Netter’s Correlative Imaging: Neuroanatomy: with NetterReference.com Access [Har/Psc ed.] 1437704158, 9781437704150

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r i 9 . 9 & s r s i n h a a i t s r e p . p i v

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The new standard for human anatomy! Netter’s Anatomy Atlas for iPad™ puts Netter’s most famous illustrations of human anatomy in the palm of your hand!

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NETTER’S

Correlative Imaging: Neuroanatomy Volume Editors

THOMAS C. LEE, MD Assistant Section Head Neuroradiology Instructor Harvard Medical School Boston, Massachusetts

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r JR., MD, PhD i 9 . SRINIVASAN MUKUNDAN, 9Network&Chief ss r i Neuroradiology n h Brighamaand Women’s Hospital a i t Associate Professor of Radiology s r Harvard University pe Boston, Massachusetts . ip Series Editor v NANCY M. MAJOR, MD Director of Diagnostic Imaging Orthopaedic Associates of Allentown Allentown, Pennsylvania

Illustrations by

Frank H. Netter, MD Contributing Illustrators

Tiffany Slaybaugh DaVanzo, MA, CMI Carlos Machado, MD

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1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY  Copyright © 2015 by Saunders, an imprint of Elsevier Inc.

ISBN: 978-1-4377-0415-0

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

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Library of Congress Cataloging-in-Publication Data Netter’s correlative imaging. Neuroanatomy / volume editors, Thomas C. Lee, Srinivasan Mukundan, Jr. ; illustrations by Frank H. Netter, contributing illustrators, Tiffany Slaybaugh DaVanzo, Carlos Machado.    p. ; cm. -- (Netter clinical science)   Correlative imaging: neuroanatomy  Neuroanatomy   Includes bibliographical references and index.   ISBN 978-1-4377-0415-0 (hardcover: alk. paper)   I. Lee, Thomas C., editor. II. Mukundan, Srinivasan, Jr., editor. III. Netter, Frank H. (Frank Henry), 1906-1991, illustrator. IV. Title: Correlative imaging: neuroanatomy. V. Title: Neuroanatomy. VI. Series: Netter clinical science.    [DNLM: 1. Nervous System--anatomy & histology--Atlases. 2. Magnetic Resonance Imaging--Atlases. WL 17]  QM451  611.8022’2--dc23

2014001295

Senior Content Strategist: Elyse O’Grady Senior Content Development Editor: Marybeth Thiel Publishing Services Manager: Patricia Tannian Project Manager: Kate Mannix Design Direction: Louis Forgione Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1

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To my wonderful parents, Wendy and Doug, for their unwavering support and encouragement To my siblings, Ashley, Hillary, MacGregor, and Alex, who have been permanent sources of love and inspiration McKinley D. Nickerson, Project Coordinator To my inspirational parents, Sun Hyee and Chang Whan Lee, who provided my foundation To my sister and brother-in-law, Jane and Richard, and their son, Alexander, for bringing bright hope for the future To my supportive wife, Ji In, who is my one and only soulmate Thomas C. Lee To my wife, Nancy, and our sons, TJ and Dev To my parents, teachers, and mentors To students past, present, and future, who, through their study and dedication, validate this effort Srinivasan Mukundan

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About the Artists FRANK H. NETTER, MD Frank H. Netter was born in 1906 in New York City. He studied art at the Art Students League and the National Academy of Design before entering medical school at New York University, where he received his MD in 1931. During his student years, Dr. Netter’s notebook sketches attracted the attention of the medical faculty and other physicians, allowing him to augment his income by illustrating articles and textbooks. He continued illustrating on the side after establishing a surgical practice in 1933, but he ultimately opted to give up his practice in favor of a full-time commitment to art. After service in the United States Army during World War II, Dr. Netter began his long collaboration with the CIBA Pharmaceutical Company (now Novartis Pharmaceuticals). This 45-year partnership resulted in the production of the extraordinary collection of medical art so familiar to physicians and other medical professionals worldwide. In 2005, Elsevier, Inc., purchased the Netter Collection and all publications from Icon Learning Systems. There are now more than 50 publications featuring the art of Dr. Netter available through Elsevier, Inc. (in the US: www.us.elsevierhealth.com/Netter; outside the US: www.elsevierhealth.com). Dr. Netter’s works are among the finest examples of the use of illustration in the teaching of medical concepts. The 13-book Netter Collection of Medical Illustrations, which includes the greater part of the more than 20,000 paintings created by Dr. Netter, became and remains one of the most famous medical works ever published. The Netter Atlas of Human Anatomy, first published in 1989, presents the anatomical paintings from the Netter Collection. Now translated into 16 languages, it is the anatomy atlas of choice among medical and health professions students the world over. The Netter illustrations are appreciated not only for their aesthetic qualities, but, more important, for their intellectual content. As Dr. Netter wrote in 1949, “. . . clarification of a subject is the aim and goal of illustration. No matter how beautifully painted, how delicately and subtly rendered a subject may be, it is of little value as a medical illustration if it does not serve to make clear some medical point.” Dr. Netter’s planning, conception, point of view, and approach are what inform his paintings and what make them so intellectually valuable. Frank H. Netter, MD, physician and artist, died in 1991. Learn more about the physician-artist whose work has inspired the Netter Reference collection: http://www.netterimages.com/artist/netter.htm CARLOS MACHADO, MD Carlos Machado was chosen by Novartis to be Dr. Netter’s successor. He continues to be the main artist who contributes to the Netter Collection of Medical Illustrations. Self-taught in medical illustration, cardiologist Carlos Machado has contributed meticulous updates to some of Dr. Netter’s original plates and has created many paintings of his own in the style of Netter as an extension of the Netter Collection. Dr. Machado’s photorealistic expertise and his keen insight into the physician/patient relationship inform his vivid and unforgettable visual style. His dedication to researching each topic and subject he paints places him among the premier medical illustrators at work today. Learn more about his background and see more of his art at: http://www.netterimages.com/artist/machado.htm TIFFANY SLAYBAUGH DAVANZO, MA, CMI Tiffany Slaybaugh DaVanzo is a Certified Medical Illustrator and graduate of the Johns Hopkins University School of Medicine’s Art as Applied to Medicine master’s degree program. She has been a self-employed medical illustrator since 2006, and her work has received numerous awards. She specializes in art for medical publications, education, and the medical legal field. The first medical text Tiffany owned was Netter’s Atlas of Human Anatomy. It currently sits on her desk tattered and littered with Post-It notes from years of hard use, but is a tribute to Dr. Netter’s influence on her art. She considers it a career highlight to be creating new artwork for the Netter collection. Tiffany lives in Tennessee with her husband and two young daughters.

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About the Editors Thomas C. Lee, MD, grew up in Toronto, Ontario. He attended Harvard College and earned an AB degree with honors in biochemical studies. He graduated from medical school at McGill University in Montreal before returning to his hometown, where he completed a residency in diagnostic radiology, followed by a fellowship in neuroradiology, at the University of Toronto. While a student at Harvard, he attended Addenbrooke’s Hospital at Cambridge University, United Kingdom, as a Weissman Awardee. As a medical student, he won the BiochemPharma Award for McGill medical student research of highest scientific merit, and as a resident, he won the Radiological Society of North America Award for research excellence. He has co-authored several peer-reviewed manuscripts and book chapters. He has lectured at many local, national, and international meetings with a focus on head, neck, and spine imaging and intervention, most recently on MRI-guided cryoablation of nerves and tumors of the head, neck, and spine. Dr. Lee is currently an instructor of radiology at Harvard Medical School, as well as assistant section head of neuroradiology at Brigham and Women’s Hospital, and is a premedical advisor for Quincy House of Harvard College. Srinivasan Mukundan, Jr., MD, PhD, grew up in Atlanta, Georgia, where he attended Emory University to study chemistry, earning his BS, MS, and PhD degrees. He then entered Emory University School of Medicine, earning his MD and completing a postdoctoral fellowship in cardiac MRI, a residency in diagnostic radiology, and a clinical fellowship in neuroradiology. Dr. Mukundan has won research awards as a graduate student, medical student, and resident. He also received the Berlex-Neuroradiology Education Research Foundation Scholar Award from the American Society of Neuroradiology and the Scholar Award from the American Roentgen Ray Society. He has co-authored more than 80 peer-reviewed manuscripts, as well as 10 book chapters and one textbook. In addition, he is a frequent speaker both nationally and internationally on a variety of topics related to neuroradiology, MRI, and preclinical imaging. Dr. Mukundan is currently an associate professor of radiology at Harvard Medical School and the section head of neuroradiology at Brigham and Women’s Hospital. In addition, he holds several other administrative positions at Brigham and Women’s Hospital, including neuroradiology network director, co-director of the Clinical Functional MRI Program, and chair of the Contrast Agent Safety Committee. He is also the first director of the Brigham and Women’s Hospital Small Animal Imaging Laboratory.

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Acknowledgments From our perspective, this project began several years ago with a phone call from Dr. Nancy Major, a dear colleague and friend. Nancy has served as the driving force behind the Netter’s Correlative Imaging series, finding the authors and helping define the unique format of this project. In our specific project, she provided support and guidance at several key stages of the project. The Elsevier publishing team is led by Elyse O’Grady, Senior Content Strategist, and Marybeth Thiel, Senior Content Development Editor. They practice their craft according to the finest traditions of book editing and publishing that have evolved from the time of the first presses. This is particularly admirable given that many of these traditions are challenged in our modern world. Mostly, Marybeth and Elyse are recognized for their patience and their passion in seeing this project through to its conclusion. Several colleagues and friends have played significant roles during the evolution of this project. We extend heartfelt gratitude to these individuals: Dr. Pamela Deaver Dr. Leahthan Domeshak Dr. Gerald Grant Dr. Jeffrey Marcus Dr. Karli Spetzler Special thanks go to Frank H. Netter, MD, often considered the “Michelangelo of Medicine,” who created and perfected this genre. Our artist, Tiffany DaVanzo, immersed herself in creating illustrations that are of high artistic quality, and then spent countless hours in conferences reviewing the fine details of the artwork on a plate-by-plate basis to ensure anatomic accuracy. Tiffany is recognized for her stewardship of the Netter tradition to which we are all committed. Finally, McKinley Nickerson served as our project coordinator. Her myriad contributions have ranged from scheduling and coordination to assistance with image segmentation and digital proofs. Simply stated, this project would never have been completed without McKinley’s participation.

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Preface The study of anatomy, by its very nature, exposes the student to both the forms and the functions responsible for the inner workings of the human body—one of the most elegant demonstrations of the synthesis of art and science. This statement is never truer than when reviewing the works of Frank H. Netter, MD (1906-1991). His monumental works of art have educated countless generations of physicians and will continue to do so for many years to come. The evolution of cross-sectional imaging technologies, including computed tomography (CT) and magnetic resonance imaging (MRI), has allowed physicians and aspiring physicians the ability to peer into the human body in many ways previously impossible. This, in turn, has forced the review of anatomy in a manner that was not contemplated when Dr. Netter began rendering his artwork more than three-quarters of a century ago. Limited spatial and temporal resolution, tissue parameters, image contrast, and partial volume averaging are all issues that confound the interpretation of MRI and CT images and are not part of conventional anatomic teaching in the dissection laboratory. Despite the changing nature of the anatomy education problem, Dr. Netter’s approach still provides the template for how to teach modern medical imaging. By directly correlating crosssectional medical images with “Netter art” that is voxel matched, the student is provided with the key to unlock the anatomy hidden within. Many existing textbooks with radiology images and clarifying illustrations focus on showing 3D renderings for better understanding of the entire course of a particular structure, such as a cranial nerve. Our goal, however, is to provide a more rigorous “slice-by-slice” reference guide for both the cross-sectional medical image and the corresponding illustration. For instance, someone may understand the general course of the facial nerve, yet still have difficulty identifying the fractional component of this structure on a single axial image. Conversely, individuals may need help identifying an unknown structure on a given image, particularly in the coronal or sagittal planes. Finally, the imaging characteristics on CT versus different sequences of MRI, such as T1- or T2-weighted imaging, can often be confusing and will hopefully be partially clarified through this book. This volume remains true to the goals of the Netter’s Correlative Imaging series. There is highquality imaging, allowing the demonstration of important anatomic structures, including structures not always included in other sources. The book also serves as a user-friendly anatomy reference for commonly employed imaging techniques of the brain, head, neck, and spine. As with the other volumes in the series, the text is not inclusive of pathology. In addition, normal variant anatomy and clinical pearls are presented. Structures are labeled using the most common terms and should be acceptable to radiologists, neurosurgeons, and neurologists. It is our hope that this volume will serve as a primary source of knowledge to the novice and as a reference text for the seasoned veteran. In either case, we hope that it will be useful on a daily basis.

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Contents PART 1  BRAIN

1

OVERVIEW OF BRAIN���������������������������������������������������������������2

2 BRAIN���������������������������������������������������������������������������������������15 Axial, 16-61 Coronal, 62-97 Sagittal, 98-123

3

THALAMUS AND BASAL GANGLIA��������������������������������������125 Axial, 126-135 Coronal, 136-145

4

LIMBIC SYSTEM���������������������������������������������������������������������147 Axial, 148-155 Coronal, 156-167 Sagittal, 168-173

5

BRAINSTEM AND CRANIAL NERVES������������������������������������175 Olfactory Nerve (CN I) Axial, 176-177 Coronal, 178-179 Optic Nerve (CN II) Axial, 180-185 Coronal, 186-197 Sagittal, 198-199 Oculomotor Nerve (CN III) Axial, 200-207 Coronal, 208-217 Trochlear Nerve (CN IV) Axial, 218-221 Coronal, 222-223 Trigeminal Nerve (CN V) Axial, 224-241 Sagittal, 242-243 Coronal, 244-245 Abducens (CN VI), Facial (CN VII), and Vestibulocochlear (VIII) Nerves Axial, 246-259 Sagittal, 260-263 Glossopharyngeal (CN IX), Vagus (CN X), Accessory (CN XI), and Hypoglossal (CN XII) Nerves Axial, 264-271

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Contents 6

VENTRICLES AND CEREBROSPINAL FLUID CISTERNS�����273 Axial, 274-285 Coronal, 286-291 Sagittal, 292-293

7

SELLA TURCICA��������������������������������������������������������������������295 Coronal, 296-303 Sagittal, 304-305

PART 2  HEAD AND NECK 8

OVERVIEW OF HEAD AND NECK����������������������������������������308

9

PARANASAL SINUSES������������������������������������������������������������321 Axial, 322-337 Coronal, 338-353

10 ORBITS�����������������������������������������������������������������������������������355 Axial, 356-367 Coronal, 368-379

11

MANDIBLE AND MUSCLES OF MASTICATION�������������������381 Axial, 382-389 Coronal, 390-397

12 TEMPORAL BONE (MIDDLE EAR, COCHLEA, VESTIBULAR SYSTEM)���������������������������������������������������������������������������������399 Axial, 400-411 Coronal, 412-419

13

ORAL CAVITY, PHARYNX, AND SUPRAHYOID NECK��������421 Axial, 422-437 Coronal, 438-453 Sagittal, 454-469

14

HYPOPHARYNX, LARYNX, AND INFRAHYOID NECK��������471 Axial, 472-487 Coronal, 488-503 Sagittal, 504-519

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Contents PART 3  SPINE 15

OVERVIEW OF SPINE������������������������������������������������������������523

16 SPINE��������������������������������������������������������������������������������������535 Cervical Spine Axial, 536-551 Coronal, 552-561 Sagittal, 562-571 Thoracic Spine Axial, 572-577 Sagittal, 578-583 Lumbosacral Spine Axial, 584-595 Sagittal, 596-605

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PART

1

BRAIN

CHAPTER 1 OVERVIEW OF BRAIN  2 CHAPTER 2  BRAIN 15 CHAPTER 3 THALAMUS AND BASAL GANGLIA 125 CHAPTER 4 LIMBIC SYSTEM   147 CHAPTER 5 BRAINSTEM AND CRANIAL NERVES 175 CHAPTER 6 VENTRICLES AND CEREBROSPINAL FLUID CISTERNS  273 CHAPTER 7 SELLA TURCICA  295

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

1

Chapter

1

OVERVIEW OF BRAIN

CEREBRUM: LATERAL VIEWS  3 CEREBRUM: MEDIAL VIEWS  4 CEREBRUM: INFERIOR VIEW  5 DURAL VENOUS SINUSES  6 DURAL VENOUS SINUSES (CONTINUED)  7 VENTRICLES OF BRAIN  8 ARTERIES OF BRAIN: INFERIOR VIEWS  9 BASAL NUCLEI (GANGLIA)  10 FOURTH VENTRICLE AND CEREBELLUM  11 CRANIAL NERVE NUCLEI IN BRAINSTEM: SCHEMA  12 INTRACRANIAL NEUROVASCULAR ANATOMY  13 INTRACRANIAL NEUROVASCULAR ANATOMY (CONTINUED) 14

2

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cerebrum: Lateral Views

Central sulcus (of Rolando)

Postcentral gyrus

Precentral gyrus

Postcentral sulcus

Precentral sulcus

Superior parietal lobule

Superior frontal gyrus Intraparietal sulcus

Superior frontal sulcus

Inferior parietal lobule Supramarginal gyrus

Middle frontal gyrus Inferior frontal sulcus

Angular gyrus Parietooccipital sulcus

Inferior frontal gyrus Opercular part Triangular part Orbital part

Occipital pole

Frontal pole

Calcarine sulcus Lateral sulcus (of Sylvius)

Lunate sulcus (inconstant)

Anterior ramus Ascending ramus Posterior ramus Temporal pole

Transverse occipital sulcus Superior temporal gyrus

Preoccipital notch

Superior temporal sulcus

Inferior temporal gyrus

Middle temporal gyrus Inferior temporal sulcus Frontal lobe Parietal lobe

Temporal lobe Occipital lobe

Parietal operculum Frontal operculum Orbital operculum Insula (island of Reil)

Short gyri Central sulcus Limen Long gyrus Circular sulcus

Temporal operculum

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

3

Cerebrum: Medial Views

Sagittal section of brain in situ

Paracentral sulcus Central sulcus (of Rolando) Paracentral lobule

Cingulate gyrus Cingulate sulcus Medial frontal gyrus

Marginal sulcus

Sulcus of corpus callosum

Corpus callosum Precuneus Superior sagittal sinus Choroid plexus of third ventricle

Fornix Septum pellucidum Interventricular foramen (of Monro) Interthalamic adhesion

Stria medullaris of thalamus Parietooccipital sulcus Cuneus Habenular commissure

Thalamus and third ventricle Subcallosal (parolfactory) area

Pineal body Posterior commissure Calcarine sulcus Straight sinus in tentorium cerebelli

Anterior commissure Subcallosal gyrus Hypothalamic sulcus Lamina terminalis

Great cerebral vein (of Galen) Superior colliculus Inferior colliculus Tectal (quadrigeminal) plate Cerebellum Superior medullary velum Fourth ventricle and choroid plexus

Supraoptic recess Optic chiasm Tuber cinereum Hypophysis (pituitary gland) Mammillary body Cerebral peduncle Pons

Cerebral aqueduct (of Sylvius)

Medial surface of cerebral hemisphere: brainstem excised Cingulate gyrus Mammillothalamic fasciculus

Inferior medullary velum Medulla oblongata Genu Rostrum Trunk Splenium

Isthmus of cingulate gyrus Parietooccipital sulcus

Mammillary body

Cuneus

Uncus

Calcarine sulcus

Optic nerve (II)

Lingual gyrus

Olfactory tract

Crus Body Column

Collateral sulcus Rhinal sulcus Medial occipitotemporal gyrus Occipitotemporal sulcus Lateral occipitotemporal gyrus

4

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

of corpus callosum

of fornix

Fimbria of hippocampus Dentate gyrus Parahippocampal gyrus

Cerebrum: Inferior View

Frontal pole of cerebrum

Sectioned brainstem

Straight gyrus Olfactory sulcus Orbital sulci

Longitudinal cerebral fissure Genu of corpus callosum Lamina terminalis Olfactory bulb Olfactory tract

Orbital gyri

Optic chiasm

Temporal pole of cerebrum

Optic nerve (CN II)

Lateral sulcus (of Sylvius)

Hypophysis (pituitary gland)

Inferior temporal sulcus

Anterior perforated substance

Inferior temporal gyrus

Optic tract Tuber cinereum Inferior (inferolateral) margin of cerebrum

Mammillary body Posterior perforated substance (in interpeduncular fossa)

Rhinal sulcus

Cerebral crus Uncus

Lateral geniculate body

Inferior temporal gyrus

Substantia nigra Medial geniculate body

Occipitotemporal sulcus

Red nucleus Pulvinar of thalamus

Lateral occipitotemporal gyrus

Superior colliculus (of corpora quadrigemina)

Collateral sulcus

Cerebral aqueduct Parahippocampal gyrus Splenium of corpus callosum Medial occipitotemporal gyrus Calcarine sulcus

Apex of cuneus Occipital pole of cerebrum Longitudinal cerebral fissure

Isthmus of cingulate gyrus

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

5

Dural Venous Sinuses Skull sectioned horizontally: superior view Superior sagittal sinus Falx cerebri Superior ophthalmic vein Anterior and posterior intercavernous sinuses

Hypophysis (pituitary gland) Optic nerve (II) Internal carotid artery Oculomotor nerve (III) Sphenoparietal sinus Trochlear nerve (IV) Ophthalmic nerve (V1)

Superficial middle cerebral vein

Maxillary nerve (V2)

Cavernous sinus

Trigeminal ganglion (Gasserian)

Basilar venous plexus

Mandibular nerve (V3)

Superior petrosal sinus

Middle meningeal artery Abducent nerve (VI)

Inferior petrosal sinus

Petrosal vein

Tentorial artery

Facial nerve (VII), intermediate nerve (of Wrisberg), and vestibulocochlear nerve (VIII)

Tentorium cerebelli

Glossopharyngeal (IX) and vagus (X) nerves

Inferior cerebral vein

Jugular foramen

Transverse sinus

Sigmoid sinus (continuation of transverse sinus)

Inferior sagittal sinus

Transverse sinus

Straight sinus

Accessory nerve (XI)

Falx cerebri

Hypoglossal nerve (XII)

Confluence of sinuses

Great cerebral vein (of Galen)

Superior sagittal sinus

Cavernous sinus Oculomotor nerve (III)

Optic chiasm Posterior communicating artery

Trochlear nerve (IV) Abducent nerve (VI) Ophthalmic nerve (V1)

Internal carotid artery Hypophysis (pituitary gland)

Maxillary nerve (V2) Sphenoidal sinus

Coronal section through cavernous sinus: posterior view

6

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Nasopharynx

Dural Venous Sinuses (Continued)

Sagittal section Superior sagittal sinus Bridging veins Falx cerebri

Inferior sagittal sinus Superior sagittal sinus Sphenoparietal sinus Tentorium cerebelli Anterior and posterior intercavernous sinuses

Great cerebral vein (of Galen) Straight sinus

Superior petrosal sinus

Transverse sinus Confluence of sinuses Falx cerebelli

Basilar venous plexus

Occipital sinus

Inferior petrosal sinus

Sigmoid sinus

To jugular foramen Vertebral venous plexus (of Batson) Sagittal arterial view

Sagittal vein view

Thalamostriate

Vein of Trolard

Callosom arginal

Superior sagittal sinus Internal cerebral vein

A2 branch at anterior cerebral artery

Inferior sagittal sinus Straight sinus

Cavernous internal carotid artery

Vein of Galen

Petrous internal Vertebral artery carotid artery

M2 Cavernous Internal Basilar sinus jugular artery branch at middle vein cerebral artery

Jugular Sigmoid bulb sinus

Vein of Labbe

Transverse sinus

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

7

Ventricles of Brain

Left lateral phantom view

Frontal (anterior) horn Central part

Right lateral ventricle

Temporal (inferior) horn

Left lateral ventricle

Occipital (posterior) horn

Cerebral aqueduct (of Sylvius) Fourth ventricle Left lateral aperture (foramen of Luschka) Left interventricular foramen (of Monro)

Left lateral recess Median aperture (foramen of Magendie)

Third ventricle Supraoptic recess Interthalamic adhesion Infundibular recess

Central canal of spinal cord

Pineal recess Suprapineal recess

Corpus callosum Septum pellucidum Lateral ventricle Caudate nucleus (body) Choroid plexus of lateral ventricle Stria terminalis Superior thalamostriate vein Body of fornix Internal cerebral vein Tela choroidea of third ventricle Choroid plexus of third ventricle Thalamus Putamen Globus pallidus

White arrow in left interventricular foramen (of Monro) Ependyma Pia mater Coronal section of brain: posterior view

8

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Lentiform nucleus

Internal capsule Third ventricle and interthalamic adhesion Hypothalamus Caudate nucleus (tail) Optic tract Choroid plexus of lateral ventricle Temporal (inferior) horn of lateral ventricle Fimbria of hippocampus Hippocampus Dentate gyrus Mammillary body Parahippocampal gyrus

Arteries of Brain: Inferior Views

Medial frontobasal (orbitofrontal) artery Anterior communicating artery Anterior cerebral artery Distal medial striate artery (recurrent artery of Heubner) Internal carotid artery Anterolateral central (lenticulostriate) arteries Middle cerebral artery Lateral frontobasal (orbitofrontal) artery Prefrontal artery Anterior choroidal artery Posterior communicating artery Posterior cerebral artery Superior cerebellar artery Basilar artery Pontine arteries Labyrinthine (internal acoustic) artery Anterior inferior cerebellar artery (AICA) Vertebral artery Anterior spinal artery Posterior inferior cerebellar artery (PICA) (cut) Posterior spinal artery

Distal medial striate artery (recurrent artery of Heubner)

Cerebral arterial circle (of Willis) (broken line)

Anterior communicating artery Anterior cerebral artery Middle cerebral artery Posterior communicating artery Anterior choroidal artery Optic tract Posterior cerebral artery Cerebral crus Lateral geniculate body Posterior medial choroidal artery Posterior lateral choroidal artery Choroid plexus of lateral ventricle Medial geniculate body Pulvinar of thalamus Lateral ventricle

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

9

Basal Nuclei (Ganglia)

A

Horizontal sections through cerebrum

B

Genu of corpus callosum

Caudate nucleus (head)

Lateral ventricle

Anterior limb of internal capsule

Genu

Septum pellucidum

Posterior limb Column of fornix

Extreme capsule Putamen

Insula (island of Reil)

Globus pallidus

Lentiform nucleus

Third ventricle

Interthalamic adhesion

External capsule

Thalamus

Claustrum

Crus of fornix

Retrolenticular part of internal capsule

Choroid plexus of lateral ventricle

Caudate nucleus (tail) Hippocampus and fimbria

Splenium of corpus callosum

Occipital (posterior) horn of lateral ventricle Habenula Organization of basal nuclei (ganglia) Caudate nucleus

Putamen

Striatum

Basal nuclei (ganglia)

B

Globus pallidus

Lentiform nucleus

Corpus striatum

A

Pineal body

Cleft for internal capsule

Caudate nucleus Levels of sections above

Body Thalamus

Head

A B

A B Pulvinar

Lentiform nucleus (globus pallidus medial to putamen) Amygdaloid body

Medial geniculate body Lateral geniculate body Caudate nucleus (tail)

Interrelationship of thalamus, lentiform nucleus, caudate nucleus, and amygdaloid body (schema): left lateral view

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Fourth Ventricle and Cerebellum

Posterior view

Habenular trigone Medial Lateral

Third ventricle

Geniculate bodies

Dorsal median sulcus

Pulvinar of thalamus

Superior cerebellar peduncle

Pineal body

Locus caeruleus

Superior colliculus

Medial eminence

Inferior colliculus

Facial colliculus

Trochlear nerve (IV)

Vestibular area

Superior medullary velum

Dentate nucleus of cerebellum

Superior Middle Inferior

Cerebellar peduncles

Striae medullares

Lateral recess

Taenia of fourth ventricle

Superior fovea

Cuneate tubercle

Sulcus limitans

Gracile tubercle

Inferior fovea

Dorsal median sulcus

Trigeminal tubercle

Lateral funiculus

Hypoglossal trigone

Cuneate fasciculus

Vagal trigone

Gracile fasciculus

Obex Choroid plexus Interthalamic adhesion

Median sagittal section

Posterior commissure

Body of fornix

Habenular commissure

Thalamus (in third ventricle)

Pineal body

Interventricular foramen (of Monro)

Splenium of corpus callosum

Anterior commissure

Great cerebral vein (of Galen)

Lamina terminalis

Lingula (I) Central lobule (II-III) Culmen (IV-V) Declive (VI) Folium (VII A)

Hypothalamic sulcus Cerebral peduncle Cerebral aqueduct (of Sylvius) Superior colliculus Tectal (quadrigeminal) plate

Vermis of cerebellum

Superior medullary velum

Inferior colliculus

Inferior medullary velum

Pons Medial longitudinal fasciculus

Tuber (VII B)

Fourth ventricle

Pyramid (VIII)

Choroid plexus of fourth ventricle

Uvula (IX)

Medulla oblongata

Vermis of cerebellum

Nodulus (X)

Median aperture (foramen of Magendie) Decussation of pyramids Central canal of spinal cord

Choroid plexus of fourth ventricle Tonsil of cerebellum

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Cranial Nerve Nuclei in brainstem: Schema

Posterior phantom view

Oculomotor nerve (III) Superior colliculus

Red nucleus Oculomotor nucleus

Lateral geniculate body

Accessory oculomotor (Edinger-Westphal) nucleus

Mesencephalic nucleus of trigeminal nerve

Trochlear nucleus Trochlear nerve (IV)

Principal sensory nucleus of trigeminal nerve

Motor nucleus of trigeminal nerve

Trigeminal nerve (V) and ganglion (Gasserian)

Trigeminal nerve (V) and ganglion

Facial nerve (VII) and geniculate ganglion

Abducent nucleus Facial nucleus

Vestibulocochlear nerve (VIII)

Geniculum (geniculate ganglion) of facial nerve

Cochlear nuclei

Superior and inferior salivatory nuclei

Anterior Posterior Vestibular nuclei

Glossopharyngeal nerve (IX)

Glossopharyngeal nerve (IX)

Vagus nerve (X)

Vagus nerve (X)

Accessory nerve (XI)

Spinal tract and spinal nucleus of trigeminal nerve Solitary tract nucleus

Nucleus ambiguus Dorsal nucleus of vagus nerve (X) Hypoglossal nucleus Accessory nucleus

Efferent fibers Afferent fibers Mixed fibers

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Intracranial Neurovascular Anatomy

Coronal arterial view

Coronal venous view

Anterior cerebral artery

Cortical vein

M3 branch of the middle cerebral artery

M2 branch of the middle cerebral artery

Superior sagittal sinus

Middle cerebral artery

Posterior cerebral artery

Torcular

Pcomm

Internal carotid artery Petrous segment of internal carotid artery

Basilar artery

Vertebral artery

Cavernous internal carotid artery

Axial arterial view

Sigmoid sinus

Transverse sinus

Jugular bulb

Axial venous view M1 branch of the middle cerebral artery

A2 branch of the anterior cerebral artery

Cavernous sinus

M2 branch of the middle cerebral artery

A1 branch of the anterior cerebral artery

Inferior petrosal sinus

M3 branch of the middle cerebral artery

Basilar artery

Vertebral artery

Cavernous internal carotid artery

Petrous internal carotid artery

Sigmoid sinus

Transverse sinus

Superior sagittal Torcular

Cortical vein

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Intracranial Neurovascular Anatomy (Continued)

Frontal arterial neck view

Oblique arterial neck view

Anterior cerebral artery Circle of Willis Internal carotid arteries External carotid arteries

Middle cerebral artery

Cavernous internal carotid artery

Cavernous internal carotid artery

Basilar artery Right internal Carotid artery

Basilar artery

Left internal carotid artery

Vertebral artery Left vertebral artery

Right common carotid artery

Left common carotid

Brachiocephalic trunk

Aortic trunk

Subclavian artery

Right external carotid

Sagittal facial artery view

Right Right Left Aorta common vertebral subclavian carotid artery artery

Sagittal facial veins view

Cavernous Basilar artery Left vertebral artery (partial) Internal Maxillary artery

Sigmoid sinus

Facial artery

Occipital artery

Facial vein

Lingual artery

Right vertebral artery Internal carotid artery

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Angular vein

Petrous internal

Superior thyroidal artery

Ascending pharyngeal artery

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Superior sagittal sinus

Torcular

Transverse sinus

Internal jugualr vein

Chapter

2

BRAIN

AXIAL 16 CORONAL 62

SAGITTAL 98

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Brain Axial 1



NORMAL ANATOMY Named after the French anatomist Paulin Trolard (1842–1910) and also known as the superior anastomotic vein, the vein of Trolard is the largest cortical vein at the convexity (see also Brain Coronal 15). The vein of Trolard anastomoses with the middle cerebral vein and the superior sagittal sinus. Note the first cranial nerves, the olfactory nerves, in the olfactory grooves along the medial inferior floor of the anterior cranial fossa. Please note there is volume averaging of cortical veins with the top of the calvaria such that the veins artifactually appear to be within the bone rather than within the cranial vault (see Brain Coronal 2).



DIAGNOSTIC CONSIDERATION A lesion, such as a metastatic lesion in the marrow, can often be missed at the vertex (vertex cranii). Diffusion-weighted magnetic resonance imaging (MRI) is often useful in identifying such lesions, not because the lesion is diffusion restricted, but because all the other structures are often low in signal, making the lesion conspicuously bright. The same principle holds for the base of the skull, where the presence of many structures can make pathologic lesions easy to overlook.

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Brain Axial 1

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17

Brain Axial 2

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Brain Axial 2

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19

Brain Axial 3

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Brain Axial 3

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Brain Axial 4

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Brain Axial 4

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Brain Axial 5



NORMAL ANATOMY The “omega sign” denotes a sulcal configuration similar to the Greek letter Ω and is one sign of the central sulcus separating the motor strip anteriorly and the sensory cortex posteriorly. The omega sign also demarcates the frontal lobe from the parietal lobe. Note that the two sulci in the midline immediately posterior to the medial ends of the central sulci should resemble a smile.

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Brain Axial 5

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25

Brain Axial 6

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Brain Axial 6

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Brain Axial 7

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Brain Axial 7

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Brain Axial 8

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Brain Axial 8

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Brain Axial 9



NORMAL ANATOMY The white matter fibers at the level of the basal ganglia known as internal capsule (Axials 10 and 11) are known as corona radiata (Axials 8 and 9) more superiorly along the lateral margins of the ventricles, and as the centrum semiovale superior to the ventricles (Axial 7).

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Brain Axial 9

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Brain Axial 10



NORMAL ANATOMY Note how the signal of the basal ganglia is not ideal on this MR sequence tailored to capture the entire brain. For better delineation, see Chapter 3.

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Brain Axial 10

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Brain Axial 11



PATHOLOGIC PROCESS The foramen of Monro (interventricular foramen) can be an important point of obstruction of cerebrospinal fluid (CSF) flow. A small colloid cyst can occasionally be found at this location and could cause obstruction in a relatively short time, rapidly becoming fatal if untreated. CSF is produced at a rate of about 500 mL/day and the subarachnoid space around the brain and spinal cord can contain only 150 mL. CSF intracranially and within the spinal canal turns over about four times a day.

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Brain Axial 11

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Brain Axial 12



NORMAL ANATOMY The habenula (Latin habena, “rein”) originally referred to the pineal gland stalk but is now commonly used to indicate a nearby group of neurons in the dorsal and caudal thalamus. The insular cortex is often the first location where an infarct in the area of the middle cerebral artery will become evident on unenhanced computed tomography (CT) of the head. Loss of differentiation of the insular gray matter from the subinsular white matter should always be evaluated.

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Brain Axial 12

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Brain Axial 13

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Brain Axial 13

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Brain Axial 14



NORMAL ANATOMY Note the small but conspicuous paired mammillary bodies anterior to the interpeduncular cistern, at the anterior end of the fornices. The mammillary bodies are part of the limbic system and are believed to add the element of smell to memories. The bodies can be enlarged and T2-weighted bright in Wernicke’s encephalopathy. Do not confuse the mammillary bodies with the paired inferior and superior colliculi, which are located on the posterior surface of the brainstem.

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Brain Axial 14

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Brain Axial 15



NORMAL ANATOMY Note that the basal cisterns are composed of the suprasellar cistern, which resembles a sixpointed star, and the smile-shaped quadrgeminal plate cistern (see also Axial 14). The six points of the suprasellar cistern include the interhemispheric fissure, two Sylvian cisterns, two ambient cisterns, and the interpeduncular cistern.



PATHOLOGIC PROCESS The interpeduncular cistern is a good anatomic feature to scrutinize; this location often first reveals subarachnoid hemorrhage when a brain aneurysm ruptures. This usually occurs from the area of the circle of Willis, which is prone to many anatomic vascular variations.

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Brain Axial 15

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Brain Axial 16



DIAGNOSTIC CONSIDERATION The temporal horns can be useful to help differentiate true hydrocephalus from ex vacuo dilation of the ventricles from central white matter volume loss. In the former case, the temporal horns are dilated and in the latter case they are not. The body of the lateral ventricles can sometimes look prominent but with normal-sized temporal horns where there is central white matter volume loss from chronic microangiopathic disease. Since the body and temporal horns are continuous structures, both should be dilated in true hydrocephalus.

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Brain Axial 16

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Brain Axial 17

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Brain Axial 17

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Brain Axial 18



DIAGNOSTIC CONSIDERATION A subtle but important finding is loss of the normal dark flow void in the basilar artery, which may indicate a clot.

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Brain Axial 18

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Brain Axial 19



NORMAL ANATOMY Note the regions with bright T2 fluid signal, including the vitreous humor, CSF in Meckel’s cave, prepontine cistern, and endolymph fluid in the cochlea, semicircular canals, and internal auditory canals. Recall that fat is also bright on fast spin-echo T2-weighted MRI.

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Brain Axial 19

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Brain Axial 20

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Brain Axial 20

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Brain Axial 21

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Brain Axial 21

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Brain Axial 22



PATHOLOGIC PROCESS Note the vessels and nerves in the pterygopalatine fossa surrounded by bright fat. Loss of this normal fat signal can be a sign of perineural spread of disease along the maxillary branch of the trigeminal nerve (V2). Meckel’s ganglion (pterygopalatine ganglion) sits in this fossa, as opposed to the Gasserian ganglion, which sits more posteriorly, in Meckel’s cave.

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Brain Axial 22

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Brain Axial 23



DIAGNOSTIC CONSIDERATIONS On most head studies, the most inferior axial image will show the upper aspect of neck structures such as the parotid glands and nasopharynx. These are often “blind spots” for the unwary neuroradiologist. Loss of the normal “divot” caused by the blind-ending fossa of Rosenmüller between the longus capitis muscle and the torus tubarius in an adult patient may be a sign of nasopharyngeal carcinoma. This can also lead to obstruction of the Eustachian tube opening with fluid in the mastoid air cells. Parotid lesions, even benign tumors such as pleomorphic adenoma, are often resected, unlike thyroid lesions, most of which do not cause symptoms.

IMAGING TECHNIQUE CONSIDERATION On fast spin-echo T2-weighted imaging, fat is bright, as on T1-weighted imaging. The best way to differentiate is to look at fluid, such as the CSF around the brainstem, which will be bright on T2-weighted imaging and gray on T1-weighted imaging. Please note that there is entry-slice phenomenon causing the lumina of the vertebral arteries to appear bright on T1-weighted imaging due to unsaturated blood entering the imaging slice; no contrast was given.

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Brain Axial 23

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Brain Coronal 1



NORMAL ANATOMY The crista galli (Latin, “crest of the cock”) is a ridge of bone arising in the midline from the cribriform plate. The crista galli is the anterior attachment point of the falx to the skull. The olfactory nerves lie to either side of the crista galli within the olfactory grooves.

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Brain Coronal 1

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Brain Coronal 2

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Brain Coronal 2

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Brain Coronal 3

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Brain Coronal 3

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Brain Coronal 4

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Brain Coronal 4

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Brain Coronal 5

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Brain Coronal 5

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Brain Coronal 6



NORMAL ANATOMY Note the mandibular branch of the trigeminal nerve (V3) descending from Meckel’s cave into the foramen ovale.

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Brain Coronal 6

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Brain Coronal 7



NORMAL ANATOMY The coronal view is often the best view for assessing the pituitary gland, infundibulum, and optic chiasm. The infundibulum may be asymmetric in some cases, as in this image, where it is slightly deviated to the right as a normal variant, but in some cases it can be deviated from a pituitary mass. A large mass can extend into the suprasellar region and compress the optic chiasm, leading to bitemporal hemianopsia.

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Brain Coronal 7

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Brain Coronal 8



NORMAL ANATOMY From the Greek meaning “under inner chamber,” the hypothalamus forms the floor of the third ventricle and contains small nuclei with a variety of functions. One of the most important functions is to provide signals from the nervous system to the endocrine system through the pituitary gland.

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Brain Coronal 8

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Brain Coronal 9



NORMAL ANATOMY The cingulate cortex is located on the medial surface of the cerebral hemisphere adjacent to the corpus callosum. The cingulate cortex is usually considered part of the limbic system, which is involved with emotion, learning, and memory. The combination of these three functions makes the cingulate cortex extremely influential in associating behavioral outcomes to motivation.

