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This document discusses the use of bone window settings on CT scans to evaluate skull lesions. It provides recommendations for using bone window settings, including for abnormal skull films, suspected congenital anomalies, enhancing lesions near the skull, and suspected metastatic disease. It then describes the appearance of the normal skull anatomy on bone window images and various common benign variants and developmental abnormalities that may be seen, such as venous lakes, doughnut lesions, and parietal thinning. Examples of several developmental diseases are also shown.
This document discusses the use of bone window settings on CT scans to evaluate skull lesions. It provides recommendations for using bone window settings, including for abnormal skull films, suspected congenital anomalies, enhancing lesions near the skull, and suspected metastatic disease. It then describes the appearance of the normal skull anatomy on bone window images and various common benign variants and developmental abnormalities that may be seen, such as venous lakes, doughnut lesions, and parietal thinning. Examples of several developmental diseases are also shown.
This document discusses the use of bone window settings on CT scans to evaluate skull lesions. It provides recommendations for using bone window settings, including for abnormal skull films, suspected congenital anomalies, enhancing lesions near the skull, and suspected metastatic disease. It then describes the appearance of the normal skull anatomy on bone window images and various common benign variants and developmental abnormalities that may be seen, such as venous lakes, doughnut lesions, and parietal thinning. Examples of several developmental diseases are also shown.
bone window setting of different primary and secondary skull tumors, bone dysplasia, congen- ital and inammatory diseases affecting the skull, and extrinsic lesions exhibiting secondary effects on the skull. The differen- tial diagnosis of lesions affecting the inner and/or outer table, or the diploic space also is pre- sented. Recommendations for routine use of bone window setting in brain CT scanning includes 1) abnormal skull lms; 2) suspected congenital anom- alies; 3) presence of enhancing lesions in close proximity to skull bone; and 4) suspected metastatic disease. B one window images that rou- tinely are acquired in CT exami- nations of the head for trauma or paranasal sinus disease can be useful in the characterization of different skull lesions. These images are excellent for demonstration of skull tables and the diploic space. Bone algorithm and l- ters also enhance the ability to visual- ize ne bony detail. Bone window images obtained in conjunction with routine brain scans may lead to fortu- itous discovery or superior characteri- zation of skull pathology. CT window widths of 600 to 2,000 Hounseld units (HU) and window lev- els of 160 HU to 500 HU accurately delineate tissues of a large difference in CT attenuation, such as bone and air. Narrower window widths (80 HU to 150 HU) and lower center levels (40 HU to 50 HU) are employed to show small dif- ferences in attenuation of soft tissues such as brain, but are not as accurate as bone window settings in depicting con- tour, edge interface, and size of bone structures. Features of the calvaria The calvaria is well differentiated into three layers: inner, middle, and outer tables. The inner and the outer tables are composed of compact bone; the middle table is composed of cancel- lous bone. The inner and outer tables vary little in thickness, except in places where they are eroded by vascular struc- tures and gyral impressions. The diploic space is composed of an irregular net- work of bony trabeculae and vascular spaces. Blood within this space may act as a uid cushion to absorb traumatic forces. 1 Normal variants Common benign lesions may repre- sent normal variants or developmental abnormalities in the skull. Such lesions usually have characteristic radiologic ndings and should not be confused with other pathological entities. Pac- chionian granulations or venous lakes (gure 1) are arachnoid extensions pro- jecting into the lumen of the main venous sinuses. The edges are further apart at the inner table level than at the outer table, indicating a benign process originating inside the skull. 