1:4, 104, II:5, 6
Conus, III:23, 132, 138, 139, 144 Cranial meninges, 1:8-15
tip, III:137, 138, 145 axial T1 C+ MR, 1:11, 12
Conus elasticus, II:218 coronal T1 C+ MR, I:13
Conus medullaris, III:9, 48, 95, 102, 112, 132, 134, coronal T2 MR, 1:14, 15
135 graphics, 1:9, 10
Cornea, II:103 Cranial nerves, 1:174-259. See also specific nerves,
Corniculate cartilage, II:217 e.g., Olfactory nerve (CNl)
Corona radiata, 1:32, 35, 36, 37, 41, 42, 44, 45, 46, axial bone CT, 1:178,179
63 axial T2 MR, 1:180-83
maturational changes, 1:47-62 in cavernous sinus, II:91
Coronal suture, 1:3, 4, 5, 6, 7 coronal T2 MR, 1:184, 185
Coronoid process, II:83, 84, 85, 139, 143, 165, 168, graphics, 1:175-77
169,293 intravenous, I:174-85
Corpus callosum, 1:42, 82 Craniocervical junction, III:56-73
body, 1:36, 37, 39, 41, 43, 45, 46, 63, 74, 75 3D-VRTNECT,III:68-70
genu, 1:31, 32, 34, 35, 36, 39, 40, 43, 45, 69, 153, axial bone CT, III:66, 67
157 coronal bone CT, III:65
maturational changes, 1:47-62 graphics, III:57-60
posterior body, 1:41 radiography, III:62-64
rostrum, 1:46 sagittal bone CT, III:61, 72
splenium, 1:29, 30, 34, 35, 37, 39, 40, 43, 44, 45, sagittal T1 MR, III:61, 72, 73
69,80,82, 154,359,1:63 Craniopharyngeal canal, II:28
Cortical artery, penetrating, 1:17, 18 Craniotomy
Cortical branches graphics, III:60
anterior cerebral artery, 1:298 lateral radiography, III:62, 63
middle cerebral artery, 1:304 sagittal bone CT and Tl MR, III:61
posterior cerebral artery, 1:312 Cribriform plate, 1:175,178,186,188,234,285,295,
Cortical segment of middle cerebral artery, 1:304, 309, II:3, 7,9,12, 13, 16, 17, 19,21,22,23,24,
305,307,308 25,29,108,109
Cortical vein, 1:10, 18,340,352-57 Cricoarytenoid muscle, posterior, II:216, 222, 228
frontal, 1:12, 350, 354, 355, 357 Cricoid cartilage, II:134, 138, 185,204,211,216,
in subarachnoid space, 1:14, 353 218,221,222,223,224,225,226,228,234,253
superficial, 1:11,12,13,14,18,335,341,354, anterior ring, II:217
355,356,357,369 plane, II:253
in superior sagittal sinus, 1:353 posterior ring, II:217
Cortical venous tributary in sulcus, 1:353 Cricopharyngeus muscle, II:151, 153
Cortical venule, 1:353 Cricothyroid joint, 11:216,222, 228
Corticobulbar tract, 1:42 Cricothyroid membrane, II:216, 217, 222, 228
Corticohypothalamic tract, 1:44 Cricothyroid muscle, 1:246

x
 INDEX
Cricothyroid space, 11:216,222 Deep white matter
Crista falciformis, 1:141,143,145,184,231,234, occipital,l:51
237, II:48, 56, 58, 61 PVSs,1:20, 24
Crista galli, 1:4,15,178,179,187,188,189,11:3,6, Deep white matter vein, 1:360, 361, 371
7,9,10,12,13,14,15,16,17,19,20,21,22,23, Dens. See Odontoid process
24,25,108,109,112 Dental anatomy, 11:292
Cruciate ligament, III:56, 57,71,72 Dentate gyrus, 1:78
Crus cerebri. See Cerebral peduncles Dentate nucleus, 1:24, 47, 48, 107, 113, 136, 138
Crus communis, 11:49,50, 59,74 Denticulate ligament, III:131, 136, 140, 142, 148
Cubital tunnel, III:205 Dermis, 1:3
Cubital tunnel retinaculum, III:207 Descending palatine artery, 1:267, 272, 273
Culmen, 1:133,139 Diaphragma sellae, 1:11, 87, 88,176,210
Cuneus, 1:39 Diencephalic membrane, 1:162,167
Cutaneous branch of median nerve, III:196, 211 Digastric muscle
Cutaneous nerve, lateral femoral, III:181 anterior belly, 1:211, II:137, 138, 162,255,262,
Cutaneous vascular plexus, 1:3 264,266,267,275,278,279,280,281,284,
285,287
posterior belly, 11:129,132,136,141,144,146,
o 171,172,175,176,177,178,179,184,192,
Danger space, 11:129,130, 150, 181, 187, 188, 193, 265,266,274,277,280,286,287
195,196,209,257 Digastric notch, II:177
Declive, 1:133, 139 Digital branch of median nerve, III:196, 211
Deep branch of radial nerve, III:196, 201, 203, 211, Diploic space, 1:3, 5,7,10
213 Diploic vein, 1:378
Deep cerebral vein, 1:358-61 Direct lateral vein, 1:360, 361, 366, 367, 371
AP CTV,1:367 Distal anterior cerebral artery, 1:299, 300, 301, 310
axial CTV,1:366 Distal basilar artery, 1:331
axial T1 C+ MR, 1:362 Distal bifurcation of internal carotid artery, 1:291,
coronal T1 C+ MR, 1:363 295,296
coronal T2 MR, 1:364, 365 Distal common carotid artery, 1:274
CTV,1:369 Distal external carotid artery, 1:272
embryologic events, 1:358 Distal intercostal artery, III:157
graphics, 1:359, 360 Dorello canal, 1:87, 220, 221
LATand AP ICA DSA, 1:361 Dorsal brainstem, maturational changes, 1:47, 48,
MRV,1:370, 371 51,52
sagittal CTV,1:368 Dorsal branch of segmental artery, III:154
Deep cervical fascia, 11:193 Dorsal cauda equina, III:138
deep layer, 11:129,130,181,187,188,193,195, Dorsal cochlear nucleus, I:129, 141, 237
196,197,198,203,209,257 Dorsal coronal venous plexus of spinal cord, III:163
middle layer, 11:127,128,129,130,141,142,148, Dorsal dural margin
149,150,159,181,187,188,196,209,232, cervical, III:37, 85, 87
257 lumbar, III:112
superficial layer, 11:127,128, 129, 130, 141, 142, Dorsal gray column, 1:251
159, 161, 162, 171, 172, 181, 182, 187, 188, Dorsal horn, III:136
196,203,209 Dorsal intermediate sulcus, III:131
Deep cutaneous vascular plexus, 1:3 Dorsal median sulcus, 1:106,129,130,180, III:131
Deep facial vein, 1:378, 386 Dorsal muscular branch of spinal artery, III:158,
Deep middle cerebral vein, 1:339, 353, 355, 356, 363, 160
371 Dorsal pons, 1:55
Deep parotid gland, 11:172,173,175,176, 177, 179 Dorsal radiculomedullary artery, III:154
Deep parotid space, 11:262 Dorsal ramus, III:153, 195
Deep peroneal nerve, III:223 Dorsal root, III:88, 131, 133, 136, 137, 143, 148, 195
Deep submandibular gland, II:261, 266, 271, 273, Dorsal root ganglion, III:149, 195
274,277,279,280 Dorsal scapular nerve, 11:203
Deep temporal artery, 1:272 Dorsal tegmentum, 1:120, 128
Dorsal vagal nucleus, 1:129,177,245,246 •
I
XI
 INDEX
Dorsolateral sulcus, III:131 nonossified, III:23
Dorsum sella, 1:90,179,285,295,327,11:5,6,9,10, superior annular, III:12
13,15,25,29,33,35,37,39 Epithalamus, 1:98
Dura, 1:8,11,12,13,15,17,18,162,11:14, III:132, Epitympanic cavity, 1:234
137, 140, 141, 143, 144, 145, 148, 149 Epitympanic cog, 11:51,68, 78
inner (meningeal) layer, 1:10, 11,353 Epitympanic recess, anterior, 11:78
outer (periosteal) layer, 1:10, 353 Epitympanic space, lateral. See Prussak space
Dura mater, 1:13, III:142 Epitympanum, 1:142, 11:47,50, 56, 57,76,77,78,80
Dural enhancement, 1:13 Erector spinae muscle, III:50, 54, 102
Dural margin Esophageal-hypopharygeal junction, 11:191,222
cervical, III:37, 85, 87 Esophagus, 11:130,134, 137, 188, 190,200,209,211,
lumbar, III:112 213,232,233, III:78
Dural nerve root sleeve, III:141, 142, 143 cervical, 11:151,216, 232
Dural sheath, optic nerve, 1:192 mass, 11:213
Dural sinuses, 1:342-51 Ethmoid(s)
AP,LATand OBL MRV,1:351 anterior, II:117
AP ICA DSA, 1:346 posterior, II:105, 117
axial T1 C+ MR, 1:348-50 Ethmoid air cells, 11:6,122
graphics, 1:343, 344 anterior, 11:15,16, 17,20,21, 105, 108, 109, 110,
LATICA DSA, 1:345 111,112
normal variants and anomalies, 1:342 infraorbital, 11:114,116
OBL ICA DSA, 1:347 posterior, 11:15,16, 17,20,29,30,33, 110, 111,
112
Ethmoid artery, anterior, 11:112
E Ethmoid artery canal, anterior, 11:6,108
Ear Ethmoid bone, 1:4, 11:3,14,17,19,20,21,22,23,
inner, 11:46,62 94-97
middle. See Middle ear Ethmoid bulla, 11:105,108, 109, 110, 111, 112, 114,
Edinger-Westphal parasympathetic nuclei, 1:198 115, 116, 117
Emissary vein, 1:361, 375, 376, 378, 383, 384 Ethmoid complex
condylar, 1:383 anterior, 11:106,115,116
mastoid, 11:44 posterior, II:106
occipital, 1:345, 346, 347 Ethmoid nerve, 1:211, 11:27
Endolarynx, 11:214 Ethmoid ostia, anterior, 11:115
Endolymphatic duct, 11:49,63 Ethmoid sinus, 1:194, 212, 11:7,22, 96, 104
Endolymphatic sac, 11:49,63 anterior, 1:188, 11:8,10,23
Endoneurium, III:197 posterior, 11:8,9, 10
Ependymal vein, 1:361 Ethmoidal foramen, 11:12,13, 16
Epicranial aponeurosis, 1:3 Eustachian tube, 11:31,143,149,151,154,156,159
Epicranial tissue, scalp, 1:2, 3 Exocciput, II:28
Epidural fat, III:90, 101, 102, 112, 114, 115, 116, External acoustic meatus, 11:4
137, 142, 145 External auditory canal, 1:227, 11:52,54, 55, 72, 75,
Epidural plexus, ventral, III:149 84,85,162,171,174,177
Epidural space. See Extradural compartment bony, 11:47
Epidural tumor, 11:197, 198 cartilaginous, 11:47
Epidural vein, III:52 External capsule, 1:20, 34, 44, 63, 65, 66, 68, 70, 71,
Epidural venous plexus, 1:383, 385 74
Epiglottic area taste fibers, 1:246 External carotid artery, 1:263, 265, 268, 270, 271,
Epiglottis, 11:139,151,185,213,215,218,219,220, 274,387,11:49,131,132,136,171,172,175,
224,225,227,231,285,287 176,183,184,231,255, III:153
fixed portion, 11:226,229 branches, 1:266
free margin, 11:132,153,192,217,218,220,226, distal, 1:272
227,229 muscular branch, 1:326
Epineurium, III:197 proximal branch, 1:274
Epiphysis
inferior annular, 111:11,12

XII
 INDEX
::s
External jugular vein, 1:351, 371, 378, 379, 380, 382, graphics, III:43 Q.
lumbar, II1:7, 28, 31, 32, 33, 36, 41, 43, 44, 47, I'D
383,385,386,387,11:133, 134, 137, 138, 185, ><
203,205 48,49,105,106,107,108,109, Ill, 112,
External medullary lamina, 1:65, 66,74 113,117
External oblique muscle, II1:54 sagittal T2 MR, II1:48, 49
External occipital protuberance, 1:7 thoracic, II1:28, 38,44, 46, 48, 49, 93, 95, 96,
External vertebral vein 97,98,99,100,101,102,103,110,134
anterior, III:164 Facet "pillar," II1:83
posterior, II1:88, 89,164,165,167,169 Facial artery, 1:263,266,267,268,269,271,272,
External vertebral venous plexus 11:279,281
anterio~III:165,166,168, 169 Facial colliculus, 1:107,110,121,122,124,151,220,
posterior, II1:165, 167, 168 221,225
Extraconal fat, 11:112 Facial nerve (CN7), 1:105,109,111,122,124,131,
Extracranial artery, 1:262-75 141,143,144,145,175,177,181,221,224-31,
Extracranial branches 235,237,11:37,48,58,59,60,61,65,171
glossopharyngeal nerve, 1:238 axial bone CT, 1:226, 227
vagus nerve, 1:244 axial T2 and Tl MR, 1:230
Extracranial segment branches, 1:224
abducens nerve, 1:220 buccal branch, 1:225, II:172
accessory nerve, 1:250 cervical branch, 1:225, II:172
facial nerve, 1:224 cisternal segment, 1:164, 224, 11:74
glossopharyngeal nerve, 1:238 coronal bone CT, 1:228, 229
hypoglossal nerve, 1:254 graphics, 1:225
trochlear nerve, 1:204 internal auditory canal segment, 1:15I, 155,
vagus nerve, 1:244 11:67,74
Extracranial veins, 1:378-87 intraparotid, 11:171,172,177,178
axial CECT, 1:387 intratemporal, 11:66-75. See also
axial T1 C+ MR, 1:383, 384 Intratemporal facial nerve
coronal CECT, 1:382 labyrinthine segment, 1:141,142,179,225,226,
coronal T1 C+ MR, 1:385, 386 229,234,237,11:48,50,51,56,57,59,67,
graphics, 1:379, 380, 387 68, 71, 74, 75, 78
sagittal CECT, 1:381 mandibular branch, 1:225, II:172
Extradural compartment, III:140, 149 mastoid segment, 1:179, 227, 228, 234, 258, 11:7,
anterior, II1:33 42,52,53,54,68,69,70,72,73,75,79,174
contrast in, II1:143, 146 motor branch, 11:67,73
fluid in, II1:145 motor nucleus, 1:121, 224, 225, 11:48,67, 73
Extradural fat, II1:141, 148, 149 nuclei, 1:52, 221
Extradural space, 1:8 oblique sagittal T2 MR, 1:231
Extramedullary compartment, intradural, III:140 origin, 1:122,124,131
Extraocular muscles, 11:90 posterior auricular branch, 1:225, II:172
Extraosseous segment of vertebral artery, 1:270, 322, posterior genu, 11:48,51, 54, 67, 68,70,73,78,
323 174
Extraspinal segment of vertebral artery, 1:322, 323, root entry zone, 11:48
324,325,326,328 root exit zone, 11:67
Extreme capsule, 1:20, 22, 34, 63, 65, 66, 68, 70, 71, solitary tract nucleus, I:121, 129, 177,224,225,
74 239,241,245,246,11:48,67, 73
Eye, 11:102-3. See also Globe in stylomastoid foramen, II:177
superior salivatory nucleus, 1:224, 225, 11:48,67,
73
F temporal branch, 1:225, II:172
Facet joint, II1:42-49, 83 tympanic segment, 1:225, 226, 228, 229, 234,
3D-VRTNECT, II1:44 11:47,48,51,55,56,57,59,67,68,71,74,
axial and sagittal NECT, II1:45-47 75,80,81,174
cervical, 111:28,34,43,44,45,48,49,64, 75, 76, zygomatic branch, 1:225, II:172
82,89,91,168,169 Facial nerve canal, 1:179, 184,258
complex, II1:85 •
I
XIII
 INDEX
Facial nerve recess, 1:226, 227, 236, II:51, 52, 68, 69,
73, 79
Facial vein, 1:351, 378, II:132, 136, 137, 138, 139,
263,264,266,267,278,279,280,281
angular branch, 1:379, 380
common, 1:341, 379, 380, 387
deep, 1:378, 386
Falciform crest, 1:236, 237
Falcotentorial junction, 1:343
False vocal cord, II:150, 215, 218, 219, 221, 225, 228
Falx cerebri, 1:9,10, 11, 12, 13, 14, 15,31,32,37,
189,329,336,337
Fascia
alar, II:129, 187, 188, 193,257
cervical. See Deep cervical fascia
Osborne, III:207
pharyngobasilar, II:148, 151
thoracolumbar, III:51, 54
Fascial "trap door," II:130, 188
Fastigium, I:149
Fat
epidural, III:90, 101, 102, 112, 114, 115, 116, 137,
142,145
extraconal, II:112
extradural, III:141, 148, 149
in parapharyngeal space, II:132
retrobulbar, 1:197
in retropharyngeal space, II:132, 133
in stylomastoid foramen, II:172
Fat pad, retromaxillary, II:106, 113, 123, 128, 131,
136, 138, 143, 145, 146, 154, 156, 161, 163, 165,
166, 167, 168
Femoral artery, III:181, 217, 221, 224
Femoral cutaneous nerve, lateral, III:181
Femoral nerve, III:181, 182, 183, 184, 185,216-21
axial STIRMR, III:220
axial T1 MR, III:221
coronal STIRMR, III:219, 220
coronal T1 MR, III:218
graphic, III:217
inflamed, III:220
muscular branches, III:217, 221, 223
Femoral vein, III:181, 217, 221, 224
Femur, III:221, 224, 225, 226, 227
Fibular head, III:227
Fifth rib, III:94
Fila olfactoria, I:186
Filum terminale, III:130, 132, 138, 139, 141, 144
Fimbria, 1:41, 63, 77, 78,80,81,82,83
First rib, II:135, III:5, 6, 8, 37, 79,81,84,86,87,94,
168,169,176,178,179
Fissures, 1:28, 160
central skull base, II:26
posterior skull base, II:36
Flexor carpi ulnaris, III:207, 208, 209
Flexor muscles and tendons, III:208, 215
xiv
Flocculus, 1:105,107,109,111,124,126,131,133,
134,137,145,150,155,181,184,213,230,235,
236, II:61
Floor of mouth, II:269, 293
Folium, 1:133, 139
Fonticulus frontalis, II:14, 24
Foramen cecum, II:3, 12, 13, 14,24,231,237
Foramen cecum remnant, II:6, 7, 13, 14, 16,20,25
Foramenlacerum, 1:178, 284, II:3, 4,7,9,26,27,
31,32,40,127,142,149,159
Foramen magnum, 1:7,257, 295, 309, 323, 325, 326,
327,376, II:3, 4, 7,8,9,36,37,40,42, III:6, 66,
84
anterior margin, III:73. See also Basion
posterior margin, III:73. See also Opisthion
Foramen of Luschka, 1:130, 131,149, 150,180,
III:167
Foramen of Magendie, 1:137,149, ISO, 154, 159
Foramen of Monro, 1:149,153,156,171,360,365
Foramen ovale, 1:93, 175, 178,210,212,216,227,
257,283,284, II:3, 4,7,8,9,26,27,31,32,41,
53,85,107,120,127,142,149,162,164,169
enlarged, II:164
mandibular nerve in, 1:88, II:127, 142, 161, 167
venous plexus in, 1:338
Foramenrotundum, 1:175,178,212,214,283,284,
344, II:3, 8, 9, 18,26,27,30,32,34,85,96,97,
107,119,120,121,123
Foramen rotundum artery, 1:267, 283, 284
Foramen spinosum, 1:175,178,212,227,257,284,
II:3, 4, 8, 9, 26, 27, 31, 41, 53, 85,120,127,142,
162
Foramina
anterior skull base, II:12
bony orbit and, II:94-97
central skull base, II:26
posterior skull base, II:36
Foraminal segment of vertebral artery, 1:270, 322,