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Brain Coronal 9

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Brain Coronal 10

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Brain Coronal 10

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Brain Coronal 11



NORMAL ANATOMY The coronal plane is an excellent view for obtaining an overview of the vertebrobasilar system in assessing for stenoses or aneurysms. In just a few coronal images, the neuroradiologist can often seen both vertebral arteries with the posterior inferior cerebellar artery origins, the anterior inferior cerebellar artery and superior cerebellar artery origins from the basilar artery, and the proximal posterior cerebral arteries originating from the basilar artery tip.

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Brain Coronal 11

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Brain Coronal 12



DIAGNOSTIC CONSIDERATION Injury to the cruciate ligaments with laxity of the odontoid (“toothlike”) process of the second cervical vertebra (C2; dens axis) is more definitively assessed with voluntary flexion and extension radiographs. However, such injury may be suspected from asymmetric positioning of the odontoid process relative to the lateral masses on coronal MR view.

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Brain Coronal 12

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Brain Coronal 13



DIAGNOSTIC CONSIDERATION Coronal imaging is the best way to assess the hippocampi, although size and abnormal signal are best assessed with T2-weighted fluid-attenuated inversion recovery (FLAIR) sequence (see Chapter 4).

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Brain Coronal 13

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Brain Coronal 14

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Brain Coronal 14

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Brain Coronal 15



NORMAL ANATOMY The internal cerebral veins, or deep cerebral veins, drain the deep portions of the hemisphere and are paired structures. Each internal cerebral vein is formed near the interventricular foramen, or foramen of Monro, by the union of the terminal and choroid veins. The veins course beneath the splenium of the corpus callosum and unite to form a short trunk, the great cerebral vein (of Galen). Just before this union, each cerebral vein receives the corresponding basal vein of Rosenthal. The basal vein is formed by the union of a small anterior cerebral vein, the deep middle cerebral vein (deep Sylvian vein), and the inferior striate veins.

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Brain Coronal 15

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Brain Coronal 16

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Brain Coronal 16

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Brain Coronal 17



NORMAL ANATOMY The cisterna magna in this view is within normal limits of size. An enlarged cisterna magna can be seen with arachnoid cysts and mega–cisterna magna.

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Brain Coronal 17

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Brain Coronal 18



DIAGNOSTIC CONSIDERATION The coronal view is perpendicular to most of the superior sagittal sinus and is often the best view for assessment of venous thrombosis in the sinus. In this view there is a small, rounded filling defect in the right transverse sinus close to midline consistent with an arachnoid g­ ranulation.

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Brain Coronal 18

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Brain Sagittal 1

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Brain Sagittal 1

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Brain Sagittal 2

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Brain Sagittal 2

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Brain Sagittal 3



NORMAL ANATOMY The lateral aspect of the cerebellar tonsils may lie lower than the midline vermis. In adults, up to 5 mm below the foramen magnum is within normal limits. The radiologist should also comment on whether the configuration is rounded or has an abnormal, pointed configuration.



DIAGNOSTIC CONSIDERATION The superior sagittal sinus lies within the sagittal plane and thus may appear irregular because of volume-averaging effects. To assess for clots, a coronal or axial plane perpendicular to the superior sagittal sinus provides a more accurate view. Note that the clivus lines up with the posterior aspect of the odontoid process, and the opisthion (posterior edge of foramen magnum) aligns with the anterior edge of the posterior arch of the first cervical vertebra (C1, atlas).

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Brain Sagittal 3

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Brain Sagittal 4

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Brain Sagittal 4

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Brain Sagittal 5

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Brain Sagittal 5

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Brain Sagittal 6



DIAGNOSTIC CONSIDERATIONS As with the floor of the middle cranial fossa, which lies in the axial plane, the tentorium cerebellum can harbor a small meningioma or dural metastasis, which may be much more conspicuous on sagittal imaging. Note also the clear view of the alveolar roots of the maxillary teeth. Inflammatory changes in the maxillary sinuses may result from periodontal disease, an area that can be overlooked in imaging of the head.

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Brain Sagittal 6

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Brain Sagittal 7



DIAGNOSTIC CONSIDERATION It is important to assess the visualized portions of the upper cervical spine on any head study. In this view, the radiologist can see the atlantooccipital articulation. Dislocation or subluxation is often much more conspicuous on a sagittal than an axial view.

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Brain Sagittal 7

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Brain Sagittal 8

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Brain Sagittal 8

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Brain Sagittal 9

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NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Brain Sagittal 9

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115

Brain Sagittal 10



DIAGNOSTIC CONSIDERATION For any patient presenting with headache, the neuroradiologist should carefully assess the dural venous sinuses (e.g., transverse and sigmoid sinuses) for evidence of a filling defect to indicate venous thrombosis. Often, a rounded filling defect with a focus of central enhancement is seen; this appearance is typical of arachnoid granulation, unlike the linear wormlike filling defect of venous clots.

116

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Brain Sagittal 10

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117

Brain Sagittal 11



DIAGNOSTIC CONSIDERATION One of the most difficult diagnoses to make in neuroradiology is cortical vein thrombosis. Clinical presentation may be simply that of a headache, with MRI showing a single cortical vein occluded. An unenhanced sagittal image may most conspicuously show a T1-weighted bright clot within a single cortical vein. If untreated, this may progress to a hemorrhagic venous infarct.

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Brain Sagittal 11

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119

Brain Sagittal 12



NORMAL ANATOMY Note that this sagittal view shows the mastoid segment of the facial nerve (seventh cranial nerve, CN VII) as it descends through the mastoid bone and exits the stylomastiod foramen. Injury to the facial nerve (e.g., temporal bone fracture) can lead to hemifacial paralysis mimicking stroke, with life-altering effects on social interaction.

120

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Brain Sagittal 12

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121

Brain Sagittal 13

IMAGING TECHNIQUE CONSIDERATION Note that the vessels such as the transverse sinus and cortical vessels are bright because contrast has been given for this sagittal reformation of an axially acquired three-dimensional spoiled GRASS (3D SPGR) sequence. The advantage of 3D-acquired sequences is that the data can then be reformatted to thinner slices or any plane with minimal degradation of quality, unlike 2D-acquired spin-echo sequences. The disadvantage is that any motion will degrade the entire sequence rather than just one slice.



DIAGNOSTIC CONSIDERATION The midline sagittal view is often recognized as important in assessing the pituitary gland, pineal gland, and cerebellar tonsils. Although the more laterally positioned sagittal views are often unappreciated in diagnostic evaluation because of the lack of symmetry, sagittal MR images are often valuable in assessing for lesions along the floor of the middle cranial fossa or at the vertex.

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Brain Sagittal 13

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Chapter

3

THALAMUS AND BASAL GANGLIA 1 3

2 4

5

AXIAL 126

1

2

3

4

5

CORONAL 136 NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

125

Thalamus and Basal Ganglia Axial 1

Cingulate gyrus

Anterior cerebral a.

Genu of corpus callosum Frontal lobe

Septum pellucidum

Sylvian fissure Caudate nucleus (head)

Corona radiata

Caudate nucleus (body)

Body of lateral ventricle Fornix

Splenium of corpus callosum Inferior sagittal sinus Parietal lobe Falx cerebri



NORMAL ANATOMY The centrum semiovale, corona radiata, and internal capsules are all continuous white matter tracts. The centrum semiovale is the white matter deep to the gray matter on the surface of the brain and has an ovular shape. On axial imaging, it is generally a term used for white matter superior to the ventricles. The corona radiata (Latin: “sunburst”) is the white matter connecting the centrum semiovale superiorly and the internal capsules inferiorly. On axial imaging the corona radiata can be seen with ventricles. The internal capsule connects the corona radiata superiorly with the pyramids of the medulla inferiorly. On axial imaging, the internal capsule is between the caudate and lentiform nucleus anteriorly and the thalamus and lentiform nucleus posteriorly.

126

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Thalamus and Basal Ganglia Axial 1

Cingulate gyrus

Anterior cerebral a. Genu of corpus callosum Frontal lobe

Septum pellucidum

Sylvian fissure

Corona radiata Body of lateral ventricle

Caudate nucleus (body)

Fornix Splenium of corpus callosum

Inferior sagittal sinus

Parietal lobe

Falx cerebri Cingulate gyrus

Anterior cerebral a. Genu of corpus callosum Frontal lobe

Septum pellucidum

Sylvian fissure

Corona radiata Body of lateral ventricle

Caudate nucleus (body)

Fornix

Inferior sagittal sinus

Falx cerebri

Splenium of corpus callosum

Parietal lobe NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

127

Thalamus and Basal Ganglia Axial 2

Cingulate gyrus

Anterior cerebral a. Genu of corpus callosum Frontal lobe

Septum pellucidum Caudate nucleus (head) Insula Sylvian fissure

Putamen Globus pallidus

Body of lateral ventricle

Thalamus Choroid plexus

Splenium of corpus callosum Inferior sagittal sinus Trigone of lateral ventricle Falx cerebri



NORMAL ANATOMY The lentiform nucleus, a triangular-shaped structure on axial imaging, consists of the globus pallidus medially and the putamen laterally. The lentiform nucleus with the caudate nucleus constitutes the basal ganglia. The basal ganglia represent a large collection of nuclei that constantly modifies movement along with the cerebellum. The motor cortex sends information to both the cerebellum and basal ganglia, and both structures send information back to cortex via the thalamus (i.e., to gain access to the cortex, signals must pass through the thalamus).

128

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Thalamus and Basal Ganglia Axial 2

Cingulate gyrus

Anterior cerebral a. Genu of corpus callosum Frontal lobe

Septum pellucidum Caudate nucleus (head) Insula

Insular cortex Sylvian fissure

Putamen Globus pallidus

Body of lateral ventricle Thalamus Choroid plexus Inferior sagittal sinus

Splenium of corpus callosum

Falx cerebri

Trigone of lateral ventricle Cingulate gyrus

Anterior cerebral a. Genu of corpus callosum Frontal lobe

Septum pellucidum Caudate nucleus (head)

Putamen

Sylvian fissure

Globus pallidus Body of lateral ventricle Thalamus Choroid plexus

Inferior sagittal sinus Falx cerebri

Splenium of corpus callosum Trigone of lateral ventricle NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

129

Thalamus and Basal Ganglia Axial 3

Anterior cerebral a. Frontal horn of lateral ventricle Septum pellucidum

Insula

Genu of corpus callosum Frontal lobe

Caudate nucleus (head)

Putamen Sylvian fissure Globus pallidus Third ventricle Thalamus Internal cerebral v.

Great cerebral v. (of Galen) Straight sinus

Falx cerebri

130

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Choroid plexus Splenium of corpus callosum

Trigone of lateral ventricle

Thalamus and Basal Ganglia Axial 3

Anterior cerebral a. Genu of corpus callosum

Frontal horn of lateral ventricle

Frontal lobe Septum pellucidum Caudate nucleus (head) Insula Putamen

Sylvian fissure

Globus pallidus

Third ventricle

Thalamus

Choroid plexus

Internal cerebral v.

Splenium of corpus callosum Great cerebral v. (of Galen) Straight sinus

Trigone of lateral ventricle

Falx cerebri Anterior cerebral a. Frontal horn of lateral ventricle

Genu of corpus callosum Frontal lobe

Septum pellucidum Caudate nucleus (head) Insula Putamen

Sylvian fissure

Globus pallidus

Thalamus

Third ventricle Choroid plexus

Internal cerebral v. Great cerebral v. (of Galen) Straight sinus Falx cerebri

Splenium of corpus callosum

Trigone of lateral ventricle NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

131

Thalamus and Basal Ganglia Axial 4

Cingulate gyrus Frontal lobe

Anterior cerebral a. Anterior limb of internal capsule

Caudate nucleus (head)

Genu of internal capsule Insula

Extreme capsule Sylvian fissure

Claustrum Putamen

External capsule

Globus pallidus Third ventricle

Posterior limb of internal capsule Thalamus

Internal cerebral v.

Choroid plexus

Great cerebral v. (of Galen)

Trigone of lateral ventricle



DIAGNOSTIC CONSIDERATION Proton-density (PD) sequence is used instead of the more routine T1-weighted sequence to accentuate the signal in the basal ganglia and thalami (compare with T1-weighted images in chapter 4).

132

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Thalamus and Basal Ganglia Axial 4

Anterior cerebral a.

Cingulate gyrus Frontal lobe

Anterior limb of internal capsule

Caudate nucleus (head)

Genu of internal capsule

Anterior commissure

Insula

Extreme capsule

Putamen

Sylvian fissure Claustrum

External capsule

Globus pallidus Third ventricle

Posterior limb of internal capsule Thalamus

Choroid plexus Trigone of lateral ventricle

Anterior cerebral a. Anterior limb of internal capsule Genu of internal capsule Insula External capsule Putamen

Great v. of Galen

Cingulate gyrus Frontal lobe Caudate nucleus (head) Anterior commissure Extreme capsule Sylvian fissure

Claustrum Globus pallidus Posterior limb of internal capsule

Third ventricle

Thalamus Choroid plexus Trigone of lateral ventricle

Great cerebral v. (of Galen)

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

133

Thalamus and Basal Ganglia Axial 5

Frontal lobe Anterior cerebral a.

Anterior limb of internal capsule Anterior commissure

Extreme capsule

Genu of internal capsule

Insula Claustrum

Sylvian fissure

Putamen Globus pallidus

Posterior limb of internal capsule

External capsule

Third ventricle Thalamus Pineal gland

Internal cerebral v.

Choroid plexus

Trigone of lateral ventricle



Straight sinus

NORMAL ANATOMY The vein of Galen (great cerebral vein) is a triangular-shaped structure on axial imaging, larger than the paired internal cerebral veins that feed into it, and larger than the inferior sagittal sinus that joins the vein of Galen to feed into the straight sinus. Loss of the normal dark flow void on T2-weighted or PD-weighted images is seen with venous sinus thrombosis.

134

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Thalamus and Basal Ganglia Axial 5

Anterior cerebral a. Extreme capsule Insula Claustrum Putamen External capsule Globus pallidus Thalamus

Frontal lobe Anterior limb of internal capsule Anterior commissure Genu of internal capsule Sylvian fissure Posterior limb of internal capsule Third ventricle Pineal gland

Internal cerebral v. Choroid plexus Trigone of lateral ventricle

Anterior cerebral a. Extreme capsule Insula Claustrum Putamen External capsule Globus pallidus

Straight sinus

Frontal lobe Anterior limb of internal capsule Anterior commissure Genu of internal capsule Sylvian fissure Posterior limb of internal capsule Third ventricle

Thalamus

Pineal gland

Internal cerebral v. Trigone of lateral ventricle

Choroid plexus

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

135

Thalamus and Basal Ganglia Coronal 1

Cingulate sulcus Cingulate gyrus

Pericallosal branches of anterior cerebral a.

Body of corpus callosum Septum pellucidum Lateral ventricle Caudate nucleus (head)

Internal capsule

Rostrum of corpus callosum

Insula

Lentiform nuclei

External capsule

Claustrum Interhemispheric fissure Sylvian fissure

Sphenoid sinus



NORMAL ANATOMY Note that from medial to lateral on this coronal MR image, the structures are septum pellucidum, lateral ventricle, caudate nucleus, internal capsule, lentiform nucleus, external capsule, claustrum, extreme capsule (difficult to see on most images), and insular cortex.

136

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Thalamus and Basal Ganglia Coronal 1

Cingulate sulcus Cingulate gyrus

Body of corpus callosum Lateral ventricle

Pericallosal branches of anterior cerebral a. Septum pellucidum

Caudate nucleus (head)

Internal capsule Insula External capsule Interhemispheric fissure

Lentiform nuclei

Claustrum Rostrum of corpus callosum Sylvian fissure

Sphenoid sinus

Cingulate sulcus Cingulate gyrus

Body of corpus callosum Lateral ventricle Internal capsule Insula External capsule Interhemispheric fissure

Frontal lobe Pericallosal branches of anterior cerebral a. Paraventricular white matter Corona radiata Septum pellucidum Caudate nucleus (head) Lentiform nuclei Claustrum Rostrum of corpus callosum Sylvian fissure

Sphenoid sinus

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

137

Thalamus and Basal Ganglia Coronal 2

Cingulate sulcus Cingulate gyrus

Centrum semiovale

Pericallosal branches of anterior cerebral a. Corpus callosum Septum pellucidum

Corona radiata Caudate nucleus (head)

Lateral ventricle Internal capsule Fornix External capsule Uncinate fasciculus

Lentiform nuclei Insula Claustrum Sylvian fissure

Nucleus accumbens septi

Anterior clinoid

Optic n. (CN II)

Temporal lobe Oculomotor n. (CN III) Ophthalmic division of trigeminal n. (V1)

Sphenoid sinus

138

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Floor of middle cranial fossa

Thalamus and Basal Ganglia Coronal 2

Cingulate gyrus Pericallosal branches of anterior cerebral a. Corpus callosum Septum pellucidum

Cingulate sulcus Centrum semiovale Corona radiata

Lateral ventricle Anterior limb of internal capsule External capsule

Caudate nucleus (head) Lentiform nuclei Insula Claustrum

Fornix Uncinate fasciculus Nucleus accumbens septi Optic n. (CN II) Sphenoid sinus

Sylvian fissure Anterior clinoid Oculomotor n. (CN III) Temporal lobe Ophthalmic division of trigeminal n. (V1) Floor of middle cranial fossa

Cingulate gyrus Pericallosal branches of anterior cerebral a. Corpus callosum Septum pellucidum

Cingulate sulcus Centrum semiovale Corona radiata

Lateral ventricle Anterior limb of internal capsule External capsule

Caudate nucleus (head)

Lentiform nuclei Insula Claustrum

Fornix Uncinate fasciculus Nucleus accumbens septi

Sylvian fissure Anterior clinoid Oculomotor n. (CN III)

Optic n. (CN II)

Temporal lobe

Sphenoid sinus

Ophthalmic division of trigeminal n. (V1) Floor of middle cranial fossa NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

139

Thalamus and Basal Ganglia Coronal 3

Cingulate gyrus

Cingulate sulcus

Centrum semiovale Corpus callosum Lateral ventricle

Septum pellucidum Anterior limb of internal capsule

Caudate nucleus

Fornix

Putamen

External capsule Extreme capsule

Insula

Globus palladus

Sylvian fissure

Claustrum Hypothalamus

Third ventricle

Mammillary body

Optic tract Suprasellar cistern

Hippocampus Pituitary gland

Cavernous internal carotid a.

Sphenoid sinus



DIAGNOSTIC CONSIDERATION Loss of differentiation between the insular cortex and the subjacent white matter (extreme and external capsules) is an early sign of infarct in middle cerebral artery territory.

140

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Thalamus and Basal Ganglia Coronal 3

Cingulate sulcus

Cingulate gyrus

Corpus callosum Septum pellucidum Anterior limb of internal capsule Fornix External capsule Sylvian fissure Insula Hypothalamus Mammillary body

Lateral ventricle Caudate nucleus Putamen Extreme capsule Claustrum Globus palladus Third ventricle Optic tract Suprasellar cistern

Hippocampus Pituitary gland Sphenoid sinus

Cingulate sulcus

Cavernous internal carotid a.

Cingulate gyrus

Corpus callosum Septum pellucidum Anterior limb of internal capsule Fornix External capsule Sylvian fissure

Lateral ventricle Caudate nucleus Putamen Extreme capsule Claustrum Globus palladus

Insula Hypothalamus Mammillary body

Third ventricle Optic tract Suprasellar cistern

Hippocampus Pituitary gland Sphenoid sinus

Cavernous internal carotid a. NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

141

Thalamus and Basal Ganglia Coronal 4

Cingulate sulcus Centrum semiovale Cingulate gyrus

Pericallosal cistern

Corpus callosum Lateral ventricle Septum pellucidum Sylvian fissure Cistern of velum interpositum Insula Interthalamic adhesion Third ventricle Posterior cerebral a. Hippocampus

Caudate nucleus Ventral lateral nucleus of thalamus Posterior limb of internal capsule Medial dorsal nucleus Putamen Substantia nigra Cerebral peduncle

Interpeduncular cistern

Superior cerebellar a. Pons

142

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Posterior cerebral a. (P2 segment) Parahippocampal gyrus

Thalamus and Basal Ganglia Coronal 4

Cingulate sulcus Cingulate gyrus Corpus callosum Septum pellucidum Sylvian fissure Cistern of velum interpositum Insula Interthalamic adhesion Third ventricle Posterior cerebral a. Hippocampus Interpeduncular cistern Superior cerebellar a. Pons

Cingulate sulcus Cingulate gyrus Corpus callosum Septum pellucidum Sylvian fissure Cistern of velum interpositum Insula Interthalamic adhesion Third ventricle Posterior cerebral a. Hippocampus Interpeduncular cistern Superior cerebellar a.

Pons

Centrum semiovale Pericallosal cistern Lateral ventricle Caudate nucleus Posterior limb of Internal capsule Ventral lateral nucleus of thalamus Putamen Medial dorsal nucleus Substantia nigra Cerebral peduncle Posterior cerebral a. (P2 segment) Parahippocampal gyrus

Centrum semiovale Pericallosal cistern Lateral ventricle Caudate nucleus Posterior limb of Internal capsule Ventral lateral nucleus of thalamus Medial dorsal nucleus Putamen Substantia nigra Cerebral peduncle Posterior cerebral a. (P2 segment) Parahippocampal gyrus NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

143

Thalamus and Basal Ganglia Coronal 5

Cingulate gyrus Centrum semiovale Corpus callosum Lateral ventricle Sylvian fissure

Choroid plexus Crus of fornix

Pulvinar of thalamus Internal cerebral v. Pineal gland Periaqueductal gray matter

Superior colliculus

Aqueduct of Sylvius

Body of hippocampus

Posterior cerebellar lobe

Pons

Middle cerebellar peduncle

IMAGING TECHNIQUE CONSIDERATION The white matter is “white” on T1-weighted MRI. One simple mnemonic to remember this fact is to think of myelin sheaths as “fatty,” with fat typically bright on T1-weighted images. Fat is not bright on standard T2-weighted images; however, most T2-weighted images are now done with multiple spin-echo pulses (e.g., Turbo-SE), which breaks the strong homonuclear forces (molecules with identical nuclei), called J-coupling, between the hydrogen (H) atoms on the long hydrocarbon chains of fat. This allows the H atoms to precess more freely, similar to the two hydrogen atoms on an H2O molecule, ­making the appearance of fat bright, like water. Note that on the superior radiology image, T2-weighted fluid-attenuated inversion recovery (FLAIR) images, the white matter is darker than the cortex.

144

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Thalamus and Basal Ganglia Coronal 5

Cingulate gyrus Corpus callosum

Centrum semiovale Lateral ventricle

Choroid plexus

Sylvian fissure

Crus of fornix Internal cerebral v.

Pulvinar of thalamus Pineal gland

Periaqueductal gray matter Aqueduct of Sylvius

Superior colliculus Body of hippocampus

Posterior cerebellar lobe Middle cerebellar peduncle

Pons

Cingulate gyrus Centrum semiovale Corpus callosum

Choroid plexus Crus of fornix Internal cerebral v. Periaqueductal gray matter Aqueduct of Sylvius

Lateral ventricle Sylvian fissure

Pulvinar of thalamus Pineal gland Superior colliculus Body of hippocampus

Posterior cerebellar lobe Middle cerebellar peduncle

Pons

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

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Chapter

4

LIMBIC SYSTEM 1 2 3 4

1

AXIAL 148

2

3 4

5 6

CORONAL 156

1

2

3

SAGITTAL 168

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

147

Limbic System Axial 1

Frontal lobe Genu of corpus callosum Frontal horn of lateral ventricle Caudate nucleus (head)

Corona radiata

Lateral ventricle Body of fornix Choroid plexus Splenium of corpus callosum

Parietal lobe

148

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Limbic System Axial 1

Frontal lobe Genu of corpus callosum Frontal horn of lateral ventricle Caudate nucleus

Corona radiata

Lateral ventricle Body of fornix Choroid plexus Splenium of corpus callosum

Parietal lobe

Genu of corpus callosum

Frontal lobe Frontal horn of lateral ventricle Caudate nucleus

Corona radiata

Lateral ventricle

Body of fornix Choroid plexus Splenium of corpus callosum

Parietal lobe

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

149

Limbic System Axial 2

Caudate nucleus (head) Putamen

Anterior limb of internal capsule Fornix

Globus pallidus

Genu of internal capsule

Thalamus Insular lobe

Posterior limb of internal capsule Choroid plexus Splenium of corpus callosum

Atrium/trigone of lateral ventricle

Cingulate gyrus



NORMAL ANATOMY Note how the fornix (Latin, “arch” or “vault”) is more easily seen as a paired structure on the T2-weighted axial magnetic resonance image (upper radiology image), compared with the fornix as seen in the Chapter 3 images focusing on the basal ganglia and thalami. The fornix is a C-shaped bundle of axons in the brain and carries signals from the hippocampus to the hypothalamus.

150

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Limbic System Axial 2

Caudate nucleus

Putamen

Globus pallidus

Anterior limb of Internal capsule

Fornix

Thalamus

Genu of internal capsule

Insula

Posterior limb of Internal capsule

Cistern of velum interpositum

Choroid plexus

Splenium of corpus callosum Cingulate gyrus

Atrium/trigone of lateral ventricle

Caudate nucleus Putamen

Anterior limb of Internal capsule

Globus pallidus

Genu of internal capsule Fornix

Thalamus Insula

Posterior limb of Internal capsule

Choroid plexus Splenium of corpus callosum Atrium/trigone of lateral ventricle Cingulate gyrus NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

151

Limbic System Axial 3

Middle cerebral a.

Anterior cerebral a.

Hypothalamus

Mammillary bodies

Parahippocampal gyrus

Subthalamic nucleus

Optic tract

Red nucleus

Cerebral aqueduct

Midbrain

Superior colliculus

Isthmus of cingulate gyrus

Quadrigeminal plate cistern Calcar avis

Posterior cerebral a. Choroid plexus Atrium/trigone of lateral ventricle

152

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Limbic System Axial 3

Middle cerebral a.

Anterior cerebral a.

Hypothalamus Mammillary bodies Parahippocampal gyrus

Subthalamic nucleus

Optic tract

Red nucleus Midbrain

Cerebral aqueduct Superior colliculus Quadrigeminal plate cistern

Posterior cerebral a. Isthmus of cingulate gyrus Choroid plexus

Calcar avis Atrium/trigone of lateral ventricle Middle cerebral a.

Anterior cerebral a.

Hypothalamus Mammillary bodies Parahippocampal gyrus

Subthalamic nucleus

Cerebral aqueduct Superior colliculus

Quadrigeminal plate cistern Calcar avis

Optic tract

Red nucleus

Midbrain Isthmus of cingulate gyrus Posterior cerebral a. Choroid plexus Atrium/trigone of lateral ventricle NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

153

Limbic System Axial 4

Supraclinoid internal carotid a. Sylvian cistern

Middle cerebral a. (M1 branch)

Infundibulum

Posterior communicating a.

Posterior clinoid Suprasellar cistern

Basilar a.

Cornu ammonis

Ambient cistern

Interpeduncular cistern Dentate gyrus

Oculomotor n. (CN III) Pars reticularis

Parahippocampal gyrus

Red nucleus

Subiculum

Perimesencephalic cistern

Midbrain Cerebral aqueduct

Temporal horn of lateral ventricle

Inferior colliculus

Temporal lobe Quadrigeminal cistern



NORMAL ANATOMY The architecture of the dentate nucleus and cornu ammonis (hippocampus) is not well defined on axial magnetic resonance imaging. Asymmetry and abnormal signal are much better appreciated on coronal MR images.

154

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Limbic System Axial 4

Infundibulum

Posterior clinoid

Supraclinoid internal carotid a.

Middle cerebral a. (M1 branch)

Sylvian cistern Suprasellar cistern Oculomotor n. (CN III)

Anterior communicating a.

Cornu ammonis

Basilar a.

Interpeduncular cistern

Precural cistern Pars reticularis

Dentate gyrus

Red nucleus

Subiculum Parahippocampal gyrus Midbrain

Ambient cistern Temporal horn of lateral ventricle

Cerebral aqueduct

Temporal lobe

Inferior colliculus Quadrigeminal cistern Infundibulum Supraclinoid internal carotid a. Sylvian cistern

Posterior clinoid Middle cerebral a. (M1 branch)

Suprasellar cistern Oculomotor n. (CN III)

Posterior communicating a.

Cornu ammonis

Basilar a.

Interpeduncular cistern

Precrural cistern

Dentate gyrus Parahippocampal gyrus Subiculum Midbrain Cerebral aqueduct Inferior colliculus

Pars reticularis Red nucleus Ambient cistern Temporal horn of lateral ventricle Temporal lobe

Quadrigeminal cistern NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

155

Limbic System Coronal 1

Cingulate gyrus Caudate nucleus (head) Genu of internal capsule Fornix Claustrum Putamen Middle cerebral a. (M2 branch) Hypothalamus Optic tract Basal nucleus, amygdala Uncal notch, ambient gyrus Basilar a.

156

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Anterior cerebral a. Body of corpus callosum Septum pellucidum External capsule Body of lateral ventricle Insula Sylvian fissure Globus pallidus Third ventricle

Suprasellar cistern

Limbic System Coronal 1

Anterior cerebral a.

Cingulate gyrus

Body of corpus callosum

Caudate nucleus (head) Genu of internal capsule

Body of lateral ventricle Septum pellucidum

Fornix

External capsule

Claustrum

Insula

Putamen

Sylvian fissure

Middle cerebral a. (M2 branch)

Globus pallidus

Hypothalamus Third ventricle

Optic chiasm Basal nucleus, amygdala

Suprasellar cistern

Uncal notch, ambient gyrus Basilar a.

Anterior cerebral a.

Cingulate gyrus

Body of corpus callosum

Caudate nucleus (head) Genu of internal capsule

Body of lateral ventricle Septum pellucidum

Fornix

External capsule

Claustrum

Insula

Putamen

Sylvian fissure

Middle cerebral a. (M2 branch)

Globus pallidus

Hypothalamus Third ventricle

Optic chiasm Basal nucleus, amygdala

Suprasellar cistern

Uncal notch, ambient gyrus

Basilar a. NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

157

Limbic System Coronal 2

Cingulate gyrus

Caudate nucleus (head) Posterior limb of internal capsule Fornix Putamen Middle cerebral a. (M2 branch)

Anterior cerebral a. Body of corpus callosum Septum pellucidum Body of lateral ventricle External capsule Claustrum Insula Globus pallidus

Choroidal fissure Hippocampus Basilar a. Tentorium

158

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Third ventricle Mammillary bodies Posterior cerebellar a. Superior cerebellar a.

Limbic System Coronal 2

Callosomarginal a. Cingulate gyrus

Body of corpus callosum

Caudate nucleus (head) Corona radiata

Body of lateral ventricle Septum pellucidum

Fornix

External capsule Claustrum

Putamen

Insula Middle cerebral a. (M2 branch)

Globus pallidus Third ventricle Mammillary bodies

Hippocampus

Posterior cerebral a. Basilar a. Superior cerebellar a. Tentorium

Cingulate gyrus Caudate nucleus (head) Posterior limb of internal capsule Fornix Putamen Middle cerebral a. (M2 branch) Choroidal fissure Hippocampus

Callosomarginal a. Body of corpus callosum Body of lateral ventricle Septum pellucidum External capsule Claustrum Insula Globus pallidus Third ventricle Mammillary bodies Posterior cerebral a.

Basilar a.

Superior cerebellar a.

Tentorium

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Limbic System Coronal 3

Callosomarginal a.

Body of corpus callosum

Caudate nucleus

Body of lateral ventricle

Septum pellucidum Claustrum

Body of fornix

External capsule

Posterior limb of internal capsule

Internal cerebral v.

Middle cerebral a. (M2 branch)

Sylvian fissure Thalamus

Putamen

Third ventricle

Middle cerebral a. (M2 branch)

Subthalamic nucleus

Choroidal fissure

Substantia nigra

Cornu ammonis

Midbrain

Dentate gyrus

Perimesencephalic cistern

Subiculum Parahippocampal gyrus Interpeduncular cistern



Pons

Posterior cerebral a. (P2 segment)

NORMAL ANATOMY The normal appearance of the hippocampus on coronal MRI is that of a jelly roll, with the dentate gyrus in the center and the four segments of the cornu ammonis wrapped around it (see Axial 4).

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Limbic System Coronal 3

Callosomarginal a. Body of corpus callosum

Septum pellucidum Claustrum

Body of lateral ventricle

External capsule

Caudate nucleus

Posterior limb of internal capsule

Body of fornix

Thalamus

Internal cerebral v.

Putamen Sylvian fissure

Middle cerebral aa. (M2 branch)

Third ventricle

Choroid fissure

Subthalamic nucleus

Cornu ammonis

Substantia nigra

Dentate gyrus

Midbrain

Subiculum Parahippocampal gyrus

Perimesencephalic cistern

Posterior cerebral a. (P2 segment)

Interpeduncular cistern Callosomarginal a. Septum pellucidum

Body of corpus callosum Body of lateral ventricle

Claustrum

Caudate nucleus Body of fornix

External capsule

Internal cerebral v. Thalamus

Posterior limb of internal capsule

Sylvian fissure Third ventricle

Putamen

Subthalamic nucleus

Choroid fissure

Substantia nigra

Cornu ammonis

Midbrain

Dentate gyrus Subiculum

Perimesencephalic cistern

Parahippocampal gyrus Posterior cerebral a. (P2 segment)

Interpeduncular cistern

Pons

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Limbic System Coronal 4

Callosomarginal a.

Body of corpus callosum

Caudate nucleus Septum pellucidum

Body of lateral ventricle

Internal cerebral v.

Body of fornix

Claustrum

Putamen

Sylvian fissure

Posterior limb of internal capsule

External capsule Thalamus

Third ventricle

Midbrain Red nucleus

Cornu ammonis

Choroidal fissure

Dentate gyrus

Posterior cerebral a.

Subiculum Parahippocampal gyrus

Perimesencephalic cistern

Pons



PATHOLOGIC PROCESS Coronal imaging through the hippocampus and amygdala is not part of routine brain MRI. However, coronal images are helpful for evaluation of temporal lobe epilepsy, which may show findings of mesial temporal sclerosis, typically seen as an asymmetrically small hippocampus and amygdala with increased T2-weighted signal. Electroencephalography (EEG) will typically show temporal lobe seizure activity localized to the abnormal side. If refractory to medication, the seizure patient can be treated with temporal lobectomy.

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Limbic System Coronal 4

Callosomarginal a.

Body of corpus callosum

Septum pellucidum Caudate nucleus

Body of lateral ventricle

External capsule

Body of fornix

Thalamus

Internal cerebral v.

Claustrum Sylvian fissure

Middle cerebral aa. (M2 branch)

Third ventricle

Choroid fissure

Red nucleus

Cornu ammonis

Midbrain

Dentate gyrus Subiculum Parahippocampal gyrus

Perimesencephalic cistern

Posterior cerebral a. (P2 segment) Pons Callosomarginal a. Body of corpus callosum

Septum pellucidum Caudate nucleus

Body of lateral ventricle

External capsule

Body of fornix

Thalamus

Internal cerebral v.

Claustrum Sylvian fissure

Posterior limb of internal capsule

Third ventricle

Putamen Choroid fissure

Red nucleus

Cornu ammonis

Midbrain

Dentate gyrus Subiculum

Perimesencephalic cistern

Parahippocampal gyrus

Pons NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

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Limbic System Coronal 5

Caudate nucleus Choroid plexus Quadrigeminal cistern

Body of corpus callosum Body of lateral ventricle Crus of fornix

Sylvian fissure Thalamus Pineal gland

Internal cerebral v.

Cerebral aqueduct Choroidal fissure Posterior cerebral a.

Dentate gyrus

Midbrain

Subiculum

Ambient cistern

Parahippocampal gyrus

Cerebellar tentorium

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Cornu ammonis

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Limbic System Coronal 5

Crus of fornix Choroid plexus

Body of corpus callosum Body of lateral ventricle Caudate nucleus

Quadrigeminal cistern Thalamus Pineal gland Cerebral aqueduct

Internal cerebral v. Sylvian fissure Choroid fissure Cornu ammonis

Posterior cerebral a.

Dentate gyrus

Ambient cistern

Subiculum

Midbrain

Parahippocampal gyrus

Cerebellar tentorium

Crus of fornix

Body of corpus callosum

Choroid plexus

Body of lateral ventricle Caudate nucleus

Quadrigeminal cistern Thalamus Pineal gland

Internal cerebral v.

Choroid fissure

Cerebral aqueduct Cornu ammonis Posterior cerebral a.

Dentate gyrus

Ambient cistern

Subiculum

Midbrain

Parahippocampal gyrus

Cerebellar tentorium

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Limbic System Coronal 6

Falx cerebri

Atrium/trigone of lateral ventricle

Splenium of corpus callosum Sylvian fissure

Fornix

Posterior cerebral a. (P4 segment)

Choroid plexus

Cornu ammonis

Great cerebral v.

Dentate gyrus Temporal horn of lateral ventricle

Subiculum Parahippocampal gyrus Inferior colliculi

Cerebellar tentorium Anterior cerebellar lobe

Superior cerebellar peduncle Superior medullary velum

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Fourth ventricle

Limbic System Coronal 6

Falx cerebri Atrium/trigone of lateral ventricle Splenium of corpus callosum

Sylvian fissure

Fornix Posterior cerebral a. (P4 segment)

Choroid plexus

Cornu ammonis

Internal cerebral v.

Dentate gyrus Subiculum

Temporal horn of lateral ventricle

Inferior colliculi (partial volume averaging) Parahippocampal gyrus

Cerebellar tentorium

Anterior cerebellar lobe

Superior cerebellar peduncle Superior medullary velum

Fourth ventricle

Falx cerebri Atrium/trigone of lateral ventricle Splenium of corpus callosum Sylvian fissure

Fornix Choroid plexus

Posterior cerebral a. (P4 segment) Cornu ammonis

Great cerebral v.

Dentate gyrus Temporal horn of lateral ventricle

Subiculum Inferior colliculi

Cerebellar tentorium

Anterior cerebellar lobe

Parahippocampal gyrus Superior cerebellar peduncle Superior medullary velum

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Limbic System Sagittal 1

Lateral ventricle

Thalamus

Body of corpus callosum Splenium of corpus callosum

Fornix Genu of corpus callosum

Quadrigeminal cistern Pineal gland

Rostrum of corpus callosum

Superior colliculus Red nucleus

Mammillary body

Inferior colliculus

Hypothalamus

Midbrain

Optic chiasm

Cerebral aqueduct

Posterior pituitary gland

Anterior cerebellar peduncle Superior cerebellar peduncle

Anterior pituitary gland

Fourth ventricle Inferior cerebellar peduncle Medulla Prepontine cistern

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Pons

Limbic System Sagittal 1

Lateral ventricle

Thalamus

Body of corpus callosum Fornix

Splenium of corpus callosum

Genu of corpus callosum

Quadrigeminal cistern

Rostrum of corpus callosum

Pineal gland Superior colliculus

Mammillary body

Red nucleus

Hypothalamus

Inferior colliculus Midbrain

Optic chiasm

Anterior cerebellar peduncle

Posterior pituitary gland

Cerebral aqueduct

Anterior pituitary gland

Superior cerebellar peduncle Fourth ventricle Prepontine cistern

Pons

Medulla

Inferior cerebellar peduncle

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Limbic System Sagittal 2

Thalamus

Insular lobe

Atrium of lateral ventricle

Putamen Globus pallidus

Collateral trigone Body of hippocampus

Choroidal fissure

Fusiform gyrus

Collateral sulcus



NORMAL ANATOMY The hippocampus is a ridge running along the floor of the temporal horn of the lateral ventricle. Venetian anatomist Aranzi (1578) first described its seahorse appearance using the Latin term hippocampus (Greek hippokampos). In 1832, Parisian surgeon de Garengeot used the term cornu ammonis (“horn of Ammon”).

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Limbic System Sagittal 2

Thalamus

Insular lobe

Putamen

Globus pallidus

Choroidal fissure

Atrium of lateral ventricle

Collateral trigone

Body of hippocampus Fusiform gyrus

Collateral sulcus

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Limbic System Sagittal 3

Putamen Globus pallidus

Trigone of lateral ventricle

Internal capsule

Hippocampus Amygdala

Parahippocampal gyrus

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Limbic System Sagittal 3

Putamen

Trigone of lateral ventricle

Globus pallidus Internal capsule Hippocampus Amygdala

Parahippocampal gyrus

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Chapter

5

BRAINSTEM AND CRANIAL NERVES

OLFACTORY NERVE (CN I) Axial 176 Coronal 178 OPTIC NERVE (CN II) Axial 180 Coronal 186 Sagittal 198 OCULOMOTOR NERVE (CN III) Axial 200 Coronal 208 TROCHLEAR NERVE (CN IV) Axial 218 Coronal 222 TRIGEMINAL NERVE (CN V) Axial 224 Sagittal 242 Coronal 244 ABDUCENS (CN VI), FACIAL (CN VII), AND ­VESTIBULOCOCHLEAR (CN VIII) NERVES Axial 246 Sagittal 260 GLOSSOPHARYNGEAL (CN IX), VAGUS (CN X), ­ACCESSORY (CN XI), AND HYPOGLOSSAL (CN XII) NERVES Axial 264

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Cranial Nerve I Axial 1



NORMAL ANATOMY The olfactory nerve, or cranial nerve (CN) I, is the first of 12 cranial nerves and provides ­innervation for the sense of smell. CN I can often be seen on axial magnetic resonance imaging of the brain at the level of the temporal lobes. Nerve fibers from the olfactory mucosa in the anterosuperior nasal cavity join with the olfactory bulb, from which signals pass through nerves running within olfactory foramina in the cribriform plate in the superior nasal cavity.