1 Another benign nding is the presence of circular lucent defects of the calvaria, known as doughnut lesions. These usually do not exceed 2 cm in diameter and may represent smaller versions of abnormal lesions such as brous dysplasia, eosinophilic granuloma, epidermoid inclusion cyst, or osteoid osteoma. 3 Some cases of doughnut lesions may be familial in nature. 4 Parietal thinning (gure 2) is charac- terized by the generally bilateral and symmetrical thinning of the parietal bones with partial or complete absence of the diploe and the outer table of the skull. 5 Parietal foramina are holes in the Value of bone window images in routine brain CT: Examinations beyond trauma Dr. Snow and Dr. Brogdon are in the Department of Radiology at University of South Alabama Medical Center in Mobile, AL. Dr. Williams was in the Department of Radiology at University of South Alabama Medical Center in Mobile, AL. Dr. Georgy is in the Department of Radiology at the Univer- sity of California in San Diego, CA. Bassem A. Georgy, MD; Ruth D. Snow, MD; Byron G. Brogdon, MD; J. Powell Williams, MD FIGURE 1. Well-defined defect in the left frontal bone (arrow) compatible with venous lake is observed in a 59-year-old woman undergoing serial CT examinations for left middle cerebral artery infarction. skull that represent a benign variant of incomplete ossication of the bones in the region of the obelion on both sides of the sagittal suture, and may be associ- ated with severe pain and headache with gentle pressure. 6 Parietal foramina also may be familial and is possibly associ- ated with faulty ossication of the clavi- cles. 7 Another abnormality that may be seen is hyperostosis frontalis interna, 8 which is characterized by thickening of the inner table that may extend to the diploe of the frontal bone; this lesion is commonly found in middle-aged women (gure 3). It is important to dif- ferentiate this normal variant from hyperostosis that may occur secondary to meningiomas. Hereditary and developmental abnormalities A long list of developmental and hereditary diseases can affect the cal- varial bones. Hodges 3 divided the hereditary abnormalities of the calvaria into ve groups: suture abnormalities, abnormalities in shape and size, increased thickness and density, gener- alized thinning, and skull defects or holes. Table 1 summarizes the radio- logical ndings of the common devel- opmental and hereditary diseases that can affect the skull calvaria (gures 4- 6). Bone window setting also is extremely valuable in the evaluation of nasal bone and temporal bone develop- mental anomalies (gure 7). FIGURE 2. Parietal thinning in a 75-year-old woman shown in a lateral skull lm (A). Bone window setting of brain CT (B) showed marked thinning of the inner and outer tables in pari- etal regions (arrows). A B FIGURE 3. Incidentally noted hyperostosis frontalis in a 72-year-old woman (A). A normal bone window of matched age and sex is illustrated (B). A B FIGURE 4: Neurobromatosis in a 3-year- old girl. Dysplasia of the right sphenoid wing is seen in a bone window image (A). Soft-tissue density, likely representing a plexiform neurofibroma, is seen filling the defect in a corresponding T1-weighted image (TR/TE= 650/16) (B). A B FIGURE 5. Osteopetrosis in a 56-year-old man showing a thick skull, increased bone density, and obliteration of the diploic space. Inammatory lesions Infections of the skull are rare because of the relative resistance of the calvarial bones to infection. When infection does occur, it usually is by direct extension from the paranasal sinuses and mastoid air cells or from trauma. 18 Subperiosteal abscess forma- tion secondary to osteomyelitis exten- sion from acute suppurative frontal sinusitis results in the well known Potts puffy tumor (gure 8). 19 Common pre- disposing factors of Potts puffy tumor are diabetes and immunosuppression. If a Pseudomonas infection extends through the cartilage of the external auditory canal to the skull base in cases of malignant otitis externa it may result in osteomyelitis. 14 Additionally, asper- gillosis and mucormycosis can invade the calvaria (gure 9). 