20 Temporal Bone: Imaging

Donald W. Chakeres and Mark A. Augustyn

COMPUTED TOMOGRAPHY: TECHNICAL CONSIDERATIONS MR IMAGING TECHNIQUES FOUR BASIC MR IMAGING PROTOCOLS ROUTINE BRAIN SURVEY HIGH-RESOLUTION T2-WEIGHTED IMAGING HIGH-RESOLUTION T1-WEIGHTED CONTRAST IMAGES MAGNETIC RESONANCE ANGIOGRAPHY CONCLUSION

Temporal bone imaging is extremely challenging, as the normal anatomy includes many small but clinically important structures, and a signicant abnormality in this area may be less than 1 mm in size. The wide range of tissues existing in the area must be evaluated simultaneously, making it impossible to develop a single optimal imaging technique for studying all potential pathology. One must use both computed tomography (CT) and magnetic resonance (MR) imaging techniques of the highest possible resolution to precisely characterize the bone, air spaces, and the wide variety of soft tissues present in the temporal bone region. Often it is necessary to use both CT and MR imaging for satisfactory tissue characterization and identication of pathology or condent exclusion of abnormalities. This chapter reviews CT and MR imaging techniques appropriate for evaluation of the temporal bone. A more complete atlas using multiplanar CT is provided in Chapter 19. CT excels in the evaluation of disorders that primarily affect air spaces or cortical bone.18 Although the wide differences in the density of the temporal bone structures produce excellent inherent image contrast on CT, soft-tissue characterization is much more limited than with MR imaging. Thus, with CT, the individual cranial nerves cannot be seen without the use of intrathecal cisternography, a technique no longer commonly used and currently replaced by high-resolution MR imaging. In contrast, MR imaging provides poor information about the air spaces and cortical bone but excellent soft-tissue contrast resolution. In addition, MR is more sensitive to the effects of gadolinium as a contrast agent than is CT to iodinated contrast agents. In fact, CT contrast enhancement may be difcult to visualize within the temporal bone itself due to the high density of the bone. For example, enhancement of the vestibule in inammatory pathology is quite conspicuous on MR (since the surrounding bone is a signal void), while the same enhancement is impossible to recognize using CT. Although

one may not be able to visualize the architecture of the normal bone and air spaces, MR imaging can still provide useful information about these structures in diseased states, as there is signal due to uid or a mass where normally there should be a signal void from either cortical bone or air. These techniques can be complementary. For example, in the case of paragangliomas, CT can best demonstrate pathologic bone destruction, while MR more clearly displays vascular invasion or intracranial extension. Fast CT imaging can be used to create postprocessed angiographic studies, but the dense bone often presents difculties in the reconstructions. MR imaging can also be used to generate excellent angiographic information; however, routine catheter angiography remains important for vascular imaging and is still the gold standard for analyzing the most challenging vascular pathology. Catheter angiography is also used to direct interventional procedures. Catheter angiography will not be discussed in this chapter.

COMPUTED TOMOGRAPHY: TECHNICAL CONSIDERATIONS

If the goal of a temporal bone CT study is to focus on the otic capsule, cortical plates, ossicles, and the air spaces alone, such as when studying a temporal bone fracture, then high-resolution bone algorithm techniques may be adequate.18 However, if it is also important to evaluate the soft tissues, as in the case of a patient with cancer of the external auditory canal (EAC), then it may be necessary to use intravenous contrast and techniques similar to those used for a brain or soft-tissue neck study. The main disadvantages of CT are poor soft-tissue denition within the bony labyrinth and internal auditory canal (IAC) and radiation exposure for the patient. Although in the past it was essential to position the patient for axial and/or coronal images (Figs. 20-1 to 1093

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Lateral malleal Head of ligament malleus

Neck of malleus

Tensor tympani tendon

Manubrium of malleus Pars flaccida of tympanic membrane

This axial CT section through the geniculate ganglion demonstrates the facial hiatus for the greater supercial petrosal nerve. The thin, bony margin between the lateral margin of the horizontal facial nerve and the middle ear is seen.

FIGURE 20-1

FIGURE 20-3 Coronal CT, malleus level. Prussaks space lies between the lateral malleal ligament and the pars accida of the tympanic membrane.