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Cranial Nerve I Axial 1

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Cranial Nerve I Coronal 1

IMAGING TECHNIQUE CONSIDERATION Clinicians should always approach loss of smell as a serious symptom and explore anatomic causes. The best imaging plane to assess the olfactory nerves is coronal, perpendicular to the long axis of the nerves. T2-weighted MR coronal images help to delineate the olfactory nerves, with surrounding cerebrospinal fluid (CSF) between the nerves and the bony walls of the olfactory grooves. In some patients, one olfactory groove may be asymmetrically lower than the other, an important consideration if the patient may be undergoing functional endoscopic sinus surgery (FES). One notable tumor centered on the olfactory nerves is esthesioneuroblastoma (olfactory neuroblastoma).

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Cranial Nerve I Coronal 1

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Cranial Nerve II Axial 1



DIAGNOSTIC CONSIDERATION The optic nerve (second cranial, CN II) is the only cranial nerve that is part of the central nervous system. CN II is a direct extension of the brain and thus is surrounded by CSF and a dural sheath. Ophthalmoscopic (funduscopic) examination of the eyes can reveal papilledema when intracranial pressure is increased. On axial imaging, flattening of the posterior aspect of the globes has been described as the most specific sign of idiopathic intracranial hypertension, also called benign intracranial hypertension or pseudotumor cerebri.

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Cranial Nerve II Axial 1

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Cranial Nerve II Axial 2

NORMAL ANATOMY AND PATHOLOGIC CONSIDERATION Sensory signals from the retina transmit posteriorly along the optic nerves until the signals join at the optic chiasm, where the medial fibers of each nerve cross to the other side. The optic chiasm is immediately superior to the pituitary gland (hypophysis) and suprasellar cistern. A large pituitary adenoma therefore can compress the crossing fibers, leading to bitemporal hemanopia (or hemianopsia), with defects in the temporal, or lateral, half of the visual field in each eye. A light object in the temporal (lateral) field of view sends light through the lens to the nasal (medial) retina, which then sends signals through the medial fibers of the optic nerves, which in turn cross midline at the optic chiasm.

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Cranial Nerve II Axial 2

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Cranial Nerve II Axial 3



NORMAL ANATOMY The optic tract contains the lateral, or temporal, nerves of the ipsilateral optic nerve and the medial, or nasal, nerves of the contralateral optic nerve. The optic tract joins the optic chiasm to the lateral geniculate nucleus (LGN). The LGN is located within the thalamus and is the primary relay center for visual information received from the retina. A mass along the optic tract can cause contralateral hemianopia, with blocked signals at the right optic tract causing a left-sided hemianopia.

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Cranial Nerve II Axial 3

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Cranial Nerve II Coronal 1



DIAGNOSTIC CONSIDERATION The coronal plane is often the best imaging plane to assess the optic nerve (CN II). Note the ring of cerebrospinal fluid around the optic nerves. As an extension of the brain and dura, the optic nerve sheath complex is subject to the same pathology, such as a glioma of the optic nerves or meningioma of the surrounding dural sheath. This coronal plane is often the best plane to identify a mass arising from the sheath and compressing the optic nerve, versus an expansion of the optic nerve.

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Cranial Nerve II Coronal 1

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Cranial Nerve II Coronal 2



NORMAL ANATOMY Note the superior ophthalmic vein above the optic nerve. Abnormal shunting of arterial blood into the cavernous sinus, as in a post-traumatic carotid cavernous fistula (CCF), will cause enlargement of the superior ophthalmic vein.

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Cranial Nerve II Coronal 2

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Cranial Nerve II Coronal 3

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Cranial Nerve II Coronal 3

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Cranial Nerve II Coronal 4

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Cranial Nerve II Coronal 4

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Cranial Nerve II Coronal 5

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Cranial Nerve II Coronal 5

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Cranial Nerve II Coronal 6



DIAGNOSTIC CONSIDERATION As the optic nerve passes posteriorly in the orbit toward the apex, it is often difficult to separate the nerve from the surrounding orbital muscles and bony walls of the apex. Subtle lesions may be detected best on a coronal oblique image aligned perpendicular to the optic nerve, as seen in this image.

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Cranial Nerve II Coronal 6

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Cranial Nerve II Sagittal 1



NORMAL ANATOMY Pathology, such as a posterior cerebral infarct involving the left occipital lobe, may result in a right-sided visual field deficit in each eye.

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Cranial Nerve II Sagittal 1

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Cranial Nerve III Axial 1



NORMAL ANATOMY The oculomotor nerve (CN III) is the third of the 12 pairs of cranial nerves. CN III arises from two nuclei. The oculomotor nucleus originates at the level of the superior colliculus and controls the striated muscle in the levator palpebrae superioris and all extraocular muscles, except the superior oblique and lateral rectus muscles (see also Optic Coronal 6). Edinger-Westphal (accessory oculomotor) nuclei supply parasympathetic fibers to the eye through the ciliary ganglia and control the sphincter pupillae muscle for pupil constriction and the ciliary muscle for ­accommodation. Fibers for the oculomotor nerve pass anteriorly from the oculomotor nucleus through the red nucleus and substantia nigra and exit the brainstem at the interpeduncular fossa.

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Cranial Nerve III Axial 1

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Cranial Nerve III Axial 2



PATHOLOGIC PROCESS The cisternal segment of the oculomotor nerve is intimately associated with blood vessels of the circle of Willis. After exiting the brainstem, CN III passes anteriorly between the posterior cerebral and superior cerebellar arteries and parallels the posterior communicating artery before entering the cavernous sinus. An aneurysm arising from the origin of the posterior communicating artery off the internal carotid artery classically causes compression of CN III, leading to oculomotor nerve palsy.

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Cranial Nerve III Axial 2

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Cranial Nerve III Axial 3

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Cranial Nerve III Axial 3

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Cranial Nerve III Axial 4



NORMAL ANATOMY Note there is an incidental tiny cyst in the middle of the pons on this image. The aqueduct is located more posteriorly.

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Cranial Nerve III Axial 4

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Cranial Nerve III Coronal 1



NORMAL ANATOMY The oculomotor nerve (CN III) is the most superior of the cranial nerves in the cavernous sinus.

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Cranial Nerve III Coronal 1

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Cranial Nerve III Coronal 2

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Cranial Nerve III Coronal 2

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Cranial Nerve III Coronal 3

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Cranial Nerve III Coronal 3

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Cranial Nerve III Coronal 4

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Cranial Nerve III Coronal 4

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Cranial Nerve III Coronal 5



NORMAL ANATOMY Note the oculomotor nerve passing between the posterior cerebral artery and superior cerebellar artery.

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Cranial Nerve III Coronal 5

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Cranial Nerve IV Axial 1



NORMAL ANATOMY The trochlear nerve (fourth cranial, CN IV) is a motor nerve innervating the superior oblique muscle of the orbit. Contraction of this muscle will point the eye medially and inferiorly toward the tip of the nose. CN IV is the thinnest cranial nerve but the longest intracranially, the only cranial nerve to exit the brainstem dorsally. The trochlear nerve is also the only cranial nerve to cross the midline posterior to the brainstem, with the medial fibers of the optic nerve the only other cranial nerve to cross the midline. The tiny incidental cyst in the middle of the pons in this axial MR image is not the aqueduct of Sylvius (cerebral aqueduct), which can be seen between the trochlear nuclei. The dark signal in the middle of the aqueduct is caused by CSF flow.

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Cranial Nerve IV Axial 1

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Cranial Nerve IV Axial 2

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Cranial Nerve IV Axial 2

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Cranial Nerve IV Coronal 1

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Cranial Nerve IV Coronal 1

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Cranial Nerve V Axial 1



NORMAL ANATOMY The trigeminal nerve (fifth cranial, CN V) is named for its three major branches: ophthalmic (V1), maxillary (V2), and mandibular (V3). CN V innervates sensation of the face and the muscles of mastication; V1 and V2 branches are cutaneous sensory nerves only, whereas V3 has cutaneous sensory and motor functions. The trigeminal nerve is the largest of the cranial nerves, and its cisternal segment has a fanshaped appearance on axial imaging as it courses from the brainstem to Meckel’s cave. The ganglion within Meckel’s cave is called the trigeminal, or Gasserian, ganglion. Meckel’s ganglion along V2 is located within the pterygopalatine fossa more anteriorly (see also Trigeminal Axial 9).

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Cranial Nerve V Axial 1

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Cranial Nerve V Axial 2

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Cranial Nerve V Axial 2

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Cranial Nerve V Axial 3



NORMAL ANATOMY The mandibular branch (V3) of the trigeminal nerve arises from the trigeminal ganglion and descends vertically out of the skull through the foramen ovale.

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Cranial Nerve V Axial 3

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Cranial Nerve V Axial 4

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Cranial Nerve V Axial 4

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Cranial Nerve V Axial 5



NORMAL ANATOMY The mandibular branch (V3) of the trigeminal nerve gives rise to the alveolar nerve, a sensory branch that courses through the alveolar canal in the mandible and exits the mental foramen into the subcutaneous tissues. A squamous cell carcinoma along the alveolar ridge of the teeth can invade the mandible and infiltrate the mandibular nerve.

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Cranial Nerve V Axial 5

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Cranial Nerve V Axial 6



NORMAL ANATOMY The mesencephalic nucleus of the trigeminal nerve senses the location of the jaw. This nucleus usually is not discernible on MRI.

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Cranial Nerve V Axial 6

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Cranial Nerve V Axial 7

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Cranial Nerve V Axial 7

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Cranial Nerve V Axial 8



NORMAL ANATOMY The spinal nucleus of the trigeminal nerve receives pain and temperature sensation from the face.

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Cranial Nerve V Axial 8

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Cranial Nerve V Axial 9



DIAGNOSTIC CONSIDERATION Loss of normally bright T1-weighted fat signal in the pterygopalatine fossa can be a sign of perineural invasion from the face.

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Cranial Nerve V Axial 9

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Cranial Nerve V Sagittal 1

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Cranial Nerve V Sagittal 1

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Cranial Nerve V Coronal 1



DIAGNOSTIC CONSIDERATION Although the trigeminal ganglion is located within Meckel’s cave, on T2-weighted MR images the appearance is that of multiple branches passing through Meckel’s cave, bathed in cerebrospinal fluid.

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Cranial Nerve V Coronal 1

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Cranial Nerves VI, VII, and VIII Axial 1



NORMAL ANATOMY The abducens (or abducent) nerve (sixth cranial, CN VI) is a somatic efferent nerve that controls movement of the lateral rectus muscle of the orbit. Palsy of CN VI leads to a defect in directing the lateral gaze. The cisternal segment of the abducens nerve enters the base of the skull at Dorello’s canal.

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Cranial Nerves VI, VII, and VIII Axial 1

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Cranial Nerves VI, VII, and VIII Axial 2



PATHOLOGIC PROCESS The abducens nerve innervates a single muscle, as does the trochlear nerve, and is only slightly larger than the trochlear. CN VI exits the brainstem between the pons and medulla medial to the facial nerve (CN VII) and passes anteriorly and superiorly to enter the skull base at a slightly acute angle into Dorello’s canal. At the tip of the petrous segment of the temporal bone, the abducens nerve makes another acute angle forward to enter the cavernous sinus, coursing alongside the cavernous segment of the internal carotid artery, and enters the orbit through the superior orbital fissure. Because of its long course from brainstem to eye and acute turns at bony structures, the abducens nerve is particularly vulnerable to injury.

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Cranial Nerves VI, VII, and VIII Axial 2

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249

Cranial Nerves VI, VII, and VIII Axial 3



DIAGNOSTIC CONSIDERATION The abducens nucleus is located in the pons along the anterior aspect of the fourth ventricle. Nerve fibers from the facial nucleus wrap medially and then posteriorly and laterally to the abducens nucleus, forming a bump on the anterior wall of the fourth ventricle called the facial colliculus. The abducens nuclei are close to the midline, as with the other nuclei that control ocular movement. The abducens axons pass from the nucleus anteriorly through the pons lateral to the corticospinal tract before exiting the brainstem and the pontomedullary junction. Infarcts of the dorsal pons can injure both the abducens nucleus, causing lateral rectus palsy, and the facial nerve fibers, resulting in an ipsilateral facial palsy. Infarcts of the ventral pons can affect the abducens nerve and the corticospinal tract, producing lateral rectus muscle palsy and contralateral hemiparesis.

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Cranial Nerves VI, VII, and VIII Axial 3

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251

Cranial Nerves VI, VII, and VIII Axial 4



NORMAL ANATOMY The facial nerve (seventh cranial, CN VII) exits the facial nucleus and wraps medial and posterior to the abducens nucleus to form a bump in the anterior wall of the fourth ventricle, called the facial colliculus. CN VII exits the brainstem at the lateral pontomedullary junction and courses through the CSF in the cerebellopontine angle anterior and parallel to the vestibulocochlear nerve (CN VIII) into the internal auditory canal. (For the segments of the facial nerve passing through bony canals as well as the semicircular canals, see Chapter 12.) The facial nerve is a motor nerve that supplies the muscles of the face. Injury to CN VII is of great clinical significance because of the stigma of ipsilateral facial palsy mimicking stroke and the impact on social interaction. The vestibulocochlear nerve (eighth cranial, CN VIII) provides both balance and hearing functions. The vestibulocochlear nerve was formerly called the “acoustic” or “auditory” nerve, but these terms did not recognize the nerve’s role in the vestibular system.

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Cranial Nerves VI, VII, and VIII Axial 4

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253

Cranial Nerves VI, VII, and VIII Axial 5



NORMAL ANATOMY The cochlear branch of the vestibulocochlear nerve (CN VIII) courses in the anteroinferior quadrant of the internal auditory canal. The cochlear nerve passes laterally into the small cochlear canal and winds within the cochlea. The inferior and posterior divisions of the vestibular branch of the vestibulocochlear nerve pass in the posterior quadrants of the internal auditory canal and provide innervation for equilibrium to the three semicircular canals.



DIAGNOSTIC CONSIDERATION The anterior inferior cerebellary artery passes close to the porous acoustic meatus (auditory canal). In some people the anterior inferior cerebellar artery can pass into the internal auditory canal. Looping of this artery into the canal, particularly deeper than halfway, may be associated with pressure symptoms on the facial or vestibulocochlear nerves, including potentially debilitating pulsatile tinnitus.

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Cranial Nerves VI, VII, and VIII Axial 5

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255

Cranial Nerves VI, VII, and VIII Axial 6



NORMAL ANATOMY The four vestibular nuclei include the medial, lateral, and inferior nuclei, located within the medulla, and the superior nucleus within the pons. The vestibular nuclei are medial to the ventral and dorsal cochlear nuclei.



PATHOLOGIC PROCESS Note that this axial image is slightly tilted, showing a slightly lower aspect of the right side of the patient’s head. The basal turn of the right cochlea is seen, as well as the middle and apical turns of the left cochlea. Note also the proximity of the petrous segment of the internal auditory canal to the basal turn. When the bony wall between this petrous segment and the basal turn is dehiscent, the patient may experience pulsatile tinnitus.

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Cranial Nerves VI, VII, and VIII Axial 6

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257

Cranial Nerves Vi, Vii, and Viii Axial 7



NORMAL ANATOMY This image is slightly more caudal than the Axial 6 image, and the basal turn of the left cochlear has now come into view. The part of the cochlear nerve in this basal turn registers higher frequencies, up to 20,000 Hz. As the cochlear nerve winds deeper into the middle and apical turns, it registers lower frequencies, down to 20 Hz.

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Cranial Nerves VI, VII, and VIII Axial 7

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259

Cranial Nerves VI, VII, and VIII Sagittal 1



NORMAL ANATOMY The sagittal MR projection is the best imaging plane for distinguishing the facial nerve and the cochlear and vestibular branches of the vestibulocochlear nerve. In this sagittal image the nerves are seen in cross section to their long axis, with the facial nerve in the anterosuperior quadrant, the cochlear nerve in the anteroinferior quadrant, the superior vestibular branch in the posterosuperior quadrant, and the inferior vestibular branch in the posteroinferior quadrant. The patient’s neck is slightly extended, tilting the facial nerve into the most superior position.

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Cranial Nerves VI, VII, and VIII Sagittal 1

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Cranial Nerves VI, VII, and VIII Sagittal 2



PATHOLOGIC PROCESS Acoustic neuroma (schwannoma) may be seen in the patient with neurofibromatosis 2 and typically arises from the vestibular branches of CN VIII.

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Cranial Nerves VI, VII, and VIII Sagittal 2

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Cranial Nerves IX, X, XI, and XII Axial 1



NORMAL ANATOMY The glossopharyngeal nerve (ninth cranial, CN IX) exits the brainstem from the lateral aspect of the upper medulla just anterior to the vagus nerve. The glossopharyngeal nerve exits the skull base through the pars nervosa, a small anteromedial compartment of the jugular foramen separated from the larger posterolateral compartment by a small bony ridge called the “jugular spine.”

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Cranial Nerves IX, X, XI, and XII Axial 1

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Cranial Nerves IX, X, XI, and XII Axial 2



NORMAL ANATOMY The nucleus ambiguus gives rise to motor fibers of the glossopharyngeal nerve and motor fibers of the vagus nerve. The inferior salivatory nucleus controls the parasympathetic input to the parotid gland and gives rise to axons traveling in the glossopharyngeal nerve. The solitary tract nucleus gives rise to fibers supplying the facial, glossopharyngeal, and vagus nerves and forms a circuit that contributes to autonomic regulation.

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Cranial Nerves IX, X, XI, and XII Axial 2

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Cranial Nerves IX, X, XI, and XII Axial 3



NORMAL ANATOMY The vagus nerve (tenth cranial, CN X) is the longest cranial nerve. CN X exits the medulla between the medullary pyramid and inferior cerebellar peduncle, passes through the pars vascularis of the jugular foramen, courses inferior into the carotid sheath between the internal carotid artery the internal jugular vein, and then passes down into the neck, chest, and abdomen to innervate the viscera (Latin vagus, “wandering”). Most vagus nerve fibers provide sensory information about the state of organs to the brain, although some output also occurs. The accessory nerve (CN XI) innervates the sternocleidomastoid and trapezius muscles of the neck and shoulder. Originally thought to be part of the brain, this nerve was designated the “eleventh cranial nerve” based on its location relative to other cranial nerves. However, the cranial component soon joins the vagus nerve, so more recently the accessory nerve is deemed to be synonymous with its spinal component and simply labeled spinal accessory nerve. The spinal accessory nerve is the only cranial nerve that forms outside the skull. Nerve outlets originate from the upper spinal cord and coalesce to form the spinal accessory nerve, which then enters the skull through the foramen magnum, joining the vagus nerve to exit the skull through the pars vascularis compartment of the jugular foramen.

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Cranial Nerves IX, X, XI, and XII Axial 3

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Cranial Nerves IX, X, XI, and XII Axial 4



DIAGNOSTIC CONSIDERATION The hypoglossal nerve (twelfth cranial, CN XII) innervates the muscles of the tongue. After exiting the medulla, CN XII exits the skull through its own canal, the hypoglossal canal, and courses anteriorly to innervate the tongue from inferiorly. This axial image shows its cisternal course immediately posterior to the intracranial segment of the vertebral artery. Damage to the hypoglossal nerve can lead to atrophy of the ipsilateral muscles of the tongue and on protrusion of the tongue, deviation toward the affected side.

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Cranial Nerves IX, X, XI, and XII Axial 4

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Chapter

6

VENTRICLES AND CEREBROSPINAL FLUID ­CISTERNS 1 2 3 4

5 6

1

AXIAL 274

2

CORONAL 286

3

1

SAGITTAL 292 NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

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Ventricles and CSF Cisterns Axial 1

Genu of corpus callosum Septum pellucidum

Frontal horn of lateral ventricle Body of lateral ventricle

Caudate nucleus

Anterior limb of internal capsule Putamen Globus pallidus Posterior limb of internal capsule

Fornix

Thalamus

Internal cerebral v.

Choroid plexus Splenium of corpus callosum Atrium

Falx cerebri

Superior sagittal sinus



NORMAL ANATOMY The ventricular system is located deep within the brain and is filled with cerebrospinal fluid (CSF). The normal appearance of CSF on magnetic resonance images is that of water. This axial MR image shows the choroid plexus within the ventricles, where CSF is produced. CSF is also seen outside the brain and within the sulci (subarachnoid space).



PATHOLOGIC PROCESS A colloid cyst is a benign lesion located near the foramen of Munro that may lead to sudden CSF obstruction, brain edema, and death if not treated with drainage and resection. CSF is produced at a rate of 500 mL daily; the intracranial vault and spinal canal contain only 150 mL, so the CSF turns over about three times each day.

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Ventricles and CSF Cisterns Axial 1

Genu of Corpus callosum Frontal horn of lateral ventricle Septum pellucidum

Caudate nucleus

Body of lateral ventricle Anterior limb of internal capsule Putamen Internal cerebral v.

Fornix

Thalamus

Posterior limb of internal capsule Choroid plexus Atrium

Splenium of corpus callosum

Falx cerebri Superior sagittal sinus

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Ventricles and CSF Cisterns Axial 2

Sylvian fissure

Third ventricle

Pineal gland

Great cerebral v. (of Galen)

Choroid plexus

Trigone of lateral ventricle

Cistern of great cerebral v.

Superior sagittal sinus



NORMAL ANATOMY At this axial level, the atrium has a triangular appearance and thus is often referred to as the trigone.

IMAGING TECHNIQUE CONSIDERATION Note that fluid is bright on T2-weighted MRI. The subcutaneous fat shows some brightness on T2-weighted images when multiple spin-echo pulses are applied (fast, or “turbo,” spin echo), as opposed to conventional spin echo T2-weighted imaging, where fat appears dark.

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Ventricles and CSF Cisterns Axial 2

Sylvian fissure Third ventricle

Pineal gland Great cerebral v. (of Galen) Choroid plexus

Trigone of lateral ventricle Cistern of great cerebral v.

Superior sagittal sinus

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Ventricles and CSF Cisterns Axial 3

Medial rectus m. Optic n. (CN II) Lateral rectus m.

Basilar a.

Internal carotid a. (cavernous segment)

Ambient cistern Interpeduncular cistern Temporal horn of lateral ventricles

Inferior colliculus Quadrigeminal cistern

Cerebral aqueduct

Cerebellar vermis

Superior sagittal sinus



PATHOLOGIC PROCESS Note that the temporal horn is a contiguous part of the lateral ventricles. Dilatation of the temporal horns is frequently a sign of hydrocephalus.

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Ventricles and CSF Cisterns Axial 3

Medial rectus m. Optic n. (CN II) Lateral rectus m.

Basilar a.

Temporal horn of lateral ventricles Ambient cistern

Cerebral aqueduct

Internal carotid a. (cavernous segment)

Interpeduncular cistern

Inferior colliculus Quadrigeminal cistern

Cerebellar vermis

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Ventricles and CSF Cisterns Axial 4

Optic chiasm

Sylvian cistern

Supraclinoid internal carotid a.

Suprasellar cistern

Temporal horn of lateral ventricle

Posterior cerebral a.

Interpeduncular cistern

Substantia nigra

Ambient cistern

Midbrain

Cerebral aqueduct

Inferior colliculus

Quadrigeminal cistern

Vermis



PATHOLOGIC PROCESS The suprasellar cistern has the shape of a six-pointed star. The interpeduncular cistern forms the posterior point of the star and is often the first location where a small amount of subarachnoid hemorrhage will layer when an aneurysm of the circle of Willis ruptures.

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Ventricles and CSF Cisterns Axial 4

Optic chiasm

Sylvian cistern

Suprasellar cistern Supraclinoid internal carotid a.

Temporal horn of lateral ventricle

Posterior cerebral a. Interpeduncular cistern Substantia nigra Ambient cistern Midbrain Inferior colliculus

Cerebral aqueduct Quadrigeminal cistern

Vermis

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Ventricles and CSF Cisterns Axial 5

Internal carotid a.

Prepontine cistern Abducens n. (CN VI)

Cochlea

Basilar a.

Cerebellopontine angle

Facial n. (CN VII)

Horizontal semicircular canal

Vestibulocochlear n. (CN VIII)

Pons

Flocculus Middle cerebellar peduncle

Fourth ventricle

Vermis



NORMAL ANATOMY The fluid in the semicircular canal is called endolymph.

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Ventricles and CSF Cisterns Axial 5

Internal carotid a.

Prepontine cistern Basilar a.

Cerebellopontine angle

Abducens n. (CN VI) Facial n. (CN VII) Vestibulocochlear n. (CN VIII) Flocculus

Cochlea Horizontal semicircular canal Pons

Fourth ventricle Middle cerebellar peduncle

Vermis

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Ventricles and CSF Cisterns Axial 6

R. internal carotid a.

L. vertebral a.

Glossopharyngeal n. (CN IX) in pars nervosa

Medullary pyramid Cerebellomedullary cistern

R. jugular bulb in pars vascularis

Medulla Decussation, medial lemniscus

Inferior cerebellar peduncle

Foramina of Magendie

Cerebellar tonsil



NORMAL ANATOMY Cerebrospinal fluid produced by the choroid plexus flows downward from the lateral ventricles, third ventricle, aqueduct of Sylvius (cerebral aqueduct), and fourth ventricle. CSF then flows out laterally through the foramina of Luschka or the midline through the foramen of Magendie. From here the CSF flows caudally around the spinal cord or cranially around the brain to the convexity, where it is absorbed by arachnoid granulations.

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Ventricles and CSF Cisterns Axial 6

R. internal carotid a.

Medullary pyramid L. vertebral a.

Glossopharyngeal n. (CN IX) in pars nervosa

Cerebellomedullary cistern

R. jugular bulb in pars vascularis

Medulla

Inferior cerebellar peduncle

Biventral lobule

Decussation, medial lemniscus

Foramina of Luschka Foramen of Magendie

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Ventricles and CSF Cisterns Coronal 1

Caudate nucleus Anterior body of lateral ventricle

Lentiform nucleus Sylvian fissure Interhemispheric fissure

Suprachiasmatic cistern Optic chiasm Infundibulum

Oculomotor n. (CN III)

Pituitary gland

Trigeminal n. (CN V)

Internal carotid a.



DIAGNOSTIC CONSIDERATION Coronal imaging is not used as often as axial MRI for assessment of the ventricles and cisterns, although the cerebrospinal fluid does provide good contrast in assessment of midline structures such as the optic chiasm, infundibulum, and pituitary gland (hypophysis).

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Ventricles and CSF Cisterns Coronal 1

Caudate nucleus

Anterior body of lateral ventricle

Sylvian fissure Suprachiasmatic cistern

Lentiform nucleus Interhemispheric fissure

Optic chiasm Infundibulum Oculomotor n. (CN III) Pituitary gland

Trigeminal n. (CN V) Internal carotid a.

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Ventricles and CSF Cisterns Coronal 2

Caudate nucleus

Third ventricle

Body of lateral ventricle Fornix

R. middle cerebral a. Posterior cerebral a. Endorhinal sulcus Temporal horn of lateral ventricle Parahippocampal gyrus

Oculomotor n. (CN III) Superior cerebellar a. Prepontine cistern Pons Cochlea

Cerebellomedullary cistern

288

Vertebral a.

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Ventricles and CSF Cisterns Coronal 2

Caudate nucleus Body of lateral ventricle

Third ventricle R. middle cerebral a.

Posterior cerebral a.

Endorhinal sulcus Temporal horn of lateral ventricle Parahippocampal gyrus

Oculomotor n. (CN III) Superior cerebellar a. Prepontine cistern Pons

Cerebellomedullary cistern

Vertebral a.

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Ventricles and CSF Cisterns Coronal 3

Falx cerebri Cingulate gyrus

Splenium of corpus callosum

Choroid plexus

Trigone of lateral ventricle

Great cerebral v. (of Galen) Quadrigeminal cistern

Tentorium

Fourth ventricle

Cerebellum

Nodulus

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Ventricles and CSF Cisterns Coronal 3

Falx cerebri Cingulate gyrus Splenium of corpus callosum

Choroid plexus

Trigone of lateral ventricle Great cerebral v. (of Galen) Quadrigeminal cistern

Tentorium Fourth ventricle Cerebellum Nodulus

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Ventricles and CSF Cisterns Sagittal 1

Body of corpus callosum

Interthalamic adhesion Pineal gland

Lateral ventricle

Quadrigeminal cistern Culmen

Third ventricle

Superior colliculus Cerebral aqueduct Inferior colliculus

Interpeduncular cistern Infundibulum

Central lobule

Suprasellar cistern

Primary fissure Declive

Pituitary gland

Fourth ventricle

Lingula

Folium

Medial lemniscus

Tuber

Prepontine cistern

Prepyramidal fissure

Nodule

Pyramis Uvula

Medulla

Foramen of Magendie Cerebellar tonsil

Obex Clava



Cerebellomedullary cistern

DIAGNOSTIC CONSIDERATION The midline sagittal plane on MR images provides a good view of the aqueduct of Sylvius (cerebral aqueduct). This long, thin, narrow channel is a relatively easy point for obstruction of CSF flow from a mass or adhesions. Dynamic MRI can be obtained in this sagittal plane to assess whether there is movement of CSF through the cerebral aqueduct.

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Ventricles and CSF Cisterns Sagittal 1

Body of corpus callosum

Interthalamic adhesion

Lateral ventricle

Quadrigeminal cistern

Third ventricle Lingula Interpeduncular cistern Infundibulum Suprasellar cistern Pituitary gland Medial lemniscus Prepontine cistern Medulla Nodule

Pineal gland Culmen Superior colliculus Central lobule Cerebral aqueduct Inferior colliculus Primary fissure Declive Fourth ventricle Folium Prepyramidal fissure Pyramis Uvula Cerebellar tonsil Foramen of Magendie

Obex Clava

Body of corpus callosum Lateral ventricle Third ventricle

Cerebellomedullary cistern

Interthalamic adhesion Pineal gland Quadrigeminal cistern Culmen Superior colliculus

Interpeduncular cistern Infundibulum Suprasellar cistern Pituitary gland Lingula Medial lemniscus Medulla Prepontine cistern Nodule Obex Clava

Inferior colliculus Central lobule Primary fissure Declive Cerebral aqueduct Fourth ventricle Folium Prepryamidal fissure Pyramis Uvula Cerebellar tonsil Foramen of Magendie Cerebellar tonsil Cerebellomedullary cistern NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

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Chapter

7

1

SELLA TURCICA

2 4 3

CORONAL 296

1

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Sella Turcica Coronal 1

Body of corpus callosum

Frontal horn of lateral ventricle

Caudate nucleus (head)

Septum pellucidum Anterior limb of internal capsule

Fornix

Putamen

Insular lobe

Interhemispheric fissure

Sylvian fissure

Anterior cerebral a.

Prechiasmatic optic n.

Temporal lobe

Cavernous internal carotid a.

Sphenoid sinus

Meckel’s cave

Vidian canal

Nasopharynx



TECHNICAL NOTE The upper MR image is a coronal T1-weighted pre-contrast sequence and the lower is a coronal T1-weighted post-contrast sequence.

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Sella Turcica Coronal 1

Body of corpus callosum Caudate nucleus (head)

Frontal horn of lateral ventricle Septum pellucidum

Fornix

Anterior limb of internal capsule

Insular lobe

Putamen Interhemispheric fissure

Sylvian fissure Prechiasmatic optic n.

Temporal lobe

Cavernous internal carotid a.

Sphenoid sinus Meckel’s cave

Nasopharynx

Vidian canal

Body of corpus callosum Caudate nucleus (head)

Fornix Insular lobe

Frontal horn of lateral ventricle Septum pellucidum Anterior limb of internal capsule Putamen

Interhemispheric fissure

Sylvian fissure Prechiasmatic optic n.

Temporal lobe Sphenoid sinus

Cavernous internal carotid a. Meckel’s cave

Nasopharynx

Vidian canal

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Sella Turcica Coronal 2

Frontal horn of lateral ventricle

Body of corpus callosum

Caudate nucleus (head) Septum pellucidum

Fornix

Anterior limb of internal capsule Insular lobe

Putamen

Sylvian fissure Branches of middle cerebral a.

Anterior cerebral a. Optic chiasm

Supraclinoid internal carotid a.

Temporal lobe

Pituitary gland Cavernous internal carotid a. Sphenoid sinus

Nasopharynx



DIAGNOSTIC CONSIDERATIONS The best magnetic resonance sequence to identify a pituitary lesion is coronal, thin, 3-mm magnified postcontrast images of the sella turcica. The sella is a transverse depression crossing the midline at the superior surface of the sphenoid bone that contains the pituitary gland, or hypophysis. Pituitary adenomas are typically less enhancing than the normal gland. Precontrast imaging is used to determine that the apparent enhancement is not intrinsic high T1-weighted signal. Intrinsically high T1 signal is most frequently seen with fat, some forms of protein, acute hemorrhage (methemoglobin), and microcalcifications.

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Sella Turcica Coronal 2

Body of corpus callosum Frontal horn of lateral ventricle

Caudate nucleus (head) Fornix

Septum pellucidum Anterior limb of internal capsule

Insular lobe Anterior cerebral a.

Putamen

Sylvian fissure Branches of middle cerebral a.

Optic chiasm

Supraclinoid internal carotid a.

Temporal lobe

Pituitary gland Cavernous internal carotid a. Sphenoid sinus

Nasopharynx

Body of corpus callosum Caudate nucleus (head)

Fornix Insular lobe Anterior cerebral a.

Frontal horn of lateral ventricle Septum pellucidum Anterior limb of internal capsule Putamen

Sylvian fissure Optic chiasm

Temporal lobe

Branches of middle cerebral a. Supraclinoid internal carotid a. Pituitary gland

Nasopharynx

Cavernous internal carotid a. Sphenoid sinus

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Sella Turcica Coronal 3

Body of corpus callosum

Frontal lobe

Caudate nucleus (head)

Frontal horn of lateral ventricle

Septum pellucidum Putamen

Anterior limb of internal capsule

Globus pallidus

Fornix Insular lobe

Suprasellar cistern

Anterior cerebral a.

Middle cerebral a.

Oculomotor n. (CN III)

Optic chiasm

Trochlear n. (CN IV)

Supraclinoid internal carotid a.

Abducens n. (CN VI)

Pituitary gland Cavernous internal carotid a.

Ophthalmic division (V1), trigeminal n. (CN V)

Temporal lobe

Maxillary division (V2), trigeminal n. (CN V)



Sphenoid sinus

PATHOLOGIC PROCESS On this coronal MR image, note the 4-mm, ovoid, hypoenhancing lesion within the inferior aspect of the pituitary gland, slightly larger toward the right. The lesion does not cause obvious displacement of the infundibulum or extend into the cavernous sinuses or sphenoid sinuses. This is consistent with a pituitary “microadenoma.” This term is a misnomer in that the lesion is not micrometers in size, but rather defined as a lesion less than a centimeter in size, versus a “macroadenoma,” which is larger than 1 cm.

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Sella Turcica Coronal 3

Body of corpus callosum Frontal horn of lateral ventricle

Caudate nucleus (head) Anterior limb of internal capsule

Frontal lobe Putamen

Insular lobe

Globus pallidus

Anterior cerebral a.

Suprasellar cistern Optic chiasm

Oculomotor n. (CN III)

Middle cerebral a.

Trochlear n. (CN IV)

Supraclinoid internal carotid a.

Abducens n. (CN VI)

Pituitary gland Cavernous internal carotid a.

Ophthalmic division (V1), trigeminal n. (CN V)

Temporal lobe Maxillary division (V2), trigeminal n. (CN V)

Sphenoid sinus

Body of corpus callosum Caudate nucleus (head) Anterior limb of internal capsule Insular lobe

Frontal horn of lateral ventricle Frontal lobe Putamen Globus pallidus

Infundibulum

Suprasellar cistern Optic chiasm

Oculomotor n. (CN III) Trochlear n. (CN IV) Abducens n. (CN VI) Ophthalmic division (V1), trigeminal n. (CN V) Maxillary division (V2), trigeminal n. (CN V)

Middle cerebral a. Supraclinoid internal carotid a. Pituitary gland Cavernous internal carotid a. Temporal lobe Sphenoid sinus

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301

Sella Turcica Coronal 4

Body of corpus callosum Caudate nucleus (head) Septum pellucidum Anterior limb of internal capsule Rostrum of corpus callosum Insular lobe

Frontal lobe Frontal horn of lateral ventricle

Putamen Globus pallidus Sylvian fissure

Anterior cerebral a. Suprachiasmatic cistern Oculomotor n. (CN III)

Optic chiasm Infundibulum

Trochlear n. (CN IV) Abducens n. (CN VI) Ophthalmic division (V1), trigeminal n. (CN V) Maxillary division (V2), trigeminal n. (CN V) Cavernous sinus (lateral sellar compartment)

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NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Pituitary gland Cavernous internal carotid a. Temporal lobe

Clivus

Sella Turcica Coronal 4

Body of corpus callosum Frontal horn of lateral ventricle

Caudate nucleus (head) Anterior limb of internal capsule

Frontal lobe

Septum pellucidum

Putamen

Rostrum of corpus callosum

Globus pallidus

Anterior cerebral a.

Sylvian fissure Optic chiasm

Suprachiasmatic cistern

Infundibulum

Oculomotor n. (CN III)

Pituitary gland

Trochlear n. (CN IV) Abducens n. (CN VI)

Cavernous internal carotid a.

Ophthalmic division (V1), trigeminal n. (CN V)

Temporal lobe

Maxillary division (V2) trigeminal n. (CN V)

Clivus

Cavernous sinus (lateral sellar compartment) Body of corpus callosum Caudate nucleus (head) Anterior limb of internal capsule Septum pellucidum Rostrum of corpus callosum Anterior cerebral a.

Suprachiasmatic cistern Oculomotor n. (CN III) Trochlear n. (CN IV) Abducens n. (CN VI) Ophthalmic division (V1), trigeminal n. (CN V) Maxillary division (V2) trigeminal n. (CN V)

Frontal horn of lateral ventricle Frontal lobe Putamen Globus pallidus Sylvian fissure Optic chiasm Infundibulum Pituitary Cavernous internal carotid a. Temporal lobe Clivus

Cavernous sinus (lateral sellar compartment) NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

303

Sella Turcica Sagittal 1 Body of lateral ventricle

Body of corpus callosum

Fornix Splenium of corpus callosum

Genu of corpus callosum

Thalamus

Rostrum of corpus callosum

Pineal region

Anterior cerebral a.

Quadrigeminal cistern Midbrain Mammillary body

Posterior cerebral a.

Prepontine cistern Optic chiasm

Fourth ventricle

Infundibulum Basilar a.

Suprasellar cistern Anterior pituitary gland

Pontomedullary junction

Posterior pituitary gland

Medulla oblongata

Axis (C1) Odontoid process (C2) Body of corpus callosum

Body of lateral ventricle Fornix Splenium of corpus callosum

Genu of corpus callosum

Thalamus Pineal region

Rostrum of corpus callosum

Quadrigeminal cistern

Anterior cerebral a.

Midbrain

Suprasellar cistern

Mammillary body

Posterior cerebral a. Optic chiasm

Pons Prepontine cistern

Infundibulum

Fourth ventricle Pontomedullary junction

Anterior pituitary gland

Medulla oblongata

Posterior pituitary gland

Axis (C1)

Basilar a.



Odontoid process

PATHOLOGIC PROCESS Acute hemorrhage may be seen with pituitary apoplexy. In these patients, attention should focus on the posterior aspect of the clivus for signs of hemorrhage extension. Note that the posterior aspect of the pituitary gland, the neurohypophysis, is normally T1 bright, the absence of which may be pathologic.

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NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Sella Turcica Sagittal 1

Body of corpus callosum Body of lateral ventricle Fornix Splenium of corpus callosum

Genu of corpus callosum

Thalamus Rostrum of corpus callosum

Pineal region Quadrigeminal cistern

Anterior cerebral a.

Midbrain Mammillary body

Suprasellar cistern

Prepontine cistern

Optic chiasm

Pons Fourth ventricle

Infundibulum Posterior cerebral a.

