NEUROIMAGING

Normal anatomy of the base of the

skull, orbit, pituitary and cranial
nerves
Shelley A Renowden

Correspondence to
Dr Shelley A Renowden,
Department of Neuroradiology,
Frenchay Hospital, Clinical
Support Services Directorate,
Bristol BS16 1LE, UK;
shelley.renowden@north-bristol.
swest.nhs.uk
Received 31 January 2012
Accepted 19 March 2012
This article illustrates the normal anat-
omy of the base of the skull, orbit, pitu-
itary and some other cranial nerves.
Figure 1 illustrates the normal anat-
omy of the base of the skull in CT.
The base of the skull is usually
imaged using CT that employs fine
cuts which most clearly images the
bony structures—all those foramina
and fossas learnt in anatomy. This
may be complemented by MRI where
there are concerns about soft tissue
abnormalities.
CT of the base of the skull is specifi-
cally indicated in patients with head
injuries where a skull base fracture is
suspected, and in the assessment of
skull base inflammatory and neoplas-
tic processes. The skull base is a thin
bony structure with various soft tissue
structures on either side, and is there-
fore often best evaluated by using a
combination of both CT and MR in
the axial and coronal planes. Where
specific pathology is suspected, MR
sequences, particularly short tau
inversion recovery and T1–weighted
gadolinium-enhanced sequences with
fat saturation, are currently found to
be the most useful.
Imaging the cerebellopontine angle
(figure 2) and the pituitary fossa (fig-
ure 3) is best achieved using MRI. The
orbit can be usefully imaged with both
CT and MR, and normal anatomy of
the orbits with both modalities is illus-
trated in figure 4.
Competing interests None.
Provenance and peer review Not commissioned;
externally peer reviewed.

Figure 1 CT skull base: axial (A–K) and coronal (L–T) images.

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Figure 1 Continued

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Figure 1 Continued

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Figure 1 Continued

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Figure 1 Continued

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Figure 2 Constructive interference in steady state MRI: a thin slice of heavily T2-weighted volume acquisition sequence, with high spatial and contrast
resolution and incorporating flow compensation—very useful for assessing the cranial nerves, particularly the 8th, for sensorineural hearing loss, 7th in
hemifacial spasm and 5th for trigeminal neuralgia.

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Figure 2 Continued

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Figure 3 MRI pituitary fossa/parasellar area:the imaging modality of choice (of course, for endocrine disturbance!) but also for assessment of visual
loss, bi-temporal hemianopia and ophthalmoplegia. T1-weighted sagittal (A, B – different patients) and coronal (C, D, F, G) and T2 coronal (E, H) images.
‘Incidentalomas’ are common in normal individuals. They are usually <10 mm, usually remain static, but some can increase in size while some others decrease.
The T1 hyperintense posterior pituitary can vary in size according to body hydration.

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Figure 3 Continued

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Figure 4 Orbital imaging: axial CT (A, B, F, G), T1-weighted MR (C, D, H, I), coronal CT (J), T1-weighted MR (K), T1-weighted gadolinium-enhanced
coronal fat saturation (L) and short tau inversion recovery (STIR) axial (M, N) and coronal MR (O) orbital images. Both CT and MR are useful in assessment
of orbital structures. Both can exclude optic nerve compressive lesions. CT is better for trauma and demonstration of calcification (maybe, optic nerve
sheath meningioma?). T1-weighted gadolinium fat-suppressed sequences optimally demonstrate pathological processes in the orbit. Suppressing the high
signal from fat optimises the effect of gadolinium enhancement. MR is optimal for visualising the optic nerve itself, particularly using STIR fat-suppressed
sequences (M, N, O). In general, STIR (a bit like a T2-weighted sequence with fat saturation) and gadolinium-enhanced T1-weighted sequences in the axial and
coronal planes are optimal for the assessment of pathology involving both the orbits and the skull base.

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Figure 4 Continued

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