20 Osteitis is seen as a focal or diffuse wavy thickening of periosteum with sclerosis of bony mar- gins; this periosteal thickening may enhance following intravenous injection of contrast material. When an infection extends into the bone marrow (osteomyelitis), 14 lytic expansion and destruction are noted and usually associated with a soft-tissue mass. Granulomatous infection is seen as a lytic area with or without sclerotic CT appearance of common developmental and hereditary diseases of the calvaria on bone window setting. Suture abnormalities 1. Craniosynostosis. Premature closure of a suture with decrease in the diameter of the skull perpendicular to the plane of the affected suture. 2. Microcephaly. Failure of normal brain growth results in failure of the skull bones to grow. 3. Widening of sutures. Due to increased intracranial pressure or hypophosphatasia. 9 Asymmetry and abnormal shape 1. Arachnoid cyst. Temporal fossa, expansion and thinning of the inner table. 10 2. Neurobromatosis. Absent sphenoid wing 11 with focal calvarial defects adjacent to lambdoid suture (gure 4). 12 3. Dandy-Walker syndrome. Large posterior fossa with elevation of the torcula and attening and thinning of the occipital bone. 13 4. Arnold-Chiari syndrome. Widening of foramen magnum, concavity of the clivus, thinning of the occipital bone and small poste- rior fossa. 14 5. Unilateral hypertrophy. Dyke-Davidoff-Massion syndrome 15 and Sturge-Weber-Dimitri syndrome. 3 Increased thickness and/or density 1. Osteopetrosis (Albers-Schonberg disease). Increased bone density of the entire skull with obliterated vascular grooves (gure 5) and encroachment on basal foramina. 16 2. Childhood anemias. Hyperplastic erythroid elements result in marked thickening of the diploe with near obliteration of the outer table (gure 6). 14 Proliferation of the hyperplastic marrow beneath the periosteum and a perpendicular array of trabeculae result in hair-on-end appearance. Obliteration of the paranasal sinuses and mastoid air cells by overgrowth of marrow more in thalassemia and sickle cell anemia. 3. Sclerostosis. Hyperostosis and sclerosis, particularly the temporal bone. 17 4. Other diseases. Van Buchems disease, Pyle disease, Engelmanns disease and Pyknodysosstosis. 16 Generalized thinning of bone 1. Osteogenesis imperfecta. Generalized thinning of the skull and persistent wormian bones. 16 2. Chronic elevation of intracranial pressure. Accentuated digital markings due to imprint of the gyral surface of the brain, beaten silver appearance. 3 3. Regional thinning. Porencephaly, chronic subdural hygroma, arachnoid cyst. Defects in the bones 1. Encephalocele. Midline frontal or occipital defect with soft-tissue mass. 14 2. Epidermoid. Sharply demarcated defect with sclerotic edge and absent overlapping of the outer table due to ectopic epithelial tissue included in bone during development. TABLE 1 FIGURE 6: Polycythemia vera in a 27-year-old man who also has leukemia in remission. Dif- fuse expansion of the diploic space (A) involving even the posterior clinoid processes and dorsumn sellae (B) is seen. A B margins and localized soft-tissue swelling. 18 Mucoceles of the paranasal sinuses often show smooth defects in relation to the sinus walls and can be seen as extending into the orbit or the intracranial cavity. 21 CT is not specic in differentiating tumor from infection; however, it can help to dene the extent of the lesion and is useful in following up the efficacy of treatment. 14 Neoplastic diseases The most frequent neoplastic involve- ment of the skull occurs by metastatic disease or invasion from adjacent neo- plasms. Table 2 shows the radiologic ndings in bone window setting of the most common primary osseous and car- CT appearance of common extraosseus benign and malignant tumors causing secondary effects on the skull on bone window setting 1. MeningiomaArises from the dural surfaces of the vault or near skull base. Hyperostosis and thickening of the calvaria adja- cent to the tumor mass is present (gure 12). Bone destruction occurs with sarcomatous degeneration. 10 En-plaque type may be difficult to distinguish the tumor itself from associated hyperostosis. 25 2. NeuromasCranial nerve sheath tumors cause uniform expansion of the affected canal or foramen. 10 Seventh and eighth nerves tumors in the IAC are the most common. Erosion of the foraminal wall suggests malignancy. 26 3. GliomasSupercial tumors may cause focal expansion of the overlying skull vault. 14 Optic nerve glioma causes enlargement of the optic foramina. 4. ChordomasWell-circumscribed destructive lesion containing bone debris and disproportionate large soft-tissue mass which enhances heterogeneously. 