Pontomedullary junction

Anterior pituitary gland

Medulla oblongata

Posterior pituitary gland

Basilar a. Axis (C1) Body of corpus callosum

Body of lateral ventricle

Odontoid process (C2)

Fornix

Genu of corpus callosum Rostrum of corpus callosum Anterior cerebral a. Suprasellar cistern Optic chiasm Infundibulum Posterior cerebral a. Anterior pituitary gland Posterior pituitary gland

Splenium of corpus callosum Thalamus Pineal region Quadrigeminal cistern Midbrain Mammillary body Prepontine cistern Pons Fourth ventricle Pontomedullary junction Medulla oblongata Basilar a. Axis (C1) Odontoid process (C2) NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

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PART

2

HEAD AND NECK

CHAPTER 8  OVERVIEW OF HEAD AND NECK 308 CHAPTER 9  PARANASAL SINUSES  321 CHAPTER 10  ORBITS 355 CHAPTER 11 MANDIBLE AND MUSCLES OF MASTICATION 381 CHAPTER 12 TEMPORAL BONE (MIDDLE EAR, COCHLEA, VESTIBULAR SYSTEM) 399 CHAPTER 13 ORAL CAVITY, PHARYNX, AND SUPRAHYOID NECK  421 CHAPTER 14 HYPOPHARYNX, LARYNX, AND INFRAHYOID NECK  471

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307

Chapter

8

OVERVIEW OF HEAD AND NECK

SKULL: ANTERIOR ASPECT  309 SKULL: LATERAL ASPECT  310 BASE OF SKULL: EXTERNAL ASPECT  311 BASE OF SKULL: BONES, MARKINGS, AND ORIFICES  312 NOSE AND PARANASAL SINUSES: CROSS SECTION  313 PHARYNX: MEDIAN SECTION  314 MUSCLES OF PHARYNX: PARTIALLY OPENED POSTERIOR VIEW 315 ARTERIES OF ORAL AND PHARYNGEAL REGIONS  316 LYMPH VESSELS AND NODES OF HEAD AND NECK  317 PATHWAY OF SOUND RECEPTION  318 SKULL, SKULL BASE, AND MENINGES  319 SKULL, SKULL BASE, AND MENINGES (CONTINUED)  320

308

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Skull: Anterior Aspect

Coronal suture

Frontal bone Glabella

Parietal bone

Supraorbital notch (foramen)

Nasion Sphenoidal bone

Orbital surface

Lesser wing Greater wing

Nasal bone

Temporal bone Lacrimal bone Ethmoidal bone Orbital plate

Zygomatic bone

Perpendicular plate

Frontal process

Middle nasal concha

Orbital surface Temporal process

Inferior nasal concha

Zygomaticofacial foramen

Vomer

Maxilla

Mandible

Zygomatic process

Ramus

Orbital surface

Body

Infraorbital foramen

Mental foramen

Frontal process

Mental tubercle

Alveolar process

Mental protuberance

Anterior nasal spine

Right orbit: frontal and slightly lateral view Orbital surface of frontal bone

Supraorbital notch

Orbital surface of lesser wing of sphenoid bone

Posterior and Anterior ethmoidal foramina

Superior orbital fissure

Orbital plate of ethmoidal bone

Optic canal (foramen) Orbital surface of greater wing of sphenoid bone Orbital surface of zygomatic bone Zygomaticofacial foramen Inferior orbital fissure Infraorbital groove

Lacrimal bone Fossa for lacrimal sac Orbital process of palatine bone Orbital surface of maxilla Infraorbital foramen

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309

Skull: Lateral Aspect

Sphenoidal bone

Parietal bone

Greater wing Frontal bone Supraorbital notch (foramen)

Temporal bone

Temporal fossa Superior temporal line

Coronal suture

Inferior temporal line

Zygomatic process Articular tubercle

Pterion

Groove for posterior deep temporal artery

Glabella

Supramastoid crest

Ethmoidal bone

External acoustic meatus

Orbital plate Lacrimal bone

Mastoid process Lambdoid suture

Fossa for lacrimal sac

Occipital bone

Nasal bone

Sutural (wormian) bone

Maxilla

External occipital protuberance (inion)

Frontal process Infraorbital foramen Anterior nasal spine Alveolar process

Squamous part

Asterion Mandible Head of condylar process Mandibular notch Coronoid process Ramus Oblique line Body Mental foramen

Zygomatic bone Zygomaticofacial foramen Temporal process Zygomatic arch

Sphenoidal bone Greater wing

Infratemporal fossa exposed by removal of zygomatic arch and mandible*

Infratemporal crest Lateral plate of pterygoid process

Pterygomaxillary fissure

Pterygoid hamulus (of medial plate of pterygoid process)

Inferior orbital fissure Infratemporal surface of maxilla Alveolar foramina Tuberosity of maxilla

Temporal bone Foramen ovale

External acoustic meatus Mandibular fossa

Pterygopalatine fossa Sphenopalatine foramen *Superficially, mastoid process forms posterior boundary.

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Articular tubercle Styloid process

Base of Skull: External Aspect

Maxilla Incisive fossa Palatine process Intermaxillary suture Zygomatic process Zygomatic bone Frontal bone Sphenoid bone Pterygoid process Hamulus Medial plate Pterygoid fossa Lateral plate Scaphoid fossa Greater wing Foramen ovale Foramen spinosum Spine

Palatomaxillary suture

Palatine bone Horizontal plate Greater palatine foramen Pyramidal process Lesser palatine foramina Posterior nasal spine

Choanae Temporal bone Zygomatic process Articular tubercle Mandibular fossa Styloid process Petrotympanic fissure Carotid canal (external opening) Tympanic canaliculus External acoustic meatus Mastoid canaliculus Mastoid process Stylomastoid foramen Petrous part Mastoid notch (for digastric muscle) Occipital groove (for occipital artery) Jugular fossa (jugular foramen in its depth) Mastoid foramen

Vomer Ala Groove for auditory (pharyngotympanic, eustachian) tube Foramen lacerum

Parietal bone Occipital bone Hypoglossal canal Occipital condyle Condylar canal and fossa Basilar part Pharyngeal tubercle Foramen magnum Inferior nuchal line External occipital crest Superior nuchal line External occipital protuberance

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311

Base of Skull: Bones, Markings, and Orifices

Frontal bone Groove for superior sagittal sinus Frontal crest Groove for anterior meningeal vessels Foramen cecum Superior surface of orbital part Ethmoidal bone Crista galli Cribriform plate Sphenoidal bone Lesser wing Anterior clinoid process Greater wing Groove for middle meningeal vessels (frontal branches) Body Jugum Prechiasmatic groove Tuberculum sellae Sella Hypophyseal fossa turcica Dorsum sellae Posterior clinoid process Carotid groove (for int. carotid a.) Clivus Temporal bone Squamous part Petrous part Groove for lesser petrosal nerve Groove for greater petrosal nerve Arcuate eminence Trigeminal impression Groove for superior petrosal sinus Groove for sigmoid sinus Parietal bone Groove for middle meningeal vessels (parietal branches) Mastoid angle Occipital bone Clivus Groove for inferior petrosal sinus Basilar part Groove for posterior meningeal vessels Condyle Groove for transverse sinus Groove for occipital sinus Internal occipital crest Internal occipital protuberance Groove for superior sagittal sinus

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Anterior cranial fossa

Middle cranial fossa

Posterior cranial fossa

Nose and Paranasal Sinuses: Cross Section

Nasal vestibule

Major alar cartilage

Vomer Inferior nasal concha

Nasal septal cartilage

Facial artery

Facial vein

Maxillary bone Maxillary sinus Sphenoidal bone

Masseter muscle Coronoid process of mandible

Medial pterygoid muscle Lateral pterygoid plate

Lateral pterygoid muscle

Levator veli palatini muscle

Cartilage of auditory tube

Pharyngeal recess

Neck of mandible

Longus capitis muscle

Parotid gland

Rectus capitis anterior muscle

Retromandibular vein

Superficial temporal artery

Glossopharyngeal nerve (IX)

Sympathetic trunk

Styloid process

Styloglossus muscle Stylohyoid muscle

Auricular cartilage Internal carotid artery

Mastoid air cells

Facial nerve (VII)

Internal jugular vein

Medulla oblongata

Vagus nerve (X) Hypoglossal nerve (XII) Accessory nerve (XI)

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313

Pharynx: Median Section

Sella turcica

Frontal sinus

Pharyngeal opening of auditory (pharyngotympanic, eustachian) tube

Sphenoidal sinus

Sphenooccipital synchondrosis Pharyngeal tonsil

Nasal septum

Pharyngeal tubercle of occipital bone

Nasopharynx

Pharyngeal raphe

Soft palate

Anterior longitudinal ligament

Palatine glands

Anterior atlantooccipital membrane

Hard palate

Apical ligament of dens

Oral cavity Anterior arch of atlas (C1 vertebra)

Incisive canal Palatine tonsil Body of tongue

Dens of axis (C2 vertebra)

Oropharynx Foramen cecum

C1

C1

Lingual tonsil Genioglossus muscle

C2

Buccopharyngeal fascia

Root of tongue Epiglottis

C3

Retropharyngeal space

Mandible Geniohyoid muscle

Prevertebral fascia and anterior longitudinal ligament

C4

Mylohyoid muscle Hyoid bone Hyoepiglottic ligament

C5

Thyrohyoid membrane Laryngopharynx Laryngeal inlet (aditus)

C6

Thyroid cartilage Vocal fold Transverse arytenoid muscle

C7

Cricoid cartilage Trachea Esophagus Esophageal muscles Thyroid gland Superficial (investing) layer of deep cervical fascia Pretracheal fascia Suprasternal space (of Burns) Manubrium of sternum

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Pharyngeal constrictor muscles

T1

Muscles of Pharynx: Partially Opened Posterior View

Basilar part of occipital bone

Pharyngeal tubercle Pharyngeal tonsil Cartilaginous part of auditory (pharyngotympanic, eustachian) tube

Styloid process Digastric muscle (posterior belly)

Pharyngobasilar fascia Choana

Stylohyoid muscle

Levator veli palatini muscle

Stylopharyngeus muscle

Superior pharyngeal constrictor muscle

Accessory muscle bundle from petrous part of temporal bone (petropharyngeus muscle)

Palatopharyngeus muscle

Medial pterygoid muscle

Middle pharyngeal constrictor muscle

Salpingopharyngeus muscle Uvula

Root of tongue Stylopharyngeus muscle

Pharyngobasilar fascia Pharyngeal raphe Superior pharyngeal constrictor muscle Hyoid bone (tip of greater horn) Middle pharyngeal constrictor muscle Epiglottis Inferior pharyngeal constrictor muscle

Pharyngoepiglottic fold Aryepiglottic fold Inferior pharyngeal constrictor muscle Longitudinal pharyngeal muscles Superior horn of thyroid cartilage

Cuneiform tubercle

Thyrohyoid membrane

Corniculate tubercle

Internal branch of superior laryngeal nerve

Transverse and oblique arytenoid muscles Posterior cricoarytenoid muscle Cricopharyngeal muscle (part of inferior pharyngeal constrictor) Longitudinal esophageal muscle

Pharyngeal aponeurosis Cricopharyngeus muscle (part of inferior pharyngeal constrictor) Posterior border of thyroid cartilage lamina Cricoid attachment of longitudinal esophageal muscle Circular esophageal muscle

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315

Arteries of Oral and Pharyngeal Regions

From ophthalmic artery

Supraorbital artery Supratrochlear artery

Middle meningeal artery Deep temporal arteries Dorsal nasal artery Masseteric artery Angular artery

Occipital artery

Infraorbital artery Sphenopalatine artery

Auriculotemporal nerve

Descending palatine artery Posterior superior alveolar artery

Transverse facial artery (cut)

Superior labial artery

Superficial temporal artery

Buccal artery

Deep temporal and anterior tympanic arteries

Buccinator muscle and parotid duct (cut)

Maxillary artery

Inferior labial artery

Posterior auricular artery

Superior pharyngeal constrictor muscle

Ascending pharyngeal artery Occipital artery and sternocleidomastoid branch

Mental branch of inferior alveolar artery

Glossopharyngeal nerve (IX)

Inferior alveolar artery and lingual branch

Ascending palatine artery

Facial artery Submental artery Mylohyoid branch of inferior alveolar artery Submandibular gland Hypoglossal nerve (XII) Suprahyoid artery External carotid artery

Facial artery Lingual artery Ascending pharyngeal artery Internal carotid artery Vagus nerve (X) Superior cervical cardiac nerve Sympathetic trunk

Superior laryngeal artery

Anterior scalene muscle

Superior thyroid artery

Phrenic nerve

Cricothyroid artery Common carotid artery Subclavian artery

316

Tonsillar artery

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Middle scalene muscle Ascending cervical artery Inferior thyroid artery Thyrocervical trunk

Lymph Vessels and Nodes of Head and Neck

Superficial parotid nodes (deep parotid nodes deep to and within parotid gland)

Subparotid node Facial nodes Nasolabial Buccinator

Occipital nodes Mastoid nodes

Mandibular nodes

Sternocleidomastoid nodes

Submandibular nodes

Superior lateral superficial cervical (external jugular) node Accessory nerve (XI) Jugulodigastric node

Submental nodes

Posterior lateral superficial cervical (spinal accessory) nodes

Suprahyoid node Superior deep lateral cervical (internal jugular) nodes

Intercalated node Inferior deep lateral cervical (scalene) node

Superior thyroid nodes Juguloomohyoid node

Thoracic duct Anterior deep cervical (pretracheal and thyroid) nodes (deep to infrahyoid muscles)

Transverse cervical chain of nodes

Anterior superficial cervical nodes (anterior jugular nodes) Jugular trunk Supraclavicular nodes* Subclavian trunk and node

*The supraclavicular group of nodes (also known as the lower deep cervical group), especially on the left, are also sometimes referred to as the signal or sentinel lymph nodes of Virchow or Troisier, especially when sufficiently enlarged and palpable. These nodes (or a single node) are so termed because they may be the first recognized presumptive evidence of malignant disease in the viscera.

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317

Pathway of Sound Reception

Frontal section Limbs of stapes

Facial nerve (VII) (cut) Base of stapes in oval (vestibular) window

Prominence of lateral semicircular canal Incus Tegmen tympani

Vestibule Semicircular ducts, ampullae, utricle, and saccule Arcuate eminence Facial nerve (VII) (cut) Vestibular nerve

Malleus (head) Epitympanic recess

Cochlear nerve Auricle

Internal acoustic meatus Vestibulocochlear nerve (VIII)

External acoustic meatus Helicotrema

Parotid gland

Scala vestibuli

Tympanic membrane Tympanic cavity Promontory Round (cochlear) window Internal jugular vein Auditory (pharyngotympanic, eustachian) tube

318

Nasopharynx

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cochlear duct containing spiral organ (of Corti)

Cochlea

Scala tympani Note: Arrows indicate course of sound waves.

Skull, Skull Base, and Meninges Frontal view of 3D skull reformat

Frontal bone

Parietal bone

Supraorbital process

Glabella

Sphenoid bone, lesser wing Superior orbital

Temporal bone

Sphenoid bone, greater wing

Lacrimal bone Nasal bone

Nasal septum

Maxilla bone

Zygomatic bone

Inferior nasal concha bone

Anterior nasal spine Infraorbital foramen Lateral view of 3D skull reformat Coronal suture

Parietal bone

Frontal bone Squamosal suture

Lambdoidal suture Occipital bone

Sphenoid bone

Temporal bone

Nasal bone Maxilla bone

External auditory meatus

Anterior nasal spine Temporal process Zygomatic process of zygomatic of temporal bone

Mandible

Mastoid process

Inferior view of 3D skullbase Frontal bone Incisive fossa Palatine process Greater palatine foramen Nasal aperture Vomer bone Foramen spinosum Styloid process Carotid canal

Palatine bone Zygomatic bone Nasal aperture Foramen ovale Foramen lacerum Jugular fossa Mastoid process

Occipital condyle

Foramen magnum

External occipital crest

Parietal bone

External occipital protuberance

Occipital bone

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319

Skull, Skull Base, and Meninges (Continued) Posterior view of 3D skull reformat Parietal foramen Sagittal suture

Parietal bone

Lambda Lambdoid suture Occipital bone Superior nuchal line External occipital protuberance

Inferior nuchal line Mastoid process

Styloid process

Inferolateral cut view of inside of 3D skull reformat Parietal bone

Coronal suture Frontal bone Frontal sinus

Groove for sigmoid sinus

Nasal bone Frontal process of maxilla Vomer bone

Jugular foramen

Palatine process Sella turcica

Carotid canal

Occipital condyle

Foramen magnum

Superior view of cut 3D skull showing inside of skullbase Frontal sinus

Optic foramen Anterior clinoid process

Ethmoid bone

Anterior fossa

Foramen rotundum Foramen ovale Foramen lacerum

Middle clinoid process Sella turcica Middle fossa

Jugular foramen Foramen magnum

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Posterior fossa

Chapter

9

PARANASAL SINUSES 1 2 3 4 5 6 7 8

AXIAL 322

12 3

4 5

6 7 8

CORONAL 338 NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

321

Paranasal Sinuses Axial 1

Frontal sinus

Frontal bone

Orbital roof Sphenoid bone

Temporal bone



NORMAL ANATOMY The paranasal sinuses are composed of the frontal sinuses, the ethmoid sinuses or ethmoid air cells, the maxillary sinuses or maxillary antra, and the sphenoid sinuses. The names are derived from the bones that form the walls of the sinuses.

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Paranasal Sinuses Axial 1

Frontal sinus

Frontal bone

Orbital roof

Sphenoid bone

Temporal bone

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323

Paranasal Sinuses Axial 2

Frontal bone

Frontal sinus

Ethmoid bone

Crista galli of ethmoid bone

Zygomatic bone Anterior ethmoid air cell

Medial rectus m. Optic n. (CN II)

Greater wing of sphenoid bone

Lateral rectus m.

Sphenoid sinus Squamous portion of temporal bone

Superior orbital fissure



NORMAL ANATOMY The sphenoid sinuses are at the center of the skull base, immediately below the sella turcica (see Chapter 7). In ancient Egypt, mummification would involve driving a metal hook through the nasal passages and the sphenoid sinuses into the brain, which would be removed through the nostrils. This tract is used in modern days to pass a scope into the sella turcica to remove pituitary adenomas.

324

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Paranasal Sinuses Axial 2

Frontal bone Frontal sinus Ethmoid bone

Crista galli of ethmoid bone Medial rectus m.

Zygomatic bone Anterior ethmoid air cell

Optic n. (CN II) Lateral rectus m.

Greater wing of sphenoid bone Sphenoid sinus

Superior orbital fissure

Squamous portion of temporal bone

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325

Paranasal Sinuses Axial 3

Nasal bone Frontal process of maxilla Olfactory recess

Anterior ethmoid air cells Ethmoid bone Nasal septum Zygomatic bone

Sphenozygomatic suture Posterior ethmoid air cells

Greater wing of sphenoid bone

Inferior orbital fissure

Foramen rotundum, maxillary division (V2), trigeminal n. (CN V)

Sphenoid sinus

Mandibular condyle



DIAGNOSTIC CONSIDERATION In the setting of trauma, careful evaluation of CT bone windows is important to identify fractures, particularly around critical structures such as the carotid canal. On MRI, subtle bone fractures may not be directly visible; therefore, secondary signs, such as the presence of a hemorrhagic fluid level in the paranasal sinuses may be the only indication of traumatic injury.

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Paranasal Sinuses Axial 3

Nasal bone Frontal process of maxilla Olfactory recess

Anterior ethmoid air cells Ethmoid bone

Posterior ethmoid air cells

Nasal septum

Zygomatic bone Inferior orbital fissure Sphenozygomatic suture Greater wing of sphenoid bone Sphenoid sinus Foramen rotundum, maxillary division (V2), trigeminal n. (CN V) Mandibular condyle

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327

Paranasal Sinuses Axial 4

Nasal bone Nasal cavity Nasal septum Lamina papyracea of ethmoid bone

Anterior ethmoid air cell Posterior ethmoid air cell

Zygomatic bone

Maxillary bone

Inferior orbital fissure

Maxillary sinus Vomer bone Pterygopalatine fossa

Sphenoid sinus

Greater wing of sphenoid bone

Mandibular condyle Vidian canal

Sphenoid body

Carotid canal



DIAGNOSTIC CONSIDERATION Fracture of the lamina papyracea, the thin bone between the orbit and the ethmoid air cells (sinuses), can be subtle. Fat herniating into the ethmoid air cells is a sign of lamina papyracea fracture.

328

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Paranasal Sinuses Axial 4

Nasal bone Nasal cavity Nasal septum Lamina papyracea of ethmoid bone

Anterior ethmoid air cell Posterior ethmoid air cell

Zygomatic bone

Maxillary bone Maxillary sinus

Inferior orbital fissure

Vomer bone Pterygopalatine fossa

Sphenoid sinus

Greater wing of sphenoid bone

Sphenoid body

Mandibular condyle

Carotid canal

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329

Paranasal Sinuses Axial 5

Nasal bone

Lacrimal bone

Nasal septum

Nasolacrimal duct Maxillary bone

Perpendicular plate of ethmoid bone Concha bullosa Zygomatic bone

Maxillary sinus

Middle meatus Middle turbinate

Pterygopalatine fossa

Nasal cavity Pterygoid process of sphenoid bone

Vomer bone

Mandible



NORMAL ANATOMY The pterygopalatine fossa houses the second division of the fifth cranial nerve (CN V), the maxillary nerve (V2). The ganglion associated with V2 lying in this fossa is known as Meckel’s (pterygopalatine) ganglion, whereas the Gasserian (trigeminal) ganglion lies in Meckel’s cave. Loss of the fat surrounding the nerve and ganglion is seen in perineural infiltration by malignancy.

330

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Paranasal Sinuses Axial 5

Nasal bone

Lacrimal bone

Nasal septum

Nasolacrimal duct Maxillary bone

Zygomatic bone

Concha bullosa Perpendicular plate of ethmoid bone Maxillary sinus

Middle meatus Middle turbinate Pterygopalatine fossa

Pterygoid process of sphenoid bone

Nasal cavity Vomer bone

Mandible

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331

Paranasal Sinuses Axial 6

Nasal septum Nasal cavity

Maxillary bone

Maxillary bone Nasolacrimal duct Infraorbital canal

Nasolacrimal duct opening into inferior meatus Vomer bone

Maxillary sinus Zygomatic bone

Mandible (coronoid process) Lateral pterygoid plate

Inferior turbinate

Medial pterygoid plate

Posterior nasal choana

Opening of eustachian tube

Mandible (ramus)

Torus tubarius Fossa of Rosenmüller Mandible (neck)

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Nasopharynx

Paranasal Sinuses Axial 6

Nasal septum Nasal cavity Infraorbital canal Maxillary bone Vomer bone

Nasolacrimal duct opening into inferior meatus Maxillary sinus Zygomatic bone

Mandible (coronoid process) Lateral pterygoid plate Medial pterygoid plate Opening of eustachian tube Torus tubarius Fossa of Rosenmüller

Inferior turbinate Posterior nasal choana Mandible (ramus) Nasopharynx

Mandible (neck)

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333

Paranasal Sinuses Axial 7

Nasal cavity

Nasal septum

Vomer bone

Inferior meatus

Inferior turbinate Maxillary bone Maxillary sinus Palatine bone Pterygoid process of sphenoid bone Inferior alveolar canal Mandible (ramus) Nasopharynx

334

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Paranasal Sinuses Axial 7

Nasal septum Nasal cavity

Vomer bone Maxillary bone

Inferior meatus Inferior turbinate

Maxillary sinus Palantine bone Pterygoid process of sphenoid bone Mandible (ramus)

Inferior alveolar canal

Nasopharynx

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335

Paranasal Sinuses Axial 8

Nasal septum

Nares

Vomer bone

Maxillary bone Hard palate

Soft palate

Maxillary molar alveolar roots

Mandible (ramus) Oropharynx



NORMAL ANATOMY Note that no true boundary exists between the nasopharynx and the oropharynx on axial images. The teeth can provide a helpful anatomic landmark. When the teeth are clearly in view, the lumen is likely that of the oropharynx. On this image, where the alveolar roots of the maxillary molar teeth are visible, along with part of the hard palate and much of the soft palate, the lumen in view is likely junctional between the nasopharynx and the oropharynx.

336

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Paranasal Sinuses Axial 8

Nasal septum Nares

Vomer bone

Maxillary bone

Hard palate

Soft palate

Mandible (ramus)

Oropharynx

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

337

Paranasal Sinuses Coronal 1

Frontal bone Frontal sinus

Nasal bone Perpendicular plate of ethmoid bone

Maxillary bone Nasal septum

Nasal cavity



NORMAL ANATOMY The frontal bone above the level of the sinuses is extremely hard. More inferiorly, however, where the frontal sinuses are located, the walls can be relatively thin.

338

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Paranasal Sinuses Coronal 1

Frontal bone Frontal sinus

Nasal bone Perpendicular plate of ethmoid bone Maxillary bone

Nasal septum

Nasal cavity

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339

Paranasal Sinuses Coronal 2

Frontal bone

Frontal sinus Crista galli of ethmoid bone Lamina papyracea of ethmoid bone

Perpendicular plate of ethmoid bone

Ethmoid bulla

Maxillary bone Nasal septum Nasal cavity

Inferior turbinate

Vomer bone



SURGICAL CONSIDERATION Functional endoscopic sinus surgery can be performed to open the nasal passages when the nasal septum is significantly deviated to one side.

340

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Paranasal Sinuses Coronal 2

Frontal bone

Crista galli of ethmoid bone Frontal sinus

Lamina papyracea of ethmoid bone Ethmoid bulla

Nasal septum

Nasal cavity

Perpendicular plate of ethmoid sinus

Maxillary bone

Inferior turbinate

Vomer bone

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

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Paranasal Sinuses Coronal 3

Frontal bone

Crista galli of ethmoid bone

Posterior ethmoid air cell

Concha bullosa

Ethmoid bone Zygomatic bone

Anterior ethmoid air cell

Concha bullosa

Osteomeatal unit

Infraorbital canal

Middle meatus Middle turbinate Maxillary sinus Inferior meatus

Nasal cavity

Inferior turbinate

Vomer bone

Maxillary bone



NORMAL ANATOMY The Coronal 3 view gives the best visualization of the osteomeatal unit. The osteomeatal complex is part of the middle meatus, which drains the frontal and maxillary sinuses and the anterior two thirds of the ethmoid air cells. When the osteomeatal unit is obstructed, these sinuses become inflamed and opacified with mucosal thickening and fluid.

342

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Paranasal Sinuses Coronal 3

Frontal bone Crista galli of ethmoid bone

Posterior ethmoid air cell

Anterior ethmoid air cell

Ethmoid bone

Osteomeatal unit

Zygomatic bone

Middle meatus

Infraorbital canal

Maxillary sinus

Middle turbinate

Inferior turbinate Inferior meatus

Nasal cavity Vomer bone

Maxillary bone

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

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Paranasal Sinuses Coronal 4

Frontal bone Olfactory groove

Ethmoid bone

Crista galli of ethmoid bone

Ethmoid air cells

Sphenoethmoid recess

Infraorbital canal

Zygomatic bone

Perpendicular plate of ethmoid bone

Middle meatus

Middle turbinate

Inferior meatus

Maxillary sinus Maxillary bone

Inferior turbinate

Vomer bone



NORMAL ANATOMY Note the paired olfactory grooves housing the olfactory nerves (cranial nerve I). An asymmetrically low olfactory groove can be important to note in patients who will undergo endoscopic sinus surgery.

344

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Paranasal Sinuses Coronal 4

Frontal bone Olfactory groove Ethmoid bone Ethmoid air cells

Infraorbital canal Middle turbinate Perpendicular plate of ethmoid bone Maxillary bone Maxillary sinus Vomer bone

Crista galli of ethmoid bone Sphenoethmoid recess

Middle meatus Zygomatic bone

Inferior meatus Inferior turbinate

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Paranasal Sinuses Coronal 5

Parietal bone Greater wing of sphenoid bone Ethmoid bone

Frontal bone Posterior ethmoid air cell

Sphenoethmoid recess

Superior turbinate Superior meatus Middle turbinate

Perpendicular plate of ethmoid bone

Middle meatus

Zygomatic bone

Inferior meatus Inferior turbinate

Maxillary sinus

Vomer bone Palatine bone Maxillary bone



PATHOLOGIC PROCESS The alveolar roots of the maxillary teeth are just underneath the maxillary sinuses. Inflammation or opacification within the inferior maxillary sinuses may be caused by periodontal disease.

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Paranasal Sinuses Coronal 5

Parietal bone Ethmoid bone Greater wing of sphenoid bone Frontal bone Posterior ethmoid air cell Perpendicular plate of ethmoid bone Superior meatus Middle meatus Zygomatic bone

Sphenoethmoid recess Superior turbinate Middle turbinate Middle meatus Inferior meatus Inferior turbinate

Maxillary sinus

Vomer bone Palatine bone Maxillary bone

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Paranasal Sinuses Coronal 6

Anterior clinoid process of sphenoid bone Optic canal

Squamous portion of temporal bone

Foramen rotundum, maxillary division (V2), trigeminal n. (CN V)

Sphenosquamosal suture

Greater wing of sphenoid bone Pterygopalatine fossa Nasal septum Mandible

Vomer bone Middle meatus Inferior turbinate

Inferior meatus

Pterygoid process of sphenoid bone

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Paranasal Sinuses Coronal 6

Anterior clinoid process of sphenoid bone Optic canal Foramen rotundum, maxillary division (V2), trigeminal n. (CN V) Greater wing of sphenoid Pterygopalantine fossa Nasal septum Mandible

Squamous portion of temporal bone Sphenosquamosal suture Vomer bone Middle meatus Inferior turbinate Inferior meatus

Pterygoid process of sphenoid bone

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Paranasal Sinuses Coronal 7

Sphenoid sinus Squamous portion of temporal bone

Vidian n. in canal

Sphenosquamosal suture

Greater wing of sphenoid bone

Vomer bone

Nasopharynx Medial pterygoid plate Lateral pterygoid plate Mandible



NORMAL ANATOMY Note that the vidian nerve may often protrude into the sphenoid sinuses, resembling a stalk on coronal images.

350

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Paranasal Sinuses Coronal 7

Sphenoid sinus Vidian n. in canal

Sphenosquamosal suture

Greater wing of sphenoid

Squamous portion of temporal bone

Medial pterygoid plate

Vomer bone

Nasopharynx Lateral pterygoid plate Mandible

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

351

Paranasal Sinuses Coronal 8

Squamous portion of temporal bone Sphenosquamosal suture Greater wing of sphenoid bone

Nasopharynx

Mandible

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NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Vidian/pterygoid canal

Foramen ovale

Paranasal Sinuses Coronal 8

Squamous portion of temporal lobe Sphenosquamosal suture

Vidian/pterygoid canal

Foramen ovale

Greater wing of sphenoid Nasopharynx Mandible

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

353

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10 ORBITS

Chapter

6 5 4 3 2 1

AXIAL 356

1

2 3 4 56

CORONAL 368 NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

355

Orbits Axial 1

Inferior rectus m.

Zygomatic arch Maxillary sinus Sphenoid sinus Anterior slope of middle cranial fossa L. internal carotid a. (precavernous segment) Temporal lobe Basilar a.

356

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Orbits Axial 1

Inferior rectus m.

Zygomatic arch

Maxillary sinus Anterior slope of middle cranial fossa Sphenoid sinus L. internal carotid a. (precavernous segment) Basilar a.

Temporal lobe

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

357

Orbits Axial 2

Nasolacrimal canal

Ciliary body Sclera Retina and choroid Vitreous body

Retrobulbar orbital fat Inferior rectus m.

Sphenoid sinus L. internal carotid a. (precavernous segment) Basilar a. Temporal lobe

358

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Orbits Axial 2

Nasolacrimal canal

Ciliary body Sclera Retrobulbar orbital fat

Vitreous humor Retina and choroid

Inferior rectus m.

Sphenoid sinus

Internal carotid a. (precavernous segment)

Basilar a.

Temporal lobe

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

359

Orbits Axial 3

Nasolacrimal canal Cornea Anterior chamber Ciliary body

Lens

Sclera Lacrimal gland Vitreous body Lateral rectus m.

Retina and choroid

Medial rectus m. Inferior rectus m. Sphenoid sinus Internal carotid a. (precavernous segment) Basilar a.



NORMAL ANATOMY The lenses are normally biconvex in shape. If this configuration is replaced by a thin line, the patient likely has had the lens removed because of cataracts and replaced with an artificial lens.

360

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Orbits Axial 3

Nasolacrimal canal Cornea Anterior chamber

Ciliary body

Lens

Sclera Lacrimal gland Vitreous body Retina and choroid

Lateral rectus m. Medial rectus m. Inferior rectus m. Sphenoid sinus Internal carotid a. (precavernous segment) Basilar a.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

361

Orbits Axial 4

Cornea Ciliary body Sclera Vitreous body Retina and choroid

Anterior chamber Lens

Lacrimal gland Optic n. (CN II) Lateral rectus m. Medial rectus m.

Optic n. (CN II) Ophthalmic a.

Temporal lobe Temporal horn of lateral ventricle

362

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Internal carotid a. Infundibulum Basilar a.

Orbits Axial 4

Cornea Anterior chamber

Ciliary body

Lens

Sclera Retina and choroid

Lacrimal gland

Vitreous body

Optic n. (CN II)

R. superior ophthalmic vv. and branches

Lateral rectus m.

R. inferior ophthalmic vv. and branches

Medial rectus m.

R. ophthalmic a.

Prechiasmatic optic n. (CN II) Internal carotid a. Infundibulum Basilar a.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

363

Orbits Axial 5

Top of globe Superior oblique m.

Trochlear sling for superior oblique m.

Lacrimal gland

R. superior ophthalmic v. and branches

Superior rectus m.

R. ophthalmic a. Levator palpebrae superioris m. Frontal lobe L. middle cerebral a. branches Optic tract

Temporal lobe

Mammillary body



PATHOLOGIC PROCESS Note the thin superior ophthalmic vein (SOV). Dilatation should lead to consideration of increased pressure within the cavernous sinus, as in carotid cavernous fistula (CCF) following trauma. Early, asymmetric filling of the cavernous sinus in the arterial phase confirms the diagnosis of CCF (see also Orbits Coronal 1).

364

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Orbits Axial 5

Superior oblique m. Trochlear sling for superior oblique m. R. superior ophthalmic vv. and branches R. ophthalmic a.

Frontal lobe

Lacrimal gland

Superior rectus m. Levator palpebrae superioris m.

L. middle cerebral a. branches Optic tract

Temporal lobe

Mammillary body

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

365

Orbits Axial 6

Superior rectus m. Lacrimal gland

R. ophthalmic a.

Levator palpebrae superioris m. Frontal lobe

Temporal lobe

Middle cerebral a. branch

Sylvian fissure



Anterior cerebral a.

NORMAL ANATOMY The lacrimal gland is located in the upper outer aspect of the orbit. It produces tears, which coat the eye in a superolateral to inferomedial direction, eventually being drained through the two lacrimal puncta leading to the canaliculi and then the nasolacrimal duct.

366

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Orbits Axial 6

Superior rectus m. Lacrimal gland

R. ophthalmic a.

Frontal lobe

Levator palpebrae superioris m.

Middle cerebral a. branch

Temporal lobe Sylvian fissure

Anterior cerebral a.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

367

Orbits Coronal 1

Levator palpebrae superioris m. Superior rectus m.

L. ophthlamic a. branch

L. superior ophthlamic v.

Superior oblique m.

L. superior ophthlamic v. branch

L. ophthlamic a.

Optic n. (CN II)

Medial rectus m.

Lateral rectus m.

Inferior rectus m.



NORMAL ANATOMY The optic nerve, cranial nerve (CN) II, is the only cranial nerve that is part of the central nervous system in that, like the brain and spinal cord, it has no ability to regenerate, unlike peripheral nerves. CN II is a direct extension of the brain and is surrounded by cerebrospinal fluid (CSF) and dura.



PATHOLOGIC PROCESS If the normally thin and flat superior ophthalmic vein (SOV) is dilated, rounded, and tortuous, increased pressure within the cavernous sinus should be suspected, as with post-trauma carotidcavernous fistula (CCF; see also Axial 5).

IMAGING TECHNIQUE CONSIDERATION Note that in the bottom MR image of Coronal 1, the white matter is brighter than the gray matter; thus this sequence must be T1 weighted (think of “fatty” myelin being bright on T1). The subcutaneous fat is dark, so this must be a fat-saturated sequence, and the vessels and mucosa are both bright, so contrast has been administered.

368

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Orbits Coronal 1

Levator palpebrae superioris m. L. ophthalmic a. branches

Superior rectus m. L. superior ophthalmic v.

Superior oblique m.

L. ophthalmic a.

L. superior ophthalmic v. branches

Medial rectus m.

Optic n. (CN II) Lateral rectus m.

Inferior rectus m.

L. ophthalmic a. branches Superior oblique m.

Levator palpebrae superioris m. Superior rectus m. L. superior ophthalmic v. branches

L. ophthalmic a.

Medial rectus m.

L. superior ophthalmic v. Optic n. (CN II) Lateral rectus m.

Inferior rectus m.

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369

Orbits Coronal 2

Levator palpebrae superioris m. Superior rectus m. L. superior ophthlamic v.

Superior oblique m. L. ophthlamic a. branch

L. superior ophthlamic v. branch

L. ophthlamic a.

Optic n. (CN II) Medial rectus m.

Lateral rectus m.

Inferior rectus m.



NORMAL ANATOMY There are five intraorbital muscles that contribute to the annulus of Zinn (the inferior oblique muscle does not). The superior oblique muscle is supplied by the trochlear nerve (CN IV) and causes the eye to point downward and medially toward the tip of the nose. The lateral rectus muscle is supplied by the abucens nerve (CN VI) and points the eye medially. The oculomotor nerve (CN III) supplies the inferior rectus, medial rectus, superior rectus, levator palpebrae superioris, and inferior oblique muscles. When there is diplopia with unilateral palsy of CN III causing the eye to point “down and out,” the clinician must consider aneurysm of the posterior communicating artery compressing the oculomotor nerve.

370

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Orbits Coronal 2

Levator palpebrae superioris m. L. superior rectus m. Superior oblique m.

L. superior ophthalmic v.

L. ophthalmic a. branches

L. superior ophthalmic v. branches

L. ophthalmic a.

Optic n. (CN II)

Medial rectus m.

Lateral rectus m. Inferior rectus m.

L. ophthalmic a. branches

Superior oblique m.

Levator palpebrae superioris m. Superior rectus m. L. superior ophthalmic v.

L. ophthalmic a.

Medial rectus m.

L. superior ophthalmic v. branches Optic n. (CN II) Lateral rectus m.

Inferior rectus m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

371

Orbits Coronal 3

Superior rectus m. L. superior ophthalmic v. Superior oblique m.

Medial rectus m.

L. superior ophthalmic v. branch L. ophthalmic a. branch Optic n. (CN II)

L. ophthalmic a.

Lateral rectus m. Inferior rectus m.

372

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Orbits Coronal 3

Superior rectus m. L. superior ophthalmic v. Superior oblique m. L. superior ophthalmic v. branches L. ophthalmic a. branches Optic n. (CN II) Medial rectus m.

Lateral rectus m.

L. ophthalmic a.

Inferior rectus m.

Superior rectus m. Superior oblique m.

L. superior ophthalmic v.

L. superior ophthalmic v. branches L. ophthalmic a. branches Medial rectus m.

Optic n. (CN II) Lateral rectus m.

L. ophthalmic a. Inferior rectus m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

373

Orbits Coronal 4

Common tendon of Lockwood Optic n. (CN II)

L. superior ophthalmic v. L. ophthalmic a.

Common tendon of Zinn, inferior/medial rectus tendons

374

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Orbits Coronal 4

Common tendon of Lockwood Optic n. (CN II) L. superior ophthalmic v. Common tendon of Zinn, inferior/medial rectus tendons

L. ophthalmic a.

Common tendon of Lockwood Optic n. (CN II) L. superior ophthalmic v. Common tendon of Zinn, inferior/medial rectus tendons

L. ophthalmic a.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

375

Orbits Coronal 5

Callosal a.

L. anterior cerebral a.

L. middle cerebral a. Optic canal containing optic n.

Anterior clinoid process Optic strut

Sphenoid sinus Foramen rotundum

Vidian n. in vidian canal Nasopharyngeal lumen



NORMAL ANATOMY The optic strut is a precise landmark between intradural and extradural/intracavernous aneurysms involving the paraclinoid segment of the internal carotid artery.

376

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Orbits Coronal 5

Callosal a. L. anterior cerebral a. L. middle cerebral a. Anterior clinoid process Optic canal containing optic n. Optic strut Sphenoid sinus

Foramen rotundum

Nasopharyngeal lumen

Vidian n. in vidian canal

Callosal a. L. anterior cerebral a.

L. middle cerebral a.

Optic canal containing optic n.