323,325,326
Foraminal venous plexus, III:168, 169
Forceps major. See Occipital forceps
Forebrain bundle, medial, 1:186, 274
Fornix, 1:30, 36, 39, 43, 45, 76,343,359,365
body, 1:41, 63, 77, 79,81,85,155
column, 1:41, 63, 68,72,77,79,81,82,84,85,
153,156,157
commissure, 1:77,85
crus, 1:41, 63, 77,80, 100
pillars, 1:34, 310, 336, 362, 365
posterior crura, 1:154
Fourth ventricle, 1:31, 33, lOS, 107, 110, 113, 118,
121, 122, 123, 124, 125, 128, 135, 136, 144, 148,
149,151,154,159,163,164,180,181,182,206,
213,222,230,235,243,249,255
apex, 1:152
choroid plexus in, 1:131,137,149,159,338
 INDEX
fastigium, 1:154,159 Glossopharyngeal nerve (CN9), I:105, 130, 131, 175,
inferior, 1:106, 107, 122, 124, 129, 130, 131, 134, 177,180,238-43,245,247,249,251,252,253,
150, 180 11:37,181, 182,262,269,272
superior, 1:108,116, 119, 135 axial bone CT, 1:242
superior recess, 1:115,119, 154, 183 axial T2 MR, 1:243
Fovea ethmoidalis, 1:188, 11:15,19,21,22,23,24, graphics, 1:239-41
108, 109 in pars nervosa, 1:255
Frontal bone, 1:2, 3, 4, 5, 6, 7, 188,11:3, 4, 5, 6, 9, Glottis, 11:214,219
13,14,15,19,20,21,23,24,25,94-97, III Gluteus maximus muscle, III:54, 189, 191
Frontal cortical vein, 1:12,350, 354, 355, 357 Gracile nucleus, I:177
Frontal crest, 11:5,12,15,19 Granular foveolae, 1:7
Frontal fibers, 1:45 Gray column, 1:251, III:131
Frontal forceps, 1:43 Gray commissure, III:131
Frontal gyrus, 1:29, 30, 34, 35, 36 Gray matter
Frontal horn, 1:149,152,153,156,157,360 central, III:136
Frontal lobe, 1:28, 31, 32, 36, 38, 39, 11:14,15 midbrain, I:114
Frontal nerve, 1:209, 211, 11:27 periaqueductal, 1:33,108,110,115,117,119,
Frontal operculum, 1:34, 38 152,201
Frontal recess, 11:96,Ill, 117 Great horizontal fissure of cerebellum, 1:324, 328
Frontal sinus, 11:5,6,7,9,13, 15, 19,20,24,25,95, Great vessels, 1:262-65
97,105,106,109,110,117 3D-VRTCECT,1:265
drainage, 11:109 graphics, 1:263
septum, II:106 LAO DSA,1:264
Frontal sulcus, superior, 1:29 Greater palatine artery, 1:267, 272, 273
Frontalis muscle, 1:5 Greater palatine canal, 11:121,122
Frontobasal artery, lateral. See Orbitofrontal artery Greater palatine foramen, 11:4,18, 108, 110, 120,
Frontomaxillary suture, 1:6 121,122
Frontopolar artery, 1:298, 299, 300, 303 Greater palatine nerve, 1:211, 11:27,119
Frontozygomatic suture, 11:97 Greater superficial petrosal nerve, 1:224, 225, 226,
11:48,67,73,75,172
Greater wing of sphenoid bone, 1:3, 4, 6,179,295,
G 309,11:3,6,7,8,15,16,27,29,30,32,33,96
Galen, vein of, 1:99, 101,335,337,341,345,346, Guyon canal, III:205
347,350,351,353,357,359,360,361,364,366, Guyon tunnel, III:208, 209
367,368,369,371,373,374,375,111:167 Gyral markings, 1:7
Gasserian ganglion. See Trigeminal ganglion Gyri, 1:28
Geniculate body Gyrus rectus, 1:33, 36,187,189,299,11:10,13,15,
lateral, 1:191,193 16,23
medial, 1:191
Geniculate fossa, 1:226
Geniculate ganglion, 1:225, 229, 11:48,51, 57, 61, H
67,68,71,74,75,78,81,172,174 Habenula, 1:68, 72
Geniculate nucleus, lateral, 1:37 Habenular commissure, 1:99, 101
Genioglossus muscle, 1:256, 11:262,263, 264, 265, Hair follicle, 1:3
266,267,271,272,273,274,275,280,283,284, Haller air cell, 11:114,116
285,286,287 Hamulus, 11:32,107, 131, 155, 156, 157, 166, 168,
Geniohyoid muscle, 1:256, 11:261,262, 269, 272, 289,290,291
275,284,285,293 Hard palate, 11:122,145, 156,269
Gliosis, around PVSs,1:24 Head and neck. See also Neck
Globe, 1:193,197,300,11:91,92,93,101,102-3 cochlea, 11:62-65
Globus pallidus, 1:20, 34, 36, 40, 41, 61, 62, 64, 65, intratemporal facial nerve, 11:66-75
66,67,68,70,71,72,73,74,75,117 middle ear and ossicles, II:76-81
Glossoepiglottic fold, 11:150,153,215,220,227 orbit, nose, and sinuses, 11:90-123
Glossoepiglottic ligament, 11:219,283 skull base, 11:2-45
suprahyoid and infrahyoid neck, 11:126-257
temporal bone, 11:46-61 •
temporomandibular joint, 11:82-87 I
xv
 INDEX
Hepatic artery, I1I:161
Heubner, recurrent artery of, 1:298, 301, 303
Hiatus semilunaris, 11:105,110, 111, 114, 115, 116,
117
High jugular bulb, 1:142
Hippocampal commissure, 1:80, 82
Hippocampal fissural cyst, 1:40, 80, 84
Hippocampal sulcus, 1:19, 78,83
Hippocampus, 1:38, 72, 76,82, 158
body, 1:37, 40, 41, 77, 79,80,81,82,84,85
fimbria, 1:41, 63, 77, 78,80,81,82,83
head, 1:33, 36, 40, 41, 77, 79,81,83,84,85, 156
histology, 1:78
tail, 1:34, 41, 77, 80, 82, 84, 85
Horizontal crest, 1:141,143,145,184,231,234,237,
11:48,56, 58, 61
Horizontal fissure
cerebellar, 1:324, 328
petrosal, 1:105,111,113,133,136,137,138,139
Horizontal segment
anterior cerebral artery, 1:169, 293, 294, 295, 296,
299,301,302,303,309
carotid canal, I:178, 179, II:120
middle cerebral artery, 1:196, 294, 295, 304, 305,
307,308,309,310,311
petrous internal carotid artery, 1:218, 229, 242,
248,253,283,286,287,288,289,11:6, 7,30,
34,39,40,43,49,53,57,71,85
posterior cerebral artery, 1:293, 296
Humeral epicondyle
lateral, I1I:207
medial, I1I:207
Humerus, III:196, 202, 205, 206, 207, 211, 212
capitellum, I1I:207, 213
supracondylar, I1I:202, 212
trochlea, I1I:207, 213
Hyaline cartilage, I1I:43, 45
Hyoepiglottic ligament, 11:215,218, 220
Hyoglossus muscle, II:136, 139
Hyoid bone, 11:130,133, 138, 153, 182, 183, 184,
185,188,196,199,209,210,213,215,217,218,
220,224,225,226,227,229,231,237,253,264,
266,285,293
Hypoglossal artery, persistent, 1:331
Hypoglossal canal, 1:130,175,178,180,227,228,
255,257,258,259,331,11:3,8,36,37,41,42,
45,53,54, I1I:65, 73
external opening, 11:43
inferior margin, 11:41
Hypoglossal eminence, 1:106, 129, 130, 131,255
Hypoglossal intra-axial axons, 1:255
Hypoglossal muscle, 1:256
Hypoglossal nerve (CN12), 1:105, 129, 130, 175, 177,
180,239,240,245,247,251,254-59,11:37,44,
45,181,182,262,269,272
axial bone CT and T2 MR, 1:257
XVI
coronal bone CT, 1:258
coronal T1 C+ MR, 1:259
graphics, 1:255, 256
Hypoglossal nucleus, 1:129,177,254,255,256,257
Hypoglossal rootlet, 1:255, 257
Hypoglossal trigone, 1:180
Hypoglossal venous plexus, 1:376, 382, 384, 385,
386, III:166, 167
Hypoglossus muscle, 11:151,262, 263, 264, 265, 266,
267,269,271,272,273,274,275,277,279,280,
281,283,284,285,287
Hypopharygeal-esophageal junction, 11:191,222
Hypopharyngeal mucosal space, II:151
Hypopharynx, 11:153,188, 190, 191,209,210,212,
213,214-29,232
axial CECT cords abducted, 11:220-22
axial CECT cords adducted, 11:223
axial T1 MR, 11:227,228
coronal 3D reformatted CT, 11:219
coronal NECT, 11:224-25
graphics, 11:215-19
post-cricoid, 11:151,153,216,222,228
posterior wall, 11:150,153,193,215,216,220,
221,223,226,227,228,229
pyriform sinus region. See Pyriform sinus
sagittal NECT, 11:226
sagittal T1 MR, 11:229
Hypophyseal artery
inferior, 1:267, 283
superior, 1:283
Hypophysis. See Pituitary gland
Hypothalamus, 1:70,74,79,84,85,167,168
infundibular stalk, 1:293
median eminence, 1:88, 95, 156
tuber cinereum, 1:87, 88, 95, 97, 195
Hypotympanum, 11:47,53, 56, 57, 69,72,76,77,
80
I
Iliac artery, I1I:54, 113, 116
Iliac crest, III:122, 123
Iliac spine, posterior, I1I:54
Iliac vein, I1I:54
Iliac wing, I1I:4, 7,8,21, 126
Iliacus muscle, I1I:54, 181,217,218,219,220
Iliocostalis muscle, I1I:53, 54
Iliohypogastric nerve, I1I:181
Ilioinguinal nerve, I1I:181
Ilium, I1I:54
Incisive foramen, 11:4
Incisive nerve, 11:293
Incudostapedial articulation, 11:52,77, 79
Incus, 11:76
body, 11:51,56, 57, 77, 78,80,81
lenticular process, 11:52,56, 77, 79, 80
 INDEX
long process, II:52, 64, 77, 79,80
short process, 1:226, II:51, 55, 56, 77, 78,80
Indusium griseum, 1:77,80
Inferior alveolar artery, 1:267, 272, II:293
Inferior alveolar nerve, 1:211, 219, II:27, 139, 162,
164,168,169,261,267,272,275,278,280,281,
291,293
Inferior anastomotic vein. See Vein of Labbe
Inferior annular epiphysis, II1:11, 12
Inferior articular facet
cervical, II1:29, 75,82,83,88
lumbar, II1:32, 105
thoracic, II1:98,99, 100, 101, 102, 103, 110
Inferior articular process
cervical, II1:34,43, 44, 45, 75
lumbar, II1:7,27, 31, 33, 39, 41, 44, 47,106,108,
111,113
thoracic, II1:38,40, 44, 46, 49, 95, 110
Inferior basal ganglia, 1:21, 23
Inferior cerebellar artery
anterior, I:107, Ill, 112, 122, 124, 130, 131, 144,
145,167,180,181,184,202,207,222,235,
236,243,249,279,281,324,329,330
posterior. See Posterior inferior cerebellar artery
Inferior cerebellar hemisphere, 1:106, 107, Ill, 113,
134,138
maturational changes, 1:47-52
Inferior cerebellar peduncle, 1:50,107,109, 122,
124,129,131,132,133,134,180,181,243
Inferior cerebellar vermis, I:134
Inferior colliculus, 1:33,99, 100, 101, 108, 113, 115,
116,183,206,207
Inferior demifacet
for costovertebral joint, II1:95, 96
for rib, II1:27, 35, 38, 93
Inferior endplate, II1:27
cervical, II1:29
lumbar, II1:36,39, 47, 108, 109
thoracic, II1:30,38,93,94, 101, 102
Inferior fissure, I:138
Inferior fourth ventricle, 1:106,107,122,124,129,
130, 131, 134, 150, 180
Inferior frontal gyrus, 1:29, 30, 36
Inferior hyoid bone, II:220
Inferior hypophyseal artery, 1:267, 283
Inferior jugular foramen, 1:257
Inferior lamina of pineal stalk, 1:101
Inferior longitudinal fasciculus, 1:42, 44
Inferior meatus, II:109, 110, 113, 115, 116, 117
Inferior medulla, 1:134
Inferior medullary velum, 1:113, 139
Inferior middle meatus, II:108
Inferior oblique capitis muscle, II1:50, 52
Inferior oblique muscle, 1:192, II:91, 92, 93
Inferior occipitofrontal fasciculus, 1:42, 44
Inferior olivary nucleus, 1:129,249,255
Inferior ophthalmic vein, 1:89, 192,338,379,380,
II:91, 99,100
Inferior orbital fissure, 1:3,178,212,284, II:7, 8,17,
18,26,30,34,95,96,97,107,108,112,120,
121, 122, 123, 167
Inferior parapharyngeal space, II:139
Inferior petrosal sinus, 1:248, 335, 338, 343, 348,
351,355,356,359,373,374,376,386, II:7, 38,
44, II1:166
Inferior pharyngeal constrictor muscle, II:150, 151
Inferior rectus muscle, 1:192,194,197, II:91, 92, 93,
112
Inferior sagittal sinus, 1:9, 12,335,342,343,345,
346,347,350,355,356,359,361,362,364,373
Inferior salivatory nucleus, 1:177, 239, 241
Inferior temporal gyrus, 1:29, 30, 36
Inferior third ventricle, 1:84
Inferior thyroid artery, 1:263, 264, II:230
Inferior thyroid gland, II:232
Inferior thyroid vein, II:232
Inferior turbinate, II:105, 106, 107, 108, 109, 110,
111,113,115,116,117
Inferior tympanic artery, II:49
Inferior vena cava, II1:113, 116, 163
Inferior vermian artery, 1:328
Inferiorvermian vein, 1:368,372,373,374,375,376
Inferior vestibular nerve, 1:124, 141, 143, 144, 181,
230,231,235,237, II:48, 58, 60
Inferior vestibular nucleus, 1:141, 237
Inferolateral trunk, 1:267, 283, 286
Infrahyoid internal jugular vein, II:183
Infrahyoid neck. See also Neck
axial CECT,II:133, 134
axial Tl MR, II:136, 137
axial T2 MR, II:138
coronal Tl MR, II:139
graphics, II:129, 130, 182, 196
Infrahyoid strap muscle, II:133, 134, 135, 137, 138,
210,211,221,223,227,232,233,235,236,237
Infraorbital artery, 1:267, 272
Infraorbital canal, II:97
Infraorbital foramen, 1:3, II:95
Infraorbital nerve, 1:192, 194,209,211,218, II:10,
27,30,90,91,95,101,106,108,109,112,119,
123
Infraorbital node, II:253
Infratemporal fossa, II:7. See also Masticator space
Infratentorial brain, 1:104-45
Infratentorial cistern, I:160
Infundibular recess of third ventricle, 1:149,152,
157,159,164,168,203
Infundibular stalk of hypothalamus, 1:293
Infundibulum
maxillary, II:108, 110, 114, 115, 116
•
I
XVII
 INDEX
pituitary, 1:88,90, 91, 92, 93, 95, 97, 168, 169, posterior limb, 1:31, 34, 40, 47,66,67,68,69,72,
182,183,191,196,201,203,216,299,339, 73
11:10,99 Internal carotid artery, 1:66, 87, 89, 90, 91,196,200,
of posterior communicating artery, 1:302 201,203,206,240,247,257,263,265,268,270,
Inguinal ligament, III:181, 217 293,294,297,302,305,383,384,386,11:44,
Inner arch of limbic system, 1:76, 77 101, 131, 132, 136, 138, 143, 144, 145, 146, 176,
Inner ear, 11:46,62 177,181,182,183,184,192,193,212,255,257,
Inner pial layer, I:17 III:153,158
Inner table, 1:3, 5, 7 in carotid canal, 11:182,183
Innominate artery, III:153 cavernous (C4) segment. See Cavernous internal
Innominate vein, III:169 carotid artery
Insula, 1:28, 33, 34, 36, 37, 41,74,308 cervical (C1) segment, 1:266, 268, 331, 11:49
Insular cortex, 1:34, 65 clinoid (C5) segment, 1:282, 283
Insular middle cerebral artery, 1:304, 305, 306, 307, distal bifurcation, 1:291, 295, 296
308,309,310,311 . intracranial, 1:278, 282-91
Insular middle cerebral vein, 1:356 AP DSA,1:288
Insular vein, 1:339 axial NECT,1:284, 285
Intercavernous plexus, 1:339 graphics, 1:283
Intercavernous sinus, 1:11,90, 335, 343, 344 lateral DSA,1:286
Intercostal artery, 1:264, III:153, 159 MRA,1:289
distal, III:157 OBLDSA,1:287
superior, 1:264 lacerum (C3) segment, 1:282, 283, 284, 286, 287,
T8, III:158 11:49
Intercostal muscle, III:55 lumen, 1:274
Intercostal nerve, 111:4 normal variants and anomalies, 1:282
Intercostal segmental artery, III:153, 154, 161 ophthalmic (C6) segment, 1:282, 283, 287, 290,
Interduralsegment 291
abducens nerve, 1:220 petrous (C2) segment. See Petrous internal
trigeminal nerve, 1:208 carotid artery
Interhemispheric fissure, 1:29,35, 157, 170,293, segments, 1:282
299,301 supraclinoid (communicating, C7) segment,
anterior cerebral artery in, 1:157,165,169 1:90,91,92,93, 169, 196,268,269,279,283,
Intermediate olfactory striae, 1:186, 187 287,290,291,295,296,297,299,305,309,
Intermediolateral column, III:136 313,11:10
Internal acoustic meatus, 1:7, 11:3,36 ultrasound, 1:275
Internal auditory canal, 1:112, 126, 127, 140-45, Internal carotid vein, 1:335
151,175,179,215,222,225,226,228,229,234, Internal cerebral vein, 1:13,32, 99,100,101,153,
258,259,11:6,10,39,43,48,50,51,54,59,61, 154,155,303,310,319,337,340,341,343,345,
67,68,71,75,78 346,347,349,350,351,356,357,359,360,361,
axial bone CT, I:142 362,363,364,365,366,367,368,369,370,371,
axial T2 MR, 1:144 373,374, III:166, 167
coronal T2 MR, I:145 in quadrigeminal cistern, 1:165
embryology, 1:140 in velum interpositum cistern, 1:99, 101, 153,
fundus, 1:141, 142, 144, 145,11:63, 74 161,170
graphics, 1:141 Internal jugular nodes, 11:204,212, 237, 253, 255,
mid-,1:144 256
sagittal T2 MR, 1:143 Internal jugular vein, 1:240, 247, 259, 341, 343, 351,
Internal auditory canal segment of facial nerve, 354,370,373,376,378,379,380,381,382,383,
1:151,155,11:67,74 385,387,11:38,44,45,53,131,132,133,134,
Internal capsule, 1:36, 42, 44, 45, 48, 65, 66, 70, 71, 135,136,137,138,143,144,145,146,176,177,
74 181,182,183,184,185,191,192,206,207,210,
anterior limb, 1:31, 34, 40, 47, 63, 66, 67, 68, 69, 211,212,233,234,236,255,257, III:155, 164,
72, 73 166, 168
genu, 1:40, 66, 67, 68, 69, 72, 73 exiting jugular foramen, 11:183
maturational changes, 1:49-62 extracranial, 1:384
infrahyoid, II:183
suprahyoid, II:183
XVIII
 INDEX
Internal mammary artery, 1:263, 264, 265, II1:153 Intracanalicular segment of optic nerve, 1:190,191,
Internal maxillary artery, 1:218, 273, 283, 11:34,49, 193, 196, 197
113,119,165,167,169 Intracranial arteries, 1:278-331. See also specific
Internal oblique muscle, II1:54 arteries
Internal occipital crest, 11:37,39 anterior cerebral artery, 1:298-303