27 Common in the clivus. 5. Sellar tumorsAdenomas are rarely aggressive but may cause destruction of the skull base (gure 13). 10 6. Glomus tumorsEnhancing mass with destruction of related bony structures (gure 14). TABLE 3 CT appearance of common benign and malignant skull tumors in bone window setting Benign tumors 1. OsteomaWell-dened dense, sessile lesion arises from external or internal tables and may extend intracranially (gure 10). May be associated with Gardner syndrome. 3,14 2. HemangiomaHamartoma starts in the diploic space, characterized by lucent areas with prominent radiating or reticulated trabeculae. May have sclerotic edge (gure 11). 3 3. ChondromaWell-dened lytic lesion with variable amount of calcication. Enhances on delayed scans due to minimal vas- cularity. 10,14 4. Ossifying bromaLucent area with varying amount of calcication. 14 Differentiated from brous dysplasia only histologically. 5. Giant cell tumorLytic mass with possible ecks of calcication in the skull base; may have soft-tissue component. 22 6. Aneurysmal bone cystLytic bubbly lesion showing contrast enhancement. 14,23 Malignant tumors 1. Osteogenic sarcomaMalignant transformation of Pagets disease or post-radiation changes. Irregular destruction or blastic expansion. May arise from the inner table and simulate intracranial mass. 24 2. ChondrosarcomaLytic and sclerotic areas with irregular calcications. Common in skull base. Soft-tissue components are present, and many have intracranial extension. 10,14 3. FibrosarcomaLytic areas with soft-tissue mass. 14 4. Fibrous histiocytomaLytic areas with occasional calcication and destruction. 14 Usually seen after radiation therapy. TABLE 2 FIGURE 7. A 35-year-old female with pulsatile tinnitus. Bone window setting of the skull base shows wide left jugular foramen (A). Collapsed image of 2D time-of-flight MR venogram shows a prominent left-sided venous system (B). A B tilaginous tumors arising from the skull bones. Tumors of neuronal origin also can cause secondary effects on the skull bones (table 3). Some tumors are particularly com- mon in the skull base; these include chordoma, chondroma, chondrosar- coma, giant cell tumors, dermoid and epidermoid tumors, sellar tumors, chemodectomas, and neuromas that arise from cranial nerves traversing skull base foramina. Coronal and sagit- tal images are very helpful in evaluation of the presence of such lesions. Scan- ning at a gantry angle of + 30 degrees to the canthomeatal line is of particular use in evaluation of the jugular foramina. 28 Metastatic disease, multiple mye- loma, and lymphomas are the most common malignant tumors affecting the calvaria, presenting chiey as multiple lytic lesions. 3 Kido et al 29 found that CT scans using bone window settings are more sensitive than skull radiographs in detecting calvarial lesions. Lytic metastases are more frequent than blastic or mixed, and usually erode either the inner or the outer table of the calvaria. Lesions of this type usually are sharply circumscribed and concave toward the eroded surface (g- ures 15 and 16). 29 Blastic metastases typically are caused by carcinoma of FIGURE 8. A 9-year-old boy with Pott's puffy tumor. Frontal skull tomogram shows a well-dened defect in the frontal bones (A). Soft-tissue mass extending on both sides of the calvaria (B) is seen. A corresponding bony defect is seen in bone window setting (C). Note also hypoplasia of the frontal sinuses. A B C FIGURE 9. A 58-year-old female with aspergillosis abscess in the orbital apex. Enhanced CT (A) shows the inammatory mass eroding into the sphenoid and ethmoid sinuses and extending into the cavernous sinus and middle temporal fossa. Corresponding bone window setting delineates the destructive process (B). Left carotid angiogram shows localized narrowing of the cavernous portion (arrow) (C). A B C FIGURE 10. A 62-year-old man with right frontal osteoma and intracranial extension. FIGURE 12. Posterior fossa meningioma in a 74-year-old woman (A). Axial CT image with the corresponding bone window setting (B). A B FIGURE 13. Pituitary macroadenoma in a 30-year-old man: (A) CT with bone window setting at the skull base showing extensive bony destruction; (B) Sagittal T1-weighted (TR/TE= 600/20) image after gadolinium injection shows extension of the tumor intracranially and into the clivus. A B FIGURE 14. A 21-year-old man with glomus jugulare tumor: (A) bone window setting of the base of the skull shows expansion and destruction of the right jugular fossa and foramen; (B) external carotid angiogram shows an extensive vascular tumor. A B FIGURE 11. A 14-year-old girl with heman- gioma of the right parieto-occipital region in lateral skull film (A) and bone window set- ting of the brain CT (B). (Image courtesy of Rac Melhem, MD, Mobile, Alabama.) A B the breast, prostate, colon, or bone. Medulloblastoma also has been reported to cause calvarial blastic metastasis. 