20-3), newer high-resolution multidetector spiral imaging systems can generate nearly isotropic voxels for multiplanar reconstructions, making the need for multiple series with direct imaging in several planes unnecessary. Postprocessing software has also improved, allowing multiplanar cross sections (Figs. 20-4 to 20-6), as well as transparent and surface volume image presentations (Figs. 20-7 to 20-12). A nearly perfect solid model of the temporal bone can be created from routine clinical CT data acquisitions. Typically, a high-resolution matrix should be used (512 512), with thin sections (0.6 to 1.5 mm) and a eld of view of 15 to 20 cm. CT images can be rapidly acquired, either sequentially or using a spiral technique. The exact technique, including collimation and reconstruction algorithms of spiral imaging, depends on the specications of a particular piece of equipment. The faster the data acquisition, the less likely it is that the examination will be degraded by motion artifact. A low-mA (70 mA) technique is adequate for most of the bony structures, but higher mA (250 to 400 mA) techniques, thicker slices (3 to 5 mm), and
Edge of oval window

contrast enhancement are necessary for the evaluation of the brain and other soft tissues. CT images are usually acquired or displayed in axial and coronal planes. For axial imaging, sections are made in a plane rotated 30 superior to the anthropologic base line (the line intersecting the inferior orbital rim and the EAC). Scans produced in this plane display the temporal bone structures to good advantage.3 This plane allows separation of the individual components of the temporal bone so that they are better visualized in their entirety, with less overlap and fewer partial volume imaging artifacts.2 Direct coronal images are usually obtained at an angle of approximately 120 from the anthropologic baseline, while reconstruction coronal images are usually oriented 90 from the anthropologic baseline. Sagittal images can be very helpful in selected situations, and postprocessing can create multiple oblique or curved projections. For example, a plane rotated approximately 45 between the coronal and sagittal planes approximates Stenvers view and produces an image section plane parallel to the long axis of the temporal bone (see Chapter 19). Curved sections parallel to structures of interest (such as segments of the facial nerve canal) can be individually created, as can three-dimensional (3D) surface

Anterior crus of stapes Manubrium of malleus Long process of incus Head of stapes

Head of malleus

Incudomalleal joint Body of incus Short process of incus Lateral part of posterior incudal ligament

Posterior crus of stapes Medial part of posterior incudal ligament

FIGURE 20-2 Axial CT, stapes level. The incus and malleus are seen lateral and anterior to the stapes. The annular ligament and footplate of the stapes cannot be seen due to volume averaging with the adjacent rim of the oval window.

FIGURE 20-4 Axial CT, incudomalleal joint. The articulation of the malleus with the incus is seen in the epitympanum.

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FIGURE 20-5 Oblique CT, incus and malleus. This view approximates the otoscopic view from the EAC.

reconstructions, allowing physical models to be created from the imaging data (Figs. 20-7 to 20-12).

MR IMAGING TECHNIQUES
The MR images in this chapter were obtained with a 1.5 Tesla General Electric Signa LX CDI Horizon imaging system. MR imaging has become the primary imaging modality for evaluation of the nonosseous components of the temporal bone region, including the major blood vessels, uid spaces (cerebrospinal uid, endolymph, perilymph), nerves, muscle, cartilage, brain, salivary glands, and fat (Figs. 20-13 to 20-22).936 The spatial resolution currently available with MR has progressed to a point where it is comparable to and can even exceed that of CT.12, 21 As spatial resolution increases, the images become nois-