Internal occipital protuberance, 1:4, 11:40 circle of Willis, 1:292-97
Internal vertebral vein graphics, 1:279-81
anterior, III:164, 168 internal carotid artery, 1:278, 282-91
posterior, II1:165, 167 middle cerebral artery, 1:304-11
Internal vertebral venous plexus overview, 1:278-81
anterio~III:88,9~ 164,165,166,167,168 posterior cerebral artery, 1:312-21
posterior, 111:164,165, 167 vertebrobasilar system, 1:322-31
Interosseous artery, II1:208, 214 Intracranial segment of optic nerve, 1:190, 191
Interosseous membrane, II1:208, 214 Intracranial tumor, 11:164
Interosseous nerve Intracranial venous system, 1:334-77. See also
anterior, II1:196, 201, 205, 208, 211, 214 specific veins and sinuses
posterior, II1:201 axial CECT, 1:336, 337
Interosseous sacroiliac ligament, III:123, 124 axial T1 C+ MR, 1:338-40
Interpeduncular cistern, 1:90, 95, 108, 110, 111, 116, cerebral veins, 1:352-71
117,118,119,126,127,155,161,162,164,166, dural sinuses, 1:342-51
167,170,171,183,184,201,202,206,215 graphics, 1:335
Interpeduncular fossa, 1:33, 115,201 LAT,OBL and AP MRY,1:341
Intersphenoidal synchondrosis, 11:28,35 overview, 1:334-41
Interspinalis muscle, II1:50, 52, 53, 54 posterior fossa veins, 1:372-77
Interspinous ligament, II1:27, 32, 37, 38, 39, 40, 41, Intradural extramedullary compartment, III:140
55, 102, 112, 116 Intradural segment of vertebral artery, 1:322, 324,
cervical, III:76, 85, 86, 87 326,327
thoracic, III:100, 101 Intradural venous channels, 1:353
Intertransverse muscle, II1:50 Intramedullary compartment, II1:140
Intervertebral disc, II1:3, 5, 24, 25, 42-49 Intranuclear cleft, III:48
3D-VRTNECT, II1:44 Intraocular segment of optic nerve, I:190, 191, 192,
axial and sagittal NECT, II1:45-47 193
cervical, II1:34, 43, 44, 45, 48, 49, 75, 76,81,85, Intraorbital segment of optic nerve, 1:190, 191, 192,
88,89,91 193, 197
graphics, II1:43 Intraparotid facial nerve, 11:171, 172, 177, 178
lumbar, II1:4, 8, 32, 33, 36, 41,43,44,47,48, Intratemporal facial nerve, 1:224, 11:66-75
49,111,112 axial bone CT, 11:68,69, 72
sagittal T2 MR, II1:48, 49 axial T1 C+ MR, 11:75
thoracic, II1:4, 8, 35, 38,44,46,48,49,93,96, axial T2 MR, II:74
97,98,99,100,101,102,103,110 coronal bone CT, 11:70,71, 73
Intervertebral disc space, II1:81, 84 graphics, 11:67
cervical, III:78 Intrathyroid vessels, 11:236
lumbar, II1:31, 44,107,108,109 Intravertebral venous sinuses, III:169
thoracic, II1:30, 94 Intrinsic tongue muscle, 1:256, I1:141, 262, 265, 271,
Intima, 1:274 272,283,284,285,286
Intra-axial segment Iris, 11:103
abducens nerve, 1:220
accessory nerve, 1:250
facial nerve, 1:224 J
glossopharyngeal nerve, 1:238 Jugular bulb, 1:179, 259, 338, 341, 343, 345, 348,
hypoglossal nerve, 1:254 351,354,359,370,373,376,381,382,384,385,
oculomotor nerve, 1:198 11:6,38,39,45,52,174, II1:167
trigeminal nerve, 1:208 apex, I1:52
trochlear nerve, 1:204 in jugular foramen, 11:44
vagus nerve, 1:244 roof, 11:6,39
•
I
XIX
 INDEX
><
QJ
"'C Jugularforamen, 1:109,130,145,175,178,179,180,
C 212,228,243,248,257,258,259,284,386,11:3,
4,10,36,37,40,42,43,53,54,70,127,142,
171,183, III:65
Jugular nodes, internal, 11:204,212, 237, 253, 255,
256
Jugular spine, 1:178, 179,242,248,253,11:37,39,53
Jugular tubercle, 1:145,179,242,248,258,259,386,
11:7,9,36,37,40,42,43,45,54, III:73
Jugular vein, 1:335, 345, III:51, 52,165,166
external, 1:351, 371, 378, 379, 380, 382, 383, 385,
387,11:133, 134, 137, 138, 185,203,205
internal. See Internal jugular vein
Jugulodigastric node, 11:132,253, 255, 266, 273, 280
Jugulodigastric reactive node, 11:279
K pedicle, 111:112,115,149
Koerner septum, 11:50,51, 78
Kyphosis, III:3
L transverse process, III:114, 121, 125
L1
body, III:107
vertebral body, III:112
Ll-2, neural foramen, III:107
12
body, III:107
exiting nerve, III:114
inferior endplate, III:107
pedicle, III:114
superior articular process, III:49
transverse process, III:106
vertebral body, III:115
L2-3, intervertebral disc, III:114, 115
L3, III:135
body, III:107
exiting nerve, III:114, 115, 116
inferior articular process, 111:107,114
inferior end plate, III:48
lamina, III:114
nerve root, III:106, 112, 141
pedicle, III:106, 114
superior articular process, III:114
superior endplate, III:48, 107
vertebral body, III:115
L3-4
facet joint, III:116
intervertebral disc, III:l13, 116
L4, III:120, 135
body, III:107
dural root sleeve and nerve, 111:141
exiting nerve, III:114, 115, 116
inferior articular process, III:112, 114, 117
inferior endplate, III:112, 115
xx
nerve, III:117
nerve root, III:4, 106
pedicle, III:106, 115, 116, 141
superior articular process, III:107
transverse process, III:114
vertebral body, III:106, 115, 116
L4-5
facet joint, III:114
intervertebral disc, III:115, 117
L5, III:120, 135
body, III:106, 107, 112, 121, 125, 126, 127
exiting nerve, III:115
inferior articular process, III:49, 117, 121, 122
inferior endplate, III:115
nerve, III:117
nerve root, III:112, 149
pars in terarcularis, III:107
spinous process, III:121, 122, 127
superior articular process, III:114, 117
superior endplate, 111:112,115
transverse foramen, III:121
vertebral body, III:115
L5-S1
facet joint, III:127
intervertebral disc, III:115, 117, 121, 122, 125,
126, 127
intervertebral disc space, III:107
Labbe, vein of, 1:335, 341, 345, 347, 349, 351, 354,
355,357,369,370,371,373,377,11:38
Labyrinthine segment of facial nerve, 1:141, 142,
179,225,226,229,234,237,11:48,50,51,56,
57,59,67,68,71,74,75,78
Lacerum segment of internal carotid artery, 1:282,
283,284,286,287
Lacrimal artery, 1:192
Lacrimal bone, 1:3, 11:94-97
Lacrimal gland, 1:197, 11:91,92, 100
Lacrimal nerve, 1:192, 211, 11:27
Lambda, 1:2, 5, 6, 7
Lambdoid suture, 1:4, 5, 6, 7
Lamella, lateral, 1:188, II:17, 19, 21, 23
Lamina
cervical, III:28, 34, 43, 44, 45, 51, 75, 82, 83, 86,
88,89,90,91
lumbar, III:7, 27, 28, 31, 32, 33, 36, 41, 47,105,
107,108,109,111,113,116,117
thoracic, III:7, 28, 30, 35, 40, 44, 46, 55, 93, 95,
96,97,98,99,100,101,102,103,110,134
Laminapapyracea,II:6, 7, 16, 19,106, 108,109,112
Lamina terminalis, 1:30,152,168,170
Lamina terminalis cistern, 1:161,165,168,169,170
Laryngeal nerve, superior, 1:246, 11:217,218
Laryngeal ventricle, 11:218,219, 225, 226, 229
 INDEX
Larynx, 11:190,209, 213, 214-29 Lateral sulcus. See Sylvian fissure
axial CECT cords abducted, 11:220-22 Lateral vein, 1:360, 361, 363, 366, 367, 371
axial CECT cords adducted, 11:223 Lateral ventricle, 1:82,148,156,364,368
axial T1 MR, 11:227,228 atrium, 1:153, 154, 158
cartilages, 11:214 body, 1:149,153,155,159
coronal 3D reformatted CT, 11:219 choroid plexus in, 1:152,153,154,155,156,159,
coronal NECT,11:224-25 314
graphics, 11:215-19 frontal horn, 1:149,152, 153, 156, 157,360
sagittal NECT, 11:226 occipital horn, 1:80, 152, 153, 158,364
sagittal T1 MR, 11:229 roof, with ependymal vein, 1:361
Lateral atlanto-axial joint, III:57 temporal horn, 1:36, 40, 41, 77, 78, 79,81,83,
Lateral atrial vein, 1:361, 362, 363, 365, 368, 369, 84,85,143,149,151,152,156,157,158
371 Lateral vestibular nucleus, 1:129,141,237
Lateral epitympanic space. See Prussak space Latissimus dorsi muscle, III:50, 53
Lateral femoral cutaneous nerve, III:181 Left common carotid artery, 1:262, 263, 264, 265
Lateral fissure. See Sylvian fissure Left subclavian artery, 1:262, 263, 264, 265
Lateral frontobasal artery. See Orbitofrontal artery Left vertebral artery, III:153
Lateral geniculate body, 1:191,193 Lemniscus, medial, 1:121
Lateral geniculate nucleus, 1:37 Lens, 11:101,103
Lateral humeral epicondyle, III:207 Lenticulostriate artery
Lateral lamella, 1:188, 11:17,19,21,23 lateral, 1:17,19,21,22,66,281,303,305,307,
Lateral lenticulostriate artery, 1:17,19,21,22,66, 311
281,303,305,307,311 medial, 1:66,281, 298, 301, 303, 305, 311
Lateral mallealligament, 11:81 Lentiform nucleus, 1:31, 32, 66
Lateral mass, III:29, 81, 84 maturational changes, 1:47-50
C1, 1:258, 259, 386, 11:42,43, 45, 257, III:14, 16, Leptomeninges. See Arachnoid; Pia
37,45,64,65,66,77,79,84,87,90,166, Lesser palatine foramen, 11:120
167, 168 Lesser palatine nerve, 1:211, 11:27
C2,1:325 Lesser trochanter, III:221
Lateral medullary segment of posterior inferior Lesser wing of sphenoid bone, 1:295, 309, 11:3,5, 9,
cerebellar artery, 1:324, 328 12,13,18,27,96
Lateral mesencephalic vein, 1:207, 336, 365, 373, Levator aponeurosis, 11:93
374,377 Levator palpebra muscle, I:192, 199, 205
Lateral occipital bone, 11:40,41, 42, 53 Levator palpebrae superioris, 1:194,197,11:91,92,
Lateral occipitotemporal gyrus, 1:29 93
Lateral olfactory striae, 1:186, 187 Levator scapulae muscle, 11:133,134, 135, 137, 138,
Lateral pharyngeal recess, 11:152,154,156,159 199,200,204,206,207, III:50, 51, 52
Lateral pons, 1:218 Levatorveli palatini muscle, 11:145,147,149,151,
Lateral posterior choroidal artery, 1:313, 314, 318, 152, 154, 156
319,320,321,324,328,368 Ligamentum fIavum, III:27, 32, 38, 39, 40, 41, 47,
Lateral pterygoid muscle, 1:211, 216, 219, 11:83,123, 91,101,102,103,110, Ill, 112, 113, 114, 116,
131, 139, 145, 147, 154, 156, 161, 165, 167, 168, 117,122
169,173 Ligamentum nuchae, 11:195,206, III:37, 52, 57,76,
Lateral pterygoid plate, 11:32,107,113,120,121, 85,86,87
123, 143, 162, 165 Lilequist membrane, 1:88, 160, 162, 167, 168, 170,
Lateral recess with choroid plexus, 1:154, 159 171,203
Lateral rectus muscle, 1:191,192,193,194,197, Limbic lobe, 1:75
11:91,92, 101 Limbic system, 1:28, 76-85
Lateral retropharyngeal node, 11:187,193,257 arches, 1:76,77
Lateral retropharyngeal space, 11:145,146,181,184, axial T2 MR, 1:84
189 coronal T1 MR, 1:79, 80
Lateral semicircular canal, 1:225, 228, 229, 234, 258, coronal T2 MR, 1:81, 82, 83
11:50,54,55,59,61,65,67,70,71,74,75,78, graphics, 1:77,78
80,172 histology, 1:78
Lateral semicircular duct, 11:49,63 sagittal T1 MR, 1:85
•
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XXI
 INDEX
><
QJ Lumbar spinal canal, III:28, 32, 33, 54, 105, 111,
""C Lingual artery, 1:266, 267, 268, 269, 271, II:262, 269,
C 271,272,273,274,275,281 113
Lingual nerve, 1:211, II:27, 162,261,262,269,272, Lumbar spine, III:I04-17. See also L1 through L5
293 3D-VRTNECT, III:108, 109
Lingual septum, II:262, 263, 265, 266, 272, 273, 275, arterial supply, III:159, 160
283,285,286,287 axial bone CT, III:110, 111
Lingual thyroid, II:226 axial T1 MR, III:113
Lingual tonsil, II:139, 141, 150, 151, 153, 155, 158, axial T2 MR, III:116, 117
191,192,229,231,256,263,265,269,273,283, coronal T1 MR, III:114, 115
285,286 exiting nerve, III:l13, 115
Lingual vein, II:273 graphics, III:105, 106
Lingula, 1:133, 139 ossification, III:12, 20
Lip mucosa, II:269 radiography, III:107
Lobes sagittal T1 MR, III:112
cerebellar, 1:132, 133 Lumbar vein, III:114, 115
cerebral, 1:28 Lumbar vertebral body, III:4, 5, 6, 8, 9, 26, 44,51,
Long ciliary nerve, 1:211 54,107,108,109,111,117
Longissimus capitis muscle, II:216, 290, III:50, 51, 3D-VRTNECT, III:36
52 anterior cortical margin, III:31, 39, 41, 47
Longissimus muscle, III:51, 53, 54 axial NECT, III:32
Longissimus thoracis muscle, III:55 axial T1 MR, III:41
Longitudinal fasciculus coronal NECT, III:33
inferior, 1:42, 44 cortical bone, III:32
medial, 1:107, 108, 110, 115, 116, 118, 119, 121, graphics, III:27, 28
122, 123, 125, 129 inferior cortical margin, III:31
superior, 1:42, 43, 44, 46 lateral cortical margin, III:31
Longitudinal fissure, 1:37 medullary bone, III:32
Longitudinal ligament posterior margin, III:33, 39
anterior, III:27, 32, 37, 38, 39, 40, 41, 43, 48, 57, radiography, III:31
72,101,102,106,112,113 sagittal T2 MR, III:39
posterior, III:27, 32, 37, 38, 39, 43, 48, 57,72,87, superior cortical margin, III:31
111,115,127,141 Lumbar vertebral endplate, III:32, 47
Longus colli muscle, II:290, III:50, 51, 52 Lumbosacral plexus, III:4
Lordosis, III:3 Lumbosacral trunk, III:120, 123, 181, 183, 187
Lower brachial plexus trunk, III:173, 174, 176 Lung apex, II:135
Lumbar artery, III:114, 115, 159 Luschka
Lumbar dural margin, III:112 foramen of, 1:130,131,149,150,180, III:167
Lumbar facet joint, III:7, 28, 31, 32, 33, 36, 41,43, joint of. See Uncovertebral joint
44,47,48,49,105,106,107,108,109,111, Lymph nodes, cervical. See Cervical lymph nodes
112, 113, 117 Lymphatic malformation, posterior cervical space,
Lumbar intervertebral disc, 1II:4, 8, 32, 33, 36, 41, II:205
43,44,47,48,49,111,112 Lymphatic ring, pharyngeal mucosal space, II:148
Lumbar intervertebral disc space, III:31, 44, 107,
108, 109
Lumbarlamina, III:7, 27, 28, 31, 32, 33, 36, 41, 47, M
105,107,108,109,111,113,116,117 Macula cribrosa, 1:142, II:55
Lumbar lordosis, III:3 Macula crib rosa foramen, 1:234
Lumbar paraspinal muscles, III:51, 54 Magendie, foramen of, 1:137, 149, 150, 154, 159
Lumbar plexus, III:180-85 Malar node, II:253
axial T1 MR, III:184 Mallealligament
axial T2 FS MR, III:185 anterior, II:78
coronal T1 MR, III:182 lateral, II:81
coronal T2 FS MR, III:183 superior, II:81
graphics, III:181 Malleoincudal articulation, II:77, 78
proximal rami contributions, III:219
Lumbar segmental artery, III:160

xxii
 INDEX
Malleus, 1:229, II:76
anterior process, II:77
head, 1:226, II:50, 51, 77, 78,81
lateral process, II:77, 81
manubrium, II:52, 53, 56, 57, 64, 69,77,79,81
neck, II:52, 77, 78,81
umbo, II:56, 77, 79,80
Mamillarybody, 1:39, 40,77,79,83,84,85,88,95,
183,195,201,206
Mammary artery, internal, 1:263, 264, 265, III:153
Mandible, II:292-93
angle, II:84, 85, 169,267,293
body, II:84
graphics, II:293
inner cortical table, II:266
Mandibular branch of facial nerve, 1:225, II:172
Mandibular condyle, 1:219, 227, II:8, 41, 53,72,83,
85, 143, 147, 165, 167, 168, 174, 177
erosion, II:163
head, II:43, 83, 84, 85, 86, 87
neck, II:83, 84, 85, 86, 87
Mandibular cortex, II:281
Mandibular foramen, II:I07, 131, 166, 168, 169,
291,293
Mandibular fossa, II:83, 84, 85, 86, 87
Mandibular molar, third, II:289, 290, 291
Mandibular nerve, 1:87, 93, 175, 176,208,209,210,
211,214,215,216,219,384, II:I0, 27, 34, 149,
161,162,163,164,167,169,261,293
branches, II:160
exiting foramen ovale, 1:93
in foramen ovale, 1:88, II:127, 142, 161, 167
perineural malignancy, II:164
Mandibular node, II:253
Mandibular notch, II:83, 84
Mandibular ramus, 1:219, II:83, 84, 85, 136, 138,
143,144,165,166,168,169,290,291
Mandibular teeth, II:289, 290, 291
Mandibular vein, 1:383
Marginal supraglottis, II:150
Marginal venous plexus, 1:376
Massa intermedia, 1:67, 68, 149, 159
Masseter muscle, 1:211, 219, II:131, 132, 136, 138,
139, 143, 144, 145, 146, 147, 161, 162, 165, 166,
168,169,175,176,177,178,179,199,265,277,
278,281,285,290
Masseteric artery, 1:272
Mastication, muscles of, II:160
Masticator nerve, 1:211, II:162
Masticator space, II:4, 18, 106, 127, 128, 129, 131,
132, 136, 138, 139, 141, 142, 143, 144, 145, 146,
147, 149, 150, 152, 154, 155, 156, 157, 160-69,
171,172, 173, 175, 176, 177, 178, 179, 182, 187,
189,262,271,277,281
axial CECT,II:165, 166
axial T1 MR, II:166, 168
coronal T1 MR, II:169
generic mass, II:163
graphics, II:161-64
infrazygomatic, II:128, 139, 142, 161, 169