30 Metastasis to the endocra- nial epidural space is prevalent in patients with prostate cancer, and may be associated with a soft-tissue mass that simulates meningioma. 3 When a calvarial metastatic deposit is detected, the presence of other skeletal deposits should be suspected. 29 Leu- kemia and lymphoma deposits usually Common calvarial lesions according to location. Outer space Diploic space Inner table All tables All scalp lesions Hematologic lesions Pacchionian granulation Acromegaly Parietal thinning (anemias, leukemias) Chronic subdural hematoma Fibrous dysplasia Osteoma Multiple myeloma Slow-growing sueprcial tumors Pagets disease Periosteal osteosarcoma Metastasis Intracranial cysts Meningioma Cushings disease Pagets disease Meningioma Metastasis Chronic phenytoin therapy Hyperostosis frontalis Multiple myeloma Bone islands Leptomeningial cysts Leukemia, lymphoma Hyperparathyroidism Osteosarcomas Shunted hydrocephalus Tuberous sclerosis Hyperparathyroidism Advanced parietal thinning Parietal foramina Advanced hyperostosis frontalis Meningiomas Cushings disease TABLE 4 FIGURE 15. Bone window setting in a 71- year-old woman with breast cancer shows multiple Iytic metastatic lesions scattered throughout the calvaria. Guidelines in differentiating benign from malignant luciences of the skull. Developmental benign lesions tend to be high in the skull and near the midline. Half epidermoids are located paramedially. Single, small lesions are likely to be benign. Large single lesions may be benign; small, single malignant lesions are very rare. Perilesional sclerosis strongly suggests a benign process. Many benign lesions are conned to the diploic space. Benign lesions have relatively smooth outlines compared to the irregular, invasive outline of malignant lesions. (Adapted from Thomas JE, Baker HL, Jr: Assessment of roentgenographic lucencies of the skull: A systematic approach. Neurology 25:99-106, 1975.) TABLE 5 FIGURE 16. A 61-year-old man with right frontal bone destruction from lung carcinoma metastasis. (A) An irregular Iytic lesion affecting mainly the inner table. (B) Enhanced T1- weighted (TR/TE=600/16) image shows an enhancing lesion in the same location. A B FIGURE 17. A 76-year-old male with multiple myeloma: (A) Enhanced axial CT scan shows an enhancing epidural metastatic lesion in the left parietal region. (B) Corresponding bone window setting shows multiple Iytic lesions with complete destruction of the calvaria at the site of the epidural lesion. A B FIGURE 18. Different radiologic features of brous dysplasia: (A) and (B) Axial and coronal bone window settings of an 8-year-old boy who displays the typical ground-glass appearance; (C) Another patient showing coarse sclerotic nodules; (D,E,F,G) A third patient shows the typical ground-glass appearance in bone window setting (D,E) and a hemorrhagic cyst with high signal uid-uid level in both T1-weighted (F) and T2-weighted (G) MR images. B A C D E F G are detected as less well-dened multi- ple lesions that tend to coalesce and sometimes resemble a coarse version of normal diploic bone; 3 a soft-tissue com- ponent may be associated. 14 Multiple myeloma (gure 17) usually presents with multiple discrete, rounded holes of variable sizes, referred to as punched- out lesions. 3 Dural based lymphoma and metastatic disease can cause erosion and destruction of the inner table and can be confused with other non-neoplastic dural lesions, such as those found in chronic infections and sarcoidosis. Endocrine, metabolic, and idiopathic lesions In hyperparathyroidism, bone win- dow images on CT scans may show a granular or mottled appearance known as the salt and pepper appear- ance. 3,31,32 Brown tumors show a low CT density similar to that of epidermoids and neurobromatosis skull defects. 