ier as a result of an inherently decreased signal-to-noise ratio within any given voxel. This produces poorer-quality images when larger matrices are used, despite better spatial resolution. There are a number of strategies to deal with the potential low signal-to-noise ratio and poor image quality. Threedimensional Fourier transform imaging (3DFT) uses radio frequency (RF) signal from an entire imaging volume during the entire acquisition rather than a single slice, thus increasing the signal-to-noise ratio. Therefore, very thin sections can be obtained for high-resolution 3DFT T1- and T2weighted images.9 Both gradient and spin-echo 3DFT techniques are possible.10, 20, 22, 24, 28 If short TE times are available and the sequences are optimized, the quality of the examination using a gradient echo technique can rival or surpass spin-echo alternatives. For T1 weighting, spoiled gradient echo imaging with short TR (50 ms) and TE (4 ms), and with ip angles of 30, generate images similar to routine spin-echo images but can also demonstrate the vessels to advantage.36 Caution must be exercised, as high signal of vessels may be mistaken for enhancement in a tumor. For this reason, some radiologists prefer standard high-resolution, thin-slice postcontrast 2D spin-echo sequences for evaluation of the IAC. Steady-state T2-weighted gradient echo images using constructive interference techniques also have excellent quality and are not marred by increased magnetic susceptibility artifacts because of their short TE times.11, 12, 20, 22, 29 One can also utilize a T2-weighted 3DFT gradient echo technique called SIMCAST (segmentinterleaved motion-compensated acquisition in a steady state).29 Two-dimensional Fourier transform and 3DFT T2weighted spin-echo imaging techniques are also possible.28 The resulting images using the gradient and spin-echo 3DFT techniques are comparable and have similar acquisition times. The signal-to-noise ratio can be improved by using dedicated phased-array surface coils specically designed for temporal bone imaging.30, 31 Such phased array coils are more effective than those obtained by simply combining a series of routine coils to a single input. Each phased-array coil is composed of two or more separate but overlapping

FIGURE 20-6 Curved coronal-sagittal CT reconstruction of the facial nerve. A, The facial nerve is seen from the IAC to the point where it exits the temporal bone at the stylomastoid foramen. B, The dark line represents the course of the curved surface in A.

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FIGURE 20-7 Surface MR imaging, reconstruction of the pinna. This is a surface volume reconstruction of an axial MR imaging 3DFT data set of 60 images. The head is viewed from laterally. The image suggests that the patient is bald, but this is due to the lack of signal from hair. Many of the details of the surface anatomy are accurately displayed. All of the deep anatomy is also available for analysis.

FIGURE 20-8 Three-dimensional CT surface reconstruction, lateral view. This surface reconstruction mimics a skull model and demonstrates the surface of the lateral mastoid; the tympanic bone, which makes up most of the EAC; the zygomatic arch; and the squamous portion of the tympanic bone (not labeled).

FIGURE 20-9 Three-dimensional CT surface reconstruction, superior view. This is a view into the posterior and middle cranial fossas from above. The temporal bone is well seen. The petrous apex is outlined by the foramen lacerum and the clivus (not labeled). The impressions for the IAC, jugular fossa, hypoglossal canal, and sigmoid sinuses are all well demonstrated.

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distortions are exaggerated with high-resolution imaging, narrow bandwidth, and high magnetic eld strength. Magnetic susceptibility artifacts may be seen as regions of high and low signal in locations near the oval and round windows not corresponding to anatomic structures (see Fig. 20-13D).20 Gradient echo techniques have been developed that use short TE times to specically suppress these artifacts since they are more pronounced with increasing TE. Though spin-echo images are not immune to these artifacts, they are less sensitive. Short TE times increase the signal-to-noise ratio by diminishing the effects of T2* decay, and short TE times limit the effects of magnetic susceptibility artifacts that occur at the air-water interfaces of the oval and round windows. 22 A short TE time allows fat and water to be in phase, thus diminishing the artifacts associated with intravoxel fat-water subtraction seen with gradient-echo high-resolution imaging.36 The ideal TE time varies with eld strength. Contrast-enhanced studies are of value in many situations.3236 An enhanced study can be acquired as 2DFT T1-weighted axial or coronal series of the whole brain. A 3DFT T1-weighted axial MR series can also be acquired.
FIGURE 20-10 Three-dimensional CT surface reconstruction, inferior view. The oval-shaped jugular fossa is just posterior to the carotid canal. The stylomastoid foramen and the mastoid tip are lateral to the jugular fossa. The foramen spinosum and ovale are just anterior to the petrous apex (not labeled).

FOUR BASIC MR IMAGING PROTOCOLS

Four basic MR imaging protocol techniques are used to address specic goals: whole brain/head imaging, high-resolution uid space imaging, high-resolution T1weighted, contrast-enhanced imaging, and MR angiography (MRA) techniques (Table 20-1). The actual sequences used vary from institution to institution and with the specic MR scanner utilized. Some radiologists feel that the demonstration of high signal in blood vessels on T1-weighted images is helpful. Others feel that signal of the small vessels in the IAC can be confusing when looking for subtle enhancement of a small eighth nerve tumor, and they therefore prefer spin echo T1-weighted images with contrast enhancement for evaluation of sensorineural hearing loss. The lack of any high signal within the canal on this sequence is a reliable

coil loops. Phased-array coils also allow shorter imaging times. The disadvantage of using these coils is that the images are not homogeneous in signal intensity, and the coils are more cumbersome for the technologist to position. Using surface coils to study the supercial structures can increase the signal-to-noise ratio approximately three to ve times compared with that of a routine head coil. Gradient echo imaging is more sensitive to a number of factors, including T2* signal loss from magnetic susceptibility artifacts, and magnetic susceptibility between water and air can result in a distortion of MR images somewhat similar to chemical shift artifact. These local magnetic eld