Anterior clinoid process

Optic strut

Sphenoid sinus Foramen rotundum Nasopharyngeal lumen

Vidian n. in vidian canal

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377

Orbits Coronal 6

L. anterior cerebral a. Middle cerebral a. Prechiasmatic optic n. (CN II)

Anterior clinoid process L. internal carotid a. (supraclinoid segment)

Sphenoid sinus

Oculomotor n. (CN III) L. internal carotid a. (cavernous segment) Ophthalmic division (V1), trigeminal n. (CN V)

Nasopharyngeal lumen

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NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Mandibular condyle

Orbits Coronal 6

L. anterior cerebral a.

Prechiasmatic optic n. (CN II)

L. middle cerebral a. Anterior clinoid process

L. internal carotid a. (cavernous segment) Sphenoid sinus

L. internal carotid a. (supraclinoid segment) Oculomotor n. (CN III) Ophthalmic division (V1), trigeminal n. (CN V)

Nasopharyngeal lumen

Mandibular condyle

L. anterior cerebral a.

Prechiasmatic optic n. (CN II)

L. middle cerebral a. Anterior clinoid process

L. internal carotid a. (cavernous segment)

L. internal carotid a. (supraclinoid segment) Oculomotor n. (CN III) Ophthalmic division (V1), trigeminal n. (CN V)

Mandibular condyle NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

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11

MANDIBLE AND ­MUSCLES OF MASTICATION

Chapter

1 2 3 4

AXIAL 382

1

2

3

4

CORONAL 390 NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

381

Mandible and Muscles of Mastication Axial 1

Orbicularis oculi m.

Medial rectus m. Optic n. (CN II)

Greater wing of sphenoid bone

Lateral rectus m.

R. supraclinoid internal carotid a.

L. middle cerebral a.

Basilar a. Temporalis m. Temporal lobe Midbrain Cerebral aqueduct Superior vermis



NORMAL ANATOMY Four paired muscles—temporalis, masseter, medial pterygoid, and lateral pterygoid—are the primary muscles of mastication, responsible for adduction and lateral motion. In the axial MR image on the next page, note the temporalis muscle superficial to the temporal lobe of the brain. These muscles are innervated by the mandibular branch (V3) of the trigeminal nerve, cranial nerve (CN) V (see Axial 2). The lateral pterygoid helps open the mouth, and the medial pterygoid helps close the mouth (“lateral lowers and medial munches”).

382

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Mandible and Muscles of Mastication Axial 1

Orbicularis oculi m. Medial rectus m. Greater wing of sphenoid bone

Optic n. (CN II)

Lateral rectus m. R. supraclinoid internal carotid a. L. middle cerebral a. Temporalis m.

Temporal lobe Basilar a. Midbrain

Cerebral aqueduct Superior vermis

Orbicularis oculi m. Medial rectus m. Greater wing of sphenoid bone R. supraclinoid internal carotid a.

Optic n. (CN II)

Lateral rectus m.

L. middle cerebral a. Temporalis m. Temporal lobe Basilar a. Midbrain Cerebral aqueduct

Superior vermis NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

383

Mandible and Muscles of Mastication Axial 2

Levator labii superioris alaeque nasi m.

Infraorbital n.

Levator labii superioris m. Maxillary sinus Zygomaticus major m. Inferior turbinate Masseter m.

Mandible (coronoid process)

Temporalis m.

Pterygopalatine fossa Vomer

Lateral pterygoid m.

Sphenoid bone

Medial pterygoid m. Clivus

CN V (V3) in foramen ovale

Lymph nodes, superior parotid gland

Middle meningeal artery in foramen spinosum

Basilar a.

L. internal carotid a. (petrous segment)

External auditory canal



NORMAL ANATOMY Note that from superficial to deep, the muscles are zygomaticus major, masseter, temporalis, and lateral pterygoid. The medial pterygoid muscle is located deeper and more caudal.



PATHOLOGIC PROCESS Denervation of the V3 branch of the trigeminal nerve can lead to atrophy of the ipsilateral muscles of mastication.

384

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Mandible and Muscles of Mastication Axial 2

Levator labii superioris alaeque nasi m. Levator labii superioris m. Infraorbital n.

Maxillary sinus Inferior turbinate

Zygomaticus major m. Masseter m. Temporalis m.

Vomer Mandible (coronoid process)

Lateral pterygoid m. Medial pterygoid m. Clivus Lymph nodes, superior parotid gland Basilar a. External auditory canal

Sphenoid bone CN V (V3) in foramen ovale Middle meningeal a. in foramen spinosum L. internal carotid a. (petrous segment)

Levator labii superioris alaeque nasi m. Infraorbital n.

Levator labii superioris m. Maxillary sinus Inferior turbinate

Zygomaticus major m. Masseter m. Temporalis m.

Vomer Mandible (coronoid process)

Lateral pterygoid m.

Pterygopalatine fossa

Medial pterygoid m.

Sphenoid bone

Clivus Lymph nodes, superior parotid gland Basilar a.

CN V (V3) in foramen ovale Middle meningeal a. in foramen spinosum L. internal carotid a. (petrous segment)

External auditory canal

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

385

Mandible and Muscles of Mastication Axial 3

Levator labii superioris m.

Zygomaticus minor m.

Maxillary sinus

Zygomaticus major m.

Temporalis m.

Masseter m.

Lateral pterygoid m. Tensor veli palatini m. Levator veli palatini m. Mandibular condyle R. internal carotid a.

386

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Longus capitis m.

Parotid gland

L. vertebral a.

Mandible and Muscles of Mastication Axial 3

Levator labii superioris m.

Maxillary sinus Zygomaticus minor m. Zygomaticus major m.

Temporalis m. Lateral pterygoid m. Tensor veli palatini m. Levator veli palatini m.

Masseter m.

Longus capitis m. Parotid gland

Mandible condyle Internal carotid a.

L. vertebral a.

Levator labii superioris m.

Zygomaticus minor m.

Maxillary sinus

Zygomaticus major m.

Temporalis m.

Masseter m.

Lateral pterygoid m. Tensor veli palatini m.

Longus capitis m.

Levator veli palatini m. Mandible condyle Internal carotid a.

Parotid gland

L. vertebral a.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

387

Mandible and Muscles of Mastication Axial 4

Medial incisor Lateral incisor 7

8

6 5

Buccinator m.

4 3

Parotid duct 2

Facial v. 1

9

Canine 10 11

1st premolar (bicuspid) 12 13 14 15 16

2nd premolar (bicuspid) 1st molar 2nd molar 3rd molar (wisdom tooth) Masseter m. Medial pterygoid m.

Oropharynx

Mandible Parapharyngeal space

Internal carotid a.

Superior pharyngeal constrictor m.

Internal jugular v.

Parotid gland

Digastric m. (posterior belly)

NOMENCLATURE The two most common dental notation systems are the International Dental Association (Fédération Dentaire Internationale, FDI) notation and the Universal numbering system (dental). The FDI system uses a two-digit numbering system in which the first number represents a tooth’s quadrant and the second number represents the number of the tooth from the midline of the face. For permanent teeth, the upper-right teeth begin with 1, the upper-left teeth with 2, the lower-left teeth with 3, and the lower-right teeth with 4. For primary teeth the sequence of numbers is 5, 6, 7, and 8 for the teeth in the upper right, upper left, lower left, and lower right, respectively. The Universal number system (dental) is used in the United States and begins labeling at the upper-right maxillary wisdom tooth as 1 and continues clockwise (see Axial 4), when viewing the open mouth from a dentist’s perspective, up to 32 at the right mandibular wisdom tooth.

388

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Mandible and Muscles of Mastication Axial 4

Medial incisor Lateral incisor Buccinator m. Parotid duct Facial v.

Canine 1st premolar (bicuspid) 2nd premolar (bicuspid) 1st molar 2nd molar 3rd molar (wisdom tooth)

Mandible

Mandible Masseter m. Medial pterygoid m.

Oropharynx Internal carotid a. Internal jugular v. Digastric m. (posterior belly)

Parapharyngeal space Superior pharyngeal constrictor m. Parotid gland

Medial incisor Lateral incisor Buccinator m.

Canine 1st premolar (bicuspid)

Parotid duct

2nd premolar (bicuspid) 1st molar

Facial v.

2nd molar 3rd molar (wisdom tooth)

Mandible

Mandible Masseter m.

Oropharynx

Medial pterygoid m. Parapharyngeal space

Internal carotid a. Internal jugular v. Digastric m. (posterior belly)

Superior pharyngeal constrictor Parotid gland

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

389

Mandible and Muscles of Mastication Coronal 1

Temporalis m. Superior m. complex (superior rectus m. and levator palpebrae superior m.)

Superior oblique m.

Medial rectus m.

Optic n. (CN II)

Lateral rectus m. Inferior rectus m. Infraorbital canal

Zygomatic process of temporal bone

Zygomaticus major m.

Orbicularis oris m.

Buccinator m.

Depressor anguli oris m.

Inferior alveolar n.



PATHOLOGIC PROCESS The inferior alveolar nerves course through the mandible in the inferior alveolar canals, exiting superficially at the mental foramina. Squamous cell carcinoma of the mandible can invade the mandible and track perineurally along the inferior alveolar nerve, back to the V3 branch of the trigeminal nerve and Meckel’s cave.

390

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Mandible and Muscles of Mastication Coronal 1

Temporalis m.

Superior oblique m. Optic n. (CN II)

Superior m. complex (superior rectus m. and levator palpebrae superior m.) Medial rectus m. Lateral rectus m. Inferior rectus m.

Zygomatic process of temporal bone Zygomaticus major m.

Infraorbital canal

Orbicularis oris m. Buccinator m. Depressor anguli oris m. Inferior alveolar n.

Temporalis m.

Superior m. complex (superior rectus m. and levator palpebrae superior m.) Medial rectus m.

Superior oblique m.

Lateral rectus m.

Optic n. (CN II)

Inferior rectus m. Infraorbital canal

Zygomatic process of temporal bone Zygomaticus major m.

Orbicularis oris m. Buccinator m. Depressor anguli oris m. Inferior alveolar n.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

391

Mandible and Muscles of Mastication Coronal 2

Temporalis m.

Vidian canal Sphenoid sinus Zygoma

Lateral pterygoid m.

Nasopharynx Medial pterygoid m. Soft palate

Dorsum of tongue

Masseter m. Styloglossus m. Genioglossus m. Hyoglossus m. Inferior alveolar n. Submandibular gland

Mylohyoid m.

Geniohyoid m.

Platysma m. Digastic m. (anterior belly)



NORMAL ANATOMY The temporalis muscle has a broad origin from the outer temporal fossa, passes deep to the zygomatic arch, and inserts onto the coronoid process of the mandible to pull back and elevate the mandible. The temporalis muscle can be felt at the temples and can be seen and felt contracting as a person bites down.

392

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Mandible and Muscles of Mastication Coronal 2

Temporalis m.

Sphenoid sinus Zygoma Nasopharynx

Dorsum of tongue

Vidian canal Lateral pterygoid m. Medial pterygoid m. Masseter m. Soft palate

Styloglossus m.

Genioglossus m.

Hyoglossus m.

Inferior alveolar n.

Mylohyoid m.

Geniohyoid m.

Platysma m.

Submandibular gland

Digastric m. (anterior belly)

Temporalis m.

Vidian canal

Sphenoid sinus Zygoma

Lateral pterygoid m. Medial pterygoid m.

Nasopharynx

Dorsum of tongue

Masseter m. Soft palate Genioglossus m.

Styloglossus m.

Inferior alveolar n.

Hyoglossus m.

Geniohyoid m.

Mylohyoid m.

Submandibular gland

Platysma m. Digastric m. (anterior belly) NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

393

Mandible and Muscles of Mastication Coronal 3

Temporalis m.

Torus tubarius Adenoids Fossa of Rosenmüller

Lateral pterygoid m. Nasopharynx

Tensor veli palatini m.

Parapharyngeal space

Eustachian tube opening Levator veli palatini m.

Mandibular ramus

Soft palate

Medial pterygoid m.

Masseter m. Intrinsic tongue mm. Genioglossus m.

Hyoglossus m. Mylohyoid m.

Submandibular gland

Geniohyoid m. Digastic m. (anterior belly) Platysma m.



NORMAL ANATOMY The medial and lateral pterygoid muscles originate from the respective medial and lateral pterygoid bone plates and pass inferiorly and laterally to insert on the inner mandible.

394

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Mandible and Muscles of Mastication Coronal 3

Temporalis m. Torus tubarius

Adenoids Fossa of Rosenmüller

Lateral pterygoid m. Nasopharynx Medial pterygoid m. Parapharyngeal space Mandibular ramus Intrinsic tongue mm. Hyoglossus m. Mylohyoid m.

Tensor veli palatini m. Eustachian tube opening Masseter m. Levator veli palatini m. Soft palate Genioglossus m. Submandibular gland

Geniohyoid m. Platysma m.

Digastric m. (anterior belly)

Temporalis m. Adenoids Torus tubarius Fossa of Rosenmüller Lateral pterygoid m.

Tensor veli palatini m.

Nasopharynx Parapharyngeal space Medial pterygoid m. Mandibular ramus Intrinsic tongue mm. Hyoglossus m. Mylohyoid m.

Eustachian tube opening Masseter m. Levator veli palatini m. Soft palate Genioglossus m. Submandibular gland

Geniohyoid m. Platysma m.

Digastric m. (anterior belly)

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

395

Mandible and Muscles of Mastication Coronal 4

Basilar a. Temporomandibular joint L. internal carotid a. (petrous segment) Lateral pterygoid m. Longus capitis m. Levator veli palatini m.

Parotid gland Medial pterygoid m.

Nasopharynx

Masseter m.

Soft palate Oropharynx

Lingual tonsil Superior pharyngeal constrictor m. Mylohyoid m.

Submandibular gland Digastic m. (anterior belly)

Platysma m. Omohyoid m.

Hyoid bone

IMAGING TECHNIQUE CONSIDERATION The temporomandibular joint (TMJ) is formed by two bones, the condyle of the mandible and the glenoid fossa of the temporal bone. The space between these bones contains an articular disc. The TMJ is one of the few synovial joints in the human body with a disc. MR images of different jaw positions can show whether the disc is torn or fails to recapture into normal position between the bones.

396

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Mandible and Muscles of Mastication Coronal 4

Basilar a. Temporomandibular joint Lateral pterygoid m. Parotid gland Medial pterygoid m. Masseter m. Lingual tonsil

L. internal carotid a. (petrous segment) Longus capitis m. Levator veli palatini m. Nasopharynx Soft palate Superior pharyngeal constrictor m. Oropharynx

Mylohyoid m. Submandibular gland Platysma m. Omohyoid m.

Digastic m. (anterior belly) Hyoid bone

Basilar a.

Temporomandibular joint

L. internal carotid a. (petrous segment) Longus capitis m.

Lateral pterygoid m. Parotid gland Medial pterygoid m. Masseter m. Lingual tonsil Mylohyoid m.

Levator veli palatini m. Nasopharynx Soft palate Oropharynx Superior pharyngeal constrictor m. Submandibular gland

Platysma m. Omohyoid m.

Digastic m. (anterior belly) Hyoid bone NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

397

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12

Chapter

TEMPORAL BONE (MIDDLE EAR, COCHLEA, VESTIBULAR SYSTEM)

1 3 5

AXIAL 400

2 4 6

1

2

3 4

CORONAL 412

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

399

Temporal Bone Axial 1

Internal carotid a.

Internal auditory canal

Superior semicircular canal Posterior semicircular canal Mastoid antrum

Sigmoid sinus



NORMAL ANATOMY The temporal bone initially may seem a daunting area for magnetic resonance imaging because of the apparent structural complexity. To understand the temporal region better, trace the hearing pathway from auricle through external auditory canal, to tympanic membrane attached to small bones (ossicles; malleus, incus, and stapes) in the middle ear cavity, through stapes stirrup on oval window, then vestibule to cochlea to inner auditory canal (IAC). The vestibulocochlear nerve (cranial nerve [CN] VIII) also provides balance with superior and inferior vestibular branches in the IAC, leading to the semicircular canals. Finally, the nearby facial nerve (CN VII) provides motor innervation to the face. These nerves can be tracked easily on computed tomography (CT) by the corresponding bony canals, although the nerves themselves are best seen on MRI (see also Chapter 5).

400

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Temporal Bone Axial 1

Internal carotid a.

Internal auditory canal

Superior semicircular canal

Posterior semicircular canal

Mastoid antrum

Sigmoid sinus

Meckel’s cave

Geniculate ganglion

Lateral semicircular canal Posterior semicircular canal

Internal auditory canal

Porus acousticus Vestibule

Fourth ventricle

Loop of sigmoid sinus

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

401

Temporal Bone Axial 2

Internal carotid a. Facial n. (CN VII), labyrinthine segment Apical turn of cochlea Epitympanum Middle turn of cochlea Aditus ad antrum

Internal auditory canal Vestibule

Mastoid antrum Vestibular aqueduct Posterior semicircular canal Sigmoid sinus Emissary v.



PATHOLOGIC PROCESS Note the fan-shaped appearance of the labyrinthine segment of the facial nerve connecting the intracanalicular segment with the geniculate ganglion more anteriorly. Damage to the facial nerve, as occurs with trauma and temporal bone fracture, leads to loss of motor control on the ipsilateral side of the face, mimicking a stroke, with profound social impact given the sensitivity to facial expression. (See facial nerve [CN VII] images in Chapter 5.)

402

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Temporal Bone Axial 2

Internal carotid a. Facial n. (CN VII), labyrinthine segment Epitympanum Apical turn of cochlea Aditus ad antrum

Mastoid antrum

Middle turn of cochlea Internal auditory canal Vestibule Vestibular aqueduct Posterior semicircular canal Sigmoid sinus Emissary v.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

403

Temporal Bone Axial 3

Internal carotid a. Facial n. (CN VII), tympanic segment Malleus (head)

Apical turn of cochlea

Prussak’s space

Modiolus Middle turn of cochlea

Epitympanum

Internal auditory canal

Mastoid antrum

Vestibule Lateral semicircular canal Vestibular aqueduct Sigmoid sinus



NORMAL ANATOMY Note the apical and middle turns of the cochlea. Counterintuitively, the tip of the cochlea (the apex) is sensitive to lower frequencies, down to 20 Hz, moving to higher frequencies in the middle turn, and up to 20,000 Hz in the basal turn. Note also the very thin vestibular aqueduct, which connects the inner ear to a balloon-shaped structure called the endolymphatic sac. Although its function is not clearly known, the endolymphatic sac may help to ensure that fluid in the inner ear contains the correct ion concentration. The vestibular aqueduct is normally less than 1 mm in diameter, or smaller than the adjacent medial limb of the superior semicircular canal (a good anatomic reference). Enlarged vestibular aqueducts, associated with hearing loss in children, are thought to be related to the same underlying defect.



PATHOLOGIC PROCESS Damage to the cochlear nerve, as in trauma with temporal bone fracture, is more classically seen with transverse fractures perpendicular to the long axis of the temporal bone, from auricle to petrous apex. Transverse fractures are more frequently associated with sensorineural hearing loss. Practically, however, many fractures combine both conditions.

404

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Temporal Bone Axial 3

Internal carotid a. Malleus (head) Facial n. (CN VII), tympanic segment Prussak’s space

Epitympanum

Apical turn of cochlea Modiolus Middle turn of cochlea Internal auditory canal Vestibule Lateral semicircular canal Vestibular aqueduct

Sigmoid sinus

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

405

Temporal Bone Axial 4

Internal carotid a. (petrous segment) Malleus

Tensor tympani m.

Prussak’s space Basal turn of cochlea

Incus

Round window

Stapes Facial n. (CN VII), mastoid segment

Sinus tympani

Pyramidal eminence/ stapedius m.

Posterior semicircular canal Sigmoid sinus



NORMAL ANATOMY The basal turn of the cochlea is connected to the stapes stirrup through the oval window. Immediately anterior to the oval window is the fissula ante fenestram, a small, connective tissue– filled cleft where the tendon of the tensor tympani muscle turns laterally toward the malleus. In otosclerosis, the most common cause of hearing loss in people age 15 to 50, a small lytic lesion often develops at the fissula ante fenestram.



DIAGNOSTIC CONSIDERATION The head of the malleus forms a “scoop of ice cream” on the cone-shaped incus. Loss of this ice cream cone appearance indicates ossicular dislocation.

406

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Temporal Bone Axial 4

Malleus

Prussak’s space

Internal carotid a. Tensor tympani m. Basal turn of cochlea

Incus Stapes Facial n. (CN VII), mastoid segment

Round window Sinus tympani

Posterior semicircular canal Pyramidal eminence/ stapedius m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

407

Temporal Bone Axial 5

Vidian canal

Mandibular n. (V3) in foramen ovale Middle meningeal a. in foramen spinosum External auditory canal

Tensor tympani m. Eustachian tube

Tympanic membrane

Internal carotid a. in carotid canal

Chorda tympani n.

Pars nervosa, of jugular foramen

Facial n. (CN VII), mastoid segment

Pars vascularis, of jugular foramen



PATHOLOGIC PROCESS The tympanic membrane separating the external auditory canal from the middle ear cavity is normally extremely thin and barely perceptible on CT. Thickening can often be caused by inflammatory or infectious conditons such as otitis media.

408

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Temporal Bone Axial 5

Vidian canal Mandibular n. (V3) in foramen ovale Middle meningeal a. in foramen spinosum Tensor tympani m. External auditory canal

Eustachian tube Carotid canal

Tympanic membrane Chorda tympani n.

Pars nervosa, of jugular foramen Pars vascularis, of jugular foramen

Facial n. (CN VII), mastoid segment

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

409

Temporal Bone Axial 6

Mandible condyle

Glenoid fossa

Stylomastoid foramen

Mastoid air cell

Loop of sigmoid sinus



NORMAL ANATOMY At the bottom of the temporal bone, the only nerve canal visible is the mastoid segment of the facial nerve. The mastoid segment descends vertically from the tympanic segment to the stylomastoid foramen at the skull base, between the styloid process and inferior aspect of the mastoid air cells.

410

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Temporal Bone Axial 6

Mandible condyle

Glenoid fossa

Stylomastoid foramen Mastoid air cell Loop of sigmoid sinus

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

411

Temporal Bone Coronal 1

Temporal bone

Epitympanum

Tegmen tympani

Geniculate ganglion

Tensor tympani m.

Middle turn of cochlea Modiolus Apical turn of cochlea Basal turn of cochlea Occipital bone

Anterior malleolar ligament

412

External auditory canal

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Tympanic membrane

Mesotympanum

Hypotympanum

Temporal Bone Coronal 1

Temporal bone

Epitympanum

Tegmen tympani

Geniculate ganglion

Apical turn of cochlea Modiolus Basal turn of cochlea Occipital bone

Anterior malleolar ligament

External auditory Tensor tympani m. Hypotympanum canal Tympanic Mesotympanum membrane

Middle turn of cochlea

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

413

Temporal Bone Coronal 2

Tegmen tympani

Horizontal/lateral semicircular canal

Superior semicircular canal

Facial n. (CN VII), tympanic segment

Vestibule

Epitympanum

Internal auditory canal

Incus

Cochlear promontory

Prussak’s space

Jugular foramen

Hypoglossal canal

External auditory canal



Scutum

Tympanic membrane

Stapes

Hypotympanum

Mesotympanum

PATHOLOGIC PROCESS The air space lateral to the neck of the malleus is known as Prussak’s space (superior recess of tympanic membrane). This space is important because cholesteatoma can occur there. A cholesteatoma forms when there is a deep retraction pocket in the tympanic membrane. The lining of the tympanic membrane is shed like skin, but if the membrane is retracted, the dead cells are trapped and can enlarge. This cholesteatoma can eventually erode the surrounding bony structures. One of the early signs differentiating simple middle ear fluid from a cholesteatoma is erosion of the scutum (bony plate) lateral to the Prussak’s space at the upper edge of the tympanic membrane. Coronal is the best imaging plane on MRI to evaluate this scutum (tympanic scute).

414

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Temporal Bone Coronal 2

Facial n. (CN VII), tympanic segment Incus

Tegmen tympani

Horizontal/lateral semicircular canal Stapes

Superior semicircular canal

Vestibule

Internal auditory canal

Epitympanum

Cochlear promontory

Jugular foramen Prussak’s space Hypoglossal canal

External auditory canal

Scutum

Tympanic membrane

Mesotympanum Hypotympanum

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

415

Temporal Bone Coronal 3

Tegmen mastoideum

Mastoid antrum

Horizontal/lateral semicircular canal

Superior semicircular canal

Common crus

Vestibule Posterior semicircular canal Jugular foramen

Facial n. (CN VII), mastoid segment



Stylomastoid foramen

NORMAL ANATOMY Coronal MR images are useful for assessing the bony roof (tegmen) of the superior semicircular canal. Loss of this roof, or semicircular canal dehiscence and communication with the cerebrospinal fluid around the brain, can lead to disruption of vestibulocochlear nerve function.

416

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Temporal Bone Coronal 3

Tegmen mastoideum

Mastoid antrum

Horizontal/lateral semicircular canal

Superior semicircular canal

Common crus

Vestibule Posterior semicircular canal Jugular foramen

Facial n. (CN VII), mastoid segment

Stylomastoid foramen

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

417

Temporal Bone Coronal 4

Mastoid antrum

Tegmen mastoideum

Posterior aspect, horizontal semicircular canal

Posterior semicircular canal

418

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Temporal Bone Coronal 4

Mastoid antrum

Tegmen mastoideum

Posterior aspect, horizontal semicircular canal

Common crus

Posterior semicircular canal

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

419

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13

Chapter

ORAL CAVITY, PHARYNX, AND SUPRAHYOID NECK

1 2 3 4 5 6 7 8 1 2

3

45 6

7

8

CORONAL 438

AXIAL 422

1

SAGITTAL 454

3 5 7 2 4 6 8

421

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 1

Nasal septum

Maxillary sinus

Temporalis m.

Masseter m. Eustachian tube opening Lateral pterygoid m. Fossa of Rosenmüller Longus capitis m.

L. internal carotid a. L. internal jugular v. Medulla Cerebellum



NORMAL ANATOMY Note the enhancement of the mucosal surfaces of the aerodigestive tract on the lower magnetic resonance (MR) image in Axial 1 after gadolinium contrast administration. The subcutaneous adipose tissue and the adipose planes between the structures in the neck are visible on both the upper pre-contrast T1-weighted MR image and the lower post-contrast T1-weighted MR image.

422

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 1

Nasal septum Maxillary sinus Temporalis m. Masseter m. Eustachian tube opening Lateral pterygoid m. Fossa of Rosenmüller Longus capitis m. L. internal carotid a. L. internal jugular v. Medulla Cerebellum

Nasal septum Maxillary sinus Temporalis m. Masseter m. Eustachian tube opening Lateral pterygoid m. Fossa of Rosenmüller Longus capitis m. L. internal carotid a. L. internal jugular v. Medulla Cerebellum

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

423

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 2

Orbicularis oris m. Nasal septum

Maxillary sinus Zygomaticus m. Masseter m.

Temporalis m.

Lateral pterygoid m. Torus tubarius Longus capitis m. R. retromandibular v. Parotid gland L. internal carotid a. Digastric m. (posterior belly)

R. vertebral a.

Medulla oblongata

L. internal jugular v.

Cerebellum



PATHOLOGIC PROCESS An axial image of the nasopharynx at the level of the foramen magnum is visible on typically every brain study. Fluid in the mastoid air cells on one side may indicate a mass obstructing the Eustachian canal opening anterior to the torus tubarius (posterior protuberance of pharyngeal opening of auditory tube). The fossa of Rosenmüller is a blind-ending divot between the torus tubarius and the longus capitis muscle more posteriorly. Asymmetric loss of this fossa may be the first sign of a nasopharyngeal lesion. Malignant spread of a nasopharyngeal carcinoma may first reach the retropharyngeal lymph node. This lymph node is normally less than 8 mm in long axis and located between the longus capitis muscle and the internal carotid artery more posterolaterally.

424

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 2

Orbicularis oris m. Nasal septum Zygomaticus m. Temporalis m.

Maxillary sinus Masseter m.

Lateral pterygoid m. Torus tubarius R. retromandibular v. Longus capitis m. R. vertebral a.

L. internal carotid a. L. internal jugular v. Digastric m. (posterior belly)

Medulla Cerebellum

Orbicularis oris m. Nasal septum Zygomaticus m. Temporalis m.

Maxillary sinus Masseter m.

Lateral pterygoid m. Torus tubarius R. retromandibular v. Longus capitis m. R. vertebral a.

L. internal carotid a. L. internal jugular v. Digastric m. (posterior belly)

Medulla Cerebellum

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

425

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 3

Zygomaticus m. Masseter m. Tongue Tensor veli palatini m. Medial pterygoid m. Palatine tonsils

Superior constrictor m. Longus capitis m.

R. retromandibular v.

Parotid gland

L. internal carotid a. L. internal jugular v. Digastric m. (posterior belly) Sternocleidomastoid m.

R. vertebral a. Semispinalis capitis m.

Splenius capitis m.

426

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 3

Zygomaticus m.

Tongue

Masseter m. Medial pterygoid m.

Palatine tonsils

Tensor veli palatini m. Superior constrictor m.

R. retromandibular v. Parotid gland

Longus capitis m. L. internal carotid a. L. internal jugular v. Digastric m. (posterior belly)

R. vertebral a.

Sternocleidomastoid m. Semispinalis capitis m. Splenius capitis m.

Zygomaticus m.

Tongue

Masseter m. Medial pterygoid m.

Palatine tonsils

Tensor veli palatini m. Superior constrictor m.

R. retromandibular v. Parotid gland

Longus capitis m. L. internal carotid a. L. internal jugular v. Digastric m. (posterior belly)

R. vertebral a.

Sternocleidomastoid m. Semispinalis capitis m. Splenius capitis m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

427

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 4

Orbicularis oris m. Medial incisor Lateral incisor Canine 1st premolar (bicuspid) Zygomaticus m.

Buccinator m.

Tongue

2nd premolar (bicuspid)

Stensen’s duct

1st molar Masseter m.

Palatine tonsil

Medial pterygoid m.

Oropharynx

Superior constrictor m. Longus colli m.

R. retromandibular v.

L. internal carotid a. L. internal jugular v.

Parotid gland

Digastric m. (posterior belly) Atlas (C1) Dens (C2)

R. vertebral a.

Sternocleidomastoid m. Rectus capitis posterior minor m. Cervical spinal cord Trapezius m. Splenius capitis m.



NORMAL ANATOMY Unlike the nasopharynx cranially or the hypopharynx caudally, the lumen of the oropharynx can be grossly identified on axial MR images by visualization of teeth.

428

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 4

Zygomaticus m. Tongue Stensen’s duct Oropharynx Palatine tonsil R. retromandibular v.

Orbicularis oris m. Medial incisor Lateral incisor Canine 1st premolar (bicuspid) Buccinator m. 2nd premolar (bicuspid) 1st molar Masseter m. Medial pterygoid m. Superior constrictor m. Longus colli m. L. internal carotid a.

Parotid gland

Digastric m. (posterior belly) L. internal jugular v.

R. vertebral a.

Dens (C2)

Cervical spinal cord

Sternocleidomastoid m. Rectus capitis posterior minor m. Trapezius m. Splenius capitis m.

Zygomaticus m. Tongue Stensen’s duct Oropharynx Palatine tonsil R. retromandibular v.

Orbicularis oris m. Medial incisor Lateral incisor Canine 1st premolar (bicuspid) Buccinator m. 2nd premolar (bicuspid) 1st molar Masseter m. Medial pterygoid m. Superior constrictor m. Longus colli m. L. internal carotid a.

Parotid gland

Digastric m. (posterior belly) L. internal jugular v.

R. vertebral a.

Dens (C2)

Cervical spinal cord

Sternocleidomastoid m. Rectus capitis posterior minor m. Trapezius m. Splenius capitis m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

429

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 5

Medial incisor Lateral incisor Canine Zygomaticus m.

1st premolar (bicuspid) Buccinator m.

Tongue

2nd premolar (bicuspid) 1st molar

Stensen’s duct

Masseter m. Palatine tonsil

Medial pterygoid m.

R. external carotid a.

Superior constrictor m.

Parotid gland

Longus capitis m.

R. internal carotid a.

Digastric m. (posterior belly) Axis (C2)

R. internal jugular v.

Sternocleidomastoid m. Obliquus capitis inferior m.

R. vertebral a.

Splenius capitis m. Rectus capitis posterior major m. Cervical spinal cord

Semispinalis capitis m. Trapezius m.



PATHOLOGIC PROCESS Lesions of the head and neck are often most easily detected by loss of normal fat planes. On these T1-weighted precontrast (upper) and postcontrast (lower) MR images, note the fat within the retromolar trigone (retromandibular triangle) located posterior to the third molar. Once a malignancy or infection has reached the parapharyngeal fat located more posteriorly, it has an easy route of spread craniocaudally from the skull base down to the inferior pericardial recess.

430

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 5

Zygomaticus m.

Buccinator m.

Tongue Stensen’s duct

Masseter m.

Palatine tonsil

Medial pterygoid m.

R. external carotid a. Parotid gland

Superior constrictor m. Digastric m. (posterior belly)

R. internal carotid a.

Longus colli m.

R. internal jugular v.

Axis (C2) Obliquus capitis inferior m.

R. vertebral a.

Cervical spinal cord

Sternocleidomastoid m. Rectus capitis posterior major m. Splenius capitis m. Trapezius m. Semispinalis capitis m.

Zygomaticus m.

Buccinator m.

Tongue Stensen’s duct

Masseter m.

Palatine tonsil

Medial pterygoid m.

R. external carotid a. Parotid gland

Superior constrictor m. Digastric m. (posterior belly)

R. internal carotid a.

Longus colli m.

R. internal jugular v.

Axis (C2) Obliquus capitis inferior m.

R. vertebral a.

Sternocleidomastoid m. Splenius capitis m.

Cervical spinal cord

Rectus capitis posterior major m. Trapezius m. Semispinalis capitis m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

431

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 6

Genioglossus m.

Orbicularis oris m.

Depressor anguli oris m. Mylohyoid m. Buccinator m.

Sublingual space (containing unencapsulated sublingual gland) Hyoglossus m.

Inferior alveolar n.

Submandibular gland

Masseter m.

Palatine tonsil Digastric m. (posterior belly)

R. external carotid a. Parotid gland

Superior constrictor m.

R. internal carotid a.

Longus capitis m.

R. retromandibular v.

Levator scapulae m. Sternocleidomastoid m.

R. internal jugular v.

Splenius capitis m.

R. vertebral a.

Obliquus capitis inferior m. Cervical spinal cord

Semispinalis capitis m. Trapezius m.

432

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 6

Orbicularis oris m. Depressor anguli oris m. Genioglossus m. Mylohyoid m. Hyoglossus m.

Buccinator m. Inferior alveolar n. Masseter m.

Submandibular gland Palatine tonsil R. external carotid a. R. internal carotid a. Longus capitis m. R. internal jugular v.

Digastric m. (posterior belly) Superior constrictor m. L. retromandibular v. Levator scapulae m.

R. vertebral a. Sternocleidomastoid m. Cervical spinal cord Semispinalis capitis m.

Obliquus capitis inferior m. Splenius capitis m. Trapezius m.

Orbicularis oris m. Depressor anguli oris m. Genioglossus m. Mylohyoid m. Hyoglossus m.

Buccinator m. Inferior alveolar n. Masseter m.

Submandibular gland Palatine tonsil

Digastric m. (posterior belly)

R. external carotid a. Longus capitis m. R. internal carotid a.

Superior constrictor m.

R. internal jugular v.

Levator scapulae m.

L. retromandibular v.

R. vertebral a. Sternocleidomastoid m. Cervical spinal cord Semispinalis capitis m.

Obliquus capitis inferior m. Splenius capitis m. Trapezius m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

433

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 7

Orbicularis oris m.

Depressor anguli oris m. Sublingual space (containing unencapsulated sublingual gland)

Mylohyoid m. Genioglossus m. Hyoglossus m.

Submandibular gland R. external carotid a.

R. internal carotid a.

Superior constrictor m. Longus capitis m. Sternocleidomastoid m.

R. internal jugular v. Levator scapulae m. R. vertebral a.

Semispinalis capitis m. Splenius capitis m.

Cervical spinal cord

Obliquus capitis inferior m. Trapezius m.

434

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 7

Orbicularis oris m. Sublingual space (containing unencapsulated sublingual gland)

Depressor anguli oris m. Mylohyoid m. Genioglossus m.

Submandibular gland Hyoglossus m.

R. external carotid a. R. internal carotid a. R. internal jugular v.

Superior constrictor m. Longus capitis m. Levator scapulae m.

Sternocleidomastoid m. R. vertebral a. Semispinalis capitis m. Cervical spinal cord

Obliquus capitis inferior m. Splenius capitis m. Trapezius m.

Orbicularis oris m. Sublingual space (containing unencapsulated sublingual space)

Depressor anguli oris m. Mylohyoid m. Genioglossus m.

Submandibular gland

R. external carotid a. R. internal carotid a. R. internal jugular v.

Hyoglossus m.

Superior constrictor m. Longus capitis m. Levator scapulae m.

Sternocleidomastoid m. R. vertebral a. Semispinalis capitis m. Cervical spinal cord

Obliquus capitis inferior m. Splenius capitis m. Trapezius m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

435

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 8

Mandible

Mylohyoid m.

Hyoid bone

R. retromandibular v.

Submandibular gland

R. external carotid a. R. internal carotid a. Sternocleidomastoid m. R. internal jugular v. R. vertebral a.

Levator scapulae m. Semispinalis capitis m. Multifidus m.

Cervical spinal cord

Semispinalis cervicis m. Splenius capitis m. Trapezius m.

436

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Axial 8

Mandible Mylohyoid m. Hyoid Submandibular gland R. external carotid a. R. internal carotid a. R. internal jugular v. Sternocleidomastoid m. R. vertebral a. Cervical spinal cord Semispinalis capitis m.

Middle constrictor m. L. retromandibular v. Levator scapulae m. Multifidus m. Semispinalis cervicis m. Splenius capitis m. Trapezius m.

Mandible Mylohyoid m.

Submandibular gland R. external carotid a. R. internal carotid a. R. internal jugular v. Sternocleidomastoid m. R. vertebral a. Cervical spinal cord Semispinalis capitis m.

Middle constrictor m. L. retromandibular v. Levator scapulae m. Multifidus m. Semispinalis cervicis m. Splenius capitis m. Trapezius m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

437

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 1

Orbit

Inferior rectus m.

Maxillary sinus Hard palate Maxilla

Buccinator m. Genioglossus m. Mandible Inferior alveolar n. Geniohyoid m. Digastric m. (anterior belly)

IMAGING TECHNIQUE CONSIDERATION Note the conspicuous contrast enhancement of the mucosal surfaces of the nasal passages on the lower postcontrast T1- weighted MR image in Coronal 1.

438

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 1

Orbit Inferior rectus m. Maxillary sinus Hard palate Maxilla Buccinator m. Genioglossus m. Mandible Inferior alveolar n. Geniohyoid m. Digastric m. (anterior belly)

Orbit Inferior rectus m. Maxillary sinus Hard palate Maxilla Buccinator m. Genioglossus m. Mandible Inferior alveolar n. Geniohyoid m. Digastric m. (anterior belly)

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

439

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 2

Inferior rectus m.

Temporalis m. Maxillary sinus

Hard palate

Buccinator m.

Genioglossus m. Mandible Inferior alveolar n. Geniohyoid m. Mylohyoid m.

Digastric m. (anterior belly)

440

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 2

Inferior rectus m. Temporalis m. Maxillary sinus Hard palate

Buccinator m. Genioglossus m. Mandible Geniohyoid m. Mylohyoid m. Digastric m. (anterior belly)

Inferior rectus m. Temporalis m. Maxillary sinus Hard palate

Buccinator m. Genioglossus m. Mandible Geniohyoid m. Mylohyoid m. Digastric m. (anterior belly)

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

441

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 3

Temporalis m.

Maxillary sinus

Soft palate

Masseter m.

Mandible Genioglossus m. Geniohyoid m. Mylohyoid m. Digastric m. (anterior belly)



DIAGNOSTIC CONSIDERATION Coronal imaging is often the best plane on MRI to assess a tongue lesion extending into the floor of mouth. The floor of the mouth is supported by the mylohyoid muscle (Greek mylai, “molar teeth”), which courses from the mandible to the hyoid bone.

442

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 3

Temporalis m. Maxillary sinus

Soft palate Masseter m.

Mandible Genioglossus m. Geniohyoid m. Mylohyoid m. Digastric m. (anterior belly)

Temporalis m. Maxillary sinus

Soft palate Masseter m.

Mandible Genioglossus m. Geniohyoid m. Mylohyoid m. Digastric m. (anterior belly)

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

443

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 4

Temporalis m.

Masseter m. Soft palate

Intrinsic lingual mm. Hyoglossus m. Genioglossus m. Geniohyoid m. Mylohyoid m. Submandibular gland

444

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 4

Temporalis m.

Masseter m. Soft palate Intrinsic lingual mm.

Hyoglossus m. Genioglossus m. Submandibular gland Geniohyoid m. Mylohyoid m.

Temporalis m.

Masseter m. Soft palate Intrinsic lingual mm.

Hyoglossus m. Genioglossus m. Submandibular gland Geniohyoid m. Mylohyoid m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

445

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 5

Sphenoid sinus

Temporalis m. Lateral pterygoid m. Masseter m.

Nasopharyngeal lumen

Soft palate

Medial pterygoid m.

Palatine tonsil

Superior constrictor m.

Facial v.

446

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Intrinsic lingual mm.

