19/10/2015

MODUL 5-2
Departemen Radiologi
Fakultas Kedokteran Universitas Diponegoro

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X Ray
- waters : inferior wall
- caldwell : superior dan lateral wall
- lateral : lateral wall
- rhese : foramen opticum
CT Scan
- Multiplanar CT, 3D rekonstruksi
- Anatomy and pathology bulbus oculi, soft tissue , orbital bones
MRI
- Multiplanar MRI
- Anatomy and pathology bulbus oculi ,soft tissue

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Sinus
ethmoidales
anterior
Dinding
Sinus lateral
ethmoidales orbita
posterior

Dinding superior
sinus maksilaris

Dinding
medial sinus Sinus maksilaris
maksilaris

Sinus frontalis

Sinus frontalis Sinus

ethmoidales Cavum orbita
Sutura frontozygomaticus anterior

Dinding Rim orbita

Linea lateral
innominata orbita Sinus
maksilaris
Dinding
superior
maksilaris

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Sinus
frontalis

Lamina cribosa

Proc clinoideus

Sella turcica

 - Both sides are generraly taken for comparison

 - Erect or supine posisition
 - Oblique ( rotate )head 37 0 of toward side of
interest. Rest patients chin, check and nose
against head unit or toble top
 - Midsagital plane will from 53 o angle with
film
 - Central ray perpendicular

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 Choice of Imaging modalities

 Clinical history from patient
 Prior alergy drugs or contrast agent
 GFR (iodium and gadolinium contrast agent)

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• CT is the first-line imaging modality for orbital

evaluation in the acute setting, with MR imaging
playing an important secondary role in the diagnostic
work-up.

• CT offers rapid image aquisition and higher spatial

resolution than MR imaging and is suitable for the
evaluation of fractures, calcifications, and radiopaque
foreign bodies.

• MR imaging offers exquisite contrast solution of the

orbital structures without exposing the patient to
ionizing radiation, and it is superior to CT in the
evaluation of orbital soft tissues

1. Evaluation of orbital trauma

2. Detection of foreign body
3. Detection of calcification
4.Evaluation of osseous, cartilaginous and
fibroosseous lesions
5. Evaluation of orbital soft tissue lesion with
suspicion of bony erosion or detection
6. Contraindication to MRI

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1. Acute proptosis
2. Suspicion of optic nerve sheath complex lesion
3. Intraocular tumor with extraocular extension
4. Detection of wood foreign body
5. Contraindications to CT

1. Surface coil (orbital or head coil) for

better visualization of structures of the
orbit
2. With contrast or without contrast ??
3. Sedation in children

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PATHOLOGICAL
FINDINGS

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 The location :
preseptal (periorbital) or postseptal (orbital)

 Periorbital cellulitis most commonly arises

from the contiguous spread of infection from
adjacent structures such as the face, teeth,
ocular adnexa or local trauma

 Orbital cellulitis most commonly caused by

paranasal sinusitis

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Development of an orbital sub-periosteal abscess is most

commonly associated with ethmoid sinusitis

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Need onsite injection contrast media in nasolacrimal duct for evaluating patency of
the duct

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 Fibrous dysplasia (FD) is a non-neoplastic

tumour-like congenital process, manifested as a
localised defect in osteoblastic differentiation
and maturation, with replacement of normal
bone with large fibrous stroma and islands
of immature woven bone. FD has a varied
radiographic appearance. If they are
asymptomatic, they do not require treatment.

Monostotic form
 ribs: 28%, most common
 proximal femur: 23%
 tibia
 craniofacial bones: 10-25%
 humerus
Polyostotic form
 often unilateral and monomelic:
one limb
 femur: 91%
 tibia: 81%
 pelvis: 78%
 foot: 73%
 ribs
 skull and facial bones: 50%
 upper extremities
 lumbar spine: 14%
 clavicle: 10%
 cervical spine: 7%

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Radiographic features
Plain film
 ground-glass matrix
 may be completely lucent (cystic) or sclerotic
 well circumscribed lesions
 no periosteal reaction