FIGURE 20-11 Three-dimensional CT surface reconstruction, from medially and slightly superiorly. This is a view of the medial surface of the temporal bone. The hypoglossal canal is seen interposed between the occipital condyle and the jugular tubercle. The IAC is seen in the midportion of the temporal bone. The vascular grooves for the sigmoid sinus and the superior petrosal sinus are well seen.

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FIGURE 20-12 Surface reconstruction from CT data. The structures are viewed from superiorly. The geniculate ganglion region of the facial nerve is well demonstrated. Note that both CT and MR imaging data can be used for this type of image display.

indicator that no eighth nerve tumor is present. A thin section 2DFT spin-echo T1-weighted sequence is obtained in the axial plane after intravenous gadolinium administration. Typical parameters include TR of 450, TE of 15, three acquisitions, a eld of view of 170 mm, and a matrix of 192 256. Some radiologists add fat suppression to eliminate potentially confusing high signal from the fat in the petrous apex.

contrast enhancement may be of value if the suspected pathology involves the fat spaces. Low- to high-resolution axial (256 256 matrix, 4 to 5 mm thick) uid-attenuated inversion recovery (FLAIR) and T2-weighted fast spin-echo (FSE) images are also used to evaluate the brain. The FLAIR images are particularly sensitive to brain pathology such as demyelination or infarcts, and they are also helpful in differentiating hemorrhage from fat.

ROUTINE BRAIN SURVEY

Routine head imaging is important to evaluate brain or other soft-tissue pathology. For example, a patient who presents with symptoms of dizziness could have pathology that results from brainstem demyelination or a tumor. For this reason, images of the whole brain are routinely obtained. Acquisition of a noncontrast T1-weighted sequence is of value to help characterize high-signal regions on contrast studies, since without a noncontrast examination, it may be difcult to differentiate fat or subacute hemorrhage. T1-weighted, contrast-enhanced studies are routinely acquired. In general, lower-resolution 2DFT T1-weighted images are acquired to evaluate the brain and adjacent soft-tissue structures, while fat saturation and

HIGH-RESOLUTION T2-WEIGHTED IMAGING

Fluid-sensitive high-resolution images are noncontrast enhanced and demonstrate the CSF and endolymphatic spaces as high signal intensity regions. The cisternal cranial nerves can be visualized without contrast using this technique since the nerves are surrounded by the higher signal intensity uid. Fluid in the otic capsule structures is best visualized utilizing this technique, making it possible to evaluate cochlear or vestibular pathology. This technique has been used as a screening technique to rule out vestibular schwannomas.36 T2-weighted high-resolution images can be acquired

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with short TR, low ip angle gradient-echo 3DFT imaging. This is achieved by preserving rather than spoiling transverse magnetization using an appropriate selection of rephasing gradients, a short TR (20 to 30 ms) and a moderate ip angle (30 to 50). Such images are referred to as steady-state or steady-state-free-precession images. Station-

ary uid with long T2 relaxation time yields high signal intensity similar to that seen on standard T2-weighted spin-echo images. However, for uid in motion (such as CSF in the cerebellopontine angle), the transverse magnetization is spoiled due to the motion, and the uid gives very low signal intensity. Other differences between steady-state

FIGURE 20-13

A to F, Axial MR imaging, IAC level. Each axial image is a gradient echo steady-state SIMCAST 0.7 mm thick, 1024 1024 matrix axial section of the right temporal bone. The images appear to be T2-weighted, although the origin of the contrast is more complicated. The CSF and other uid spaces demonstrate high signal intensity. The brain is intermediate in signal intensity, and the bone and pneumatized air spaces are signal voids. The IAC contains the seventh and eighth nerves. They are seen as thin, linear low signal intensity structures in the canal. The cochlea, vestibule, and semicircular canals are well seen. This section is not made 30 from the anthropologic baseline, so the complete lateral semicircular canal is not seen. The endolymphatic sac is seen posterior and medial to the posterior semicircular canal. In D the apparent notch (arrow) in the margin of the vestibule is susceptibility artifact. E is a magnied view of the cochlea at approximately the same level as D. Note the interscalar septum (arrow). Compare to the image provided by CT in Figures 19-10 and 19-11.