mandibular nerve malignancy, II:164
suprazygomatic, II:127, 128, 139, 161, 167, 169
Mastoid air cells, 1:179, 258, II:5, 6, 39, 42, 50, 59,
69,85,174
Mastoid antrum, 1:142, 226, 228, 234, II:50, 51, 54,
55,68,70,78
Mastoid canaliculus, II:69
Mastoid emissary vein, II:44
Mastoid nodes, II:253
Mastoid process, 1:4, 6, 7, II:4, 9, 42, 84, 85
cervical, III:81
Mastoid segment offacial nerve, 1:179, 227, 228,
234,258, II:7, 42, 52, 53, 54, 68, 69, 70, 72, 73,
75, 79, 174
Mastoid sinus, 1:230
Mastoid tip, 1:227, 228, 258, II:8, 41, 53, 54, 61, 70,
131,136,171,172,175,177,179,203,205,207
Maxilla, 1:6, II:292-93
Maxillary alveolar ridge, II:290, 291
Maxillary artery, 1:266, 267, 268, 269, 271, 272, 273,
381, II:161
internal, 1:218, 273, 283, II:34, 49,113,119,165,
167, 169
Maxillary bone, II:4, 94-97
Maxillary infundibulum, II:I08, 110, 114, 115, 116
Maxillary nerve, 1:87,88,89, 94,175,176,181,208,
209,210,211,214,215,216,217,218,344,
II:27, 112, 119
Maxillary ostium, II:115
Maxillary ridge, II:131, 145
Maxillary sinus, 1:194, 212, 218, II:I0, 18,34,95,
96,97,104,105,106,108,109,110,112,113,
115,116,119,120,122,123,167
McCrae line, III:62
McGregor line, III:60, 61, 62
McRae foramen magnum line, III:60
Meckel cave, 1:88, 89, 91, 92, 93, 107, 123, 124, 125,
144,167,168,181,185,195,196,208,211,213,
214,216, 218,222, 344, 348,II:lO,33,34, 59,
75, 123, 162, 169
dural wall, 1:169, 213, 215
with trigeminal fascicles, 1:164,168,213,218
with trigeminal ganglion, 1:209, 210
with trigeminal nerve rootlets, 1:210
Medial atrial vein, 1:361, 362, 365, 366, 371
Medial forebrain bundle, 1:186, 274
Medial frontal gyrus, 1:30
Medial geniculate body, 1:191
Medial humeral epicondyle, III:207
Medial lemniscus, 1:121
Medial lenticulostriate artery, 1:66, 281, 298, 301,
303,305,311 •
I
xxiii
 INDEX
Medial longitudinal fasciculus, 1:107, 108, 110, 115,
116,118,119,121,122,123,125,129
Medial occipitotemporal gyrus, 1:29
Medial olfactory striae, I:186, 187
Medial posterior choroidal artery, 1:99, 162,313,
314,319,321,324,328,359
Medial pterygoid muscle, 1:211, 216, 219, 11:131,
132, 136, 138, 139, 143, 144, 145, 146, 147, 156,
161,162,165,166,168,169,173,175,176,177,
178,179,199,265,267,274,277,280,281,286,
287,290,291
Medial pterygoid plate, 11:32,107, 113, 120, 121,
131,143,155,156,157,162,165,166,168,289,
290,291
Medial rectus muscle, 1:191, 192, 193, 194, 197,
11:91,92, 101, 112
Medial retropharyngeal node, 11:187,257
Medial rib, III:8, 40, 44, 95, 96, 97, 98, 99
Medial vestibular nucleus, 1:129, 141,237
Median atlanto-axial joint, III:57
Median crest of sacrum, III:119
Median eminence, 1:88, 95, 156
Median fissure, ventral, 1:129, III:131, 133, 136
Median nerve, 111:173,201, 203, 205, 208, 209,
210-15
axial PO FSMR, III:215
axial T1 MR, III:212-14
branches, III:196, 211
graphic, III:195, 196,211
Median raphe, 11:193
Median sulcus, 11:283
anterior, III:84
dorsal, 1:106,129,130,180, III:131
Median vein, anterior, III:163
Mediastinal node
anterior, 11:237
superior, 11:212,253
Mediastinum, superior, 11:234
Medulla, 1:49, 50,104,105,106,111,113,126,127,
128-31,134,139,150,155,163,180,184,207,
223,236,259,11:44, III:167
axial T2 MR, 1:130, 131
graphics, I:129
inferior, I:134
ventral (anterior), 1:128
Medullary artery, III:153, 154
Medullary cistern, 1:106,150,159,161,163,170
vertebral artery in, 1:166, 170
vertebrobasilar confluence in, I:163
Medullary lamina, external, 1:65, 66, 74
Medullary olive, 1:105, 106, 109, 129, 130
Medullary pyramid, 1:105, 106, 109, 129, 130,249,
253,257
Medullary vein, 1:335, 346, 360, 361, 363, 371,
III:163
xxiv
Medullary velum
anterior, 1:149,152
inferior, 1:113, 139
superior, 1:113, 115, 116, 119, 121, 133, 139, 159,
183,206
Medullary venous plexus, anterior, 1:373
Meningeal artery
accessory, 1:283
middle. See Middle meningeal artery
posterior, 1:324
Meninges. See Cranial meninges; Spinal meninges
Meningohypophyseal artery, 1:267
Meningohypophyseal trunk, 1:283, 286, 316
Mental foramen, 1:219, 11:84,280, 293
Mental nerve, 11:293
. Mesencephalic membrane, 1:162
Mesencephalic nucleus, 1:121, 208, 209
Mesencephalic vein
lateral, 1:207, 336, 365, 373, 374, 377
posterior, 1:374
Mesencephalon. See Midbrain
Mesenteric artery, superior, III:161
Mesotympanum, 1:142, 11:47,54, 57,71,76,77,81
Metopic suture, 1:6
Midbrain, 1:31, 33, 97,104,105,113,114-19,126,
139,152,183,201,206,207,314
axial T1 MR, 1:116,117
axial T2 MR, 1:118, 119
enlarged PVSs,1:25
graphics, I:115
PVSs,I:19
Middle anastomotic vein. See Superficial middle
cerebral vein
Middle arch of limbic system, 1:76, 77
Middle brachial plexus trunk, 111:173,174,175,176
Middle cerebellar peduncle, 1:45, 46, 107, 109, 110,
111,113,121,122,123,124,125,126,132,133,
135,137,138,144,181,182,207,213,218,235,
236,11:174
maturational changes, 1:51-62
Middle cerebral artery, 1:17, 66, 91, 93, 185,278,
290,293,302,304-11
30-VRT CTA,1:309
anterior temporal branch, 1:316
AP OSA, 1:307
bifurcation, 1:295, 305, 307, 308, 309, 310
branches, 1:304
cortical (M4) segment, 1:304, 305, 307, 308
CTA,1:310, 311
embryology, 1:304
genu, 1:92
graphics, 1:279, 280, 281, 305
horizontal (M1) segment, 1:196, 294, 295, 304,
305,307,308,309,310,311
insular (M2) segment, 1:304, 305, 306, 307, 308,
309,310,311
 INDEX
LATDSA,1:306
MRA,1:308
normal variants and anomalies, 1:304
opercular (M3) segment, 1:304, 305, 307, 308,
310,311
in sylvian fissure, 1:164,165,169
trifurcation, 1:308
vascular territory, 1:278, 280, 281, 304
Middle cerebral vein
deep, 1:339, 353, 355, 356, 363, 371
insular, 1:356
superficial, 1:11, 339, 341, 345, 346, 347, 349,
353,354,355,356,357,361,377
Middle cranial fossa, 1:4, 295, 309, II:5, 6,16,29,
106, 120
Middle deep temporal artery, 1:272
Middle ear, II:46, 47, 76-81, III:202, 206
axial bone CT, II:78, 79
coronal bone CT, II:80, 81
graphics, II:77
Middle frontal gyrus, 1:29, 30, 35, 36
Middle meatus, II:108, 112, 113, 114, 115, 116, 117
inferior, II:108
posterior, II:108
Middle meningeal artery, 1:267, 271, 272, 283, 301,
II:10, 34, 49, 127, 162
in foramen spinosum, 1:214, 218, II:167
groove, 1:7
posterior branch, 1:272
Middle pharyngeal constrictor muscle, II:151, 158
Middle scalene muscle, II:134, 135, 137, 138, 195,
198,199,200,201,202,206,207, III:51, 52,
176,179
Middle temporal gyrus, 1:29, 30, 36
Middle turbinate, II:105, 107, 108, 109, 111, 112,
113, 115, 116, 117
Modiolus, 1:141, 142, 144,237, II:52, 60, 64, 65
Molar, third mandibular, II:289, 290, 291
Monro, foramen of, 1:149,153,156,171,360,365
Motor branch
accessory nerve, 1:252
facial nerve, II:67, 73
Motor nucleus
facial nerve, 1:121, 224, 225, II:48, 67,73
trigeminal nerve, 1:121, 208, 209, 213
Mouth. See Oral cavity
Mililer muscle, II:93
Multifidus muscle, III:50, 51, 52, 53, 54, 55,113,
116
Muscles of mastication, II:160
Muscular branch
external carotid artery, 1:326
femoral nerve, III:217, 221, 223
median nerve, III:196, 211
occipital artery, 1:268, 269
segmental artery, III:153, 154
spinal artery, III:153, 154, 157, 158, 159, 160
vertebral artery, 1:326, 328
Musculocutaneous nerve, III:173, 196,201,205,211
Myelination, 1:42. See also White matter
Mylohyoid cleft, II:264, 266, 273, 277, 279, 280, 287
Mylohyoid muscle, 1:211, 219, II:136, 141, 142, 144,
162,176,260,261,262,263,264,265,266,267,
269,271,272,273,274,275,277,278,279,280,
283,284,285,286,287,293
Mylohyoid nerve, 1:211, II:162, 261, 293
Mylohyoid ridge, II:261, 267, 272, 275, 278, 281,
293
N
Nasal airway, II:139
Nasal bone, 1:3, II:9, 10, 13, 14, 19,24,25,94,95,
96,112
Nasal branch of sphenopalatine artery, 1:273
Nasal cartilage, II:14
Nasal cavity, 1:178, 217, II:104, 113, 151
Nasal conchae, 1:272
Nasal epithelium, 1:186
Nasal pharynx, 1:94, II:107, 117
Nasal septum, 1:188, II:106, 108, 109, 113
Nasal suture, 1:3
Nasal turbinate. See Turbinate
Nasal vault, II:108, 109
Nasociliary nerve, 1:192
Nasofrontal suture, 1:6
Nasolacrimal apparatus, II:90
Nasolacrimal duct, II:96, 97, 105, 106, 109, 110, 112,
113,115,117
Nasolacrimal sac, II:109
Nasomaxillary suture, II:96
Nasopharyngeal airway, 1:216, II:32, 113, 139
Nasopharyngeal carotid space, 1:240, II:41, 44, 181
Nasopharyngeal internal carotid artery, 1:180
Nasopharyngeal mucosal blush, 1:272
Nasopharyngeal mucosal space, II:127, 128, 142,
151,159
Nasopharyngeal tissue, 1:93,97
Nasopharynx, 1:94, II:107, 117
Neck, II:126-257
axial CECT, II:132-35
axial T1 MR, II:136, 137
axial T2 MR, II:138
carotid space, II:180-85
cervical lymph nodes, II:252-57
cervical trachea and esophagus, II:244-51
coronal T1 MR, II:139
graphics, II:127-30
hypopharynx-larynx, II:214-29
masticator space, II:160-69
overview, II:126-39
parapharyngeal space, II:140-47 •
I
xxv
 INDEX
parathyroid glands, 1I:238-43
parotid space, II:170-79
perivertebral space, 1I:194-201
pharyngeal mucosal space, II:148-59
posterior cervical space, 1I:202-7
retropharyngeal space, II:186-93
thyroid gland, 1I:230-37
visceral space, 1I:208-13
Neck vein, 1:378
Nerve root sleeve, III:89, 148, 149
Nerve roots, spinal, III:130
Neural arch, III:11, 14, 15, 16, 17, 19,20,21
ossification centers, III:16
posterior, III:12, 14, 18, 19,20
Neural foramen, llI:3, 17, 18,43,45
cervical, III:34, 65, 75, 76, 77,82,83,85,88,89,
90,91
lumbar, III:6, 32, 33, 39, 41, 47, 49, 108, 112,
113,116,117
thoracic, III:30, 35, 38, 40, 46, 49, 93, 94, 95, 96,
97,98,99,100,101,102,103,110, Ill, 134,
143
Neurocentral synchondrosis, III:12, 15, 17, 18, 19,
20
Neurohypophysis, 1:86, 97
Neuropore, anterior, 1I:14, 20
Nodulus, 1:107, 133, 135, 136, 139
Nose and sinuses, II:104-13
axial bone CT, 1I:106
axial T1 MR, II:112, 113
coronal bone CT, 1I:107-9
graphics, 1I:105
sagittal bone CT, II:110, 111
Nuchal line, superior, 1:7
Nucleus ambiguus, 1:129, 177,239,241,245,246,
251,252
Nucleus gracilis, 1:149, III:131
Nucleus pulposus, III:27, 39, 40, 42, 43, 48, 103, 106
o rootlets, 1:202
Obex, 1:149, 150, III:131
Oblique capitis inferior, III:50, 52
Oblique capitis superior, III:50
Oblique muscle
external, III:54
inferior, 1:192, 1I:91, 92, 93
internal, III:54
superior, 1:192,194, 197, 205,1I:91, 92
Obturator internus muscle, III:191
Obturator nerve, III:120, 181, 187
Occipital artery, 1:267, 268, 269, 271, 328
Occipital bone, 1:2, 3, 4, 5, 6, 1I:3, 4, 5, 6, 7,8,9,
36,40,149
clival, 1I:8,9, 24, 25, 28, 30, 33, 34, 35, 40, 41,
43,44,45,53
XXVI
condylar (lateral), 1I:40, 41, 42, 53
squamous, 1:7,1I:39, 40
Occipital condyle, 1:258, 259, 386, 1I:4,8, 9, 42, 45,
54, 136, III:16, 37, 45, 65, 66, 69, 70, 73, 77,84,
86,87,166
Occipital crest, internal, 1I:37, 39
Occipital emissary vein, 1:345, 346, 347
Occipital fibers, 1:45, 46
Occipital forceps, 1:43, 44
Occipital horn, 1:80, 152, 153, 158,364
Occipital lobe, 1:28, 29, 30, 32, 33, 34, 35, 38
Occipital nodes, 1I:253
Occipital protuberance
external, 1:7
internal, 1:4, 1I:40
Occipital sinus, 1:335, 343
Occipital vein, 1:380
Occipital white matter, deep, 1:51
Occipitofrontal fasciculus, 1:42, 44, 45
Occipitomastoid suture, 1:4, 7, 1I:5, 6, 7,37,39,40,
53
Occipitotemporal gyrus, 1:29, 36, 41
Occipitotemporal sulcus, 1:29, 77, 78
Oculomotor cistern, 1:200, 203
Oculomotor nerve (CN3), 1:87, 88, 90, 92, 93, 94,
95,105,108,112,118,119,127,166,167,168,
175,176,182,183,184,185,195,196,198-
203,205,207,210,215,216,217,221,223,293,
313,344, 1I:27, 33, 91, 95
axial T1 MR, 1:201
axial T2 MR, 1:200, 201
cavernous, 1:198, 199
cisternal, 1:87,198
coronal T2 MR, 1:202, 203
extracranial, 1:198
graphics, 1:199
in interpeduncular cistern, 1:159,166,171
intra-axial, 1:198
in oculomotor cistern, 1:182
in posterior cavernous sinus, 1:169
Oculomotor nuclear complex, 1:198
Oculomotor nucleus, 1:110,115,117,199,201
Odontoid apex, III:ll
Odontoid ligament, III:56
Odontoid ossification centers, III:16
Odontoid process, 1:251, 259, 325, 1I:42, 45, III:11,
14,16,57,59,63,64,65,71,77,90,166,168
articular facet, III:58
base,'III:68, 69, 72,90
base junction with C2 body, III:67
lateral margin, III:73
posterior cortical margin, III:167
Odontoid synchondrosis, III:14
Odontoid tip, III:66, 68, 69, 70
Odontoid tip ossification center, III:16, 17, 71, 72

Olecranon, III:207, 213
Olfactory bulb, 1:77, 175, 186, 187, 188, 189,11:13
Olfactory glands (of Bowman), 1:186
Olfactory mucosa, 1:188, 11:17,19,21
Olfactory nerve (CN1), 1:175,186-89,11:13
coronal NECT,1:188
coronal T2 MR, 1:188
graphics, 1:187
trigone, 1:299
Olfactory receptor cells, 1:186
Olfactory recess, 1:285, 11:21,22,108,109
Olfactory striae
lateral, 1:186,187
medial, 1:186,187
Olfactory sulcus, 1:29,33, 36,187,189
Olfactory tract, 1:33,36,77,84,175,186,187,188,
189
Olfactory trigone, 1:187
Olivary eminence, 11:28
Olivary nucleus, inferior, 1:129, 249, 255
Olive, 1:180,243
Omohyoid muscle, 11:203
anterior belly, 1:256
inferior belly, 11:203
Operculae, 1:28
Opercular segment of middle cerebral artery, 1:304,
305,307,308,310,311
Ophthalmic artery, 1:90,192,194,197,267,269,
283,286,287,288,289,290,300,301,11:90,91,
93, 100
Ophthalmic nerve, 1:87,88, 94, 175, 176,208,209,
210,211,217,344,11:27
Ophthalmic segment of internal carotid artery,
1:282,283,287,290,291
Ophthalmic vein, 11:90
inferior, 1:89, 192,338,379,380,11:91,99, 100
superior, 1:11,192,194,197,339,355,379,380,
11:91,92,93,99, 100
Opisthion, III:57, 64, 66, 69, 72, 78,85,86, 155
Optic canal, 1:3, 175, 179,285,290,11:3,5,6,9,
18,26,27,29,95,96,97,107,121
Optic chiasm, 1:90,91, 92, 93, 94, 95, 97, 157, 169,
183,185,190,191,193,196,203,215,11:99,101
Optic disc, 1:193
Optic nerve (CN2), 1:92,94, 95, 169, 175, 176, 183,
190-97,293,299,11:10, 13,27,34,91,95,
101,103,112
axial STIRMR, 1:193
axial T1 MR, 1:197
chiasmatic segment, 11:101
cisternal segment, 11:99
coronal T1 MR, I:194
coronal T2 MR, 1:195,196
graphics, 1:191,192
head, 11:99,103
intracanalicular segment, 11:99,100, 101
INDEX
intraorbital segment, 11:99,100,101
in optic canal, 1:88, 90
sagittal T1 MR, 1:197
Optic nerve-sheath complex, 11:91,92, 93, 98-101
axial coronal STIRMR, 11:101
coronal and axial T1 MR, 11:100
graphics, 11:99
Optic pathway, I:190
Optic radiation, 1:190, 191
Optic recess, 1:149,159,168,203
Optic sheath, 11:99,100, 103
Optic strut, 11:95,97, 99, 100
Optic tract, 1:63,87, 91,119,156,157,159,167,
183,185,190,191,193,195,201,203,206,210,
223,293,11:99, 101
Oral cavity, 11:159,260-67
axial CECT,11:263,264
axial T2 MR, 11:265,266
coronal T1 MR, 11:267
floor of mouth, 11:269,293
graphics, 11:261,262
mandible and maxilla, 11:292-93
mucosal surface, 11:159,269
overview, 11:260-67
retromolar trigone, 11:288-91
sublingual space, 11:270-75
submandibular space, 11:276-81
tongue, 11:282-87
Oral mucosal space, 11:260,262,268-69,272,278
Oral pharynx, 11:153,219, 256, 269
Oral tongue, 11:139,155,158,257,260,261,269,
291
Orbit, II:15, 90-93
bones and foramina, 11:94-97
coronal T1 MR, 11:92
graphics, 11:91
oblique sagittal T1 MR, 11:93
oculomotor nerve at, I:199
Orbit periosteum, 1:191
IS, Orbital apex, 11:17
Orbital branch, 1:211
Orbital fissure
inferior, 1:3,178,212,284,11:7,8,17,18,26,30,