Submandibular gland

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 5

Sphenoid sinus Temporalis m. Nasopharyngeal lumen

Lateral pterygoid m. Masseter m.

Palatine tonsil

Soft palate Medial pterygoid m.

Superior constrictor m.

Palatine tonsil

Intrinsic lingual mm. Facial v. Submandibular gland

Sphenoid sinus Temporalis m. Nasopharyngeal lumen

Lateral pterygoid m. Masseter m.

Palatine tonsil

Soft palate Medial pterygoid m.

Superior constrictor m.

Palatine tonsil

Intrinsic lingual mm. Facial v. Submandibular gland

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

447

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 6

Lateral pterygoid m.

Adenoids

Masseter m.

Levator veli palatini m.

Uvula

Medial pterygoid m. Palatine tonsil

Epiglottis

448

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Submandibular gland

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 6

Adenoids Lateral pterygoid m. Levator veli palatini m. Uvula

Masseter m. Medial pterygoid m.

Palatine tonsil

Epiglottis

Submandibular gland

Adenoids Lateral pterygoid m. Levator veli palatini m. Uvula

Masseter m. Medial pterygoid m.

Palatine tonsil

Epiglottis

Submandibular gland

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

449

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 7

Pons

Foramen magnum Dens

Parotid gland

Lateral mass of atlas (C1) R. internal jugular v. Axis (C2) Sternocleidomastoid m.

R. internal carotid a.

Longus capitis m.



DIAGNOSTIC CONSIDERATION Although axial imaging is the plane conventionally used for measuring the long axis of neck lymph nodes, the coronal plane is often useful for visualizing the entire craniocaudal length of the jugular and spinal accessory lymph node chains.

450

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 7

Pons Foramen magnum

Parotid gland

Dens Lateral mass of atlas (C1)

R. internal jugular v.

Axis (C2)

R. internal carotid a. Sternocleidomastoid m. Longus capitis m.

Pons Foramen magnum

Parotid gland

Dens Lateral mass of atlas (C1)

R. internal jugular v.

Axis (C2)

R. internal carotid a. Sternocleidomastoid m. Longus capitis m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

451

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 8

Cerebellum

R. sigmoid sinus

L. vertebral a. Posterior arch of atlas (C1) Rectus capitis posterior major m. Splenius capitis m.

R. vertebral a.

Spine of axis (C2) Semispinalis capitis m.

Semispinalis cervicis m.



DIAGNOSTIC CONSIDERATION Tumors may arise from muscle, such as leiomyosarcoma, but are relatively rare. Muscles are often a source of pain, but this is usually benign. Bone, however, particularly vertebral body marrow, is a common target for metastases.

452

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Coronal 8

Cerebellum R. sigmoid sinus

L. vertebral a. Posterior arch of atlas (C1) R. vertebral a.

Rectus capitis posterior major m. Splenius capitis m. Spine of axis (C2) Semispinalis capitis m. Semispinalis cervicis m.

Cerebellum R. sigmoid sinus

L. vertebral a. Posterior arch of atlas (C1) R. vertebral a.

Rectus capitis posterior major m. Splenius capitis m. Spine of axis (C2) Semispinalis capitis m. Semispinalis cervicis m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

453

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 1

Hypophysis

Pharyngeal tonsil (adenoid)

Soft palate

Nasopharynx Intrinsic lingual mm. Uvula

Orbicularis oris m. Genioglossus m.

Superior constrictor m.

Geniohyoid m.

Lingual tonsil

Mylohyoid m.

Epiglottis Hyoid bone

Platysma m.

Middle constrictor m.

Pre-epiglottic space Thyroid cartilage

Inferior constrictor m.



NORMAL ANATOMY Note that the midline MR image in Sagittal 1 is aligned on the pharynx, which consists of the oropharynx, nasopharynx, and hypopharynx (nose is slightly off midline). The pharyngeal lumen is the common pathway of the respiratory and digestive tracts. Air enters the nose, passes inferiorly and anteriorly to the trachea, crossing over the path of food entering the mouth, which then passes inferiorly and posteriorly to the esophagus. The anterior location of the trachea allows for safe percutaneous access through the cricothyroid membrane in patients with upper airway obstruction at or above the level of the vocal cords.

454

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 1

Hypophysis

Soft palate

Pharyngeal tonsil adenoid Nasopharynx Uvula

Intrinsic lingual mm. Superior constrictor m. Orbicularis oris m.

Lingual tonsil

Genioglossus m. Geniohyoid m. Mylohyoid m.

Epiglottis Hyoid bone

Platysma m. Pre-epiglottic space

Middle constrictor m.

Thyroid cartilage Inferior constrictor m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

455

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 2

Hypophysis

Soft palate

Nasopharynx

Intrinsic lingual mm.

Superior constrictor m.

Orbicularis oris m.

Uvula

Genioglossus m. Hyoglossus m.

Hypopharynx

Geniohyoid m.

Epiglottis

Mylohyoid m.

Hyoid bone

Platysma m.

Middle constrictor m. Laryngeal ventricle

Thyroid cartilage

Inferior constrictor m.



DIAGNOSTIC CONSIDERATION Sagittal imaging may be the best plane for assessing invasion by nasopharyngeal carcinoma into the clivus or incidental metastasis of vertebral bodies.

456

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 2

Soft palate

Hypophysis Nasopharynx

Intrinsic lingual mm.

Orbicularis oris m. Genioglossus m. Hyoglossus m. Geniohyoid m. Mylohyoid m. Platysma m. Thyroid cartilage

Uvula

Superior constrictor m.

Hypopharynx Epiglottis Hyoid bone Middle constrictor m. Laryngeal ventricle Inferior constrictor m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

457

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 3

Superior constrictor m. Soft palate Nasopharynx

Intrinsic lingual mm. Genioglossus m. Hyoglossus m.

Vallecula

Geniohyoid m. Epiglottis

Mylohyoid m. Hyoid bone

Middle constrictor m.

Platysma m. Pre-epiglottic space

Inferior constrictor m.

Thyroid cartilage



PATHOLOGIC PROCESS Note the thinness of the epiglottis. Marked thickening of the epiglottis may result from viral infection (supraglottitis, epiglottitis) in children. The “thumbprint” sign on lateral radiographs identifies epiglottic thickening, which can lead to life-threatening airway obstruction. With the advent of Haemophilus influenzae type B vaccine, the incidence of supraglottitis has decreased greatly. Currently, the most common reason for epiglottic thickening is post–radiation therapy changes in adult patients.

458

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 3

Soft palate

Nasopharynx

Intrinsic lingual mm.

Superior constrictor m.

Genioglossus m. Hyoglossus m. Hyoid bone

Vallecula

Epiglottis

Geniohyoid m. Mylohyoid m. Platysma m. Pre-epiglottic space Thyroid cartilage

Middle constrictor m. Inferior constrictor m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

459

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 4

Maxillary sinus

Longus capitis m.

Medial pterygoid m.

Intrinsic lingual mm.

Semispinalis capitis m. Obliquus capitis superior m.

Hyoglossus m. Digastric m. (anterior belly) Platysma m.

Obliquus capitis inferior m. Semispinalis cervicis m. Longus colli m. Arytenoid cartilage

460

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 4

Maxillary sinus

Medial pterygoid m.

Longus capitis m. Semispinalis capitis m.

Intrinsic lingual mm.

Obliquus capitis superior m.

Hyoglossus m.

Obliquus capitis inferior m.

Digastric m. (anterior belly) Platysma m. Thyroid cartilage

Semispinalis cervicis m. Longus capitis m. Arytenoid cartilage

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

461

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 5

Maxillary sinus Lateral pterygoid m.

Medial pterygoid m.

Longus capitis m. Semispinalis capitis m. Obliquus capitis superior m.

Tongue

Obliquus capitis inferior m. Sublingual gland

Greater cornu, hyoid bone

Submandibular gland

Semispinalis cervicis m.

Platysma m.

Longus colli m. R. vertebral a.

462

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 5

Maxillary sinus

Lateral pterygoid m.

Longus capitis m.

Medial pterygoid m.

Semispinalis capitis m.

Tongue

Sublingual gland Submandibular gland Platysma m.

Obliquus capitis superior m. Obliquus capitis inferior m. Greater cornu, hyoid bone Semispinalis capitis m. Semispinalis cervicis m. Longus colli m. R. vertebral a.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

463

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 6

Maxillary sinus Temporalis m. Lateral pterygoid m.

Medial pterygoid m.

Mandible

Obliquus capitis superior m. Obliquus capitis inferior m.

Splenius capitis m. Platysma m.

R. common carotid a. Trapezius m.

464

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 6

Maxillary sinus Temporalis m. Lateral pterygoid m.

Medial pterygoid m.

Mandible

Obliquus capitis superior m. Obliquus capitis inferior m.

Splenius capitis m. Platysma m.

R. common carotid a. Trapezius m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

465

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 7

Temporalis m.

External auditory canal Masseter m. Parotid gland

Splenius capitis m.

Sternocleidomastoid m.



Anterior scalene m.

DIAGNOSTIC CONSIDERATION The off-midline sagittal CT images are typically of limited diagnostic utility given the lack of symmetry as on axial images. Certain structures, however, such as the occipitocervical junction and facet joints, can be better assessed on the sagittal plane.

466

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 7

Temporalis m.

External auditory canal Masseter m.

Parotid gland

Splenius capitis m.

Sternocleidomastoid m.

Anterior scalene m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

467

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 8

Zygomatic process of temporal bone

Temporal bone

External auditory canal

Parotid gland

Sternocleidomastoid m.

468

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Oral Cavity, Pharynx, and Suprahyoid Neck Sagittal 8

Zygomatic process of temporal bone

Temporal bone

External auditory canal

Parotid gland

Sternocleidomastoid m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

469

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14

Chapter

HYPOPHARYNX, LARYNX, AND INFRAHYOID NECK 1 3

2

4 5 6 7 8

1 2

AXIAL 472

3

4 5

6

7

8

CORONAL 488

1 2 4 6 8 3 5 7

SAGITTAL 504 NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

471

Hypopharynx, Larynx, and Infrahyoid Neck Axial 1

Digastric m. (anterior belly)

Submandibular gland Oropharynx Posterior wall, hypopharynx

Piriform sinus

Longus colli m.

L. external carotid a.

R. internal jugular v.

L. internal carotid a.

Sternocleidomastoid m.

L. vertebral a. Levator scalpulae m.

Multifidus m. Semispinalis capitis m. Semispinalis cervicis m. Splenius capitis m. Trapezius m.



DIAGNOSTIC CONSIDERATION Axial 1 on the next page shows both a T2-weighted sequence (upper image) and a T1-weighted image (lower). Note that cerebrospinal fluid (CSF) around the spinal cord is bright on T2-weighted magnetic resonance imaging and dark gray on T1-weighted MRI. Usually the brightest structure on T1-weighted imaging is fat. Note that the fat is somewhat bright on T2-weighted imaging because most T2 MRIs are now performed with fast spin-echo or “turbo” spin-echo techniques that use multiple radiofrequency (RF) pulses per echo time and make fat signal appear more like water signal.

472

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Axial 1

Digastric m. (anterior belly) Submandibular gland Posterior wall, hypopharynx

Oropharynx

Longus colli m. R. internal jugular v.

Piriform sinus L. external carotid a.

Sternocleidomastoid m.

L. internal carotid a. L. vertebral a.

Multifidus m. Semispinalis cervicis m.

Levator scapulae m. Semispinalis capitis m. Splenius capitis m. Trapezius m.

Digastric m. (anterior belly) Submandibular gland Posterior wall, hypopharynx Longus colli m. R. internal jugular v. Sternocleidomastoid m.

Oropharynx

Piriform sinus L. external carotid a. L. internal carotid a. L. vertebral a.

Multifidus m. Semispinalis cervicis m.

Levator scapulae m. Semispinalis capitis m. Splenius capitis m. Trapezius m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

473

Hypopharynx, Larynx, and Infrahyoid Neck Axial 2

Strap mm. Thyroid cartilage Aryepiglottic fold Piriform sinus

L. external carotid a. L. internal carotid a.

Longus colli m.

L. internal jugular v. Sternocleidomastoid m.

L. vertebral a.

Levator scalpulae m. Multifidus m. Semispinalis capitis m.

Semispinalis cervicis m.

Splenius capitis m. Trapezius m.



DIAGNOSTIC CONSIDERATION Imaging of the neck can be difficult because many critical structures are compressed within a relatively small space. One diagnostic approach to MRI and CT of the neck is to assess the structures from central to peripheral, starting with the airway. Impending airway obstruction should be recognized early in evaluation of the neck. The airway is often the first structure to be exposed to carcinogenic agents and viruses. A primary hypopharyngeal squamous cell carcinoma may first appear as a slight asymmetry in the mucosal surfaces of the hypopharynx. The next structure to assess is the usual site of malignancy spread, the lymph nodes, which generally follow the venous structures. The largest venous structure in the neck is the internal jugular vein, and thus the jugular lymph node chain typically contains the largest lymph nodes. The largest node is at the top of this chain, the jugulodigastric lymph node, which serves as a common point of lymphatic drainage for the head. Next, specialized glands of the head and neck can be assessed, including parotid, submandibular, and thyroid glands. Finally, structures are assessed at the edge of a neck study, such as the brain above, the spine and top of the lungs, and structures common to many parts of the body (e.g., vessels, bones, muscles, subcutaneous tissue, skin contours).

474

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Axial 2

Strap mm. Thyroid cartilage Aryepiglottic fold

L. external carotid a.

Piriform sinus L. internal carotid a. Longus colli m.

L. internal jugular v. L. vertebral a.

Sternocleidomastoid m.

Levator scapulae m. Semispinalis capitis m.

Multifidus m. Splenius capitis m. Semispinalis cervicis m. Trapezius m.

Strap mm.

Thyroid cartilage Aryepiglottic fold

L. external carotid a. L. internal carotid a.

Piriform sinus L. internal jugular v. Longus colli m. Sternocleidomastoid m.

L. vertebral a. Levator scapulae m. Semispinalis capitis m.

Multifidus m. Splenius capitis m. Semispinalis cervicis m. Trapezius m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

475

Hypopharynx, Larynx, and Infrahyoid Neck Axial 3

Strap mm. Thyroid cartilage Thyroarytenoid m.

False vocal cord

Post-cricoid cartilage hypopharynx

Cricoid cartilage Inferior constrictor m.

Longus colli m. L. external carotid a.

R. internal jugular v.

L. internal carotid a. L. vertebral a.

Sternocleidomastoid m. Longissimus capitis m.

Levator scalpulae m.

Multifidus m. Semispinalis capitis m.

Semispinalis cervicis m.

Splenius capitis m. Trapezius m.

PATHOLOGIC CONSIDERATION Note the medial deviation of the right vocal cord with a focus of dark signal deep to the mucosal surface. This finding suggests previous Teflon injection for vocal cord paralysis, to help bring one cord in contact with the normal-moving cord.

476

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Axial 3

Strap mm. Thyroarytenoid m.

Thyroid cartilage False cord Cricoid cartilage

Post-cricoid cartilage hypopharynx Longus colli m. R. internal jugular v. Sternocleidomastoid m.

Inferior constrictor m. L. external carotid a. L. internal carotid a. L. vertebral a. Levator scapulae m. Semispinalis capitis m.

Longissimus capitis m. Multifidus m. Semispinalis cervicis m.

Splenius capitis m. Trapezius m.

Strap mm. Thyroid cartilage Thyroarytenoid m. False cord Cricoid cartilage Post-cricoid cartilage hypopharynx Longus colli m. R. internal jugular v. Sternocleidomastoid m.

Inferior constrictor m. L. external carotid a. L. internal carotid a. L. vertebral a. Levator scapulae m. Semispinalis capitis m.

Longissimus capitis m. Multifidus m. Semispinalis cervicis m.

Splenius capitis m. Trapezius m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

477

Hypopharynx, Larynx, and Infrahyoid Neck Axial 4

Strap mm. Thyroid cartilage Cricoid cartilage

True vocal cord

Post-cricoid cartilage hypopharynx

Thyroarytenoid gap

Inferior constrictor m.

L. common carotid a.

Internal jugular v. Longus colli m. Sternocleidomastoid m. Anterior scalene m.

L. vertebral a.

Longissimus capitis m. Levator scapulae m.

Multifidus m.

Semispinalis cervicis m.

Semispinalis capitis m. Splenius capitis m. Trapezius m.

IMAGING TECHNIQUE CONSIDERATION The vocal cords should be symmetric. Medial deviation of one of the vocal cords suggests palsy, and the neuroradiologist should look carefully for a lesion or enlarged lymph node along the course of the recurrent laryngeal nerves.

478

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Axial 4

Cricoid cartilage Post-cricoid hypopharynx Inferior constrictor m. R. internal jugular v. Sternocleidomastoid m. Anterior scalene m. Longissimus capitis m. Multifidus m. Semispinalis cervicis m.

Strap mm. Thyroid cartilage True vocal cord Thyroarytenoid gap L. common carotid a. Longus colli m. L. vertebral a. Levator scapulae m. Semispinalis capitis m. Splenius capitis m. Trapezius m.

Cricoid cartilage Post-cricoid hypopharynx Inferior constrictor m. Common carotid a. Internal jugular v. Sternocleidomastoid m. Anterior scalene m. Longissimus capitis m. Multifidus m. Semispinalis cervicis m.

Strap mm. Thyroid cartilage True vocal cord Thyroarytenoid gap L. common carotid a. Longus colli m. Vertebral a. Levator scapulae m. Semispinalis capitis m. Splenius capitis m. Trapezius m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

479

Hypopharynx, Larynx, and Infrahyoid Neck Axial 5

Strap mm. Trachea Thyroid gland

Common carotid a.

Cervical esophagus

Internal jugular v.

Longus colli m.

Vertebral a.

Medial scalene m.

Sternocleidomastoid m. Anterior scalene m.

Longissimus capitis m.

Multifidus m.

Levator scapulae m. Splenius capitis m.

Trapezius m.

Semispinalis cervicis m.



PATHOLOGIC PROCESS The membranous space in the midline between the thyroid cartilage caudally and the cricoid ring caudally is the site for emergency cricothyrotomy (cricoid tracheotomy). Puncture of the cricothyroid membrane with an angiocatheter allows airway access in cases of obstruction at the level of the vocal cords or higher. The subcutaneous spaces in the midline are relatively avascular.

480

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Axial 5

Trachea

Strap mm.

R. common carotid a. R. internal jugular v. Sternocleidomastoid m. Anterior scalene m. R. vertebral a. Multifidus m. Splenius capitis m. Semispinalis cervicis m.

Thyroid gland Cervical esophagus Longus colli m. Medial scalene m. Longissimus capitis m. Levator scapulae m. Trapezius m.

Strap mm. Trachea R. common carotid a.

Thyroid gland

R. internal jugular v. Cervical esophagus Sternocleidomastoid m.

Longus colli m.

Anterior scalene m. R. vertebral a. Multifidus m. Splenius capitis m. Semispinalis cervicis m.

Medial scalene m. Longissimus capitis m. Levator scapulae m. Trapezius m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

481

Hypopharynx, Larynx, and Infrahyoid Neck Axial 6

Thyroid gland isthmus Trachea R. common carotid a.

Strap mm. Thyroid gland Cervical esophagus

Sternocleidomastoid m. Anterior scalene m.

Longus colli m.

Medial scalene m.

L. internal jugular v.

Posterior scalene m.

L. vertebral a.

Longissimus capitis m.

Multifidus m.

1st rib

Splenius capitis m. Semispinalis cervicis m.

482

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Trapezius m. Rhomboid m.

Levator scalpulae m.

Hypopharynx, Larynx, and Infrahyoid Neck Axial 6

Thyroid gland isthmus Trachea Strap mm. R. common carotid a. Sternocleidomastoid m.

Thyroid gland Cervical esophagus

Anterior scalene m. Medial scalene m. Posterior scalene m. Longissimus capitis m. Multifidus m. Semispinalis cervicis m. Splenius capitis m.

L. internal jugular v. Longus colli m. L. vertebral a. 1st rib Levator scapulae m. Trapezius m. Rhomboid m.

Thyroid gland isthmus Trachea Common carotid a. Sternocleidomastoid m. Anterior scalene m. Medial scalene m. Posterior scalene m. Longissimus capitis m. Multifidus m. Splenius capitis m. Semispinalis cervicis m.

Strap mm. Thyroid gland Cervical esophagus L. internal jugular v. Longus colli m. L. vertebral a. 1st rib Levator scapulae m. Trapezius m. Rhomboid m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

483

Hypopharynx, Larynx, and Infrahyoid Neck Axial 7

L. common carotid a. Sternocleidomastoid m.

Trachea

Esophagus

Strap mm.

L. internal jugular v. L. vertebral a.

Anterior scalene m.

L. superior thoracic a.

Intercostal m.

Trapezius m.



Rhomboid m.

Erector spinae m.

2nd rib

Lung

NORMAL ANATOMY The trachea below the bony cricoid ring has firm, cartilaginous material along the lateral and anterior sides, but a softer, membranous portion that is often straight (or concave) along the posterior wall.

484

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Axial 7

Strap mm. Trachea Sternocleidomastoid m. L. internal jugular v. Anterior scalene m.

L. common carotid a. L. superior thoracic a. L. vertebral a.

Intercostal m.

Esophagus Lung

Trapezius m. Rhomboid m.

2nd rib Erector spinae m.

Strap mm. Sternocleidomastoid m.

Trachea L. common carotid a.

Anterior scalene m.

L. superior thoracic a. L. vertebral a.

Intercostal m.

Esophagus Lung 2nd rib

Trapezius m.

Erector spinae m.

Rhomboid m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

485

Hypopharynx, Larynx, and Infrahyoid Neck Axial 8

Trachea Brachiocephalic a. Sternocleidomastoid m.

L. subclavian a.

Esophagus



L. brachiocephalic v. Clavicle L. common carotid a.

Lung

SURGICAL CONSIDERATION The left innominate (brachiocephalic) vein passes immediately posterior to the suprasternal notch. It drains venous blood from the left internal jugular vein and left subclavian vein, crosses the midline, and joins right innominate vein to form the superior vena cava. In midline sternotomy, when injury involves the left innominate vein, control can be obtained by hooking a finger deep to the suprasternal notch and pulling upward.

486

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Axial 8

Sternocleidomastoid m.

Clavicle Brachiocephalic v.

R. brachiocephalic a. Trachea

Esophagus

Sternocleidomastoid m.

Common carotid a. Subclavian a. Lung

Clavicle Brachiocephalic v.

R. brachiocephalic a. Trachea

Esophagus

Common carotid a. Subclavian a. Lung

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

487

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 1

Submandibular gland

False vocal cord Paraglottic space

True vocal cord

Thyroid cartilage

Thyroarytenoid m.

Subglottis

Strap mm.

Cricoid cartilage

IMAGING TECHNIQUE CONSIDERATION Coronal imaging is used less often than axial imaging when assessing the neck. However, the ability to see the craniocaudal extent of the jugular lymph node chain in the anterior neck and the spinal accessory lymph node chain in the posterior neck often makes enlarged lymph nodes more conspicuous on coronal MR images.

488

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 1

Submandibular gland False vocal cord Paraglottic space Thyroid cartilage Subglottis

True vocal cord Thyroarytenoid m. Strap mm.

Cricoid cartilage

Submandibular gland False vocal cord Paraglottic space Thyroid cartilage Subglottis

True vocal cord Thyroarytenoid m. Strap mm.

Cricoid cartilage

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

489

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 2

Submandibular gland

Thyroid cartilage R. external carotid a.

Thyroarytenoid m.

Paraglottic space Cricoid cartilage

Strap mm.

Trachea

Thyroid gland



PATHOLOGIC PROCESS Note the asymmetric dark focus associated with the right vocal cord, suggestive of previous Teflon injection for vocal cord palsy.

490

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 2

Submandibular gland Thyroid cartilage R. external carotid a. Thyroarytenoid m.

Paraglottic space Cricoid cartilage

Strap mm.

Trachea

Thyroid gland

Submandibular gland R. external carotid a. Thyroid cartilage Thyroarytenoid m.

Paraglottic space Cricoid cartilage Trachea

Strap mm.

Thyroid gland

     

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

491

Hpopharynx, Larynx, and Infrahyoid Neck Coronal 3

Submandibular gland

R. external carotid a.

Piriform sinus

Thyroid cartilage

Aryepiglottic m. with aryepiglottic fold

Strap mm.

Arytenoid cartilage

Trachea

Thyroarytenoid m.

Thyroid gland Sternocleidomastoid m.

492

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 3

Submandibular gland R. external carotid a. Strap mm. Thyroid cartilage

Piriform sinus Aryepiglottic m. with aryepiglottic fold Arytenoid cartilage Thyroarytenoid m.

Trachea

Sternocleidomastoid m.

Thyroid gland

Submandibular gland R. external carotid a. Strap mm. Thyroid cartilage

Piriform sinus Aryepiglottic m. with aryepiglottic fold Arytenoid cartilage Thyroarytenoid m.

Trachea

Sternocleidomastoid m.

Thyroid gland

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

493

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 4

Submandibular gland Longus colli m.

Sternocleidomastoid m.

R. internal jugular v.

Inferior constrictor m.

R. common carotid a. Clavicle

Trachea

Esophagus

494

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Anterior scalene m.

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 4

Longus colli m.

Submandibular gland

Sternocleidomastoid m. Inferior constrictor m.

R. common carotid a. R. internal jugular v. Trachea

Clavicle

Esophagus

Anterior scalene m.

Submandibular gland

Longus colli m.

Sternocleidomastoid m. Inferior constrictor m.

R. common carotid a. R. internal jugular v. Trachea

Clavicle

Esophagus

Anterior scalene m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

495

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 5

Internal jugular v. Sternocleidomastoid m. Vertebral a.

C5 vertebral body

Middle scalene m.

C6 vertebral body Posterior scalene m.

Trachea

496

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 5

Internal jugular v.

Sternocleidomastoid m.

Vertebral a.

C5 vertebral body C6 vertebral body

Middle scalene m.

Posterior scalene m. Trachea

Internal jugular v.

Sternocleidomastoid m.

Vertebral a. C5 vertebral body C6 vertebral body Middle scalene m.

Posterior scalene m. Trachea

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

497

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 6

Spinalis cervicis m. Levator scapulae m. Sternocleidomastoid m. Spinal cord Middle scalene m. Posterior scalene m. Trapezius m.

Lung



NORMAL ANATOMY On the Coronal 6 image, cervical nerve roots are seen exiting the foramina to form the brachial plexus. This plexus is formed at cervical vertebrae C5, C6, C7, and C8 and the first thoracic vertebra (T1). Note that C8 is the only nerve without a corresponding vertebra; thus it exits through the C7-T1 foramen. Nerves above this level exit above the corresponding vertebra (e.g., C7 exits spinal canal through C6-C7 foramen), and nerves below this level exit below the corresponding vertebra (e.g., T1 exits through T1-T2 foramen).



PATHOLOGIC PROCESS Metastatic lymph nodes in the neck typically are anterior to the spinal column and do not invade the brachial plexus, except in florid disease. More often, a tumor in the top of the lungs may involve the brachial plexus, known as a Pancoast tumor (pulmonary sulcus tumor).

498

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 6

Spinalis cervicis m. Levator scapulae m. Sternocleidomastoid m. Spinal cord

Middle scalene m.

Trapezius m. Posterior scalene m.

Lung

Spinalis cervicis m. Levator scapulae m. Sternocleidomastoid m. Spinal cord

Middle scalene m.

Trapezius m. Posterior scalene m.

Lung

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

499

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 7

Semispinalis cervicis m. Longissimus cervicis m. Multifidus m. Splenius cervicis m. Levator scapulae m. Posterior scalene m. 2nd rib Trapezius m.

Lung

500

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Supraspinatus m.

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 7

Semispinalis cervicis m. Longissimus cervicis m. Splenius cervicis m. Multifidus m. Trapezius m. Levator scapulae m. Posterior scalene m. Supraspinatus m. 2nd rib

Lung

Semispinalis cervicis m. Longissimus cervicis m. Splenius cervicis m. Multifidus m. Trapezius m. Levator scapulae m. Posterior scalene m. Supraspinatus m. 2nd rib

Lung

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

501

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 8

Spinous process Semispinalis cervicis m. Splenius cervicis m. Multifidus m. Levator scapulae m. Trapezius m.

2nd rib

Spinal cord

502

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Lung

Hypopharynx, Larynx, and Infrahyoid Neck Coronal 8

Spinous process Splenius cervicis m. Semispinalis cervicis m. Multifidus m. Trapezius m. Levator scapulae m. 2nd rib

Lung Spinal cord

Spinous process Splenius cervicis m. Semispinalis cervicis m. Multifidus m. Trapezius m. Levator scapulae m.

2nd rib

Lung Spinal cord

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

503

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 1

C3 vertebral body Hyoid bone Epiglottis

Laryngeal ventricle False vocal cord Thyroid cartilage True vocal cord Subglottis Cricoid cartilage Thyroid isthmus

Trachea Esophagus Manubrium

IMAGING TECHNIQUE CONSIDERATION Although the Sagittal 1 plane is ideally a midline image, most patients will show a slight curvature caused by positioning or scoliosis. This sagittal image is fairly well centered on the hypopharynx and upper trachea, although the lower trachea is seen curving off the plane of image, as are the lower cervical and upper thoracic spinous processes.

504

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 1

Epiglottis

Hyoid bone

C3 vertebral body

Laryngeal ventricle False vocal fold True vocal fold Thyroid cartilage Subglottis Cricoid cartilage Thyroid isthmus Trachea Esophagus Manubrium

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

505

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 2

Hyoid bone Laryngeal vestibule Pre-epiglottic space Thyroid cartilage Arytenoid cartilage True vocal cord Subglottis Cricoid cartilage Thyroid isthmus

Trachea

Manubrium



NORMAL ANATOMY Usually the vertebra with the most palpable spinous process is C7. This patient has subcutaneous tissue that does not allow for palpation of the C7 spinous process tip. However, note how much farther posteriorly the C7 process extends than the tip of C3, C4, C5, or C6. The most accurate way of labeling spine levels is to count from C1. The hyoid bone is anterior to C3.

506

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 2

Hyoid bone Pre-epiglottic space Thyroid cartilage True vocal fold Arytenoid cartilage Subglottis Cricoid cartilage Thyroid isthmus Trachea

Manubrium

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

507

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 3

Hyoid bone Pre-epiglottic space

Thyroid cartilage True vocal cord Arytenoid cartilage Cricoid cartilage Thyroid gland

Sternocleidomastoid m.

Manubrium

508

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 3

Hyoid bone Pre-epiglottic space Thyroid cartilage True vocal fold Arytenoid cartilage Cricoid cartilage Thyroid gland

Sternocleidomastoid m. Manubrium

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

509

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 4

Hyoid bone

Thyroid cartilage Arytenoid cartilage Cricoid cartilage

Thyroid gland

Sternocleidomastoid m.

Lung

Manubrium



NORMAL ANATOMY The cervical neural foramina rarely line up on a single plane as in lumbar imaging, where the ­anatomic structures such as the foramina and pedicles are much larger. In the Sagittal 4 CT image, the upper neural foramina can be seen, but not the lower foramina because of c­ urvature of the cervical spine from positioning or scoliosis. Thus, assessment of cervical foraminal ­stenosis is often best done on axial images, where there is symmetry for comparison.



DIAGNOSTIC CONSIDERATION Although measurement of cervical lymph nodes is performed on axial imaging by convention, the sagittal plane can often increase the conspicuity of an enlarged lymph node, because the internal jugular and spinal accessory lymph node chains can be seen along their entire length.

510

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 4

Hyoid bone

Thyroid cartilage Arytenoid cartilage Cricoid cartilage

Thyroid gland

Sternocleidomastoid m. Manubrium

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

511

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 5

Splenius capitis m. Internal jugular v.

Semispinalis cervicis m.

Common carotid a.

Sternocleidomastoid m.

Trapezius m.

Thyroid lobe

Clavicle

1st rib Longissimus cervicis m.

Lung Rhomboid m.

512

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 5

Common carotid a. Interior jugular v.

Sternocleidomastoid m. Thyroid lobe

Splenius capitis m Semispinalis cervicis m.

Trapezius m. 1st rib Longissimus cervicis m.

Clavicle Rhomboid m. Lung

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

513

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 6

Levator scapulae m. Sternocleidomastoid m.

Middle scalene m. Anterior scalene m.

Internal jugular v. Semispinalis cervicis m. Brachial plexus Subclavian a.

Brachiocephalic v.

Trapezius m. 1st rib

Clavicle Rhomboid m. Lung

514

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 6

Internal jugular v.

Levator scapulae m. Middle scalene m.

Sternocleidomastoid m. Anterior scalene m. Brachial plexus Subclavian a.

Anterior scalene m. Semispinalis cervicis m. Trapezius m. 1st rib

Brachiocephalic v. Clavicle Rhomboid m. Lung

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

515

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 7

Levator scapulae m. Sternocleidomastoid m. Semispinalis cervicis m. Middle scalene m. Anterior scalene m. 1st rib Subclavian a. Trapezius m.

Clavicle Lung

516

Rhomboid m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 7

Levator scapulae m. Sternocleidomastoid m.

Anterior scalene m.

Semispinalis cervicis m. Middle scalene m. Trapezius m.

Subclavian a.

Clavicle

Lung

Rhomboid m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

517

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 8

Sternocleidomastoid m. Middle scalene m. 1st rib

Semispinalis cervicis m.

Subclavian a.

Trapezius m.

Clavicle

Lung Rhomboid m.

518

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Hypopharynx, Larynx, and Infrahyoid Neck Sagittal 8

Sternocleidomastoid m.

Middle scalene m. 1st rib

Semispinalis cervicis m.

Trapezius m.

Subclavian a.

Clavicle Rhomboid m.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

519

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PART

3

SPINE

CHAPTER 15 OVERVIEW OF SPINE  523 CHAPTER 16  SPINE 535

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521

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15

Chapter

OVERVIEW OF SPINE

VERTEBRAL COLUMN  524 CERVICAL VERTEBRAE: C1 (ATLAS) AND C2 (AXIS)  525 CERVICAL VERTEBRAE: C3, C4, AND C7  526 EXTERNAL CRANIOCERVICAL LIGAMENTS  527 INTERNAL CRANIOCERVICAL LIGAMENTS  528 THORACIC VERTEBRAE  529 LUMBAR VERTEBRAE  530 VERTEBRAL LIGAMENTS: LUMBOSACRAL REGION  531 VERTEBRAL LIGAMENTS: LUMBAR REGION  532 LUMBAR REGION OF BACK: CROSS SECTION  533

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

523

Vertebral Column

Anterior view Atlas (C1) Axis (C2)

Left lateral view

Posterior view

Atlas (C1)

Atlas (C1)

Axis (C2)

Axis (C2) Cervical curvature

Cervical vertebrae

C7

C7

C7

T1

T1

T1

Thoracic vertebrae

Thoracic curvature

T12

L1

T12

T12 L1

L1

Lumbar vertebrae Lumbar curvature L5 L5

L5

Sacrum (S1-S5) Sacrum (S1-S5)

Sacrum (S1-S5) Sacral curvature Coccyx

524

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Coccyx

Coccyx

Cervical Vertebrae: C1 (Atlas) and C2 (Axis)

Anterior tubercle Articular facet for dens

Anterior arch

Lateral mass

Transverse process Tubercle for transverse ligament of atlas

Transverse foramen Superior articular surface of lateral mass for occipital condyle

Anterior articular facet (for anterior arch of atlas)

Dens

Pedicle Superior articular facet for atlas

Interarticular part

Spinal canal Posterior arch

Posterior tubercle Groove for vertebral artery

Inferior articular facet for C3

Atlas (C1): superior view

Axis (C2): anterior view

Posterior arch

Posterior tubercle

Spinal canal

Transverse process

Transverse process

Body

Dens Superior articular facet for atlas

Posterior articular facet (for transverse ligament of atlas) Transverse process

Interarticular part

Transverse foramen Inferior articular surface of lateral mass for axis

Articular facet for dens Anterior arch

Anterior tubercle

Atlas (C1): inferior view

Inferior articular process

Spinous process

Axis (C2): posterosuperior view Dens Atlas (C1)

Superior articular surface for occipital condyle

Axis (C2) Posterior articular facet (for transverse ligament of atlas)

C3

C4

Upper cervical vertebrae, assembled: posterosuperior view

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

525

Cervical Vertebrae: C3, C4, and C7 Inferior aspect of C3 and superior aspect of C4 showing the sites of the facet and uncovertebral articulations

Bifid spinous process

C3 Inferior aspect

Lamina Spinal canal

Inferior articular process and facet

Pedicle

Foramen transversarium

Posterior tubercle

Costal lamella

Anterior tubercle

Transverse process

Area for articulation of left uncinate process of C4 Vertebral body

Left uncinate process

Articular surface of right uncinate process

Superior articular process and facet

Groove for spinal nerve (C4)

C4 Superior aspect

Inferior articular process

4th cervical vertebra: anterior view Superior articular process Lamina

Inferior articular facet Body Foramen transversarium

7th cervical vertebra: anterior view Superior articular process Septated foramen transversarium Uncinate process Costal lamella Articular surface Articular surface

Spinous process Uncinate process

Posterior tubercle Anterior tubercle

Bony spicule dividing foramen transversarium Transverse process Inferior articular facet for T1

Posterior tubercle Body

Anterior tubercle (inconspicuous)

Transverse process

7th cervical vertebra (vertebra prominens): superior view Body Uncinate process Costal lamella Foramen transversarium* Inconspicuous anterior tubercle (transverse process)

Articular surface of uncinate process Foramen transversarium (septated) Groove for C7 spinal nerve Transverse process (posterior tubercle) Superior articular process and facet

Pedicle

Inferior articular process Lamina

Spinal canal Spinous process

*The foramina transversaria of C7 transmit vertebral veins, but usually not the vertebral artery, and are asymmetric in this specimen.