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FIGURE 20-14 A to E, Coronal MR imaging from anterior to posterior. As in Figure 20-13, the uid spaces are visualized as high signal. Nerves are seen crossing the bright signal of the CSF within the IAC.

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FIGURE 20-15 A to G, Sagittal MR imaging from medial to lateral. The facial nerve and the branches of the vestibulocochlear nerve are seen in the IAC in the medial images. The facial nerve travels in the anterior superior aspect of the canal. The cochlear nerve lies in the anterior inferior portion of the canal. The superior and inferior vestibular nerves lie in their respective portions of the posterior canal. More laterally, uid is seen in the vestibule and the semicircular canals. Illustration continued on following page

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FIGURE 20-15
previous page.

Continued. For legend see

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FIGURE 20-15 Continued. In G the facial nerve is seen as a thin line of signal. Although not uid, there is enough signal from the soft tissue of the nerve to be contrasted against the signal void of the bone and air in the mastoid.

and standard T2-weighted spin-echo images include high signal for fatty tissue (with a short T1 relaxation time) and low signal intensity for all other tissues (gray matter, white matter, and muscle). Typical parameters of an unspoiled 3DFT axial series include 0.8 mm thick sections, a 512 288 matrix, 60 slices, TR of 17, TE of 4, ip angle of 30, NEX 1.36 Postprocessing of the image data can create any specic projection or surface desired. A common spin-echo alternative to this type of T2weighted sequence is a 3DFT FSE technique that utilizes a TR of 5000, TE of 100, echo train of 16, matrix of 512 384, and a small eld of view. Fat and spatial saturation pulses may be needed to suppress chemical shift and blood ow artifacts.

HIGH-RESOLUTION T1-WEIGHTED CONTRAST IMAGES

A high-resolution, contrast-enhanced T1-weighted technique similar to the T2-weighted studies can be acquired using a 3DFT technique to evaluate the temporal bone, but in this case the uid spaces have low signal intensity and the nerves have higher signal intensity. This technique is also used to generate MRA images. Intravenous contrast enhancement is commonly used in conjunction with this type of technique. This sequence is ideal for identication of subtle changes, like those seen with vestibulitis or small vestibular tumors. T1-weighted gradient-echo images can be acquired by using a moderate TR (30 to 50 ms) and ip angle (30 to 50) and by spoiling (destroying residual transverse magnetization). Spoiling is achieved by using spoiler gradients or, more efciently, by utilizing RF spoiling (i.e., by randomizing the RF excitation pulse phase). Spoiling is needed to eliminate T2 contrast components from the acquired signal, thus yielding T1weighted images that can be used to increase the visualization of the gray-white matter interfaces and create other section planes using postprocessing of the volume data sets. Routine spin-echo T1-weighted images can be utilized, but the resolution is signicantly lower. As vessels can be bright with 3D gradient echo sequences, some radiologists prefer the standard 2DFT FSE sequences. Although the images are slightly thicker, the in-plane resolution is high and the images depict the anatomy very well. Flow-related signal is less likely to be confused with subtle enhancement.

MAGNETIC RESONANCE ANGIOGRAPHY

FIGURE 20-16 Sagittal MR imaging, descending facial nerve level. At the posterior genu, the facial nerve turns inferiorly, exiting the temporal bone through the stylomastoid foramen.

Finally, a dedicated MRA acquisition may be of value in specic instances (Figs. 20-21 and 20-22). Different

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FIGURE 20-17 Curved MR imaging reconstruction of the facial nerve. A, Axial T1-weighted image of the left parotid region from a 60 image 3DFT data set. The curved white line represents the course of a curved reconstruction following the facial nerve from the brainstem into the parotid. Note the geniculate ganglion bend. B, Curved surface reconstruction. Note that the facial nerve can be followed in continuity from the brainstem into the parotid. The internal auditory canal (IAC) demonstrates high signal intensity because these are not spoiled images. Therefore, the stationary CSF in the IAC generates a high signal. This novel presentation simplies the interpretation because the nerve is visible over a long segment.