34,95,96,97,107,108,112,120,121,122,
123, 167
100, superior, 1:3,90,175,179,212,214,285,11:3,6,
7, IS, 16, 18,26,27,29,30,33,95,96,97,
107, 121, 122
Orbital gyri, 1:29, 189
Orbital mucosal blush, 1:272
Orbital plate of frontal bone, 1:188
Orbital roof, 11:5,IS, 19,21
Orbital septum, 11:93
Orbital sulcus, 1:29
Orbital vein, 1:378
•
I
XXVII
 INDEX
Orbitofrontal artery, 1:298, 299, 300, 301, 303, 305, Palatopharyngeus muscle, 11:157
306 Palmar muscular branch of median nerve, III:196,
Orbitosphenoid, 11:28 211
Organ of Corti, 1:141, 237, 11:63 Papilla, circumvallate, 11:261,269, 283
Oropharyngeal airway, 11:193 Paraglottic space, 11:215,218, 220, 221, 223, 225,
Oropharyngeal mucosal blush, 1:272 227,228
Oropharyngeal mucosal space, 11:127,128,142,151, Parahippocampal gyrus, 1:29, 30, 36, 37, 38, 41, 77,
159,277 78,79,81,83,85,187
Oropharynx, 11:153,219, 256, 269 Paramedian thalamic artery, 1:73
Osborne fascia, II1:207 Paranasal sinuses, 11:104
Osseous spiral lamina, 11:54,63 Parapharyngeal space, 11:128, 129, 131, 132, 136,
Ossicles, 11:76-81 138, 139,11:140-47,11:149, 150, 152, 154, 155,
Ossification, III:10-25 156, 157, 158, 159, 161, 162, 163, 165, 166, 168,
axial bone CT, II1:14-21 169,171,172,175,176,177,178,179,181,182,
cervical vertebra, II1:14-18 184,187,188,189,193,257,263,265,267,281
coccyx, II1:22 axial CECT,11:143, 144
graphics, III:11-13, 23 axial T1 MR, II:145, 146
lumbar vertebra, II1:20 coronal Tl MR, 11:147
patterns, II1:10 fat in, 11:132
sacrum, 111:21 graphics, 11:141,142
sagittal bone CT, II1:22 inferior, 11:139
sagittal T1 MR, II1:24 Paraspinal muscles, 11:133,134, 135, 137, 138, 195,
sagittal T2 MR, II1:25 199,203,206,207, II1:50-55
thoracic vertebra, III:19 axial CECT, II1:52-54
Ostiomeatal unit, 11:114-17 cervical, II1:51, 52
coronal bone CT, 11:116 coronal CECT, II1:55
graphics, 11:115 graphics, II1:51
sagittal bone CT, II:117 lumbar, II1:51, 54
Outer arch of limbic system, 1:76, 77 thoracic, II1:53
Outer dural layer, 1:10, 353 thoracolumbar, II1:54
Outer pial layer, I:17 Paraspinal perivertebral space, 11:128,129, 130, 132,
Outer table, 1:3, 5, 7, 10 133,134,135,137,138,195,196,199,200,203,
Oval window, 1:228, 229, 11:51,64, 71, 77, 78 204,205,206
Parasympathetic fibers, chorda tympani nerve, 11:73
Parasympathetic nuclei, I:198
p Paraterminal gyrus, 1:77
Pachymeninges. See Dura Parathyroid gland, 1:247, 11:209,232, 236
Palatal mucosal blush, 1:272 Parathyroid node, 11:232
Palate Paratracheal node, 1:247, 11:209,212, 232, 237
hard, 11:122,145, 156,269 Parietal artery, 1:306
soft, 1:241, 11:145,151,155,157,159,285 Parietal bone, 1:2, 3, 4, 5, 6, 7, 11:3,4
Palatine artery, 1:267, 272, 273 Parietal foramen, I:7
Palatine bone, 11:4,9, 94, 95 Parietal lobe, 1:28, 32, 35, 37, 38
Palatine canal, greater, 11:121, 122 Parietomastoid suture, 1:6
Palatine foramen Parietooccipital artery, 1:279, 313, 314, 315, 317,
greater, 11:4,18, 108, 110, 120, 121, 122 318,319,320,321,328,330
lesser, 11:120 Parietooccipital sulcus, 1:30, 34, 35, 39,161,165
Palatine nerve, 11:119,123 Parietooccipital vascular blush, 1:315
greater, 1:211, 11:27,119 Parotid duct, 11:131,136,138,175,177,178,179
lesser, 1:211, 11:27 Parotid gland, 1:219, 230, 11:47,136, 143, 166, 168
Palatine process, 11:9 accessory, 11:136,166,177,179
Palatine tonsil, 11:132,139,143,144,147,150,151, deeplobe,II:17~173,175,17~177,179
152,155,157,158,159,191,192,265,267,269, lobes, 11:145,146, 147
273,274,281,283,286,289,291 malignancy, II:174
Palatoglossus muscle, 1:256, 11:150,261, 269, 283, superficial lobe, 11:173,175
284,286,287 tail, 11:136,174,176,279
Parotid nodes,.II:I72, 253, 255
XXVIII
 INDEX
coronal Tl and STIRMR, III:198
Parotid space, II:4, 127, 128, 129, 131, 132, 136, 138, graphics, III:195-97
139, 141, 142, 143, 144, 145, 146, 147, 161, 162, Peripheral white matter, III:136
163,165,166,168,170-79,182,189,206, Peritentorial cisterns, 1:160
III:117 Perivascular spaces (PVSs),1:8, 15, 16-25, 72
anterior, II:127, 142, 161 axial FLAIRMR, 1:24
axial CECT,II:175, 176 axial Tl C+ MR, 1:25
axial Tl MR, II:l77, 178 axial T2 MR, 1:19, 20, 23, 24, 25
axial T2 FSMR, II:179 coronal T1 MR, 1:25
deep, II:262 coronal T2 MR, 1:21, 22, 24
generic mass, II:173 graphics, 1:17, 18
graphics, II:171-74 normal variants and anomalies, 1:16
perineural malignancy, II:174 Perivenular space, 1:18
Pars distalis, 1:88 Perivertebral space, II:130, 132, 141, 181, 182, 185,
Pars interarcularis, III:31, 33, 36 194-201,207
cervical, III:43, 75 axial CECT,II:199, 200
lumbar, III:47, 49, 105, 106, 107, 108 axial T2 and coronal STIRMR, II:201
thoracic, III:44 graphics, II:195-98
Pars intermedia, 1:86, 88 paraspinal component, II:128, 129, 130, 132,
Pars nervosa, 1:88, 178, 179,239,242,248,253, II:6, 133,134,135,137,138,195,196,199,200,
37,38,39,40,53 203,204,205,206
Pars tuberalis, 1:88 prevertebral component, II:128, 129, 130, 132,
Pars vascularis, 1:178,179,242,248,253, II:6, 7,37, 133, 134, 135, 136, 138, 152, 154, 155, 156,
38,39,40,53,69 157, 158, 187, 188, 189, 191, 192, 193, 195,
Patella, III:227 196,197,198,199,200,201,202,203,205,
Pedicle, III:3, 6, 30 206,209,210,211
cervical, III:28, 29, 34, 43, 45,75,76,89,91 Peroneal nerve, common, III:222-27
lumbar, lII:8, 27, 28, 31, 32, 33, 36, 39, 41, 47, axial Tl MR, III:224-27
105,106,107,108,109, Ill, 117 graphic, III:223
thoracic, lII:8, 27, 28, 30, 35, 38, 40, 46, 49, 53, Perpendicular plate of ethmoid bone, II:17, 19,21,
93,94,95,96,97,98,99,100,101,102,103, 22,23
110,134 Petroclinoid ligament, 1:199
Penetrating artery, 1:23,281 Petrooccipital fissure, 1:179, 242, 248, II:6, 7, 30, 31,
Penetrating branches. See Perforating branches 37,40,43,44
Penetrating cortical artery, 1:17, 18 Petrooccipital suture, 1:4
Penetrating lenticulostriate artery, 1:21 Petrosal fissure, 1:138
Percheron, artery of, 1:73 horizontal, 1:105, Ill, 113, 133, 136, 137, 138,
Perforating branches 139
anterior cerebral artery, 1:298 Petrosal nerve, greater superficial, 1:224, 225, 226,
basilar artery, 1:281, 324, 328 II:48, 67,73,75,172
middle cerebral artery, 1:304 Petrosal sinus
posterior cerebral artery, 1:312 inferior, 1:248, 335, 338, 343, 348, 351, 355, 356,
Periaqueductal gray matter, 1:33, 108, 110, 115, 117, 359,373,374,376,386, I1:7,38, 44, III:166
119,152,201 superior, 1:90, 335, 338, 339, 343, 348, 355, 357,
Pericallosal artery, 1:171, 298, 299, 300, 301, 302, 360,375,377,379,380,382, 385,II:38
303,368 Petrosal vein, 1:164, 338, 339, 365, 372, 373, 374,
Pericallosal branch of anterior cerebral artery, 1:319 375,377
Pericallosal cistern, 1:161, 171 Petrosal venous plexus, 1:374
Pericallosal pial plexus, 1:300, 301 Petrosquamosal suture, 1:6
Pericranium, 1:2,3 Petrous apex, 1:4,142,179,242,248,253,285, II:5,
Perineurium, III:197 6,30,39,40,50,57,59
Perioptic cerebrospinal fluid, II:99, 100, 101, 103 air cells, II:85
Periorbita, 1:191, II:90 marrow, 1:218, II:10, 51,75
Periosteal dural layer, 1:10, 353 Petrous carotid canal, 1:286, 288
Peripheral nerves, III:194-227
axial Tl and FST2 MR, III:199 •
I
XXIX
 INDEX
Petrous internal carotid artery, 1:89, 90, 92, 93, 212, Pituitary gland, 1:86-97, 169, 176, 182, 185, 196,
214,268,269,270,282,381 210,216, ll:24, 33
genu, 1:283,284, 286, 287, 288, 289 axial T1 C+ MR, 1:89, 90
horizontal, 1:218, 229, 242, 248, 253, 283, 286, coronal T1 C+ MR, 1:93, 94
287,288, 289, ll:6, 7,30,34,39,40,43,49, coronal T2 MR, 1:91, 92
53,57, 71,85 graphics, 1:87,88
vertical, 1:219,227, 229, 242, 248, 283, 286, 287, normal variants, 1:86
288,289, ll:7, 10,31,40,49,53,56,71, 174 sagittal fat-saturated T1 MR, 1:97
Petrous temporal bone, 1:4,ll:3, 9, 27, 28, 30, 36, 37 sagittal T2 MR, 1:95, 96
Pharyngeal artery, ascending, 1:266, 267, 268, 269, Pituitary infundibulum, 1:88, 90, 91, 92, 93, 95, 97,
271, ll:49 168,169,182,183,191,196,201,203,216,299,
Pharyngeal constrictor muscle, ll:144, 146,215,216, 339, ll:lO, 99
286,287 Planum sphenoidale, ll:3, 9, 12, 13, 18,24,25,35
inferior, ll: 150, 151 Platysma muscle, 1:274, ll:132, 133, 134, 137, 138,
middle, ll:151, 158 139,147,176,181,262,264,266,267,275,277,
superior, ll:147, 149, 150, 151, 152, 155, 157,261, 278,279,280,281,283,284,285,287
265,289,290,291 Pneumatized pterygoid process, ll:10
Pharyngeal mucosal space, ll:4, 127, 128, 129, 131, Pons, 1:33,45, 97,104,105,107,111,112,113,
132, 136, 137, 138, 139, 141, 142, 143, 144, 145, 120-27,135,138,139,144,159,181,182,184,
146,147,148-59,162,168,187,188,191,192, 200,202,213,214,222,223,236,259, ll:45,
193 III:167
axial T1 MR, ll:154, 155 axial T1 MR, 1:122, 123
axial T2 MR, ll:156-58 axial T2 MR, 1:124, 125
barium swallow, ll:153 coronal T2 MR, 1:126,127
coronal T1 C+ MR, ll:159 dorsal, 1:55
generic mass, ll:152 graphics, 1:121
graphics, ll:149-51, 152, 159 lateral, 1:218
Pharyngeal plexus, 1:246 maturational changes, 1:53-62
Pharyngeal recess, lateral, ll:152, 154, 156, 159 superior, 1:135
Pharyngobasilar fascia, ll:148, 151 ventral (anterior), I:120, 184
Pharyngoepiglottic fold, ll:151, 215, 227 Ponticulus posticus, 1:325
Pharyngotympanic groove, ll:4 Pontine belly, 1:145,185,195
Pharynx. See also Hypopharynx Pontine fibers, transverse, 1:46
nasal portion, 1:94, ll:107, 117 Pontine membrane, anterior, 1:124
oral portion, ll:153, 219, 256, 269 Pontine perforating branches of basilar artery, 1:324
sensory from, 1:241 Pontine venous plexus, 1:11
Phrenic nerve, ll:195, 199 Pontomedullary junction, 1:113, 126, 127, 131, 139,
Pia, 1:8,9, 10, 16-25, 162,353, III:140, 142, 144, 184,230,236
145 Pontomesencephalicvein, anterior, 1:372, 373, 374
axial FLAIRMR, 1:24 Pontomesencephalic venous plexus, anterior, 1:339,
axial T1 C+ MR, 1:25 368,377
axial T2 MR, 1:19, 20, 23, 24, 25 Popliteal artery and vein, III:225, 226, 227
coronal T1 MR, 1:25 Porus acusticus, 1:142, 144, 145, 181, 184,234,236,
coronal T2 MR, 1:21, 22, 24 237, ll:37, 39, 43, 50, 55, 61
graphics, 1:17, 18 facial nerve in, 1:231
Pia mater, 1:10,III:142 posterior margin, ll:42
Pial plexus, pericallosal, 1:300, 301 Porus trigeminus, 1:179, 209, 213, 214, 218, ll:53
Pineal gland, 1:98,99, 100, 101, 159,337,365 Postcentral gyrus, 1:29,30, 35, 38, 39
Pineal recess ofthird ventricle, 1:99, 101, 149 Postcentral sulcus, 1:29
Pineal region, 1:98-101 Postcentral sulcus artery. See Anterior parietal artery
coronal T2 MR, 1:100 Postcommunicating segment of anterior cerebral
graphics, 1:99 artery, 1:170,293, 294, 296, 299, 300, 301, 302,
sagittal T2 MR, 1:101 303,311
Piriformis muscle, III:120, 123, 187, 188, 189, 190 Posterior arch, lll:6, 11,29,37,63,64,67,72,73,
Pisiform, III:208, 209, 215 78,79,84,85,86,87,168
Posterior atlanta-occipital membrane, III:56, 57

xxx
 INDEX
Posterior auricular artery, 1:266, 267, 268, 272
Posterior auricular branch of facial nerve, 1:225,
11:172
Posterior auricular vein, 1:380, 383
Posterior cerebral artery, 1:95,118,125,127,166,
182,184,185,195,199,200,201,202,205,206,
207,210,223,286,296,297,300,306,308,
312-21,324,327,328,329,330,331,359,366,
367,368
ambient (P2) segment, 1:152, 164, 166,294,312,
313,314,315,316,317,320,321
anterior temporal branch, 1:316
AP CTA, 1:318
AP VADSA, 1:315
axial CTA, 1:321
branches, 1:312
calcarine (P4) segment, 1:312, 313, 314, 315, 316,
317,318,319
embryology, 1:312
"fetal" origin, 1:316
graphics, 1:279, 280, 281, 313
horizontal segment, 1:293, 296
LAT,AP ICA DSA, 1:316
lateral CTA, 1:319, 320
lateral VADSA, 1:314
MRA,1:317
normal variants and anomalies, 1:312
precommunicating (PI) segment, 1:293, 294, 295,
312,313,315,317,318,321,327,330
quadrigeminal (P3) segment, 1:312, 313, 314,
315,316,317,318,319,320
splenial branch, 1:299, 319, 324
vascular territory, 1:278, 280, 281, 312
Posterior cervical line, II1:63
Posterior cervical space, 11:129,132, 133, 134, 135,
136,137,138,144,176,178,184,185,199,200,
202-7
axial CECT, 11:206
coronal T1 MR, 11:207
generic mass, 11:205
graphics, 11:203,204, 205
nodal stations/diseases, 11:204
Posterior cervical spine, II:195
Posterior chamber of globe, Il:102, 103
Posterior choroidal artery
lateral, 1:313, 314, 318, 319, 320, 321, 324, 328,
368
medial, 1:99,162,313,314,319,321,324,328,
359
Posterior clinoid process, 11:3,5, 29, 37
Posterior commissure, 1:42, 99, 101, 152,11:221
Posterior communicating artery, 1:182, 200, 203,
279,283,286,289,291,293,294,295,296,297,
302,308,313,314,317,319,321,327,328,330
Posterior cranial fossa, 1:4, 104,11:5,6
Posterior cribriform plate, 11:16
Posterior cricoarytenoid muscle, 11:216,222, 228
Posterior ethmoid(s), 11:105,117
Posterior ethmoid air cells, 11:15,16, 17,20,29,30,
33, 110, 111, 112
Posterior ethmoid complex, 11:106
Posterior ethmoid nerve, 1:211, 11:27
Posterior ethmoid sinus, 11:8,9, 10
Posterior ethmoidal foramen, 11:12,13,16
Posterior fossa cistern, I:160
Posterior fossa vein, 1:372-77
AP VADSA, 1:375
axial T1 C+ MR, 1:376, 377
graphics, 1:373
LATDSA,1:374
Posterior iliac spine, II1:54
Posterior inferior cerebellar artery, 1:111, 112, 163,
180,243,253,279,281,324,326,327,328,329,
330,331
anterior medullary segment, 1:324, 329, 330
branches, 1:328
caudal loop, 1:330
hemispheric branches, 1:328
lateral medullary segment, 1:324, 328
posterior medullary segment, 1:328
supratonsillar segment, 1:324, 328
tonsillar (cranial loop), 1:330
Posterior intercavernous sinus, 1:90, 335
Posterior interosseous nerve, II1:201
Posterior longitudinal ligament, II1:27, 32, 37, 38,
39,43,48,57,72,87, Ill, 115, 127, 141
Posterior medullary segment of posterior inferior
cerebellar artery, 1:328
Posterior meningeal artery, 1:324
Posterior mesencephalic vein, 1:374
Posterior middle meatus, 11:108
Posterior neural arch, III:12, 14, 18, 19,20
Posterior parietal artery, 1:306
Posterior perforated substance, 1:166
Posterior pituitary vascular blush, 1:286
Posterior radiculomedullary artery, III:153
Posterior (dorsal) ramus, II1:153, 195
Posterior ring, 1:325, 11:217
Posterior scalene muscle, II:134, 135, 137, 195, 198,
200,206, II1:51, 52,176
Posterior segment of globe, 11:102
Posterior segmental artery, II1:154
Posterior semicircular canal, 1:228, 234, 11:50,51,
54,59,60,64,65,74,75
Posterior semicircular duct, 11:49,63
Posterior septal branch, of sphenopalatine artery,
1:273
Posterior skull base, 11:27,36-45
axial bone CT, 11:39-41
axial T1 C+ MR, 11:44
coronal bone CT, 11:42,43
coronal T1 C+ MR, Il:45 •
graphics, Il:37, 38 I
XXXI
 INDEX
Posterior spinal artery, 1II:153, 154
Posterior spino-laminar line, 1II:63, 64
Posterior stapes crura, I1:52, 77
Posterior superior recess, I:151
Posterior temporal artery, 1:207, 313, 314, 315, 317,
318,320
Posterior temporal lobe, 1:315
Posterior thalamoperforating artery, 1:297, 313, 314,
315,319,324,328
Posterior third ventricle, 1:165
Posterior tonsillar pillar, II:150
Posterior tubercle, 1II:34, 44, 58, 75,82,83
Posterior vertebral line, III:78
Postolivary sulcus, 1:106, 130, 180,243,249,253
Postsphenoid, I1:28, 35
Prebiventral fissure, 1:133, 139
Precentral cerebellar vein, 1:337, 349, 364, 368, 372,
373,374