526

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

External Craniocervical Ligaments

Anterior view Basilar part of occipital bone Pharyngeal tubercle Anterior atlantooccipital membrane Capsule of atlantooccipital joint Posterior atlantooccipital membrane

Atlas (C1)

Lateral atlantoaxial joint (exposed ) Anterior longitudinal ligament

Capsule of lateral atlantoaxial joint

Posterior view

Axis (C2)

Posterior atlantooccipital membrane

Occipital bone

Capsule of zygapophyseal joint (C3-C4)

Capsule of atlantooccipital joint Transverse process of atlas (C1)

Anterior atlantooccipital membrane

Capsule of atlantooccipital joint

Capsule of lateral atlantoaxial joint Axis (C2)

Posterior atlantooccipital membrane

Atlas (C1)

Ligamenta flava Vertebral artery

Suboccipital nerve (dorsal ramus of C1 spinal nerve)

Ligamenta flava Body of axis (C2) Ligamentum nuchae

Intervertebral discs (C2-C3 and C3-C4)

Zygapophyseal joints (C4-C5 and C5-C6) Anterior tubercle of C6 vertebra (carotid tubercle of Chasssaignac) Spinous process of C7 vertebra (vertebra prominens)

Vertebral artery T1 vertebra

Supraspinous ligament Right lateral view

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

527

Internal Craniocervical Ligaments

Clivus

Upper part of vertebral canal with spinous processes and parts of vertebral arches removed to expose ligaments on posterior vertebral bodies: posterior view

Tectorial membrane

Capsule of atlantooccipital joint

Deeper (accessory) part of tectorial membrane (atlantoaxial ligament) Posterior longitudinal ligament

Atlas (C1) Capsule of lateral atlantoaxial joint

Alar ligaments

Axis (C2) Capsule of zygapophyseal joint (C2-C3)

Atlas (C1) Superior longitudinal band Cruciate ligament

Transverse ligament of atlas Inferior longitudinal band

Axis (C2)

Deeper (accessory) part of tectorial membrane (atlantoaxial ligament)

Principal part of tectorial membrane removed to expose deeper ligaments: posterior view Apical ligament of dens Anterior atlantoocipital ligament Alar ligament Atlas (C1)

Posterior articular facet of dens (for transverse ligament of atlas) Anterior tubercle of atlas Alar ligament

Axis (C2)

Cruciate ligament removed to show deeper ligaments: posterior view

Synovial cavities

Dens Transverse ligament of atlas Median atlantoaxial joint: superior view

528

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Thoracic Vertebrae

Superior articular process and facet

Body Spinal canal Superior costal facet

Pedicle Transverse costal facet

Body Superior vertebral notch (forms lower margin of intervertebral foramen)

Superior costal facet

Transverse process

Pedicle Inferior articular process Transverse costal facet Lamina

Superior articular facet

Inferior costal facet Inferior vertebral notch

Spinous process

Spinous process

T6 vertebra: lateral view

T6 vertebra: superior view Superior articular process and facet Body

Spinal canal Superior articular process and facet

7th rib

Transverse process

T7

Costal facet

Spinous process

Inferior articular process and facet T8

Spinous process of T7 vertebra

T12 vertebra: lateral view

Transverse process of T9 vertebra T9 Inferior articular process (T9)

Lamina

Spinous process (T9)

T7, T8, and T9 vertebrae: posterior view

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

529

Lumbar Vertebrae

Anulus fibrosus

Vertebral body Spinal canal

Nucleus pulposus

Pedicle

Transverse process

Intervertebral disc

Accessory process

Superior articular process Mammillary process Lamina

Superior articular process

Spinous process Pedicle

Transverse process

L2 vertebra: superior view

Vertebral body

Spinal canal

Spinous process L1 Inferior articular process

Intervertebral disc

Superior articular process Mammillary process

Vertebral body

Transverse process

Inferior vertebral notch

L2

Intervertebral (neural) foramen

Pars interarticularis

Superior vertebral notch

L3

Accessory process

Mammillary process

Lamina

L3

Spinous process of L3 vertebra

L4

Lamina Inferior articular process

L4

L3 and L4 vertebrae: posterior view

530

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

L5

Articular facet for sacrum

Lumbar vertebrae, assembled: left lateral view

Vertebral Ligaments: Lumbosacral Region

Superior articular process

Anterior longitudinal ligament

Transverse process Lamina Inferior articular process

Body of L1 vertebra

Pedicle (cut)

Pedicle

Posterior longitudinal ligament

Intervertebral foramen

Intervertebral discs

Spinous process Interspinous ligament

Ventral ramus of L2 spinal nerve

Supraspinous ligament

Superior articular processes; facet tropism (difference in facet axis) on right side Spinous process

L4 spinal nerve

Lamina Transverse process

Body of L5 vertebra

Inferior articular process Ligamentum flavum

Dorsal ramus of L5 spinal nerve

Iliolumbar ligament Iliac crest

Auricular surface of sacrum (for articulation with ilium)

Posterior superior iliac spine

Sacrum Coccyx

Posterior inferior iliac spine

Left lateral view

Posterior sacroiliac ligaments Greater sciatic foramen Spine of ischium

Lateral and posterior sacrococcygeal ligaments

Sacrospinous ligament Lesser sciatic foramen Sacrotuberous ligament

Ischial tuberosity Posterior view

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

531

Vertebral Ligaments: Lumbar Region

Inferior articular process Capsule of zygapophyseal joint (partially opened ) Anterior longitudinal ligament

Superior articular process Transverse process

Lumbar vertebral body

Spinous process Ligamentum flavum

Intervertebral disc

Interspinous ligament Anterior longitudinal ligament

Supraspinous ligament Intervertebral foramen

Posterior longitudinal ligament

Posterior vertebral segments: anterior view Pedicle (cut surface)

Pedicle (cut surface)

Ligamentum flavum

Posterior surface of vertebral bodies Lamina Posterior longitudinal ligament

Superior articular process

Intervertebral disc

Transverse process

Inferior articular facet

532

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Lumbar Region of Back: Cross Section

Descending (2nd) part of duodenum Kidney Renal fascia (anterior and posterior layers)

Inferior vena cava Pancreas Anterior longitudinal ligament

Perirenal fat Pararenal fat Peritoneum Extraperitoneal (subserous) fascia (areolar tissue)

Crura of diaphragm Superior mesenteric artery and vein Mesentery Abdominal aorta

Transversalis fascia

Duodenojejunal junction Body of L2 vertebra Psoas major muscle and fascia Lumbar spinal nerve Transverse process

External oblique muscle

Spinal dura mater

Internal oblique muscle

Cauda equina

Transversus abdominis muscle Tendon of origin of transversus abdominis and internal oblique muscles Serratus posterior inferior muscle Latissimus dorsi muscle Quadratus lumborum muscle

Spinous process of L1 vertebra Supraspinous ligament Erector spinae muscle Thoracolumbar fascia (posterior layer) Thoracolumbar fascia (middle layer) Thoracolumbar fascia (anterior layer— quadratus lumborum fascia)

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

533

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16 SPINE

Chapter CERVICAL SPINE

THORACIC SPINE

LUMBOSACRAL SPINE

1 3 2 5 4 6 7 8

1 2 34 56

1 2 3

AXIAL 536

AXIAL 572

AXIAL 584

1 2 345

CORONAL 552

3 1 2

SAGITTAL 578

5 31 42

SAGITTAL 596

5 31 42

SAGITTAL 562

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

535

tahir99-VRG & vip.persianss.ir

Cervical Spine Axial 1

L. internal carotid a. Superior cortex of anterior arch C1

Styloid process L. internal jugular v.

Atlanto-occipital joint

Occipital condyle

L. vertebral a.

Foramen magnum



PATHOLOGIC PROCESS Note on these images that the nasopharynx is often seen on cervical spine imaging. The neuroradiologist should always check for symmetry of the Eustachian tube opening and fossa of Rosenmüller just anterior to the longus capitis muscle to ensure that no nasopharyngeal lesion is present (see Chapter 13).

IMAGING TECHNIQUE CONSIDERATION Spinal imaging can be daunting at first due to the complex three-dimensional (3D) anatomy of the vertebrae and the critical implications of damage to the spine. This is particularly true taking into account various signal characteristics on magnetic resonance imaging (MRI) and motion artifact from vessel pulsation and respiration. A good principle is that computed tomography (CT) and MRI are complementary. In general, CT better delineates the architecture of the dense bones, the cortex of which does not provide much MR signal, and MRI is better at providing contrast to the soft tissues, such as the spinal cord. Although CT (top image) would be better at showing a subtle fracture of the vertebral artery foramen, MRI (bottom image) would be better at delineating hematoma in the wall of the vertebral artery from dissection. Another good principle for learning spinal anatomy is that the lower the level in the spine, the larger the vertebrae and the easier it is to understand the anatomy. Thus it is often best to start with the lumbar spine, learning both diagnostic principles and image-guided intervention, and to work up the spine as familiarity with spinal anatomy increases.

536

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY tahir99-VRG & vip.persianss.ir

Cervical Spine Axial 1

Superior cortex of anterior arch C1

Styloid process Occipital condyle

Atlanto-occipital joint

Foramen magnum

Longus capitis m. Anterior atlanto-occipital membrane Occipital condyle

Vertebral a. Cervicomedullary junction Foramen magnum

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

537

tahir99-VRG & vip.persianss.ir

Cervical Spine Axial 2

Anterior arch C1

Parapharyngeal fat

Styloid process L. internal carotid a. Longus capitis m.

Anterior atlantodental joint L. internal jugular v.

C1 lateral mass

L. vertebral a. Odontoid tip Transverse ligament



DIAGNOSTIC CONSIDERATION The predental space, or distance between the anterior aspect of the dens and the posterior border of the anterior arch of C1 (atlas), should measure 3 mm or less in the adult patient. Widening of this space or asymmetry of soft tissue lateral to the odontoid raises concern for cruciate ligament injury. The best imaging test is voluntary flexion and extension sequences on lateral cervical radiographs to check for change in the predental space measurement. However, in the patient who has pain limiting motion, or in the unconscious patient, CT or MRI can provide secondary signs such as fracture of C1 or C2 (axis), hemorrhage along the dura, and edema within the soft tissues.

538

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY tahir99-VRG & vip.persianss.ir

Cervical Spine Axial 2

Anterior arch C1 Longus capitis m.

C1 lateral mass

Styloid process Anterior atlantodental joint

Odontoid tip

Transverse ligament

Anterior arch C1 Longus capitis m.

C1 lateral mass

Anterior atlantodental joint

Odontoid tip Transverse ligament

Cervical cord

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

539

tahir99-VRG & vip.persianss.ir

Cervical Spine Axial 3

L. external carotid a.

R. inferior alveolar n.

L. internal carotid a. Atlantoaxial joint

L. internal jugular v.

C1 superior articular facet

Base of odontoid L. vertebral a.

Transverse process

Transverse foramen Transverse ligament Cruciate ligament

C1 posterior arch



PATHOLOGIC PROCESS Somewhat counterintuitively, a fracture through the larger base of the odontoid process is less serious than a fracture more superiorly near the tip. The better, more proximal blood supply at the odontoid base allows better healing and less chance of avascular necrosis.

540

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY tahir99-VRG & vip.persianss.ir

Cervical Spine Axial 3

R. inferior alveolar n. Atlantoaxial joint C1 superior articular facet Transverse process Transverse ligament

Base of odontoid

Transverse foramen Cruciate ligament

C1 posterior arch

Atlantoaxial joint C1 superior articular facet Base of odontoid Transverse process

Transverse ligament

Transverse foramen

Cruciate ligament

Cervical cord C1 posterior arch

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

541

tahir99-VRG & vip.persianss.ir

Cervical Spine Axial 4

L. external carotid a. L. internal carotid a. L. internal jugular v.

Junction base of odontoid with body C2 L. vertebral a.

Spinal canal

542

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY tahir99-VRG & vip.persianss.ir

Cervical Spine Axial 4

Junction base of odontoid with body C2

Spinal cord

L. external carotid a. L. internal carotid a. L. internal jugular v. Junction base of odontoid with body C2 L. vertebral a. Spinal cord

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

543

tahir99-VRG & vip.persianss.ir

Cervical Spine Axial 5

Oropharyngeal lumen L. external carotid a. L. internal carotid a. C2 inferior body L. internal jugular v. C2 transverse process L. vertebral a. C2 transverse foramen

C2 lamina

C2 spinous process

IMAGING TECHNIQUE CONSIDERATION The MR images (lower) are axial 3D T2* gradient images. The advantages over standard 2D spin-echo sequences are the higher spatial resolution and the ability to reformat in any plane. Motion, however, tends to cause all the images of the sequence to become blurred.

544

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY tahir99-VRG & vip.persianss.ir

Cervical Spine Axial 5

Oropharyngeal lumen

C2 inferior body C2 transverse process

L. vertebral a. C2 transverse foramen

C2 lamina

C2 spinous process

Oropharyngeal lumen

C2 inferior body C2 transverse process

L. vertebral a. C2 transverse foramen

Cervical cord

C2 lamina

C2 spinous process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

545

tahir99-VRG & vip.persianss.ir

Cervical Spine Axial 6

L. external carotid a. C3 transverse process anterior tubercle

L. vertebral a.

C2-C3 intervertebral disc

L. internal jugular v.

L. internal carotid a.

C2-C3 neural foramen

C3 uncinate process

C3 superior articular process

C2-C3 facet joint

C2 inferior articular process

C2 lamina

C2 bifid spinous process



PATHOLOGIC PROCESS Uncovertebral osteophytes at the posterolateral aspects of the vertebral body can cause narrowing of the foramina and impingement of exiting nerve roots. Some osteophytes may be confluent with a broad-based disc-osteophyte complex across the entire posterior aspect of the vertebral body that can chronically flatten the spinal cord.

546

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cervical Spine Axial 6

C2 transverse process anterior tubercle C2-C3 intervertebral disc C3 uncinate process C2-C3 facet joint

C2-C3 neural foramen C3 superior articular process C2 inferior articular process C2 lamina

C2 bifid spinous process

C2 transverse process anterior tubercle C2-C3 intervertebral disc C3 uncinate process C2-C3 facet joint

Cervical cord

L. vertebral a. C2-C3 neural foramen C3 superior articular process C2 inferior articular process

C2 lamina

C2 bifid spinous process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

547

Cervical Spine Axial 7

Epiglottis

C3 vertebral body C3 transverse process anterior tubercle

Transverse foramen L. external carotid a.

C3 transverse process posterior tubercle

L. vertebral a. L. internal carotid a.

C3 pedicle L. internal jugular v. C3 superior articular process C3 lamina

C2 bifid spinous process



DIAGNOSTIC CONSIDERATION Note that the bony vertebral artery foramina, also called transverse foramina, are symmetric in this patient (Cervical Axial 7). A careful search for fracture lines across these foramina in the setting of trauma will help reveal vertebral artery dissection. Angiography (CTA or MRA) of the cervical arteries often shows some asymmetry in the lumina. If corresponding asymmetry exists in the bony foramina, the cause is likely a congenitally hypoplastic side rather than a dissection.

548

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cervical Spine Axial 7

Epiglottis C3 transverse process anterior tubercle

C3 vertebral body

C3 transverse process posterior tubercle

L. vertebral a. Transverse foramen

C3 pedicle C3 superior articular process C3 lamina

C2 bifid spinous process

Epiglottis

C3 transverse process anterior tubercle

C3 vertebral body

C3 transverse process posterior tubercle

L. vertebral a.

C3 pedicle

Transverse foramen

C3 superior articular process C3 lamina

C2 bifid spinous process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

549

Cervical Spine Axial 8

Epiglottis Hyoid bone C3-C4 intervertebral disc L. common carotid a. L. vertebral a. L. internal jugular v. C4 superior articular process C3-C4 facet joint C3 inferior articular process C3 lamina

C3 spinous process

550

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cervical Spine Axial 8

Epiglottis Hyoid bone C3-C4 intervertebral disc C4 superior articular process C3-C4 facet joint C3 inferior articular process C3 lamina

C3 spinous process

C3-C4 intervertebral disc

C4 superior articular process C3-C4 facet joint C3 inferior articular process C3 lamina

C3 spinous process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

551

Cervical Spine Coronal 1

Condyloid process

Mandibular ramus

R. internal jugular v.

C3 vertebral body

C4 vertebral body C5 transverse process anterior tubercle C5 vertebral body

C6 transverse process anterior tubercle

C6 vertebral body

IMAGING TECHNIQUE CONSIDERATION The temporomandibular joints (TMJs) can often be seen in coronal imaging of the cervical spine. In Cervical Spine Coronal 1, there is slight rotation of positioning such that the patient’s left TMJ on the right side of the image is slightly more anterior and better seen than the right TMJ.

552

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cervical Spine Coronal 1

Condyloid process

Mandibular ramus

R. internal jugular v.

C3 vertebral body

C4 vertebral body

C5 vertebral body

C6 vertebral body

C5 transverse process anterior tubercle

C6 transverse process anterior tubercle

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

553

Cervical Spine Coronal 2

Clivus

Mandibular ramus C1 anterior arch Styloid L. internal carotid a. C2 vertebral body C3 transverse process anterior tubercle R. vertebral a. R. internal jugular v. C4 transverse process posterior tubercle Transverse foramen

C2-C3 intervertebral disc C3 vertebral body C3-C4 intervertebral disc C4 vertebral body C4-C5 intervertebral disc C5 vertebral body

C5 transverse process posterior tubercle

C5-C6 intervertebral disc C6 vertebral body

C6 transverse process

C6-C7 intervertebral disc C7 vertebral body

554

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cervical Spine Coronal 2

Clivus C1 anterior arch Mandibular ramus

C2 vertebral body C2-C3 intervertebral disc C3 transverse process anterior tubercle

C3 vertebral body

C3-C4 intervertebral disc C4 transverse process posterior tubercle

Vertebral a.

C4-C5 intervertebral disc

C4 vertebral body

C5 transverse process posterior tubercle

C5 vertebral body

C5-C6 intervertebral disc C6 transverse process C6-C7 intervertebral disc

C6 vertebral body

C7 vertebral body

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

555

Cervical Spine Coronal 3

Basion Occipital condyle

Condyloid process

L. internal jugular v. R. internal carotid a.

Alar ligament

C1 lateral mass

Odontoid process C1 transverse process

Atlantoaxial joint

C2 vertebral body

C2 transverse process Uncinate process

C2-C3 intervertebral disc

C3 pedicle

C3 vertebral body

Intervertebral foramen C4 superior articular process

C3-C4 intervertebral disc C4 vertebral body

C4 inferior articular process

C4-C5 intervertebral disc

C5 superior articular process

C5 vertebral body

C5 inferior articular process

C5-C6 intervertebral disc

C6 superior articular process

C6 vertebral body

Basivertebral v.

C6-C7 intervertebral disc C7 vertebral body



DIAGNOSTIC CONSIDERATION The coronal image is a good plane on which to assess for asymmetric positioning of the odontoid process. Note that in Cervical Spine Coronal 3 there is slightly more space to the right side of the patient’s odontoid (left side of the image), although this is likely caused by slight rotation of the patient’s neck or perhaps slight normal variation rather than trauma in this patient. The edges of the atlantoaxial joints are shown to be well aligned.

556

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cervical Spine Coronal 3

Basion Condyloid process

C1 lateral mass Atlantoaxial joint C2 transverse process Uncinate process C3 pedicle Intervertebral foramen C4 superior articular process C5 superior articular process

Occipital condyle Alar ligament Odontoid process C1 transverse process C2 vertebral body C2-C3 intervertebral disc C3 vertebral body C3-C4 intervertebral disc C4 vertebral body C4-C5 intervertebral disc

C5 inferior articular process

C5 vertebral body

C6 inferior articular process

C5-C6 intervertebral disc

Basivertebral v.

C6 vertebral body C6-C7 intervertebral disc C7 vertebral body

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

557

Cervical Spine Coronal 4

Occipital condyle C1 lateral mass C1 transverse process

Atlanto-occipital joint Odontoid process

Atlantoaxial joint C2 articular pillar

C3 articular pillar

C4 articular pillar

C5 articular pillar

C6 articular pillar

C7 articular pillar

558

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Spinal cord

Cervical Spine Coronal 4

Occipital condyle C1 lateral mass Atlanto-occipital joint C1 transverse process

Odontoid process

Atlantoaxial joint C2 articular pillar

C3 articular pillar

C4 articular pillar

Spinal cord

C5 articular pillar

C6 articular pillar

C7 articular pillar

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

559

Cervical Spine Coronal 5

Mastoid air cells

Occipitomastoid suture

Condylar canal

C1 posterior arch

C2 lamina

C3 spinous process

C4 spinous process

C5 spinous process

C6 spinous process

C7 lamina

560

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cervical Spine Coronal 5

Mastoid air cells Occipitomastoid suture

Condylar canal C1 posterior arch

C2 lamina

C3 spinous process

C4 spinous process C5 spinous process C6 spinous process C7 lamina

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

561

Cervical Spine Sagittal 1 Basion Anterior atlanto-occipital membrane Opisthion

Apical ligament Cruciate ligament C1 anterior arch Anterior atlantodental joint

Tectorial membrane C1 posterior arch

Base of odontoid process C2 spinous process

C2-C3 intervertebral disc

Interspinous ligament

C3 vertebral body

C3 spinous process

C3-C4 intervertebral disc

Spinal cord

C4 vertebral body

C4 spinous process

C4-C5 intervertebral disc

Venous plexus

C5 vertebral body C5 spinous process

C5-C6 intervertebral disc C6 vertebral body

C6 spinous process

C6-C7 intervertebral disc C7 spinous process

C7 vertebral body

IMAGING TECHNIQUE CONSIDERATION The midline sagittal cervical image is arguably the most important image in spinal imaging. Injury to the cord above C3 can lead to respiratory loss and death. The diaphragms are innervated by C3, C4, and C5 (“C3, 4, 5 keep the diaphragm alive”), and cord injury below this level can lead to quadriplegia. The most palpable spinous process is usually that of C7. Recall that there are eight cervical nerves, so in the cervical region, a nerve root exits just above its corresponding vertebral body (e.g., C7 nerve root exits C6-C7 neural foramen). In the thoracic region, where there are typically 12 exiting nerve roots and 12 vertebral bodies, and in the lumbar region, where there are typically five lumbar vertebral bodies and five exiting nerve roots, the nerve root exits just below the corresponding vertebral body (e.g., L5 nerve root exits at L5-S1 neural foramen). Considerable variation exists, however, such as a lumbarized first sacral (S1) vertebral body or an accessory rib; thus, with any spinal imaging analysis, the examiner should declare the numbering of levels used. The best method is to count down from C1. Note the clear view of the aerodigestive tract lumen, which should always be assessed. Narrowing of the lumen from prevertebral soft tissue swelling may indicate cervical spine injury. Above C4, the prevertebral soft tissue should be not more than one-third the distance of the anterior-to-posterior measurement of the vertebral body. The nasopharynx is somewhat bulky in this case because of normally prominent adenoidal tissue in this relatively young patient, with little cervical degenerative disc disease.

562

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cervical Spine Sagittal 1

Basion Anterior atlanto-occipital membrane Apical ligament Cruciate ligament C1 anterior arch Anterior atlantodental joint Longus capitis m. Base of odontoid process C2-C3 intervertebral disc C3 vertebral body C3 inferior vertebral endplate C4 superior vertebral endplate

Opisthion Tectorial membrane C1 posterior arch C2 spinous process Interspinous ligament C3 spinous process Venus plexus C4 spinous process

C4 vertebral body C4-C5 intervertebral disc

Spinal cord C5 spinous process

C5 vertebral body C5-C6 intervertebral disc C6 vertebral body

C6 spinous process C7 spinous process

C6-C7 intervertebral disc C7 vertebral body Basion Anterior atlanto-occipital membrane Apical ligament Cruciate ligament C1 anterior arch Anterior atlantodental joint Longus capitis m. Base of odontoid process C2-C3 intervertebral disc C3 vertebral body C3 inferior vertebral endplate C4 superior vertebral endplate

Opisthion Tectorial membrane C1 posterior arch C2 spinous process Interspinous ligament Venus plexus C3 spinous process C4 spinous process

C4 vertebral body C4-C5 intervertebral disc C5 vertebral body C5-C6 intervertebral disc

Spinal cord C5 spinous process C6 spinous process

C6 vertebral body C6-C7 intervertebral disc C7 vertebral body

C7 spinous process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

563

Cervical Spine Sagittal 2

C1 anterior arch C1 posterior arch Odontoid process

C2 inferior articular process

C2-C3 intervertebral disc C3 vertebral body

Ligamentum nuchae

C3-C4 intervertebral disc

C3 lamina Dorsal dura margin

C4 vertebral body

C4 lamina

C4-C5 intervertebral disc

Spinal cord

C5 vertebral body

C5 lamina

C5-C6 intervertebral disc

Cerebrospinal fluid

C6 vertebral body

C6 lamina

C6-C7 intervertebral disc C7 inferior articular process

C7 vertebral body



NORMAL ANATOMY Note the slight spurring of the endplates of the uncovertebral joint at the posterolateral edge of the C2-C3 disc space. This is due to normal aging. Although generally not present at the level of the foramen magnum, the cerebellar tonsils, if seen, should not protrude more than 5 mm below this foramen best assessed on sagittal images. Tonsils protruding more than 5 mm indicate a Chiari malformation or, more seriously, mass effect in the intracranial vault, causing the cerebellar tonsils to herniate downward.

564

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cervical Spine Sagittal 2

C1 anterior arch C1 posterior arch Odontoid process C2 inferior articular process C2-C3 intervertebral disc

Ligamentum nuchae C3 lamina

C3-C4 intervertebral disc C4 vertebral body

Dorsal dura margin C4 lamina Spinal cord

C5 vertebral body

C6 vertebral body

C5 lamina C6 lamina Cerebrospinal fluid

C7 vertebral body

C1 anterior arch

C7 inferior articular process

C1 posterior arch

Odontoid process C2 inferior articular process C2-C3 intervertebral disc

Ligamentum nuchae C3 lamina

C3-C4 intervertebral disc C4 vertebral body C5 vertebral body

Dorsal dura margin C4 lamina Spinal cord C5 lamina

C6 vertebral body

C6 lamina Cerebrospinal fluid

C7 vertebral body

C7 inferior articular process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

565

Cervical Spine Sagittal 3

C1 lateral mass Atlantoaxial joint C2 vertebral body

C1 posterior arch

C2 inferior articular facet

Longus capitis m.

C2-C3 facet joint

C3 pedicle

C3 superior articular facet

C4 vertebral body

C3 inferior articular facet

C5 uncinate process

C4 lamina

C5 vertebral body C5 lamina C6 uncinate process C6 vertebral body

C6 lamina

C7 uncinate process C7 vertebral body C7-T1 facet joint complex

566

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cervical Spine Sagittal 3

C1 lateral mass Atlantoaxial joint C2 vertebral body Longus capitis m. C3 pedicle C4 vertebral body C5 uncinate process C5 vertebral body C6 uncinate process C5 vertebral body C7 uncinate process

C1 posterior arch Obliquus capitis inferior m. C2 inferior articular facet C2-C3 facet joint C3 superior articular facet C3 inferior articular facet C4 lamina C5 lamina C6 lamina

C7 vertebral body C7-T1 facet joint complex

C1 lateral mass Atlantoaxial joint C2 vertebral body Longus capitis m.

C1 posterior arch Obliquus capitis inferior m. C2 inferior articular facet C2-C3 facet joint

C3 pedicle C4 vertebral body C5 uncinate process

C3 superior articular facet C3 inferior articular facet C4 lamina

C5 vertebral body C6 uncinate process C5 vertebral body

C5 lamina C6 lamina

C7 uncinate process C7 vertebral body

C7-T1 facet joint complex

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

567

Cervical Spine Sagittal 4

Occipital condyle Atlanto-occipital joint C1 lateral mass

C1 posterior arch

Atlantoaxial joint C2 pars interarticularis Vertebral a.

C2 inferior articular facet C3 superior articular facet C3 inferior articular facet C4 superior articular facet

Neural foramina

C4 inferior articular facet C4-C5 facet joint C5 pars interarticularis C6 pedicle C7 superior articular facet C7 pedicle



NORMAL ANATOMY The parasagittal CT (top) and MR (bottom) images in Cervical Spine Sagittal 4 demonstrate the normal relationship of the occipital condyle and atlas (C1) arch, as well as the atlantoaxial joint and cervical facet joints. The foramina are somewhat difficult to assess on these images compared with lumbar imaging because of the smaller nature of the cervical vertebra and confounding vertebral artery foramina. Narrowing of the cervical foramina is therefore often better seen on axial imaging.

568

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cervical Spine Sagittal 4

Occipital condyle Atlanto-occipital joint C1 lateral mass

C1 posterior arch

Atlantoaxial joint C2 pars interarticularis Vertebral a.

C2 inferior articular facet C3 superior articular facet

Neural foramina

C3 inferior articular facet C4 superior articular facet C4 inferior articular facet C4-C5 facet joint C5 pars interarticularis C5-C6 facet joint complex C6 pedicle C7 superior articular facet C7 pedicle

Occipital condyle Atlanto-occipital joint C1 lateral mass

C1 posterior arch

Atlantoaxial joint Vertebral a.

C2 pars interarticularis C2 inferior articular facet C3 superior articular facet

Neural foramina

C3 inferior articular facet C4 superior articular facet C4 inferior articular facet C4-C5 facet joint C5 pars interarticularis C5-C6 facet joint complex C6 pedicle C7 superior articular facet C7 pedicle

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

569

Cervical Spine Sagittal 5

Internal carotid a. C1 transverse process

C1 transverse foramen

Vertebral a.

C5 posterior tubercle C6 inferior articular facet C6 posterior tubercle C7 superior articular facet

T1 vertebral body 1st rib

570

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Cervical Spine Sagittal 5

Internal carotid a. C1 transverse process

C1 transverse foramen Vertebral a.

C5 posterior tubercle C6 inferior articular facet C6 posterior tubercle

1st rib

C7 superior articular facet

T1 vertebral body

Internal carotid a. C1 transverse process

C1 transverse foramen Vertebral a.

C5 posterior tubercle C6 inferior articular facet C6 posterior tubercle

1st rib

C7 superior articular facet

T1 vertebral body

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

571

Thoracic Spine Axial 1

Esophagus

Descending aorta

Azygos v.

Anterior longitudinal ligament T8 vertebral body

Posterior longitudinal ligament T8 superior costal facet

Costovertebral joint

T8 spinal n. root

T8 pedicle

Spinal cord

Rib head

Anterior costotransverse ligament

T8 transverse process

Costotransverse joint Tubercle of rib T7 spinous process

IMAGING TECHNIQUE CONSIDERATION Note that the Thoracic Spine Axial 1 MR image (bottom) is a T2-weighted sequence (CSF is bright) with the now-routine “turbo” or fast spin-echo technique (fat is bright). The thoracic vertebrae are larger and require less spatial resolution than in the cervical region. Unlike the cervical region from the third (C3) through seventh (C7) cervical vertebrae, there are no uncovertebral joints in the thoracic region, but instead costovertebral junctions.

572

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Thoracic Spine Axial 1

Descending aorta Anterior longitudinal ligament Posterior longitudinal ligament Costovertebral joint T8 pedicle Rib head

T8 transverse process

T8 vertebral body

T8 superior costal facet T8 spinal n. root Spinal cord Anterior costotransverse ligament Costotransverse joint Tubercle of rib T7 spinous process

Descending aorta Anterior longitudinal ligament Posterior longitudinal ligament Costovertebral joint T8 pedicle Rib head

T8 transverse process

T8 vertebral body

T8 superior costal facet T8 spinal n. root Spinal cord Anterior costotransverse ligament Costotransverse joint Tubercle of rib

Ligamentum flavum T7 spinous process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

573

Thoracic Spine Axial 2

Esophagus Descending aorta Azygos v. Anterior longitudinal ligament

T8 vertebral body Posterior longitudinal ligament T8 spinal nerve root Intervertebral foramen

Spinal cord

Interspinous ligament

T8 lamina

T7 spinous process



NORMAL ANATOMY The spinal artery of Adamkiewicz, the major blood supply to the thoracic and lumbar portions of the spinal cord, typically arises from the left T10 intercostal artery and enters the left T10T11 neural foramen before making a hairpin turn on the anterior surface of the cord. In two thirds of cases, the artery will arise from the same side as the descending aorta, and as a variant arise several levels above or below T10 in a bell curve distribution.

574

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Thoracic Spine Axial 2

Descending aorta Anterior longitudinal ligament Posterior longitudinal ligament

Spinal cord

T8 vertebral body

T8 spinal n. root Intervertebral foramen

T8 lamina Interspinous ligament T7 spinous process

Descending aorta Anterior longitudinal ligament Posterior longitudinal ligament

Spinal cord

T8 vertebral body

T8 spinal n. root Intervertebral foramen

T8 lamina Interspinous ligament T7 spinous process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

575

Thoracic Spine Axial 3

Esophagus Descending aorta Azygos v. Anterior longitudinal ligament T8-T9 annulus fibrosus T8-T9 nucleus pulposus

Costovertebral joint T9 rib head

Posterior longitudinal ligament

Spinal cord

T8 spinal n. root

T9 superior articular process

T8-T9 facet joint

T8 inferior articular process

Ligamentum flavum

T8 lamina



NORMAL ANATOMY Note the facet joint, which is composed of the superior articular process of the vertebra below, is anterior to the inferior articular process of the vertebra above.

576

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Thoracic Spine Axial 3

Descending aorta Anterior longitudinal ligament T8-T9 annulus fibrosus T8-T9 nucleus pulposus Costovertebral joint

Posterior longitudinal ligament

T9 rib head Spinal cord T9 superior articular process T9 inferior articular process

T8 spinal n. root T8-T9 facet joint Ligamentum flavum

T8 lamina

Descending aorta Anterior longitudinal ligament T8-T9 annulus fibrosus T8-T9 nucleus pulposus Costovertebral joint

Posterior longitudinal ligament

T9 rib head Spinal cord T9 superior articular process T9 inferior articular process

T8 spinal n. root T8-T9 facet joint Ligamentum flavum

T8 lamina

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

577

Thoracic Spine Sagittal 1

T1 vertebral body Posterior longitudinal ligament

T2 spinous process

Anterior longitudinal ligament

T2 lamina Supraspinous ligament

T2-T3 intervertebral disc Manubrium of sternum

T4 lamina

T3 vertebral body

T4 spinous process

Sternal angle T4-T5 intervertebral disc T5 vertebral body

Interspinous ligament

Body of sternum

T6 lamina

T6-T7 intervertebral disc T7 vertebral body

T6 spinous process T7 lamina

T7-T8 intervertebral disc

T7 spinous process

T9 vertebral body

Superior endplate Inferior endplate

T9-T10 intervertebral disc

Spinal cord

T10 vertebral body

T10 lamina

T10-T11 intervertebral disc

Ligamentum flavum

T11 vertebral body

T11 lamina

T11-T12 intervertebral disc

Conus medullaris

T12 vertebral body

T12 lamina

T12-L1 intervertebral disc

T12 spinous process

T10 spinous process

Cauda equina



NORMAL ANATOMY There is a normal anterior-to-posterior expansion of the spinal cord near the conus, just as there is a normal cervical cord expansion where the brachial plexus nerve roots arise. This should not be confused with expansion from an intramedullary lesion.

578

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Thoracic Spine Sagittal 1

T1 vertebral body Posterior longitudinal ligament Anterior longitudinal ligament T2-T3 intervertebral disc T3 vertebral body Manubrium of sternum Sternal angle Body of sternum T4-T5 intervertebral disc T5 vertebral body T6-T7 intervertebral disc T7 vertebral body T8-T9 intervertebral disc T9 vertebral body T9-T10 intervertebral disc T10 vertebral body T10-T11 intervertebral disc T12 vertebral body T12-L1 intervertebral disc

Posterior longitudinal ligament Anterior longitudinal ligament T1 vertebral body T2-T3 intervertebral disc T3 vertebral body Manubrium of sternum Sternal angle T4-T5 intervertebral disc T5 vertebral body Body of sternum T6-T7 intervertebral disc T7 vertebral body T8-T9 intervertebral disc T9 vertebral body T9-T10 intervertebral disc T10 vertebral body T10-T11 intervertebral disc

T12 vertebral body T12-L1 intervertebral disc

T2 spinous process T2 lamina Supraspinous ligament T4 spinous process T4 lamina Interspinous ligament T6 lamina T6 spinous process T7 lamina T7 spinous process Superior endplate Inferior endplate Spinal cord T9 lamina Ligamentum flavum T11 lamina T11 spinous process Conus medullaris T12 lamina T12 spinous process Cauda equina T1 spinous process T1 lamina Supraspinous ligament T2 spinous process T2 lamina T4 spinous process T4 lamina Interspinous ligament T6 lamina T6 spinous process T7 lamina T7 spinous process Superior endplate Inferior endplate Spinal cord T9 lamina Ligamentum flavum T11 lamina T11 spinous process Conus medullaris T12 lamina T12 spinous process Cauda equina

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

579

Thoracic Spine Sagittal 2

T2 pedicle

T2-T3 intervertebral disc

T2-T3 facet joint

T3 vertebral body

T3 superior articular process T3 intervertebral foramen

T4 vertebral body T4-T5 intervertebral disc

T5 pedicle

T5 vertebral body T5-T6 intervertebral disc

T6 superior articular process

T6 vertebral body

T6 inferior articular process

T6-T7 intervertebral disc

T7 pedicle

T7 vertebral body

T7 intervertebral foramen

T7-T8 intervertebral disc

T7-T8 facet joint

T8 vertebral body

T8 inferior articular process

T9 vertebral body

T9 pedicle

T8 pedicle

T9 intervertebral foramen

T9-T10 intervertebral disc

T10 pedicle

T10 vertebral body

T10 inferior articular process

T10-T11 intervertebral disc

T11 inferior articular process

T11 vertebral body

T11-T12 facet joint

T11-T12 intervertebral disc

T12 superior articular process

T12 vertebral body

T12 inferior articular process

T12-L1 intervertebral disc



NORMAL ANATOMY Note that the thoracic vertebral anatomy is larger than the cervical vertebral anatomy, making the foramina much easier to appreciate on parasagittal imaging, along with the absence of the confounding vertebral foramina.

580

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Thoracic Spine Sagittal 2

T2-T3 intervertebral disc T3 vertebral body T4 vertebral body T4-T5 intervertebral disc T5-T6 intervertebral disc T6 vertebral body T7-T8 intervertebral disc T8 vertebral body T8-T9 intervertebral disc T9-T10 intervertebral disc T10-T11 intervertebral disc T11 vertebral body T11-T12 intervertebral disc T12 vertebral body T12-L1 intervertebral disc

T2 pedicle T2-T3 facet joint T3 superior articular process T3 intervertebral foramen T5 pedicle T6 superior articular process T6 inferior articular process T7 pedicle T7-T8 facet joint T8 pedicle T8 inferior articular process T9 pedicle T9 intervertebral foramen T10 pedicle T10 inferior articular process T11 inferior articular process T11-T12 facet joint T12 superior articular process T12 inferior articular process

T1 vertebral body T2-T3 intervertebral disc T3 vertebral body T4 vertebral body T4-T5 intervertebral disc T5-T6 intervertebral disc T6 vertebral body T7-T8 intervertebral disc T8 vertebral body T8-T9 intervertebral disc T9-T10 intervertebral disc T10-T11 intervertebral disc T11 vertebral body T11-T12 intervertebral disc T12 vertebral body T12-L1 intervertebral disc

T1 pedicle T2 pedicle T2-T3 facet joint T3 superior articular process T3 intervertebral foramen T5 pedicle T6 superior articular process T6 inferior articular process T7 pedicle T7-T8 facet joint T8 pedicle T8 inferior articular process T9 pedicle T9 intervertebral foramen T10 pedicle T10 inferior articular process T11 inferior articular process T11-T12 facet joint T12 superior articular process T12 inferior articular process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

581

Thoracic Spine Sagittal 3

T2 transverse process 2nd rib T3 transverse process

3rd rib Manubrium of sternum

T4 transverse process

4th rib

Costotransverse joint

5th rib

T5 transverse process

Head of 6th rib Neck of 7th rib

T6 transverse process Costotransverse joint T7 intervertebral foramen

Neck of 8th rib Costovertebral joint

T8 intervertebral foramen

T9 vertebral body

T9 transverse process

T9-T10 intervertebral disc

T9-T10 facet joint

T10 vertebral body

T10 inferior articular process

T10-T11 intervertebral disc

T11 superior articular process

T11 vertebral body T11-T12 intervertebral disc T12 vertebral body T12-L1 intervertebral disc

582

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

T11 pedicle

T12 superior articular process

Thoracic Spine Sagittal 3

2nd rib

T2 transverse process

3rd rib

T3 transverse process

Manubrium of sternum

T4 transverse process

4th rib

Costotransverse joint

5th rib

T5 transverse process

Head of 6th rib Neck of 7th rib

T6 transverse process

Neck of 8th rib

Costotransverse joint T7 intervertebral foramen

Costovertebral joint

T8 intervertebral foramen

T10 vertebral body

T9 transverse process

T10 intervertebral foramen T11 vertebral body T11 intervertebral foramen T12 vertebral body

T9-T10 facet joint T10 inferior articular process T11 superior articular process T11 pedicle T12 superior articular process

2nd rib

T2 transverse process

3rd rib

T3 transverse process

Manubrium of sternum

T4 transverse process

4th rib 5th rib

Costotransverse joint T5 transverse process

Head of 6th rib

T6 transverse process

Neck of 7th rib

Costotransverse joint

Neck of 8th rib Costovertebral joint T10 vertebral body T10 intervertebral foramen T11 vertebral body T11 intervertebral foramen T12 vertebral body

T7 intervertebral foramen T8 intervertebral foramen T9 transverse process T9-T10 facet joint T10 inferior articular process T11 superior articular process T11 pedicle T12 superior articular process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

583

Lumbosacral Spine Axial 1

Air in small intestine Anterior longitudinal ligament

R. common iliac a.

Annulus fibrosus

R. common iliac v.

Nucleus pulposus Neural foramen

L4 spinal nerve dorsal root ganglion L5 spinal nerve root

Posterior longitudinal ligament

Cauda equina

L5 superior articular process L4-L5 facet joint

Thecal sac

L4 inferior articular process

Ligamentum flavum

Epidural fat Erector spinae m.

L4 spinous process



NORMAL ANATOMY It is easier to see the triangle of posterior epidural fat on the CT image (top) than on the turbo T2-weighted MR sequence (bottom), where both fluid and fat are bright. Fat has a density of about 10 to −50 Hounsfield units (HU), the scale used to measure density on CT, and appears dark gray, whereas the laterally adjacent right and left ligamentum flavum and spinal canal anteriorly are of soft tissue density, measuring about +40 HU. This epidural fat is an important target for steroid injection in patients with lumbar degenerative disease and for anesthetic medication injection in pregnant patients during labor and delivery.

584

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Lumbosacral Spine Axial 1

Air in small intestine Anterior longitudinal ligament Annulus fibrosus Nucleus pulposus Neural foramen L4 spinal n. dorsal root ganglion L5 spinal n. root Cauda equina

Posterior longitudinal ligament L5 superior articular process L4-L5 facet joint

Thecal sac

Erector spinae m.

L4 inferior articular process

L4 spinous process

Anterior longitudinal ligament Annulus fibrosus Nucleus pulposus

L4 spinal n. dorsal root ganglion L5 spinal n. root Cauda equina

Neural foramen Posterior longitudinal ligament L5 superior articular process

Thecal sac L4-L5 facet joint L4 inferior articular process Erector spinae m. L4 spinous process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

585

Lumbosacral Spine Axial 2

R. common iliac a.

Anterior longitudinal ligament Annulus fibrosus

R. common iliac v.

Nucleus pulposus L4 ventral ramus of spinal n.

L5 vertebral body

L4 dorsal ramus of spinal n.

Posterior longitudinal ligament

L5 spinal n. root

Thecal sac

Cauda equina

L5 superior articular process

Ligamentum flavum

L4-L5 facet joint

Iliac wing

L4 inferior articular process Epidural fat

Erector spinae m.