14 An accentuated temporal line due to subligamentous bone resorption under the temporalis muscle has been described recently as a radiologic sign of hyperparathyroidism. 33 In acromegaly, hypertrophic thicken- ing of all the skull tables and expansion of the paranasal sinuses and sella turcica can be noted. Diffuse osteoporosis may be seen in Cushings syndrome. 3,34 In hypothyroidism (myxedema), retardation of cranial and facial development is man- ifested by an absence or underdevelop- ment of paranasal sinuses and poor pneumatization of the mastoid air cells. Additionally, there is a delay in closure of the sutures, with poorly differentiated inner and outer tables and poorly devel- oped diploic space. 3,34 In hypervita- minosis A, generalized osteoporosis with a thin, poorly mineralized skull is usually seen, associated with relatively dense suture margins and hydrocephalus. 35 Generalized increased bone density and thickening with metastatic calcication in the falx, tentorium, and dura are seen in cases of hypervitaminosis D. 35 Sclero- sis and coarse trabeculation are associ- ated with uorine ingestion. 36 In brous dysplasia, the radiologic appearance will depend on the propor- tion of brous tissue to bone (gure 18). 31,37 Three categories of radiologic appearances of brous dysplasia have been described: pagetoid type, which involves expansion of the bone with areas of sclerosis and luciences (mixed type); sclerotic type; and cystic type, which may be complicated by sponta- neous hemorrhage. 31,38,39 The outer table has a thin and delicate appearance, with diffuse widening of the diploic space. Areas of poorly-dened dense nodules 14 or the characteristic homogeneous ground-glass appearance also are com- monly seen. 3 Extensive sclerosis may affect the base of the skull, sphenoid bones, or temporal bones. 14 Arterial grooves generally are enlarged, indicat- ing hypervascularity of the tumor. 3 The lesions may cause facial deformities, and may encroach upon the cranial nerves. 14 Bone window images of a patient with Pagets disease can show a contin- uous spectrum of the disease, from the early active lytic phase (osteoporosis circumscripta) to the dense sclerosis of the healing phase (cotton-wool appear- ance) (gure 19). Sutures and vascular grooves do not restrict the progress of this disease. 14 Softening of the skull base occurs with basilar invagination and compression on the basal foramina. Sar- comatous degeneration may occur and is characterized by bone destruction or adjacent bulky soft-tissue masses. 40 Eosinophilic granuloma are usually well-dened lytic lesions that rarely have sclerotic margins. Two characteris- tic radiologic ndings have been described in relation to eosinophilic granuloma: 3 beveled edges due to greater involvement of the outer table than the inner table (gure 20) and but- ton sequestrum 41 due to a bone island or density within the lesion. However, these ndings, besides being rare, also have been described with other lesions. 3,42 Eosinophilic granuloma can heal spontaneously or with radiation therapy, especially in children. 43 Conclusion Judicious use of bone window set- tings in conjunction with routine brain FIGURE 19. A 72-year-old man with advanced Pagets disease. (A) and (B) are CT topogram and bone window settings through skull base, respectively, showing diffuse thickening of the calvaria with mixed sclerotic and Iytic changes. Bone softening causing basilar invagination is also noted. (Image courtesy of John R. Hesselink, MD, San Diego, California.) A B FIGURE 20. Bone window setting on CT of a 4-year-old-female with unusually large eosinophilic granuloma with characteristic beveled edges (arrow). (Image courtesy of Rac Melhem, MD, Mobile, Alabama.) CT scanning allows better characteriza- tion of associated bony lesions. The ability to dene the origin of the lesion may be helpful in reaching the nal diagnosis (table 4). In a study of 333 patients with calvarial translucencies, Thomas and Baker 44 suggested some guidelines to reach a nal diagnosis based on plain lm ndings (table 5). The following indications are suggested for routine use of bone window settings in brain CT examinations: 1) abnormal skull lm; 2) suspected congenital abnormalities; 3) presence of an enhan- cing lesion in relation to the skull bones; and 4) suspected metastatic disease. AR References 1. Ethier R: Thickness and texture. 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