Precentral gyrus, 1:29, 30, 35, 38, 39
Precentral sulcus artery, 1:306
Precommunicating segment
anterior cerebral artery, 1:169, 293, 294, 295, 296,
299,301,302,303,309
posterior cerebral artery, 1:293, 294, 295, 312,
313,315,317,318,321,327,330
Precuneus, 1:30
Pre-epiglottic space, I1:215, 218, 220, 225, 226, 227,
229
Prefrontal artery, 1:306
Preganglionic segment of trigeminal nerve, 1:87,
145,175,182,184,195,208,209,211,213,214,
215, 218,222, I1:27,61
Prenasal space, I1:14
Preolivary sulcus, 1:106, 129, 130, 177, 180,249,253,
257
Prepiriform area, 1:187
Prepontine cistern, 1:9,90, 107, 110, 123, 125, 15I,
159,161,162,167,170,171,182,200,203,213
abducens nerve in, 1:223
anterior inferior cerebellar artery in, 1:167
basilar artery in, 1:164,166,167,170
Prepontine segment of trigeminal nerve, 1:184
Prepyramidal fissure, 1:105, 113, 133, 139
Presphenoid, I1:28,35
Pretectal nucleus, 1:191,193
Prevertebral muscle, I1:133, 135, 136, 143, 144, 145,
154, 156, 158, 190, 191, 192, 193, 195, 197, 198,
199,200,210,211,235,257, 1II:50
Prevertebral soft tissue, 1II:79,85
Prevertebral soft tissue line, 1II:78, 86, 87
Prevertebral space, I1:128, 129, 130, 132, 133, 134,
135, 136, 138, 152, 154, 155, 156, 157, 158, 187,
188, 189, 191, 192, 193, 195, 196, 197, 198, 199,
200,201,202,203,205,206,209,210,211,
1II:37
Primary fissure, 1:105, 113, 133, 136, 139
XXXII
Proatlantal intersegmental artery, 1:331
Projection fibers, 1:42, 46
Pronator quadratus muscle, 1II:208, 214
Pronator teres muscle, 1II:207, 213
Proximal basilar artery, 1:331
Proximal branch of external carotid artery, 1:274
Prussak space, I1:50, 51, 56, 68,77,78,80
Psoas muscle, 1II:8,32, 33, 50, 51,54, 110, 111, 113,
114, 115, 116
femoral nerve descending through, 1II:217, 218,
219,220
lumbar plexus traveling along, 1II:181, 182, 183,
184,185
Pterion, 1:2, 6
Pterygoid canal. See Vidian canal
Pterygoid muscle
lateral, 1:211, 216, 219, I1:83, 123, 131, 139, 145,
147,154,156,161,165,167,168,169,173
medial, 1:211, 216, 219, I1:131, 132, 136, 138,
139, 143, 144, 145, 146, 147, 156, 161, 162,
165,166,168,169,173,175,176,177,178,
179,199,265,267,274,277,280,281,286,
287,290,291
Pterygoid plate
aerated, I1:123
lateral, I1:32, 107, 113, 120, 121, 123, 143, 162,
165
medial, I1:32, 107, 113, 120, 121, 131, 143, 155,
156,157,162,165,166,168,289,290,291
Pterygoid process, 1:219, I1:9,34
Pterygoid venous plexus, 1:338, 345, 346, 355, 361,
378,379,380,381, 383, 384, 386, 387, I1:145,
165,169
Pterygoid wing of sphenoid bone, II:113, 139
Pterygomandibular gap, I1:263
Pterygomandibularraphe, 11:146,151,155,157,
166,260,261,269,289,290,291
Pterygomaxillary fissure, I1:8, 18,30,31,106,107,
108, 120, 121, 123, 165, 167
Pterygopalatine fossa, 1:267, 268, 284, 11:8,10, 18,
30,31,33,34,96,106,107,108,110,113,
118-23, 165, 167
axial bone CT, 11:120
axial T1 MR, I1:123
coronal bone CT, I1:121
graphics, II:119
sagittal bone CT, 11:122
Pterygopalatine ganglion, 1:211, 212, 218, 219,
I1:27, 119, 123
Pudendal nerve, III:120, 181, 187
Pulvinar thalamus, 1:41, 68,71,72,73
Putamen, 1:34, 36, 40, 41, 48, 61, 62, 64, 65, 66, 67,
68,69,70,71,72,73,74,75,117
PVSs. See Perivascular spaces (PVSs)
Pyramid, 1:133, 139, 180,243
Pyramidal decussation, I:105
 INDEX
Pyramidal eminence, 1:226, 227, 228, 11:51,54,70,
73, 79
Pyriform sinus, 11:150,151,153,193,210,212,215,
219,220,221,223,224,225,227,228
Pyriform sinus apex, 11:216,219, 224
Q Retromaxillaryfatpad, 11:106,113,123,128,131,
Quadrangular membrane, 11:218
Quadratus lumborum muscle, I1I:51, 54,181,217
Quadriceps femoris tendon, I1I:226
Quadrigeminal cistern, 1:9,31,101,105,116,119,
136,139,152,161,162,164,165,170,206,318
CSF in, 1:23
internal cerebral vein in, 1:165
Quadrigeminal plate. See Tectum
Quadrigeminal segment of posterior cerebral artery,
1:312,313,314,315,316,317,318,319,320
R Retropharyngeal space, 11:127,128, 129, 130, 132,
Radial nerve, I1I:173, 196,200-203,206,211,212,
213
axial T1 MR, I1I:202, 203
deep branch, III:196, 201, 203, 211, 213
graphic, I1I:201
superficial branch, I1I:196, 201, 203, 211, 213
Radicular vein, I1I:163
Radiculomedullary artery, I1I:153, 154
Radius, II1:196, 205, 208, 209, 211, 214
Ramus(i)
anterior (ventral), II1:195
brachial plexus, II1:173-76, 178, 179
lumbar plexus, II1:181-83
mandibular, 1:219, 11:83,84, 85,136,138,143,
144,165,166,168,169,290,291
posterior (dorsal), II1:153, 195
spinal, 1:326
Ranawat measurement, II1:62
Rectus capitis muscle, I1I:50
Rectus muscle
inferior, 1:192, 194, 197,11:91,92,93, 112
lateral, 1:191,192,193,194,197,11:91,92,101
medial, 1:191,192,193,194,197,11:91,92,101,
112
superior, 1:192,194,197,199,11:91,92,93,101
Recurrent artery of Heubner, 1:298, 301, 303
Recurrent laryngeal nerve, 1:246, 247, 11:134,181,
209,216,222,232
Red nucleus, 1:41,81, 84,108,115,117,119,137,
199
Rediund-]ohneliline, I1I:60, 62
Reissner membrane, 11:63
Renal artery, III:161
Restiform body. See Inferior cerebellar peduncle
Reticular formation, 1:114
Retina, I:192, II:102, 103
Retinal artery and vein, I:192, 11:99
Retrobulbar fat, 1:197
Retrocondylar vein, I1I:66, 167
Retromandibular vein, 1:378, 380, 383, 384, 386,
387,11:131,136,138,143,166,171,172,175,
176, 177, 178, 179, 184, II1:52
136, 138, 143, 145, 146, 154, 156, 161, 163, 165,
166, 167, 168
Retromolar trigone, 11:166,168,261,288-91
axial T1 MR, 11:291
axial T2 MR, 11:290
graphics, 11:289
mucosa, 11:269,289
Retro-olivary sulcus, 1:257
Retropharyngeal node, 11:253,257
cervical, 11:257
lateral, 11:187,193,257
medial, 11:187,257
136, 137, 138, 141, 142, 146, 149, 150, 155, 157,
158,181,185,186-93,195,196,197,199,200,
206,209,210,211,213,233,257
axial bone CT and T2 MR, 11:193
axial CECT, 11:191
axial T1 MR, 11:192
fat in, 11:132,133
generic mass, 11:189,190
graphics, 11:187-90
lateral, 11:145,146,181,184,189
Retropulvina cistern, 1:152
Retrozygomatic node, 11:253
Rhomboid muscle, I1I:50
Rib(s), II1:95, 99,103
with costotransverse joint, II1:5
with costovertebral joint, II1:5
fifth, II1:94
first, 11:135,I1I:5, 6, 8, 37, 79,81,84,86,87,94,
168,169,176,178,179
inferior demifacet for, I1I:27, 35, 38, 93
medial portion, II1:8, 40, 44, 95, 96, 97, 98, 99
ossification center, III:19
overlapping, I1I:30
second, II:135, II1:84, 179
superior demifacet for, II1:27, 35, 38, 93
thoracic, I1I:5, 30, 35, 46, 55,107
twelfth, II1:5, 94
Right vertebral artery, III:153
Rolandic sulcus. See Central sulcus
Rosenthal, basal vein of, 1:99, 100, 101, 165, 195,
207,318,321,335,336,339,340,343,345,346,
349,353,355,356,357,359,360,361,363,364,
365,366,367,368,369,371,373, III:166
Rotatores muscle, I1I:50, 55
Rotundum notch, 11:121 •
I
xxxiii
 INDEX
Round window, II:52, 79 Sagittal sinus
membrane, II:64 inferior, 1:9, 12,335,342,343,345,346,347,350,
niche, 1:228, II:55, 64, 70 355,356,359,361,362,364,373
superior, 1:5,9, 10, 11, 12, 13, 14, 15,39,303,
s 335,341,342,343,345,346,347,349,350,
351,353,354,355,356,357,363,369,370,
Sl, III:120, 135 371,375, II:38
body, III:107, 112, 114, 115, 119, 121, 122, 125, Sagittal suture, 1:5, 6, 7
126,127 Salivatory nucleus
nerve, III:112, 114, 117, 122, 123, 126 inferior, 1:177, 239, 241
superior articular process, III:49, 117, 119, 122 superior, 1:224, 225, II:48, 67, 73
superior endplate, III:119 Santorini fissures, II:47
vertebral body, III:106, 115 Scala media, 1:141, 237, II:62, 63
Sl-2, disc remnant, III:122, 127 Scala tympana, 1:141, 237, II:60, 62, 63, 65
Sl-3, ventral nerve, III:120 Scala vestibula, 1:141, 237, II:60, 62, 63, 65
S2, III:120 Scalene muscle, III:50, 175
nerve, III:123 anterior, II:134, 135, 137, 138, 191, 195, 198, 199,
vertebral body, III:144 200,201,202,206,207, III:51, 52,174,176,
S3, III:120, 127 179
Sacral ala, III:4, 8, 54,107, 114, 119, 121, 122, 123, middle, II:134, 135, 137, 138, 195, 198, 199,200,
124,125,126,218 201,202,206,207, III:51, 52,176,179
Sacral articular process, III:114 posterior, II:134, 135, 137, 195, 198,200,206,
Sacral canal, III:119, 123, 124, 127 III:51, 52,176
Sacral crest, III:121, 122, 124, 127 Scalp, 1:2-7, 14
Sacral facet joint, III:122 3D-VRTNECT, 1:6,7
Sacralforamen, III:8, 107, 119, 121, 122, 123, 124, axial NECT, 1:4, 5
125,126 embryology, 1:2
Sacral hiatus, III:121, 127 graphics, 1:3
Sacral plexus, III:120, 186-91 layers, 1:2, 3, 5
axial T1 MR and FST2 MR, III:189-91 sagittal T1 MR, 1:5
coronal T1 MR, III:188 Scalp vein, 1:341, 351, 378, 384
graphics, III:187 Scapula, III:7
Sacral promontory, III:119, 121, 127 Scapular nerve, dorsal, II:203
Sacral root, III:4, 126 Sciatic nerve, III:4, 120, 123, 181, 186-91,223,224
Sacral rudimentary disc, III:127 axial T1 and FS T2 MR, III:199
Sacrococcygeal joint, III:119, 125, 127 axial T1 MR and FST2 MR, III:189-91
Sacroiliac joint, III:8, 21, 54, 107, 114, 115, 119, coronal T1 MR, III:188
121, 122, 124, 125, 126 graphics, III:187
epiphyseal plate, III:12 Sclera, 1:192, 197, II:99, 102, 103
synovial component, III:123, 124 "Scotty dog," III:107
Sacroiliac ligament, interosseous, III:123, 124 Scutum, 1:229, II:47, 52, 55, 56, 57, 71, 77, 78, 79,
Sacrum, III:3, 6, 9, 26, 118-27. See also Sl through 80
S3 Sebaceous gland, 1:3
3D-VRTNECT,III:121 Second rib, II:135, III:84, 179
articular process, III:114 Segmental artery, III:38, 106, 159
axial NECT, III:124 dorsal branch, III:154
axial T2 MR, III:122, 123 lumbar, III:114, 115
body, III:119 muscular branch, III:153, 154
coronal NECT, III:125 posterior, III:154
coronal T1 MR, III:126 thoracic, III:153, 154, 161
graphics, III:119, 120 ventral branch, III:153
lateral radiography, III:125, 127 Segmental ganglion, III:41
median crest, III:119 Segmental nerve, III:39
ossification, III:13, 21 sulcus for, III:43, 44
pelvic surface, III:119, 121, 122, 124, 126, 127 thoracic, III:38
sagittal T2 MR, III:127 Segmental vein, III:38, 106, 114, 115, 163

xxxiv
 INDEX
Sella, 1:86-97, II:5, 15 axial bone CT, II:5-8
axial T1 C+ MR, 1:89, 90 axial T1 MR, II:ll
coronal T1 C+ MR, 1:93, 94 central, II:26-35
coronal T2 MR, 1:91, 92 graphics, II:3, 4
floor, 1:89, 92 overview, II:2-11
graphics, 1:87, 88 posterior, II:36-45
sagittal fat-saturated T1 MR, 1:97 sagittal bone CT and T1 MR, II:10
sagittal T2 MR, 1:95, 96 Skull base segment
Sella turcica, 1:285, Il:9, 29, 35, 96 accessory nerve, 1:250
Semicircular canal glossopharyngeal nerve, 1:238
lateral, 1:225, 228, 229, 234, 258, II:50, 54, 55, 59, hypoglossal nerve, 1:254
61,65,67,70,71,74,75,78,80,172 vagus nerve, 1:244
posterior, 1:228, 234, II:50, 51, 54, 59, 60, 64, 65, Soft palate, 1:241, II:145, 151, 155, 157, 159,285
74, 75 Solitary tract nucleus, 1:121,129,177,224,225,239,
superior, 1:229, 234, 236, 237, II:50, 54, 55, 56, 241,245,246, II:48, 67, 73
59,61 Sphenoethmoidal recess, II:105, 108, 117
Semicircular duct Sphenoid bone, 1:94, II:4, 14,41,94, 149, 167
lateral, II:49, 63 body, II:8, 24, 25, 29, 32, 34
posterior, II:49, 63 greater wing, 1:3, 4, 6, 179,295,309, II:3, 6, 7,8,
superior, II:49, 63 15,16,27,29,30,32,33,96
Semilunar ganglion. See Trigeminal ganglion lesser wing, 1:295, 309, II:3, 5, 9, 12, 13, 18,27,
Semispinalis muscle, 1II:50,51, 52 96
Semispinalis thoracis muscle, 1II:55 pterygoid wing, II:l13, 139
Sensory branch of superior laryngeal nerve, 1:246 Sphenoid ostia, II:105
Sensory nucleus of trigeminal nerve, 1:121, 208, Sphenoid sinus, 1:4,87, 89, 97,176,210,212,214,
209,213 217,218,257,285, II:5, 6, 7, 10, 13, IS, 16, 17,
Septal blush, 1:272 18,20,24,25,29,30,31,33,34,35,97, lOS,
Septal vein, 1:335, 336, 337, 340, 345, 350, 359, 360, 106,107,108,110, Ill, 112, 117, 120, 121, 122,
361,362,363,366,370 123, 139
Septum, frontal, II:106 ostium, II:17
Septum pellucidum, 1:41,69, 77, 79,81, 153, 155, in sphenoid body, II:29
156,157,365 Sphenooccipital fissure, 1:212
Septum posticum, 1II:140, 142 Sphenooccipital synchondrosis, 1:242, 248, 257,
Short arcuate fibers, 1:43 II:7, 8,17,25,26,28,30,31,35,39, 40,lII:17
Short ciliary nerve, 1:211 Sphenopalatine artery, 1:267, 272, 273
Sigmoid plate, 1:242, II:39, 50, 53 nasal branch, 1:273
Sigmoid sinus, 1:107,142,242,248,335,338,341, posterior septal branch, 1:273
342,343,345,347,348,351,354,370,376,384, Sphenopalatine foramen, II:8, 18,31,105,107,113,
385,II:6, 7,36,38,39,40,44,50,51,52, 75, 120, 121, 123
174,183, 1II:167 Sphenopalatine fossa. See Pterygopalatine fossa
Singular canal, 1:234, 1I:51 Sphenoparietal sinus, 1:335, 339, 343, 345, 348, 349,
Singular nerve, 1:141,142,237, II:48 355,356,361,377
Sinonasal overview, II:104-13 Sphenosquamosal suture, 1:4
axial bone CT, II:106 Sphenotemporal suture, II:96
axial T1 MR, II:112, 113 Sphenozygomatic suture, II:96
coronal bone CT, II:107-9 Spinal accessory nerve, I:130, 177, 180, 251, 252,
graphics, II:105 253, 1II:71
sagittal bone CT, II:110, 111 Spinal accessory node, II:204, 206, 212, 237, 253,
Sinus confluence. See Torcular Herophili 255
Sinus tympani, 1:226, 227, 228, II:51, 54, 68, 69,70, Spinal arterial supply, 1II:152-61
73, 79 3D-VRTCECT,1II:155, 156
Skin, scalp, 1:2, 3, 4, 5 AP DSA,1II:157, 158, 159
Skull, 1:2-7 axial CTA,1II:160
Skull base, II:2-45 coronal CTA, III:161
3D-VRTbone CT, II:9 graphics, III:153, 154
anterior, II:12-25 sagittal CTA, III:158 •
I
xxxv
 INDEX
><
CIJ Spinal artery
"'0
C anterior, 1:324, III:142, 153, 154, 157, 158, 159,
161
posterior, II1:153, 154
Spinal branch of vertebral artery, 1:326
Spinal canal, II1:6
central, III:131
cervical, II1:28, 67,75,83
lumbar, II1:28, 32, 33, 54, 105, 111, 113
spinal cord within, III:134
thoracic, II1:28, 53, 93, 95, 96, 97, 98, 99, 100,
101,102,103,110,134
Spinal cord, III:130-39, 141, 142, 143, 144, 148,
149
axial CISS, II1:136
axial T2 MR, II1:136, 137
cervical, 1:105,106,163,11:207, II1:9, 37, 71, 76,
82,84,85,86,87,88,90,91,164
coronal CT myelogram, III:133, 134
coronal STIRMR, III:135
graphics, II1:131, 132
ligaments, III:140
longitudinal ultrasound, II1:138
sagittal T2 MR, II1:135
thoracic, II1:9,38, 40, 48, 101, 102, 103, 163
transverse ultrasound, II1:139
Spinal ganglion, II1:149, 195
Spinal ligaments, II1:26-41
Spinal meninges, III:140-49
axial and coronal T1 MR, III:149
axial CT myelogram, III:143, 146, 147
axial T1 C+ MR, II1:149
axial T2 MR, II1:148
graphics, II1:141, 142
sagittal CT myelogram, III:146, 147
ultrasound, III:144, 145
Spinal nerve, junction of dural nerve root sleeve
and, II1:142
Spinal nerve roots, III:130
Spinal nucleus, 1:129,177,208,209,239,241,245,
246,251,252,253
Spinal radicular artery, 1:326
Spinal ramus, 1:326
Spinal veins and venous plexus, II1:162-69
axial T1 C+ MR, 111:164,165
CECTMIP, III:168, 169
coronal T1 C+ MR, II1:166, 167
graphics, II1:163
Spinalis thoracis muscle, II1:53, 55
Spine, II1:2-127. See also Cervical spine; Lumbar
spine; Thoracic spine
arterial supply, II1:152-61
brachial plexus, II1:172-79
cervical, II1:74-91
craniocervical junction, II1:56-73
intervertebral disc and facet joints, II1:42-49
XXXVI
lumbar, III:104-17
lumbar plexus, III:180-85
meninges and compartments, III:140-49
ossification, III:10-25
paraspinal muscles, II1:50-55
peripheral nerves, III:194-227