FIGURE 20-18 Three-dimensional reconstruction of MR imaging data. The data set is a 3D volume acquisition. The thresholds are set to include the uid of the IAC and labyrinth.

FIGURE 20-19 Oblique MR imaging of the cochlea. This is an oblique MR imaging reconstruction of the right temporal bone. The original data set was a 60 slice free precession highresolution series. The section plane is obliqued to parallel the long axis of the temporal bone. The plane is a steep sagittal section intersecting the descending facial nerve posteriorly and the carotid canal anteriorly. A long segment of the cochlear spiral is seen, with the appearance of a spring.

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FIGURE 20-20 Double oblique MR imaging and CT, endolymphatic sac. A, Reconstruction of axial CT images. This is a double oblique section completely paralleling the at plane of the endolymphatic sac. The sac is triangular in shape, similar to a Christmas tree, with the apex pointing at the common crus. The base of the sac broadens inferiorly. B, The identical projection on a different patient generated from 60 free precession 3DFT MR image series. This type of presentation of the endolymphatic sac is easier to analyze than the multiple short segments seen on routine imaging.

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FIGURE 20-21 Two-dimensional time-of-ight MR image. Anterior surface reconstruction MRA. This is a surface reconstruction of a 2D MR angiogram acquisition obtained without any saturation pulses or contrast enhancment. It allows visualization of both the arterial and venous systems. The carotid and jugular vessels in the neck are parallel to each other. As they enter the temporal bone, they separate, with the carotid artery turning medially and the jugular vein laterally. The carotid is anterior to the jugular system.

FIGURE 20-22

Two-dimensional time-of-ight MR imaging, lateral projection. The perspective is from the medial to lateral. The diverging carotid artery and jugular vein are well demonstrated. The jugular vein turns enter the sigmoid sinus.

Table 20-1 MR IMAGING PROTOCOLS

Sequence T2 FSE C T1 SE C 3DFT-GE T2 C 3DFT-FSE T2 C 3D GE T1 C+ 3DFT-MRA C 2DFT-MRV C Plane Axial Coronal Axial Axial Axial Axial Axial TR 5000 500 30 5000 17 48 26 TE 100 12 4 100 4.2 7 7 NEX/Echoes 1/16 1/1 1/1 1/16 1/1 1/1 1/1 Matrix 384 256 384 256 512 256 512 384 512 288 512 192 256 192 Flip Angle 90/180 90/180 30 90/180 30 20 60

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techniques must be utilized for visualization of arterial versus venous anatomy. For arterial studies, 3DFT sequences generate the best detail and are usually not acquired with contrast enhancement. The 3DFT T1-weighted highresolution technique previously described can be used as an excellent MRA technique as well. MRA sequences are designed to minimize stationary tissue signal by using a TE for which fat and water are out of phase or by using magnetization transfer. Flow compensation decreases signal from the moving CSF and thereby increases the contrast-tonoise-ratio between the blood vessels and the CSF in MRA; therefore, the soft-tissue detail may be poor. Although current MRA can provide high-quality images, they cannot substitute for traditional catheter angiography in many cases. Venous anatomy must be studied using a different technique since the venous structures are much more sensitive to saturation because of slower ow rates. For venous anatomy, a technique employing a series of contiguous 2DFT coronal or axial images without saturation pulses is commonly used. Both the arteries and veins are seen, but there is usually little confusion. Common parameters include a TR of 26, a TE of 7, a ip angle of 60, a matrix 256 192, no spatial saturation pulses, and a eld of view of 24 cm. If saturation pulses are used, there is potential for demonstration of an articial thrombosis, caused by low signal intensity resulting from saturation of inowing spins. This is a time of ight technique, so coronal and axial images have different advantages to avoid saturation effects. Postprocessing of these volume data sets can be used to create detailed 3D projections in different planes and perspectives.

CONCLUSION
Temporal bone imaging remains at the forefront of the development of high-resolution imaging techniques of the body. The improved detection and understanding of temporal bone pathology provided by modern imaging methods allows for a very precise assessment of most pathologic entities. A thorough understanding of the anatomy is very important in correctly assessing pathology. The myriad formats in which the same anatomic region is presented continue to challenge radiologists.

REFERENCES
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