CT
 ground-glass opacities: 56%
 homogeneously sclerotic: 23%
 cystic: 21%
 well-defined borders
 expansion of the bone, with intact overlying bone
 endosteal scalloping may be seen

MRI
 MRI is not particularly useful in differentiating fibrous
dysplasia from other entities as there is marked
variability in the appearance of the bone lesions, and
they can often resemble a tumour or more aggressive
lesions.
 T1: heterogeneous signal, usually intermediate

 T2: heterogeneous signal, usually low, but may have

regions of higher signal
 T1 C+ (Gd): heterogeneous contrast enhancement 4

Nuclear Medicine
 Demonstrates increased tracer uptake on Tc99 bone
scans (lesions remain metabolically active into
adulthood).

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 Meningiomas are extra-axial tumours and represent the most common tumour of
the meninges. They are a non-glial neoplasm that originates from the arachnoid
cap cells of the meninges. They are typically benign with a low recurrence rate but
rarely can be malignant.

Clinical presentation
 asymptomatic.
 headache: 36%
 paresis: 22%
 change in mental status: 21%
 focal neurological deficits
 convexity/parasagittal: seizures and hemiparesis
 basisphenoid: visual field defect
 cavernous sinus: cranial nerve deficit(s)
 frontal: anosmia (although often become very large before becoming symptomatic)
 dural venous sinus invasion/dural venous sinus thrombosis
 intraosseous extension: may be hyperostotic or osteolytic and may result in local
mass effect (e.g. proptosis)

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Plain radiography
 Plain films no longer have a role in the diagnosis or management of
meningiomas. Historically a number of features were observed,
including:
 enlarged meningeal artery grooves
 hyperostosis or lytic regions
 Calcification

CT
 60% slightly hyperdense to normal brain, the rest are more isodense
 20-30% have some calcification 8
 72% brightly and homogeneously contrast enhance 8, less frequent in
malignant or cystic variants
 hyperostosis
 typical for meningiomas that abut the base of the skull
 need to distinguish reactive hyperostosis from skull vault invasion
(eventually involves the outer table too)
 lytic regions: particularly in higher grade lesions
 pneumosinus dilatans

MRI
As is the case with most other intracranial pathology, MRI is the investigation of
choice for the diagnosis and characterisation of meningiomas. When
appearance and location is typical, the diagnosis can be made with a very high
degree of certainty. In many instances however the appearances are atypical.
Meningiomas typically appear as extra-axial masses with a broad dural base.
They are usually homogeneous and well circumscribed, although many variants
are encountered.
Signal characteristics include:
T1
isointense: ~60-90%
somewhat hypointense: 10-40% compared to grey matter
T1 C+ (Gd): usually intense and homogeneous enhancement
T2
isointense: ~50%
hyperintense: 35-40%
usually correlates with soft textures and hypervascular tumours
DWI: atypical and malignant subtypes may show greater than expected
restricted diffusion although recent work suggests that this is not useful in
prospectively predicting histological grade
MR spectroscopy
MR perfusion

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 Orbital pseudotumour is an idiopathic

inflammatory condition that usually involves
the extraocular muscles although, in some
cases there is inflammatory change involving
the uvea, sclera, lacrimal gland and retrobulbar
soft tissues. The exact aetiology is not known.

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Radiographic features
 Imaging demonstrates enlargement of the muscle belly of one (or
more) occular muscles with involvement of the tendinous
insertion. Involvement of the tendinous insertion distinguishes it
from thyroid associated orbitopathy (TAO) in which the insertion
point is spared. Additional inflammation can be seen in
surrounding tissues, including the lacrimal gland. It can appear as
infiltrative mass and extends outside of the orbit via superior or
inferior orbital fissures. Extension into the cavernous sinus,
meninges, and dura can occur.

MRI
 Reported signal characteristics include
 T1: affected region typically iso to hypo intense
 T2: affected region typically hypo intense due to fibrosis and with
more progression of fibrosis it becomes more hypointense
 T1 C + (Gd): diffuse enhancement

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T1 T1 C + Fat sat

TERIMA KASIH

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