sacral plexus and sciatic nerve, II1:186-91
sacrum and coccyx, III:118-27
spinal cord and cauda equina, II1:130-39
thoracic, II1:92-103
veins and venous plexus, III:162-69
vertebral body and ligaments, II1:26-41
vertebral column overview, II1:2-9
Spino-laminar line
cervical, III:78, 79
posterior, II1:63, 64
Spinous process, III:17
cervical, III:7, 28, 29, 34, 43, 44, 45, 63, 75,82,
83,85,88,90,91
lumbar, II1:6, 7,27,28,31,32,33,36,39,41,44,
47,51,54,105,107,108,109, Ill, 112, 113,
116,117
sacral, III:7
thoracic, II1:5, 6, 7,27,28,30,35,38,40,44,46,
55,93,94,95,96,97,98,99,100,101,102,
103, 110, 134
Spiral ganglia, 1:141, 237, 11:63
Splenial artery, 1:313, 314, 319
Splenial branch
anterior cerebral artery, 1:299
posterior cerebral artery, 1:299, 319, 324
Splenius capitis muscle, II1:50, 51, 52
Splenius cervicis muscle, II1:50, 52
Squamosal suture, 1:4, 6
Squamous occipital bone, 1:7, 11:39,40
Squamous suture, 1:4, 6
Squamous temporal bone, 1:3, 4, 6, 7, 11:5,50, 85
Stapedius muscle, 1:227, 11:46,51, 52, 68, 69, 73, 76,
79
Stapedius nerve, 1:224, 225, 11:67,172
Stapes, 11:56,76
crura, 11:52,55, 77, 79,80
footplate, 11:77,79,80
head, 11:55,77, 79,80
Sternocleidomastoid muscle, 11:132,133,134,136,
137,138,141,144,175,176,178,185,199,200,
203,205,206,207,233,234,235,236,255,279,
II1:51, 52,174,175
Sternohyoid muscle, 1:256, 11:209
Sternomastoid muscle, 1:274
Sternothyroid muscle, 1:256, 11:209
Straight gyrus, 1:29
Straight sinus, 1:9,11,14,310,335,337,339,341,
342,343,345,347,349,350,351,355,357,359,
360,362, 364, 366,368,369, 373,374, II:38
 INDEX
Strap muscle. See Infrahyoid strap muscle
Stratum radiata, 1:81, 82
Styloglossus muscle, 1:256, 11:144,146,151,284,286
Stylohyoid ligament, II:151
Stylohyoid muscle, 11:284
Styloid process, 11:4,41, 54,70,83,84,131,143,
144,145,171,172,175,181,182,184, 189,
III:66
inferior ti p, II:184
marrow, 11:69
Stylomandibular gap, II:173
Stylomastoid foramen, 1:178, 225, 227, 228, 258,
11:4,8,9,36,41,42,53,54,67,70,73,85,127,
142,171,174,175
facial nerve in, 1:230
fat in, II:172
Stylopharyngeus muscle, 1:241, 11:144,146,151,
284,286
Subaponeurotic areolar tissue, scalp, 1:2, 3, 5
Subarachnoid spaces/cisterns, 1:8, 10, 16, 17, 18,
160-71, 192, 193, 194, III:140, 141, 142, 143,
144,147, 148
axial T2 MR, 1:163-65
coronal T2 MR, 1:166-69
graphics, 1:161,162
sagittal T2 MR, 1:170,171
trabeculae in, 1:10,15,17,162
Subcallosal area, 1:39, 77,85
Subcallosal gyrus area, 1:187
Subclavian artery, 1:262, 263, 264, 265, 323, 11:135,
207,234, III:153, 155, 174, 175, 177
Subclavian vein, III:169, 177
Subcortical white matter, 1:47,53,54,56-62
PVSs,1:19, 21, 22
Subcutaneous fibroadipose tissue, scalp, 1:2, 3, 4, 5
Subdural space, 1:8,III:140, 141, 142
contrast in, III:147
Subependymal vein, 1:335, 360, 363
Subfrontal cistern, I:179
Subglottis, 11:192,211, 214, 219
Subiculum, 1:78, 83
Subinsular region, PVSs,1:22
Subinsular white matter, PVSs,1:19, 22
Sublingual gland, 11:261,262, 264, 265, 269, 271,
272,273,274,275,280,293
Sublingual space, 11:127,260, 262, 263, 267,
270-75,277,278,285
axial CECT, 11:273
axial T2 FSMR, 11:274
coronal T1 MR, 11:275
graphics, 11:271,272
isthmus connecting, 11:263,265, 274
lateral compartment, 11:274
medial compartment, 11:274
Submandibular duct, 11:261,262, 269, 271, 272,
280,293
Submandibular gland, 1:219, 11:132,137,138,139,
144,147,169,176,184,185,199,210,255,256,
262,263,264,266,267,273,279,281,287,293
anterior margin, 11:281
deep portion, 11:261,266, 271, 273, 274, 277,
279,280
hilum, 11:280
superficial portion, 11:261,266, 271, 273, 274,
277,278,280
Submandibular node, 11:253,255, 256, 262, 264,
266,277,278,279
Submandibular space, 11:127,128,129,130,133,
137,138,139,141,142,144,147,161,176,210,
260,262,263,264,269,271,272,276-81
axial CECT, 11:279
axial T2 MR, 11:277,280
coronal T1 MR, 11:277,281
graphics, 11:277,278
vertical horseshoe of, 11:267
Submental node, 11:253,255
Suboccipital fissure, 1:105, 113, 133, 139
Suboccipital muscles, III:50
Suboccipital vein, 1:374
Suboccipital venous plexus, 1:341, 351, 375, 376,
381, 383, 385, II:38
Subpial space, 1:8,10,18, III:140
Substantia nigra, 1:41,72,75,81,108,110,115,
117,119,199
Subthalamic nucleus, 1:75, 81, 84
Subthalamus, 1:64
Sulci, 1:28
Sulcus terminalis, I:71
Superficial branch ofradial nerve, III:196, 201, 203,
211,213
Superficial cerebral vein, 1:352-57
AP DSA,1:356
embryologic events, 1:352
graphics, 1:353, 354
LATlCA DSA,1:355
MRV,CTV,1:357
Superficial choroidal vein, 1:374
Superficial cortical vein, 1:11,12,13,14,18,335,
341,354,355,356,357,369
Superficial cutaneous vascular plexus, 1:3
Superficial middle cerebral vein, I:11,339,341,345,
346,347,349,353,354,355,356,357,361,377
Superficial parotid gland, 11:173,175
Superficial peroneal nerve, III:223
Superficial petrosal nerve, greater, 1:224, 225, 226,
11:48,67, 73, 75, 172
Superficial space, 11:210,211
Superficial submandibular gland, 11:261,266, 271,
273,274,277,278,280
Superficial temporal artery, 1:6,266, 267, 268, 269,
271,272,273
Superficial temporal vein, 1:380 •
I
XXXVII
 INDEX
><
QJ
"'C
Superior alveolar artery, 1:267, 268, 272, 273
C Superior anastomotic vein. See Vein of Trolard
Superior annular epiphysis, IIl:12
Superior articular facet
cervical, IIl:29, 75,82,83
lumbar, IIl:27, 105
sacral, III:121
thoracic, IIl:27, 93, 98, 99, 100, 101, 102, 103,
110
Superior articular process
cervical, IIl:34, 43, 44, 45, 75
lumbar, IIl:7, 28, 33, 36, 39, 41, 44, 47, 49, 105,
106,107,108,109, Ill, 113
thoracic, IIl:38, 40, 44, 46, 49, 95, 110
Superior cerebellar artery, 1:112, 127, 166, 182, 184,
185,195,199,200,202,205,207,210,223,279,
281,296,313,317,324,327,328,329,330
Superior cerebellar cistern, 1:101, 105, 133, 139, 161,
162, 165, 170, 171
Superior cerebellar hemisphere, I:108, 110, 111, 113,
135,138
Superior cerebellar peduncle, 1:33, 107, 110, 116,
118,119,121,123,125,132,133,135,137,151,
182, 183
Superior cerebellar vermis, I:110
Superiorcolliculus,l:31,99, 100, 101, 108,110,113,
115,117,119,191,193,201
Superior demifacet
for costovertebral joint, IIl:95, 96
for rib, IIl:27, 35, 38, 93
Superior endplate, IIl:27
cervical, IIl:29
lumbar, IIl:36, 39, 47, 108, 109
thoracic, IIl:30, 38, 93, 94, 101, 102
Superiorfourth ventricle, 1:108, 116, 119, 135
Superior frontal gyrus, 1:29, 30, 34, 35, 36
Superior frontal sulcus, 1:29
Superior hypophyseal artery, 1:283
Superior intercostal artery, 1:264
Superior laryngeal nerve, 1:246
internal branch aperture, II:217, 218
sensory branch, 1:246
Superior longitudinal fasciculus, 1:42, 43, 44, 46
Superior mallealligament, II:81
Superior mediastinal node, II:212, 253
Superior mediastinum, II:234
Superior medullary velum, 1:113, 115, 116, 119, 121,
133,139,159,183,206
Superior mesenteric artery, IIl:161
Superior nuchal line, 1:7
Superior oblique capitis muscle, IIl:50
Superior oblique muscle, 1:192, 194, 197,205, II:91,
92
Superior occipitofrontal fasciculus, 1:42
Superior ophthalmic vein, 1:11, 192, 194, 197,339,
355,379,380, II:91, 92, 93, 99, 100
xxxviii
Superior orbital fissure, 1:3,90, 175, 179,212,214,
285, II:3, 6, 7, 15, 16, 18,26,27,29,30,33,95,
96,97,107,121,122
Superior parietal lobe, 1:35
Superior petrosal sinus, 1:90, 335, 338, 339, 343,
348,355,357,360,375,377,379,380,382,385,
II:38
Superior petrosal vein, 1:164
Superior pharyngeal constrictor muscle, II:147, 149,
150,151,152,155,157,261,265,289,290,291
Superior pons, 1:135
Superiorrecess of fourth ventricle, 1:115, 119, 154,
183
Superior rectus muscle, 1:192, 194, 197, 199, II:91,
92,93,101
Superior sagittal sinus, 1:5, 9,10,11, 12, 13, 14, 15,
39,303,335,341,342,343,345,346,347,349,
350,351,353,354,355,356,357,363,369,370,
371,375, II:38
Superior salivatory nucleus, 1:224, 225, II:48, 67, 73
Superior semicircular canal, 1:229, 234, 236, 237,
II:50, 54, 55, 56, 59, 61
Superior semicircular duct, II:49, 63
Superior temporal gyrus, 1:30, 36
Superior thyroid artery, 1:263, 266, 267, 268, 269,
271, II:230, 231, 232
Superior thyroid gland, II:232
Superior turbinate, 1:188, II:105, 115, 117
Superior vena cava, IIl:168, 169
Superior vermian artery, 1:279, 324, 328
Superior vermian cistern, 1:337
Superiorvermian vein, 1:336, 372, 373, 374, 377
Superior vestibular nerve, 1:141, 143, 144,230,231,
235,237, II:48, 58, 59, 65,74
Superior vestibular nucleus, I:141, 237
Supra clinoid internal carotid artery, 1:90, 91, 92,
93,169,196,268,269,279,283,287,290,291,
295,296,297,299,305,309,313, II:10
Supracondylar humerus, IIl:202, 212
Supraglottic larynx, II:21O
Supraglottis, II:150, 214, 219
Suprahyoid internal jugular vein, II:183
Suprahyoid neck. See also Neck
axial CECT,II:131, 132
axial T1 MR, II:136
axial T2 MR, II:138
coronal T1 MR, II:139
graphics, II:127, 128, 129, 182, 196
Supramarginal gyrus, 1:30, 34, 35
Supraorbital foramen, 1:3, II:95
Supraorbital nerve, 1:192, 211, Il:27, 91
Supraorbital notch, 1:6
Suprapineal recess of third ventricle, 1:99, 100, 101,
149
Suprascapular artery, 1:263, 265
 INDEX
Suprasellar cistern, 1:9, 31, 90, 91, 92, 95,116,152, Tegmen tympani, 1:228, 229, II:43, 47, 56, 57, 61
156,157, 161, 162, 164, 167, 168, 169, 170, 171, Tegmentum
196 dorsal, 1:120, 128
Supraspinous ligament, III:27, 32, 37, 38, 39, 40, 41, mesencephalic, 1:114, 115
55,101,102,103,112,116,122 Tela choroidea, I:148
Supratentorial brain, 1:28-101 Temporal artery
Supratentorial cisterns, 1:160 anterior, 1:305, 306, 307, 308, 309, 313, 314, 315,
Supratonsillar segment of posterior inferior 320
cerebellar artery, 1:324,328 deep, 1:272
Sweat duct, 1:3 posterior, 1:207, 313, 314, 315, 317, 318, 320
Sweat gland, 1:3 superficial, 1:6,266, 267, 268, 269, 271, 272, 273
Sylvian fissure, 1:15, 29, 31, 33, 34, 36, 37, 38,164, Temporal bone, 1:2, II:3, 4, 6, 7,46-61, 95
165,168,169,305 axial bone CT, II:50-53
Sympathetic chain, 1:247, II:133, 195 axial T2 MR, II:59, 60
Sympathetic ganglion, III:195 coronal bone CT, II:54-57
Sympathetic trunk, II:181 coronal T2 MR, II:61
Synchondrosis, III:14, 15, 17, 19,20 graphics, II:47-49
fused, III:14, 17,21 petrous, 1:4, II:3, 9, 27, 28, 30, 36, 37
intersphenoidal, II:28, 35 sagittal T2 MR, II:58
neurocentral, III:12, 15, 17, 18, 19,20 squamous, 1:3, 4, 6, 7, II:5, 50, 85
odontoid, III:14 Temporal branch
sphenooccipital, 1:242, 248, 257, II:7, 8,17,25, cerebral artery, 1:316
26,28,30,31,35,39,40, III:17 facial nerve, 1:225, II:l72. See also Intratemporal
facial nerve
Temporal gyrus
T inferior, 1:29, 30, 36
T1 middle, 1:29, 30, 36
exiting nerve, III:77 superior, 1:30, 36
pedicle, III:86 Temporal horn of lateral ventricle, 1:36, 40, 41, 77,
transverse process, III:79, 84, 178 78,79,81,83,84,85,143,149,151,152,156,
vertebral body, III:94 157,158
T3, II:130, 188 Temporal lobe, 1:28, 31, 32, 33, 36, 37, 38,143,231,
T5 237,315, II:33, 61,174
body, III:94 Temporal operculum, 1:38
costovertebral joint, III:94 Temporal vein, superficial, 1:380
pedicle, III:94 Temporal white matter, maturational changes,
T6, III:48 1:51-62
T7, III:48 Temporalis muscle, 1:4,5, 211, 218, 219, II:131, 136,
T8 139,145,147,161,162,165,167,168,169,290
body, III:94 Temporalis tendon, II:165, 166, 167, 168, 169,291
inferior endplate, III:94 Temporomandibular joint, II:40, 82-87
vertebral body, III:48 bone CT, II:85
T9, III:94 capsule, I1:83
no, III:94 graphics, II:83, 84
T12 inferior compartment, II:83
ribs, III:107 ligaments, II:82
root exit level, III:4 sagittal n MR, II:86
spinous process, III:94 sagittal T2 MR, II:87
vertebral body, III:94 superior compartment, II:83
Taste fibers Temporooccipital artery, 1:306, 308
anterior, II:73 Temporoparietal suture, 1:3, 4, 6
epiglottic area, 1:246 Tensor palatini muscle, II:145
Tectorial membrane, III:56, 57, 72, 73 Tensor tympani muscle and tendon, 1:227, 229,
Tectum, 1:101,113,114,115,136,139,318 II:46,52,53,57,69, 75, 76, 79,81
Teeth, II:289, 290, 291, 292 Tensorveli palatini muscle, II:149, 151, 154, 155,
Tegmen mastoideum, II:54 156, 168 •
I
XXXIX
 INDEX
Tentorial branch of meningohypophyseal trunk,
1:283,286,316
Tentorialfissure, 1:105,113,133,136,139
Tentorial incisura, 1:9, 15
Tentorial vein, 1:11, 31, 339, 349, 373, 377
Tentorium cerebelli, 1:9,11, 13, 14, 15,31,33,37,
39,99,111,113,126,137,138,184,329,336,
364
apex, 1:11,337
with tentorial incisura, 1:343
with tentorial vein, 1:336
Terminal vein, 1:99, 360, 361, 368, 371
Thalamic "blush," 1:314
Thalamic nuclei, 1:65
Thalamic vein, 1:374
Thalamoperforating artery, 1:281, 318, 328
anterior, 1:297, 314, 328
posterior, 1:297, 313, 314, 315, 319, 324, 328
Thalamostriate vein, 1:320, 335, 337, 340, 345, 346,
350,356,359,360,361,362,363,366,370,371
Thalamus, 1:28, 31, 32, 34, 37, 39, 40, 64-75, 82,
85,99,117,153,193,360
axial CECT, 1:67
axial T1 MR, 1:68, 69
axial T2 MR, 1:72, 73
coronal STIRMR, I:74, 75
coronal T1 MR, 1:70, 71
graphics, 1:65, 66
maturational changes, 1:49-62
pulvinar, 1:41, 68, 71, 72, 73
ventrolateral, 1:48
Thecal sac, III:32, 33, 41, 89, 113, 114, 115, 116,
117, 122, 126, 127, 149
termination, III:126, 127, 146
Third mandibular molar, II:289, 290, 291
Third ventricle, 1:34, 36, 67, 70, 71, 79,82,88,99,
117,126,127,148,149,152,155,156,162,166,
167,184,185,195,196,202,203,359,360,365
anterior, 1:165
choroid plexus in, 1:99,149, 156, 159, 170,314
inferior, 1:84
infundibular recess, 1:149,152,157,159,164,
168,203
optic (chiasmatic) recess, 1:149,159,168
pinealrecess, 1:99, 101, 149
posterior, 1:165
suprapineal recess, 1:99, 100, 101, 149
Thoracic aorta, 1:263
Thoracic facet joint, III:28, 38, 44, 46, 48, 49, 93,
95,96,97,98,99,100,101,102,103,110,134
Thoracic intervertebral disc, III:4, 8, 35, 38,44,46,
48,49,93,96,97,98,99,100,101,102,103,
110
Thoracic intervertebral disc space, III:30, 94
Thoracic kyphosis, III:3
xl
Thoracic lamina, III:7, 28, 30, 35, 40, 44, 46, 55, 93,
95,96,97,98,99,100,101,102,103,110,134
Thoracic nerve, III:195
Thoracic paraspinal muscles, III:53
Thoracic rib, III:5, 30, 35, 46, 55, 107
Thoracic segmental artery, III:153, 154, 161
Thoracic segmental nerve, III:38
Thoracic spinal canal, III:28, 53, 93, 95, 96, 97, 98,
99, 100, 101, 102, 103, 110, 134
Thoracic spinal cord, III:9, 38, 40, 48, 101, 102, 103,
163
Thoracic spine, III:92-103. See also T1 through T12
3D-VRTNECT,III:96, 97
arterial supply, III:153, 154, 157, 158, 159
axial bone CT, III:98, 99
axial T2 MR, III:103
coronal CT myelogram, III:95
exiting nerve, III:93
graphics, III:93
ossification, III:19
radiography, III:94
sagittal CT myelogram, III:lOO
sagittal T1 MR, III:lOl
sagittal T2 MR, III:102
veins and venous plexus, III:163
Thoracic vertebral body, III:4, 6, 8, 9, 26, 53, 93, 98,
99,100,101,102,103,110
3D-VRTNECT,III:35
anterior cortical margin, III:30, 40, 94, 96, 100,
101, 102
axial T2 MR, III:40
graphics, III:27, 28
lateral cortical margin, III:30, 38, 46, 94, 96, 97
posterior cortex, III:95
posterior cortical margin, III:30, 94
posterior dural margin, III:102
radiography, III:30
sagittal T2 MR, III:38
Thoracic vertebral endplate, III:36, 46, 93, 98, 99
Thoracolumbar fascia, III:51, 54
Thoracolumbar junction, III:92
Thoracolumbar muscles, III:54, 55
Thyroarytenoid gap, II:216, 221, 228
Thyroarytenoid muscle, II:216, 218
Thyrocervical trunk, 1:263, 264, 265, 271, II:232,
III:153, 155, 158
Thyroepiglottic ligament, II:221, 223
Thyroglossal duct tract, II:231, 237
Thyrohyoid ligament, II:217
Thyrohyoid membrane, II:217, 218, 224
Thyroid artery
inferior, 1:263, 264, II:230
superior, 1:263, 266, 267, 268, 269, 271, II:230,
231,232
 INDEX
Thyroid cartilage, I1:133, 134, 185,210,211,212, Torus tubarius, 1:217, I1:32, 143, 149, 151, 152, 154,
213,215,216,218,220,221,222,223,224,225, 156,159
226,227,228,229,231,234 Trabeculae, subarachnoid, 1:10,15,17,162
anterior lamina, I1:217 Trachea, II:130, 153, 191,207,209,211,212,213,
inferior cornu, I1:211, 216, 217, 222, 228 219,224,226,231,232,233,234,235,236,237
superior cornu, I1:217 air column, I1I:94
Thyroid gland, II:134, 135, 151, 181, 185, 191, 192, first ring, I1:217
199,209,211,216,222,224,225,230-37 in visceral space, II:137
axial CECT, I1:233 wall mass, I1:213
capsule, I1:232 Tracheoesophageal groove, 1:247, II:134, 211, 213,
coronal CECT, Il:234 233,235
graphics, Il:231, 232 Transethmoidal segment of olfactory nerve, I:186
inferior, I1:232 Transverse abdominis muscle, I1I:54
isthmus, I1:231, 232, 233, 234, 235, 236, 237 Transverse cervical nodes, Il:253
lesions graphic, I1:237 Transverse facial artery, 1:268, 272
lobe, 11:231,232, 233, 234, 235, 236, 237 Transverse foramen, I1I:14, 17,28,34,58
mass in visceral space, Il:212, 213 cervical, I1I:43, 44, 45, 66, 71, 75,82,83,88,89,
pyramidal lobe, Il:233 90
superior, Il:232 vertebral artery in, I1I:155
ultrasound, Il:235, 236 Transverse intrinsic muscle "shadow," I1:263
in visceral space, I1:137, 138 Transverse ligament, I1I:57, 66,71,73,90
Thyroid notch, I1:217, 220, 221, 223, 227 Transverse pontine fibers, 1:46
Thyroid vein, inferior, 1l:232 Transverse process, 1l:195, IlIA, 5, 6, 8, 18,20
Tibia, I1I:227 anterior tubercle, I1I:28, 34, 43, 44, 58, 75,82,
Tibial nerve, I1I:222-27 83,89
axial T1 MR, I1I:224-27 cervical, I1I:28, 29, 34, 43, 44, 45, 66, 75, 77,82,
graphic, I1I:223 88,89,91
Tongue, Il:282-87 with costotransverse joint, I1I:96, 97
anterior taste fibers, I1:73 lumbar, I1I:7, 28, 31, 32, 33, 36, 41, 44, 47, 54,
axial T2 MR, I1:286, 287 105,107,108,109,111,113
base, 1:241, I1:229 ossification center, I1I:18, 20
graphics, I1:283, 284 posterior tubercle, I1I:34, 44, 58, 75,82,83
intrinsic muscle, 1:256, I1:141, 262, 265, 271, 272, thoracic, I1I:27, 28, 30, 35, 40, 93, 95, 98, 99,
283,284,285,286 103,110
oral, II:139, 155, 158,257,260,261,269,291 Transverse sinus, 1:11,14,108,335,339,341,342,
root, I1:262, 267, 269, 272, 278, 285, 287 343,346,347,348,349,351,354,357,369,370,
sagittal and coronal T1 MR, I1:285 373,375,377, I1:38,I1I:167
Tonsil Trapezius muscle, II:132, 133, 134, 135, 137, 199,
anterior, I1:261 200,203,205,206, I1I:50,51,52,53
cerebellar, 1:106, 107, 109, 111, 113, 126, 133, Trapezoid body, 1:121
134,136,137,138,139,150,151,236,329, Trigeminal artery, persistent, 1:331
I1:44, I1I:37, 71 Trigeminal fascicles, 1:91, 164, 168,213,215,218
lingual, II:139, 141, 150, 151, 153, 155, 158, 191, Trigeminal ganglion, 1:87, 88, 89, 91, 93,121,199,
192,229,231,256,263,265,269,273,283, 208,209,210,211,214,215,216,218,344,
285,286 I1:27,33,91, 119, 162, 169
palatine, Il:132, 139, 143, 144, 147, 150, 151, Trigeminal nerve (CN5), 1:87, 89, 105, 107, 110, 111,
152,155,157,158,159,191,192,265,267, 112,121,123,125,126,127,175,176,177,182,
269,273,274,281,283,286,289,291 185,195,199,202,207,208-19,221,236, I1:91,
Tonsillar pillar, I1:150, 263, 269, 283 95
anterior, I1:150, 263, 269, 283 axial bone CT, 1:212
posterior, 1l:150 axial T1 C+ MR, 1:214
Tonsillar posterior inferior cerebellar artery, 1:330 axial T1 MR, 1:218, 219
Tonsillar vein, 1:373, 376 axial T2 MR, 1:213
Tooth, I1:289, 290, 291, 292 in cerebellopontine angle cistern, 1:155, 164
Torcular Herophili, 1:11,14,335,341,342,343,345, coronal T1 C+ MR, 1:216, 217
349,356,357,369,370,377, 1l:38 coronal T2 MR, 1:215 •
I
xli
 INDEX
graphics, 1:209-11 U
interdural segment, 1:208
intra-axial segment, 1:208 Ulna, 11I:205,208, 209, 211, 214, 215
mandibular (V3) division. See Mandibular nerve Ulnar artery, 11I:213,215
maxillary (V2) division. See Maxillary nerve Ulnar nerve, III:173, 195, 196,201,202,203,204-9,
in Meckel cave, 1:157,158 211,212,213,214,215
mesencephalic nucleus, 1:121, 208, 209 axial PO FSMR, 11I:209
motor nucleus, 1:121, 208, 209, 213 axial T1 MR, 11I:206-8
nuclei, 1:129, 208 graphic, 11I:205
ophthalmic (VI) division. See Ophthalmic nerve Uncal recess oftemporal horn, 1:40, 79, 84
preganglionic (cisternal) segment, 1:87,145,175, Uncinate fasciculus, 1:42, 44
182,184,195,208,209,211,213,214,215, Uncinate gyrus, 1:79, 83
218,222, II:27, 61 Uncinate process, II:108, 110, 114, 115, 116,11I:29,
prepontine segment, 1:184 34,43,45,65,75,76,85,88,89,91
root entry zone, 1:121, 182,209,211,213,214, Uncovertebral joint, 11I:29,34, 75
II:27 Uncus, 1:29, 30, 33, 40, 77, 79,83,84,187,195,200,
sagittal T2 MR, 1:218 202,206
sensory nucleus, 1:121, 208, 209, 213 Upper brachial plexus trunk, 11I:173,174,175,176,
spinal nucleus, 1:129,177,208,209,239,241, 178,179
245,246,251,252,253 Upper cervical cord, 1:163
Trochlea, 11I:207,213 Uvea, II:102
Trochlear nerve (CN4), 1:87, 88, 94, 105, 108, 115, Uvula, 1:133,136,139, II:139, 147, 151, 152, 159,
116,118,119,175,176,177,183,204-7,210, 285
216,217, 221, 344, II:27, 91,95
axial T2 MR, 1:206 V
cisternal, 1:87,204, 205
coronal T2 MR, 1:207 Vagal nucleus, dorsal, 1:129,177,245,246
decussation, 1:205 Vagus nerve (CNlO), 1:105,129,130,131,175,177,
graphics, 1:205 180,239,240,243,244-49,251,252,255, II:37,
Trochlear nucleus, 1:115, 116,204,205 133,181,182,185,232
Trolard, vein of, 1:12, 14,354,355,356,357,361, axial bone CT, 1:248
363 axial T2 MR, 1:249
True vocal cord, II:153, 211, 215, 216, 218, 219, 221, graphics, 1:245-47
222,223,225,228,234 nuclei, 1:129
Tuber, 1:133, 139 Vallecula, 1:133, 136, 137, II:132, 139, 150, 153,215,
Tuber cinereum, 1:87, 88, 95, 97, 195 219,220,225,226,227,229,264
Tuberculum sellae, II:13, 15,27,29 Vein(s)
Tuberous sclerosis, 11I:95 extracranial,I:378-87
Tunica fibrosa, II:102, 103 intracranial, 1:334-77
Tunica interna, II:I02, 103 spinal, 11I:162-69
Tunica vasculosa, II:102 Vein of Galen, 1:99, 101,335,337,341,345,346,
Turbinate 347,350,351,353,357,359,360,361,364,366,
inferior, II:105, 106, 107, 108, 109, 110, 111, 113, 367,368,369,371,373,374,375,11I:167
115,116,117 Vein of Labbe, 1:335, 341, 345, 347, 349, 351, 354,
middle, II:105, 107, 108, 109, 111, 112, 113, 115, 355,357,369,370,371,373,377, II:38
116,117 Vein of Trolard, 1:12,14,354,355,356,357,361,
superior, 1:188, II:105, 115, 117 363
Twelfth rib, 11I:5,94 Velum interpositum, 1:160, 343
Tympanic annulus, 1:228, 229, II:47, 55, 56, 57, 69, Velum interpositum cistern, 1:101, 161, 162, 165,
72,77,80,81 170
Tympanic artery, inferior, II:49 Vena cava
Tympanic bone, II:84 inferior, 11I:113,116, 163
Tympanic membrane, 1:229, II:47, 53, 55, 57,76 superior, 11I:168,169
Tympanic segment of facial nerve, 1:225, 226, 228, Venous "lake," 1:3, 10,353
229,234, II:47, 48, 51, 55, 56, 57, 59, 67, 68,
71,74,75,80,81,174

xlii
 INDEX
Venous plexus Vermian artery
anterior medullary, 1:373 inferior, 1:328
anterior ponto mesencephalic, 1:339, 368, 377 superior, 1:279, 324, 328
basilar, 1:90, 222 Vermian cistern, superior, 1:337
basivertebral, 1II:24 Vermian vein
clival, 1:88, 89, 97, 162,335,338,343,345,348, inferior, 1:368, 372, 373, 374, 375, 376
351,355,370,374,376,377,384,386,II:38 superio~I:336,372,373,374,377
epidural, 1:383, 385 Vermis. See Cerebellar vermis
in foramen ovale, 1:338 Vertebral artery, I:106, 109, Ill, 112, 126, 127, 130,
foraminal, III:168, 169 145,163,180,184,185,223,236,253,257,259,
hypoglossal, 1:376, 382, 384, 385, 386, III:166, 263,264,265,267,270,271,278,325,329,387,
167 II:37, 44, 45, 133, 135, 136, 137, 138, 183, 195,
marginal,I:376 197,198,199,200,201,202,207,257, III:37,
in neural foramen, III:164, 165, 166, 167, 168 45,51,52,71,73,84,88,90,133,159,164,165,
petrosal,I:374 167, 168, 175. See also Vertebrobasilar system
pontine, I: 11 anterior spinal branch, 1:326
pterygoid, 1:338, 345, 346, 355, 361, 378, 379, branches, 1:322
380,381,383,384,386,387, II:145, 165, 169 in C2 transverse foramen, III:37, 52, 87, 89
spinal, III:162-69 in cerebellomedullary cistern, I:163
suboccipital, 1:341, 351, 375, 376, 381, 383, 385, cervical, 1:331, III:89, 91
II:38 course, 1II:155, 156, 158
vertebral. See Vertebral venous plexus extraosseous (VI) segment, 1:270, 322, 323
in vidian canal, 1:217 extraspinal (V3) segment, 1:322, 323, 324, 325,
Venous sinus, 1:10 326,328
dural, 1:342-51. See also Dural sinuses flow void, III:90, 91, 149
endothelium, 1:10 foraminal (V2) segment, 1:270, 322, 323, 325,
in travertebral, III:169 326
Venous sinus confluence. See Torcular Herophili intradural (V4) segment, 1:322, 324, 326, 327
Ventral brainstem, maturational changes, 1:47, 48, loop, II:183, 184
51,52 in medullary cistern, I:150
Ventral branch of segmental artery, III:154 muscular branch, 1:326, 328
Ventral cauda equina, III:138 normal variants and anomalies, 1:322
Ventral cochlear nucleus, 1:129, 141,237 origins, III:153
Ventral dural margin, cervical, III:37, 87 in premedullary cistern, 1:166,170
Ventral epidural plexus, III:149 vascular territory, 1:322
Ventral gray column, 1:251 venous plexus surrounding, 1II:164, 167
Ventral horn, III:131, 136 Vertebral body, II:195, III:3, 25, 26-41. See also
Ventral median fissure, 1:129, III:131, 133, 136 Cervical vertebral body; Lumbar vertebral
Ventral medulla, I:128 body; Thoracic vertebral body
Ventral pons, 1:55 3D-VRTNECT,1II:34-36
Ventral radiculomedullary artery, 1II:154 axial NECT, III:32
Ventral ramusO), III:195 axial T1 MR, III:41
brachial plexus, 1II:173-76, 178, 179 axial T2 MR, III:40
lumbar plexus, 1II:181-83 branch to, III:158
Ventral root, 1II:131, 133, 136, 137, 143, 148, 195 complete, 1II:24
Ventral white commissure, 1II:131 coronal NECT, III:33
Ventricles, 1:148-59. See also Fourth ventricle; destruction, II:197, 198
Lateral ventricle; Third ventricle fused sacral, III:4
axial T2 MR, 1:150-53 graphics, 1II:27, 28
coronal T2 MR, 1:154-57 postcentral branch, III:153, 154
graphics, 1:149 posterior cortical margin, 1II:28
sagittal T2 MR, 1:158-59 radiography, III:29-31
Ventricular branches of posterior cerebral artery, sagittal T2 MR, 1II:37-39
1:312 Vertebral canal. See Spinal canal
Ventrolateral sulcus, III:131
Ventrolateral thalamus, 1:48 •
I
xliii
 INDEX
><
QJ
""C
Vertebral column, I1I:2-49. See also Spine Vestibular nucleus, 1:141, 233
C 3D-VRT NECT, I1I:5, 6 inferior, 1:141, 237
coronal NECT, I1I:7, 8 lateral, 1:129, 141,237
graphics, I1I:3, 4 medial, 1:129, 141,237
overview, I1I:2-9 superior, 1:141, 237
sagittal CT, III:6 Vestibule, 1:109, 142,226,234,236,258,11:49,50,
sagittal T2 MR and CT myelogram, I1I:9 51,54,55,59,60,61,63,64,68,70,73,74,75,
Vertebral endplate, I1I:27, 28, Ill, 113. See also 78
Inferior endplate; Superior end plate Vestibulocochlear nerve (CN8), 1:105, 109, Ill, 122,
cervical, I1I:43, 45, 88, 89, 91 124,129,131,141,143,144,145,175,177,181,
lumbar, I1I:32, 47 184,221,230,231,232-37,11:37,58,60,61,74
thoracic, I1I:36, 46, 93, 98, 99 axial and coronal bone CT, 1:234
Vertebral foramen. See Neural foramen axial T2 MR, 1:235
Vertebral ossification center, I1I:24, 25 in cerebellopontine cistern, 1:164
Vertebral vein, 1:386, 387, 11:133,135,195,197,198, coronal T2 MR, 1:236
200 graphics, 1:233
anterior external, 111:164 in internal auditory canal, 1:151,155
anterior internal, I1I:164, 168 nuclei, 1:141, 233
posterior external, I1I:88, 89, 164, 165, 167, 169 origin, I:122, 124, 131
posterior internal, I1I:165, 167 sagittal T2 MR, 1:237
Vertebral venous channels, I1I:163 Vidian artery, 1:283
Vertebral venous plexus, 1:378, 385, 387 Vidian canal, 1:94, 178,211,212,217,284,11:8, 10,
anterior external, III:163, 165, 166, 168, 169 26,31,32,34,41,97,107,120,121,122,123
anterior internal, I1I:88, 90, 163, 164, 165, 166, Vidiannerve, 1:211,217,218, 11:27,119
167, 168 Virchow-Robin spaces. See Perivascular spaces (PVSs)
posterior external, III:165, 167, 168 Visceral space, 11:129,130, 133, 134, 135, 182, 185,
posterior internal, I1I:163, 164, 165, 167 191,192,196,199,208-13
Vertebrobasilar confluence, in medullary cistern, axial CECT, 11:210,211
1:163 coronal CECT, 11:212
Vertebrobasilar junction, 1:166 generic mass graphic, 11:213
Vertebrobasilar system, 1:104, 322-31 graphics, 11:209
3D-VRTCTA,1:323, 325, 327 sagittal NECT, 11:213
AP DSA, 1:329 thyroid mass graphic, 11:212
DSA,1:326 Visceral space nodes, 11:253
embryology, 1:322 Visual cortex, 1:190,191
graphics, 1:323, 324, 331 Vitreous chamber, 11:101,102, 103
lateral DSA, 1:328 Vocal cord
MRA,1:330 false, 11:150,215, 218, 219, 221, 225, 228
Vertical crest, 1:141, 237, 11:48 true, 11:153,211, 215, 216, 218, 219, 221, 222,
Vertical horseshoe of submandibular space, 11:267 223,225,228,234
Vertical plate, 11:20 Vocal ligament, 11:216,218
Vertical segment Vocal process, 11:216,221
anterior cerebral artery, 1:170, 293, 294, 296, 299, Vocalis muscle, 11:216,218
300,301,302,303,311 Vomer, 11:4,9
carotid canal, I:178, 11:4
petrous internal carotid artery, 1:219, 227, 229,
242,248,283,286,287,288,289,11:7, 10, w
31,40,49,53,56,71,174 Wackenheim line, I1I:60, 61
Vestibular aqueduct, bony, 11:50,51, 54 Welcher basal angle, I1I:60, 62
Vestibular membrane, 11:63 White commissure, ventral, III:131
Vestibular nerve, 1:232 White matter
inferior, 1:124,141,143,144,181,230,231,235, cerebellar, 1:45,109,113,135,137,138
237,11:48,58,60 collateral, 1:77, 78,81,83
superior, 1:141,143,144,230,231,235,237, deep
11:48,58,59,65, 74 occipital, 1:51
PVSs, 1:20, 24

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 INDEX
peripheral, III:136
subcortical, 1:47, 53, 54, 56-62
PVSs,1:19, 21, 22
subinsular, PVSs,1:19, 22
temporal, maturational changes, 1:51-62
White matter tracts, 1:28,42-64
axial T1 MR
32 weeks premature, 1:47
birth, 1:49
3 months, 1:51
6 months, 1:53
9 months, 1:55
12 months, 1:57
18 months, 1:59
3 years, 1:61
axial T2 MR
32 weeks premature, 1:47
birth, 1:50
3 months, 1:52
6 months, 1:54
9 months, 1:56
12 months, 1:58
18 months, 1:60
3 years, 1:62
coronal STIRMR, 1:63
graphics, 1:43, 44
maturation, 1:42
3T DTl, 1:45, 46
White matter vein, deep, 1:360, 361, 371

z
Zinn, annulus of, 1:191, 194, 199,205
Zonule fibers of globe, II:I03
Zygapophyseal joint. See Facet joint
Zygomatic arch, 1:7, II:8, 9, 10,83,84,85, 127, 128,
139, 161, 162, 165, 167, 168, 169
Zygomatic bone, II:4, 9, 94-97
Zygomatic branch of facial nerve, 1:225, II:I72
Zygomaticofrontal suture, 1:3, 6
Zygomaticomaxillary suture, II:97
Zygomaticotemporal suture, 1:6

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