L5 spinous process



PATHOLOGIC PROCESS Below the pars of the second lumbar vertebra (L2), the conus gives rise to multiple nerves called the cauda equina (Latin, “horse’s tail”). A relatively large disc herniation in the lumbar region may not result in significant neural symptoms because these cauda equina nerves may move out of the way, unlike the cord in the thoracic and cervical region. At the lateral aspect of the spinal canal, however, even a small disc protrusion may cause nerve impingement if there is ligamentum flavum hypertrophy that further narrows the lateral recess from posteriorly. With this lateral recess narrowing, the descending L5 nerve that has not yet exited the spinal canal would be impinged, by a lateral L4-5 disc herniation, not the L4 nerve root exiting the neural foramen.

586

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Lumbosacral Spine Axial 2

Anterior longitudinal ligament Annulus fibrosus Nucleus pulposus L4 ventral ramus of spinal n. L5 vertebral body L4 dorsal ramus of spinal n. L5 spinal n. root Cauda equina Thecal sac

Posterior longitudinal ligament L5 superior articular process L4-L5 facet joint L4 inferior articular process

Erector spinae m.

L5 spinous process

Anterior longitudinal ligament Annulus fibrosus Nucleus pulposus L4 ventral ramus of spinal n. L5 vertebral body L4 dorsal ramus of spinal n. L5 spinal n. root Cauda equina Thecal sac

Posterior longitudinal ligament L5 superior articular process L4-L5 facet joint L4 inferior articular process

Erector spinae m. L5 spinous process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

587

Lumbosacral Spine Axial 3

R. common iliac a. Anterior longitudinal ligament R. common iliac v. L5 vertebral body

Posterior longitudinal ligament

L5 pedicle L5 transverse process

Cauda equina Thecal sac

L5 superior articular process

Ligamentum flavum

L4 inferior articular process

Iliac wing L5 lamina Erector spinae m.

588

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

L5 spinous process

Lumbosacral Spine Axial 3

Anterior longitudinal ligament L5 vertebral body

Posterior longitudinal ligament

Cauda equina

Thecal sac

L5 pedicle L5 transverse process L5 superior articular process L4 inferior articular process L5 lamina

Erector spinae m.

L5 spinous process

Anterior longitudinal ligament L5 vertebral body

L5 pedicle Posterior longitudinal ligament

L5 transverse process L5 superior articular process

Cauda equina L4 inferior articular process Thecal sac

Erector spinae m.

L5 lamina

L5 spinous process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

589

Lumbosacral Spine Axial 4

R. common iliac a.

Anterior longitudinal ligament

R. common iliac v. L5 vertebral body Posterior longitudinal ligament L5 descending n. root

L5 pedicle L5 transverse process Cauda equina

S1 n. root Ligamentum flavum

Thecal sac

Iliac wing

L5 lamina

Erector spinae m. L5 spinous process

590

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Lumbosacral Spine Axial 4

Anterior longitudinal ligament Posterior longitudinal ligament

L5 vertebral body L5 pedicle

L5 descending n. root

S1 n. root

L5 transverse process Cauda equina Iliac wing Thecal sac

Erector spinae m.

L5 lamina L5 spinous process

Anterior longitudinal ligament L5 vertebral body Posterior longitudinal ligament L5 pedicle L5 descending n. root L5 transverse process S1 n. root

Cauda equina Iliac wing Thecal sac

Erector spinae m.

L5 lamina L5 spinous process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

591

Lumbosacral Spine Axial 5

R. common iliac a.

R. common iliac v.

Posterior longitudinal ligament

Anterior longitudinal ligament L5 vertebral body L5 spinal n. dorsal root ganglion L5 transverse process

S1 descending n. root Thecal sac

S1 superior articular process Cauda equina

Ligamentum flavum

L5-S1 facet joint

Iliac wing

L5 lamina

Erector spinae m. L5 spinous process

592

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Lumbosacral Spine Axial 5

Anterior longitudinal ligament L5 vertebral body Posterior longitudinal ligament

L5 spinal n. dorsal root ganglion L5 transverse process

S1 descending n. root

S1 superior articular process L5-S1 facet joint

Thecal sac

Iliac wing L5 lamina

Erector spinae m. L5 spinous process

Anterior longitudinal ligament L5 vertebral body Posterior longitudinal ligament

S1 descending n. root

L5 spinal n. dorsal root ganglion L5 transverse process S1 superior articular process

Thecal sac

L5-S1 facet joint Iliac wing L5 lamina

Erector spinae m. L5 spinous process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

593

Lumbosacral Spine Axial 6

R. common iliac a. R. common iliac v.

Anterior longitudinal ligament

L5 vertebral body

L5 spinal n. dorsal root ganglion Posterior longitudinal ligament Sacral ala Thecal sac

S1 spinal n. root S1 superior articular process L5-S1 facet joint

Iliac wing Ligamentum flavum

L5 inferior articular process L5 spinous process

Erector spinae m.

594

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Lumbosacral Spine Axial 6

Anterior longitudinal ligament L5 vertebral body L5 spinal n. dorsal root ganglion Sacral ala Posterior longitudinal ligament Thecal sac

S1 spinal n. root S1 superior articular process L5-S1 facet joint Iliac wing

Erector spinae m.

L5 inferior articular process

L5 spinous process

Anterior longitudinal ligament L5 vertebral body L5 spinal n. dorsal root ganglion Sacral ala Posterior longitudinal ligament

S1 spinal n. root S1 superior articular process L5-S1 facet joint

Thecal sac

Iliac wing L5 inferior articular process

Erector spinae m.

L5 spinous process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

595

Lumbosacral Spine Sagittal 1

Spinal cord

Posterior longitudinal ligament L1 vertebral body

Supraspinous ligament

Anterior longitudinal ligament

L1 lamina

Annulus fibrosus of L1-L2 intervertebral disc

Conus medullaris

Nucleus pulposus of L1-L2 intervertebral disc

L1 spinous process Thecal sac

L2 vertebral body

Cauda equina Interspinous ligament

L3 vertebral body

Epidural fat L4 vertebral body L4 lamina L4 spinous process L5 vertebral body

L5 lamina L5 spinous process

Nucleus pulposus of L5-S1 Annulus fibrosus of L5-S1 Sacrum (S1)

Air in small intestine



NORMAL ANATOMY The conus of the spinal cord is typically at or above the pars of L2. A lower location can be seen with a tethered cord and spina bifida. Note that normal, healthy vertebral discs are well hydrated, showing as bright T2 signal, although not as bright as the cerebrospinal fluid.

IMAGING TECHNIQUE CONSIDERATION Recall that on “turbo” or fast spin-echo T2-weighted imaging, unlike nonturbo T2-weighted imaging, the fat is also bright.

596

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Lumbosacral Spine Sagittal 1

Posterior longitudinal ligament L1 vertebral body Anterior longitudinal ligament Annulus fibrosus of L1-L2 intervertebral disc Nucleus pulposus of L1-L2 intervertebral disc L2 vertebral body

Spinal cord Supraspinous ligament L1 lamina L1 spinous process Conus medullaris Thecal sac Cauda equina

L4 vertebral body

Interspinous ligament Ligamentum flavum L4 spinous process

Nucleus pulposus of L5-S1 Annulus fibrosus of L5-S1

L4 lamina L5 spinous process L5 lamina

Sacrum (S1) Posterior longitudinal ligament L1 vertebral body Anterior longitudinal ligament Annulus fibrosus of L1-L2 intervertebral disc Nucleus pulposus of L1-L2 intervertebral disc L2 vertebral body

Spinal cord Supraspinous ligament L1 lamina L1 spinous process Conus medullaris Thecal sac Cauda equina Interspinous ligament

L4 vertebral body

Ligamentum flavum L4 spinous process

Nucleus pulposus of L5-S1 Annulus fibrosus of L5-S1

L4 lamina L5 spinous process L5 lamina

Sacrum (S1)

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

597

Lumbosacral Spine Sagittal 2

Posterior longitudinal ligament

Spinal cord

L1 vertebral body Anterior longitudinal ligament L2 vertebral body Annulus fibrosus of L2-L3 intervertebral disc Nucleus pulposus of L2-L3 intervertebral disc L3 vertebral body

L1 lamina Ligamentum flavum L1 inferior articular process Thecal sac L2 inferior articular process Cauda equina L3 inferior articular process

L4 vertebral body L4 inferior articular process L5 ventral n. root L5 vertebral body

Nucleus pulposus of L5-S1 Annulus fibrosus of L5-S1 Sacrum (S1)

Sacrum (S2)

598

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

L5 dorsal n. root L5 inferior articular process S1 ventral n. root S1 dorsal n. root

Lumbosacral Spine Sagittal 2

Posterior longitudinal ligament L1 vertebral body Anterior longitudinal ligament

L1 lamina L1 inferior articular process

L2 vertebral body Annulus fibrosus of L2-L3 intervertebral disc Nucleus pulposus of L2-L3 intervertebral disc

Ligamentum flavum L2 lamina L2 inferior articular process Cauda equina

L3 vertebral body

Thecal sac

L4 vertebral body

L4 inferior articular process

L5 vertebral body Nucleus pulposus of L5-S1 Annulus fibrosus of L5-S1 Sacrum (S1)

L5 ventral n. root L5 dorsal n. root L5 inferior articular process S1 ventral n. root S1 dorsal n. root

Posterior longitudinal ligament L1 vertebral body Anterior longitudinal ligament

L1 lamina L1 inferior articular process

L2 vertebral body Annulus fibrosus of L2-L3 intervertebral disc Nucleus pulposus of L2-L3 intervertebral disc

Ligamentum flavum L2 lamina L2 inferior articular process Cauda equina

L3 vertebral body

Thecal sac

L4 vertebral body

L5 ventral n. root L5 dorsal n. root

L5 vertebral body Nucleus pulposus of L5-S1 Annulus fibrosus of L5-S1 Sacrum (S1)

L4 inferior articular process S1 ventral n. root S1 dorsal n. root L5 inferior articular process

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

599

Lumbosacral Spine Sagittal 3

L1 superior articular process L1 pedicle

L1 vertebral body

L1 dorsal root ganglion

L1-L2 intervertebral disc

L1 intervertebral foramen L2 superior articular process L2 pedicle

L2 vertebral body

L2 dorsal root ganglion L2 intervertebral foramen L3 superior articular process L3 pedicle

L2-L3 intervertebral disc L3 vertebral body

L3 intervertebral foramen L3 inferior articular process L4 pedicle

L3-L4 intervertebral disc L4 vertebral body

L4 pars interarticularis L4 inferior articular process

L4-L5 intervertebral disc

L4-L5 facet joint

L5 vertebral body

L5 superior articular process

L5-S1 intervertebral disc

L5 pars interarticularis L5 spinal nerve

Sacrum (S1)

Sacrum (S2)



NORMAL ANATOMY Note how much better the neural foramina are seen in the lumbar region than in the thoracic or cervical region because of the larger size and absence of confounding vertebral artery foramina. The lumbar foramina are typically keyhole shaped on parasagittal imaging, with the exiting nerve root in the larger upper aspect of the foramen.

600

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Lumbosacral Spine Sagittal 3

L1 vertebral body L1-L2 intervertebral disc L2 vertebral body L2-L3 intervertebral disc L3 vertebral body L3-L4 intervertebral disc L4 vertebral body

L1 superior articular process L1 pedicle L1 dorsal root ganglion L1 intervertebral foramen L2 superior articular process L2 pedicle L2 dorsal root ganglion L2 intervertebral foramen L3 superior articular process L3 pedicle L3 intervertebral foramen L3 inferior articular process L4 pedicle

L4-L5 intervertebral disc

L4 pars interarticularis L4 inferior articular process

L5 vertebral body L5-L6 intervertebral disc Sacrum

L4-L5 facet joint L5 superior articular process L5 pars interarticularis L5 spinal n.

L1 vertebral body

L1 superior articular process L1 pedicle

L1-L2 intervertebral disc

L1 dorsal root ganglion L1 intervertebral foramen L2 superior articular process L2 pedicle L2 dorsal root ganglion L2 intervertebral foramen

L2 vertebral body L2-L3 intervertebral disc L3 vertebral body L3-L4 intervertebral disc L4 vertebral body L4-L5 intervertebral disc L5 vertebral body L5-L6 intervertebral disc Sacrum

L3 superior articular process L3 pedicle L3 intervertebral foramen L3 inferior articular process L4 pedicle L4 pars interarticularis L4 inferior articular process L4-L5 facet joint L5 superior articular process L5 pars interarticularis L5 spinal n.

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

601

Lumbosacral Spine Sagittal 4

12th rib

L1 vertebral body

L1 transverse process L2 vertebral body

L2 transverse process L3 superior articular process

Lumbar a. L3 vertebral body

L3 pars interarticularis L4 superior articular process

L4 vertebral body

L4 pars interarticularis

L5 pedicle

L5 superior articular process

L5 vertebral body

L4 inferior articular process

L5 dorsal n. root ganglion L5 intervertebral foramen Sacrum (S1)

Sacral foramina

602

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

L5 inferior articular process L5-S1 facet joint

Lumbosacral Spine Sagittal 4

L1 vertebral body L1 transverse process L2 vertebral body L2 transverse process L3 vertebral body L3 superior articular process

Lumbar a.

L3 pars interarticularis

L4 pedicle L4 vertebral body

L4 superior articular process L4 pars interarticularis

L5 pedicle

L5 superior articular process

L5 vertebral body

L4 inferior articular process

L5 dorsal n. root ganglion L5 intervertebral foramen

L5 inferior articular process

Sacrum (S1)

L5-S1 facet joint

Anterior sacral foramina

L1 vertebral body

L1 transverse process

L2 transverse process

L2 vertebral body

L3 superior articular process

Lumbar a.

L3 pars interarticularis

L3 vertebral body

L4 superior articular process

L4 pedicle

L4 pars interarticularis

L4 vertebral body

L5 superior articular process

L5 pedicle

L4 inferior articular process

L5 vertebral body L5 inferior articular process

L5 dorsal n. root ganglion

L5-S1 facet joint

L5 intervertebral foramen Sacrum (S1) Anterior sacral foramina

     

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

603

Lumbosacral Spine Sagittal 5

12th rib

L1 transverse process

L2 transverse process

Psoas major m.

L3 transverse process

L4 transverse process

L5 pars interarticularis

L5 pedicle

Sacrum



NORMAL ANATOMY Lumbosacral Spine Sagittal 5 shows the standard five lumbar transverse processes, although variants can include a missing or accessory rib or a lumbarized S1 vertebral segment. Care must always be taken to declare the numbering of levels used when describing pathology in the spine. The best method is counting down from C1 (atlas), but in the absence of whole-spine imaging, a clearly identifiable landmark should be used.

604

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

Lumbosacral Spine Sagittal 5

L1 transverse process Psoas major m. L2 transverse process

L3 transverse process

L4 transverse process L5 pars interarticularis L5 pedicle Sacrum

L1 transverse process

Psoas major m.

L2 transverse process

L3 transverse process

L4 transverse process L5 pars interarticularis L5 pedicle Sacrum

NETTER’S CORRELATIVE IMAGING: NEUROANATOMY

605

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Index A

ABCs, emergency, 474 Abdominal aorta, 533f Abducens nerve (CN VI), 6f–7f, 208f–214f, 244f–250f, 246, 252f–254f, 282f–284f, 300f–304f, 370 anatomy of, 246 palsy of, 246 pathologic process of, 248 Abducens nerve tract (CN VI), 250f–252f Abducens nucleus, 12f, 250f–252f diagnostic consideration for, 250 Accessory muscle bundle from petrous part of temporal bone, 315f–316f Accessory nerve (CN XI), 6f–7f, 12f, 268f–270f, 313f–314f, 317f–318f anatomy of, 268 Accessory nucleus, 12f Accessory oculomotor (Edinger-Westphal) nucleus, 12f, 200 Accessory process, 530f–531f Acoustic (auditory) meatus, external, 56f–60f, 78f–80f Acoustic neuroma, 262 Adenoids, 394f–396f, 448f–450f Aditus, 402f–404f Airway, 474 Ala, 311f–312f Alar ligament, 528f–529f, 556f–558f Alveolar artery and nerve, inferior, canal for, 67f–68f Alveolar foramina, 310f–311f Alveolar nerve, 230 inferior, 390, 390f–394f, 432f–433f, 438f–440f, 540f–542f in mandibular canal, 116f–118f pathologic process, 390 Ambient cistern, 44f–46f, 154f–156f, 278f–282f Amygdala, 76f–80f, 172f–173f basal nucleus of, 156f–158f cortical nucleus of, 158f–160f pathologic process of, 162 Amygdaloid body, 10f–11f Angular artery, 316f–317f Angular gyrus, 3f–4f Annulus fibrosus, 530f–531f, 584f–588f Anterior chamber, 180f–182f, 360f–364f Anterior choroidal artery, 9f–10f Anterior clinoid process, 66f–70f, 73f–74f, 138f–140f, 376f–379f Anterior commissure, 4f–5f, 11f–12f, 38f–42f, 98f–100f, 132f–136f Anterior costotransverse ligament, 572f–574f Anterior deep cervical (pretracheal and thyroid) nodes, 317f–318f Anterior ethmoidal foramina, 309f–310f Anterior longitudinal ligament, 314f–315f, 527f–528f, 531f–533f, 572f–580f, 584f–600f Anterior perforated substance, 5f–6f Anterior spinal artery, 9f–10f

Anterior superficial cervical nodes, 317f–318f Anterior tubercle, 525f–527f of atlas, 528f–529f of C6 vertebra, 527f–528f Anterolateral central (lenticulostriate) arteries, 9f–10f Antrum, 402f–404f maxillary sinus, 240f–242f Apical ligament, 562f–564f of dens, 528f–529f Aqueduct of Sylvius, 8f–9f, 11f–12f, 144f–145f Arcuate eminence, 318f Arcuate fasciculus, 118f–122f Areolar tissue, 533f Articular facet for dens, 525f–526f for sacrum, 530f–531f Articular process, of uncinate process, 526f–527f Articular surface, 526f–527f Aryepiglottic fold, 315f–316f, 474f–476f aryepiglottic muscle with, 492f–494f Aryepiglottic muscle, 492f–494f Arytenoid cartilage, 460f–462f, 492f–494f, 506f–512f Arytenoid muscles, transverse and oblique, 315f–316f Ascending cervical artery, 316f–317f Ascending palatine artery, 316f–317f Ascending pharyngeal artery, 316f–317f Atlanto-occipital joint, 536f–538f, 558f–560f, 568f–570f capsule of, 527f–528f lateral, capsule of, 528f–529f Atlantoaxial joint, 540f–542f, 556f–559f, 566f–570f lateral, 527f–528f capsule of, 527f–528f median, superior view, 528f–529f Atlantoaxial ligament, 528f–529f Atlantodental joint, anterior, 538f–540f, 562f–564f Atlantooccipital articulation, 108f–112f Atlantooccipital membrane anterior, 314f–315f, 527f–528f, 537f–538f, 562f–564f posterior, 527f–528f Atlas (C1), 86f–92f, 428f, 524f–525f, 527f–529f anterior arch of, 98f–106f, 314f–315f, 525f–526f anterior tubercle of, 528f–529f body of, 108f–110f inferior view of, 525f–526f lateral mass of, 78f–86f, 450f–452f posterior arch of, 98f–106f, 452f–454f superior articular facet for, 525f–526f superior view of, 525f–526f transverse ligament of, 528f–529f posterior articular facet for, 525f–526f tubercle for, 525f–526f transverse process of, 527f–528f

Atrium, 274f–276f normal anatomy of, 276 Auditory canal external, 84f–88f, 384f–386f, 408f–410f, 412f–416f, 466f–469f internal, 84f–86f, 400f–406f, 414f–416f normal anatomy of, 52 Auditory tube, 318f cartilaginous part of, 315f–316f groove for, 311f–312f pharyngeal opening of, 314f–315f Auricle, 86f, 90f–94f, 318f Auricular cartilage, 313f–314f Auricular surface of sacrum, 531f–532f Auriculo-temporal nerve, 316f–317f Axis (C1), 304f–305f Axis (C2), 86f–88f, 90f–92f, 430f–432f, 450f–452f, 524f–525f, 528f–529f anterior view of, 525f–526f body of, 74f, 76f–86f, 527f–528f dens of, 78f–86f, 98f–106f, 314f–315f inferior articular surface of lateral mass for, 525f–526f posterosuperior view of, 525f–526f spine of, 452f–454f Azygos vein, 572f, 574f, 576f

B

Basal cistern, normal anatomy of, 44 Basal ganglia normal view of, 128 Basal nuclei (ganglia), organization of, 10f–11f Basal nucleus, amygdala, 156f–158f Basal vein of Rosenthal, 88f–90f left, 90f–92f normal anatomy of, 90 Basilar artery, 9f–10f, 48f–56f, 80f–84f, 154f–160f, 190f–192f, 200f–208f, 214f–222f, 224f–228f, 234f–236f, 240f–242f, 246f–256f, 278f–280f, 282f–284f, 304f–305f, 356f–360f, 362f–364f, 382f–386f, 394f–397f diagnostic consideration for, 50 in prepontine cistern, 98f–100f superior cerebellar origin from, 82 tip, 80f–84f, 82 Basilar venous plexus, 6f–8f Basion, 556f–558f, 562f–564f Basisphenoid, 74f–80f Basivertebral vein, 556f–558f Benign intracranial hypertension, 180 Bifid spinous process, 526f–527f Bitemporal hemanopia, 182 Biventral lobule, 270f–271f, 284f–286f Body spicule, dividing foramen transversarium, 526f–527f Brachial plexus, 498, 514f–516f Brachiocephalic artery, 486f–488f

Note: Page numbers with “f” denote figures; “t” tables.

607

Index Brachiocephalic vein, 486f–488f, 514f–516f surgical consideration in, 486 Brain arteries of, inferior view, 9f–10f axial, 15f coronal, 15f coronal section through cavernous sinus, posterior view, 6f–7f high convexities of, 18f–20f left lateral phantom view of, 8f–9f sagittal, 15f Brain in situ, sagittal section of, 4f–5f Brainstem cerebral hemisphere, medial surface of, 4f–5f cranial nerve nuclei in, 12f Bridging veins, 7f–8f, 112f–114f, 118f–120f Buccal artery, 316f–317f Buccinator muscle, 62f–66f, 388f–392f, 428f–434f, 438f–442f and parotid duct, 316f–317f Bucco-pharyngeal fascia, 314f–315f

C

C1 anterior arch, 538f–540f, 554f–556f, 562f–566f superior cortex of, 536f–538f lateral mass, 538f–540f, 556f–560f, 566f–570f posterior arch, 540f–542f, 560f–570f superior articular facet, 540f–542f transverse foramen, 570f–572f transverse process, 556f–560f, 570f–572f C2 articular pillar, 558f–560f bifid spinous process, 546f–550f inferior articular facet, 566f–570f inferior articular process, 546f–548f, 564f–566f inferior body, 544f–546f lamina, 544f–548f, 560f–562f pars interarticularis, 568f–570f spinous process, 544f–546f, 562f–564f transverse foramen, 544f–546f transverse process, 544f–546f, 556f–558f anterior tubercle, 547f–548f vertebral body, 554f–558f, 566f–568f C2-C3 facet joint, 546f–548f, 566f–568f C2-C3 intervertebral disc, 546f, 554f–558f, 562f–566f normal anatomy of, 564 C2-C3 neural foramen, 546f–548f C3 articular pillar, 558f–560f inferior articular facet, 566f–570f inferior articular process, 550f–552f inferior vertebral endplate, 563f–564f lamina, 548f–552f, 564f–566f pedicle, 548f–550f, 556f–558f, 566f–568f spinous process, 550f–552f, 560f–564f superior articular facet, 566f–570f superior articular process, 546f–550f superior vertebral endplate, 563f–564f transverse process anterior tubercle, 546f, 548f–550f, 554f–556f posterior tubercle, 548f–550f uncinate process, 546f–548f vertebra, 525f–526f inferior aspect of, 526f–527f vertebral body, 504f–506f, 548f–550f, 552f–558f, 562f–564f C3-C4 facet joint, 550f–552f C3-C4 intervertebral disc, 550f–552f, 554f–558f, 562f–566f

608

C4 articular pillar, 558f–560f inferior articular facet, 568f–570f inferior articular process, 556f lamina, 564f–568f spinous process, 560f–564f superior articular facet, 568f–570f superior articular process, 550f–552f, 556f–558f transverse process posterior tubercle, 554f–556f vertebra, 525f–526f superior aspect of, 525f–526f vertebral body, 552f–558f, 562f–568f C4-C5 facet joint, 568f–570f C4-C5 intervertebral disc, 554f–558f, 562f–564f C5 articular pillar, 558f–560f inferior articular process, 556f–558f lamina, 564f–568f pars interarticularis, 568f–570f posterior tubercle, 570f–572f spinous process, 560f–564f superior articular process, 556f–558f transverse process anterior tubercle, 552f–553f posterior tubercle, 554f–556f uncinate process, 566f–568f vertebral body, 496f–498f, 552f–558f, 562f–568f C5-C6 facet joint complex, 569f–570f C5-C6 intervertebral disc, 554f–558f, 562f–564f C6 articular pillar, 558f–560f inferior articular facet, 570f–572f inferior articular process, 557f–558f lamina, 564f–568f pedicle, 568f–570f posterior tubercle, 570f–572f spinous process, 560f–564f superior articular process, 556f transverse process, 554f–556f anterior tubercle, 552f–553f uncinate process, 566f–568f vertebra, anterior tubercle of, 527f–528f vertebral body, 496f–498f, 552f–558f, 562f–567f C6-C7 intervertebral disc, 554f–558f, 562f–564f C7 anatomy of, 506 articular pillar, 558f–560f inferior articular process, 564f–566f lamina, 560f–562f pedicle, 568f–570f spinous process, 562f–564f superior articular facet, 568f–572f uncinate process, 566f–568f vertebra, 524f–525f vertebral body, 554f–558f, 562f–568f C7-T1 facet joint complex, 566f–568f Calcar avis, 152f–154f Calcarine fissure, 104f–108f Calcarine sulcus, 3f–6f Callosal artery, 376f–378f Callosomarginal artery, 160f–164f Calvarium inner table of, 116f–118f outer table of, 116f–118f Canine, 388f–390f, 428f–430f Caroticojugular spine, 116f–118f Carotid canal, 236f–238f, 250f–252f, 328f–330f, 409f–410f internal carotid artery in, 408f

Carotid tubercle of Chassaignac, 527f–528f Cartilage, of auditory tube, 313f–314f Cauda equina, 533f, 578f–580f, 584f–593f, 596f–600f Caudate, 242f–244f Caudate nucleus, 74f–78f, 82f–88f, 108f–110f, 140f–144f, 148f–152f, 160f–166f, 190f–192f, 274f–276f, 286f–290f body, 8f–9f, 30f–32f, 78f–82f, 126f–128f head, 10f–11f, 32f–40f, 68f–74f, 104f–108f, 126f, 128f–134f, 136f–140f, 156f–160f, 296f–304f tail, 8f–11f Cavernous sinus, 6f–7f, 46f–49f, 68f–74f, 104f–108f lateral sellar compartment, 302f–304f Central incisor, 388f–390f, 428f Central sulcus, 3f–5f, 20f–28f, 102f, 104f–108f, 112f–118f, 120f–122f normal anatomy of, 24 Central tegmental tract, 206f–208f Centrum semiovale, 22f–30f, 32, 108f–112f, 114f–116f, 138f–140f, 142f–145f normal anatomy of, 126 Cerebellar artery anterior inferior (AICA), 9f–10f, 246f–250f, 254f–256f diagnostic consideration for, 254 left anterior inferior, 214f–216f left superior, 216f–218f posterior, 158f–159f posterior inferior (PICA), 9f–10f, 82 right posterior inferior, 216f–218f right superior, 82f superior, 9f–10f, 142f–144f, 158f–160f, 288f–290f Cerebellar lobe anterior, 166f–168f, 226f–228f, 234f–236f, 246f–248f, 280f–282f posterior, 144f–145f posteroinferior, 257f–260f, 264f–266f, 268f–271f posterosuperior, 224f–226f, 246f–252f, 258f–260f, 264f–266f, 268f–270f Cerebellar peduncle anterior, 168f–170f inferior, 11f–12f, 168f–170f, 236f–238f, 252f–260f, 264f–266f, 284f–286f middle, 11f–12f, 50f–52f, 86f–88f, 104f–106f, 144f–145f, 162f–164f, 224f–226f, 242f–244f, 246f–258f, 282f–284f brachium pontis, 52f–54f, 106f–108f superior, 11f–12f, 48f–50f, 88f–90f, 166f–170f, 226f–228f, 234f–236f, 246f–250f Cerebellar tentorium, 164f–168f Cerebellar tonsil, 98f–104f, 236f–238f, 284f, 292f–293f in adults, 102 diagnostic consideration for, 122 lateral aspect of, normal anatomy of, 102 pathologic process in, 564 superior, 54f–56f Cerebellar vermis, 92f–96f, 278f–280f inferior, 54f–56f nodule of, 88f–92f superior, 48f–50f Cerebellomedullary cistern, 284f–286f, 288f–290f, 292f–293f Cerebellopontine angle, 282f–284f Cerebellum, 4f–5f, 44f–46f, 98f–122f, 290f–292f, 422f–426f, 452f–454f dentate nucleus of, 11f–12f

Index Cerebellum (Continued) flocculus of, 54f–56f horizontal fissure of, 88f–90f horizontal sections through, 10f–11f inferior, vermis of, 54f–55f interhemispheric fissure of, 88f–92f nodulus of, 50f–56f tonsil of, 11f–12f vermis of, 40f–44f central lobule (II-III), 11f–12f culmen (IV-V), 11f–12f declive (VI), 11f–12f folium (VII A), 11f–12f lingula (I), 11f–12f nodulus (X), 11f–12f pyramid (VIII), 11f–12f tuber (VII B), 11f–12f uvula (IX), 11f–12f Cerebral aqueduct, 5f–6f, 40f–48f, 152f–156f, 164f–166f, 168f–170f, 232f–234f, 278f–282f, 292f–293f, 382f–384f of Sylvius, 4f–5f, 8f–9f, 11f–12f, 84f–90f, 98f–102f Cerebral arterial circle (of Willis), 9f–10f Cerebral artery anterior, 9f–10f, 66f–68f, 70f–74f, 126f–136f, 152f–154f, 156f–160f, 298f–305f, 366f–368f, 376f–379f A1 portion, 74f–76f branches of, 66f–68f pericallosal branches of, 71f–74f, 136f–140f middle, 9f–10f, 71f–72f, 152f–154f, 232f–234f, 300f–302f, 364f–368f, 376f–379f, 382f–384f branches of, 70f–71f, 298f–300f, 364f–368f M1 branch, 74f–76f, 154f–156f M2 branch, 72f–74f, 156f–164f posterior, 9f–10f, 142f–144f, 152f–154f, 159f–160f, 162f, 164f–166f, 246f–250f, 281f–282f, 288f–290f, 304f–305f P2 segment, 142f–144f, 160f–164f P4 segment, 166f–168f Cerebral crus, 5f–6f, 9f–10f Cerebral hemisphere, medial surface of, 4f–5f Cerebral peduncle, 4f–5f, 11f–12f, 42f, 44f, 84f–86f, 142f–144f right, 45f–46f Cerebral vein accessory deep, 94f–96f inferior, 6f–7f internal, 8f–9f, 32f–38f, 86f–92f, 98f–102f, 130f–132f, 134f–136f, 144f–145f, 160f–166f normal anatomy of, 90 superficial middle, 6f–7f Cerebrospinal fluid (CSF), 36, 274, 564f–566f anatomy of, 284 around brainstem, imaging technique consideration for, 60 diagnostic consideration for, 286, 292 flow of, 284 in Meckel’s cave, 52 pathologic process of, 274 in prepontine cistern, 52 Cerebrum horizontal section of, 10f–11f inferior (inferolateral) margin of, 5f–6f inferior view, 5f–6f lateral views of, 5f–6f medial view of, 4f–5f occipital pole of, 5f–6f

Cervical cord, 539f–542f, 545f–548f Cervical curvature, 524f–525f Cervical foramen stenosis, assessment of, 510 Cervical nerve roots, 498 Cervical spinal cord, 428f–438f Cervical spine axial, 535f coronal, 535f diagnostic consideration in, 538, 548 imaging technique consideration in, 536, 544, 562 normal anatomy of, 568 sagittal, 535f upper, diagnostic consideration for, 110 Cervical vertebrae, 524f–525f upper, posterosuperior view of, 525f–526f Cervicomedullary junction, 60f–62f, 98f–102f, 537f–538f Choana, 311f–312f, 315f–316f, 332f–334f Cholesteatoma, 414 Chorda tympani nerve, 408f–410f Choroid, 358f–366f Choroid plexus, 11f–12f, 30f–34f, 36f–42f, 82f–84f, 86f–96f, 108f–116f, 128f–136f, 144f–145f, 148f–154f, 164f–168f, 274, 274f–278f, 290f–292f of 4th ventricle, 11f–12f 4th ventricle and, 4f–5f of lateral ventricle, 8f–11f passing through right foramen of Monro, 85f–86f of 3rd ventricle, 4f–5f, 8f–9f Choroidal fissure, 158f–166f, 170f–172f Ciliary body, 358f–364f Cingulate cortex, 66f–90f normal anatomy of, 78 Cingulate gyrus, 4f–5f, 64f–66f, 126f–130f, 132f–134f, 136f–145f, 150f–152f, 156f–160f, 290f–292f isthmus of, 4f–6f, 152f–154f Cingulate sulcus, 4f–5f, 104f–106f, 136f–144f Cingulum, 66f–76f white matter tract, 102f–106f Circle of Willis, 44 Circular esophageal muscle, 315f–316f Cisterna magna, 60f–62f, 88f–96f, 98f–102f, 270f–271f normal anatomy of, 94 Claustrum, 10f–11f, 36f–40f, 74f–84f, 110f–112f, 132f–142f, 156f–164f, 222f–224f Clava, 292f–293f Clavicle, 486f–488f, 494f–496f, 512f–519f Clivus, 44f–52f, 98f–104f, 236f–238f, 302f–304f, 384f–386f, 528f–529f, 554f–556f diagnostic consideration for, 102 Coccyx, 524f–525f, 531f–532f Cochlea, 240f–242f anatomy of, 404, 406 apical turn of, 402f–406f, 412f–414f basal turn of, 258f–260f, 282f–284f, 406f–408f, 412f–414f cochlear duct, containing spiral organ (of Corti), 318f helicotrema, 318f middle turn of, 254f–256f, 402f–404f, 412f–414f pathologic process of, 256 promontory of, 414f–416f scala vestibuli, 318f Cochlear canal, 254f Cochlear nerve (CN VIII), 240f–242f, 254f–258f, 260f–264f, 318f anatomy of, 258 pathologic process in, 404

Cochlear nerve tract, 256f Cochlear nuclei anterior, 12f posterior, 12f Cochlear promontory, 414f–416f Collateral sulcus, 4f–6f, 170f–172f Collateral trigone, 170f–172f Colloid cyst, 274 Common carotid artery, 316f–317f, 464f–466f, 476f–488f, 494f–496f, 512f–514f, 550f–551f Common crus, 416f–419f Common iliac artery, 584f, 586f, 588f–595f Common iliac vein, 584f, 586f, 588f–595f Common tendon of Lockwood, 374f–376f Common tendon of Zinn, 196f–198f, 374f–376f Communicating artery anterior, 9f–10f posterior, 6f–7f, 9f–10f, 154f–156f Condylar canal, 560f–562f Condylar process, 72f, 74f–80f Condyloid process, 552f–553f, 556f–558f Confluence of sinuses (torcular Herophili), 6f–8f, 96f–98f Constrictor muscle inferior, 454f–460f, 476f–480f, 494f–496f middle, 437f–438f, 454f–460f superior, 426f–436f, 446f–448f, 454f–460f superior pharyngeal, 388f–390f, 396f–397f Conus medullaris, 578f–580f, 596f–598f Cornea, 360f–364f Corniculate tubercle, 315f–316f Cornu ammonis, 154f–156f, 160f–168f normal anatomy of, 154, 170 Corona radiata, 30f–34f, 32, 108f–110f, 112f–114f, 126f–128f, 138f–140f, 148f–150f normal anatomy of, 126 Coronal imaging, in neck, 488 Coronal plane, 186 Coronal suture, 18f–36f, 38f–42f, 44f–46f, 98f–102f, 104f–108f, 110f, 112f–116f, 118f–120f, 122f–123f, 309f–311f Coronoid process, mandible, 228f–230f Corpus callosum, 8f–9f, 85f–86f, 138f–145f, 242f–244f body of, 68f–84f, 86f–88f, 98f–106f, 136f–138f, 156f–166f, 168f–170f, 292f–293f, 296f–305f genu of, 4f–6f, 10f–11f, 32f–38f, 66f–68f, 98f–108f, 126f–132f, 148f–150f, 168f–170f, 274f–276f, 304f–305f rostrum of, 4f–5f, 136f–138f, 168f–170f, 302f–305f splenium of, 4f–6f, 10f–12f, 32f–38f, 88f–94f, 98f–106f, 126f–132f, 148f–152f, 166f–170f, 274f–276f, 290f–292f, 304f–305f sulcus of, 4f–5f trunk of, 4f–5f Corpus medullare cerebelli, 224f–226f, 236f–238f, 246f–260f, 266f–270f Corpus striatum, 108f–110f Cortical nucleus, amygdala, 158f–160f Cortical vein, 96f–98f thrombosis of, diagnostic consideration for, 118 Cortical vessels, imaging technique consideration for, 122 Corticospinal tract, 250f–252f Costal facet inferior, 529f–530f superior, 529f–530f transverse, 529f–530f

609

Index Costal lamella, 526f–527f Costotransverse joint, 572f–574f, 582f–584f Costovertebral joint, 572f–574f, 576f–578f, 582f–584f Cranial fossa anterior, 312f–313f middle, 312f–313f diagnostic consideration for, 108 floor of, 138f–140f posterior, 312f–313f Cricoid cartilage, 314f–315f, 476f–482f, 488f–492f, 504f–512f Cricoid ring, pathologic process in, 480 Cricoid tracheotomy (cricothyrotomy), 480 Cricopharyngeus muscle, 315f–316f Cricothyroid artery, 316f–317f Cricothyrotomy (cricoid tracheotomy), 480 Crista galli, 48f–50f, 62f–64f of ethmoid bone, 324f–326f, 340f–348f normal anatomy of, 62 Cruciate ligament, 528f–529f, 540f–542f, 562f–564f inferior longitudinal band, 528f–529f injury to, diagnostic consideration for, 84 superior longitudinal band, 528f–529f transverse ligament of atlas, 528f–529f Crura of diaphragm, 533f Cuneate fasciculus, 11f–12f Cuneate tubercle, 11f–12f Cuneiform tubercle, 315f–316f Cuneus, 4f–5f apex of, 5f–6f

D

Decussation of pyramids, 11f–12f Deep cervical fascia, superficial (investing) layer of, 314f–315f Deep temporal and anterior tympanic arteries, 316f–317f Deep temporal arteries, 316f–317f Dens, 428f–430f, 450f–452f, 525f–526f, 528f–529f apical ligament of, 314f–315f, 528f–529f articular facet for, 525f–526f Dental notation systems, 388 Dentate gyrus, 4f–5f, 8f–9f, 154f–156f, 160f–168f Dentate nucleus, 52f normal anatomy of, 154 Depressor anguli oris muscle, 390f–392f, 432f–436f Descending aorta, 572f–578f Descending palatine artery, 316f–317f Diencephalon, 198 Diffusion-weighted magnetic resonance imaging (MRI), of vertex cranii lesions, 16 Digastric muscle, 315f–316f anterior belly of, 392f–397f, 438f–444f, 460f–462f, 472f–473f posterior belly, 388f–390f, 424f–434f Diploic space, 62f, 64f, 66f–72f, 74f, 76f, 78f, 80f–82f, 84f, 86f, 88f, 90f, 92f–94f, 96f, 98f–102f, 104f–108f, 110f, 112f–118f, 120f, 122f Distal medial striate artery, 9f–10f Dorsal cochlear nucleus, 256f Dorsal dura margin, 564f–566f Dorsal median sulcus, 11f–12f Dorsal nasal artery, 316f–317f Dorsal pons, infarcts of, 250 Dorsum sellae, 202f–208f Duodenojejunal junction, 533f Duodenum, descending part of, 533f

Dura, 62f, 64f, 66f–72f, 74f, 76f, 78f, 80f–82f, 84f, 86f, 88f, 90f, 92f–94f Dura mater, 104f–108f, 110f, 112f–120f metastasis of, 108 Dural venous sinuses, 6f–7f diagnostic consideration for, 116

Eye anterior compartment of, 50f–56f, 114f–118f posterior compartment of, 48f–52f, 54f–56f, 114f–118f containing vitreous humor, 53f–54f Eyeball, 46f–48f

E

F

Edinger-Westphal (accessory oculomotor) nucleus, 12f, 200 Electroencephalography (EEG), 162 Emergency ABCs, 474 Emissary vein, 402f–404f Endolymph, 282 in cochlea, normal anatomy of, 52 Endolymph fluid, 52 Endolymphatic sac, 404 Endorhinal sulcus, 288f–290f Endoscopic sinus surgery, functional, 340 Ependyma, 8f–9f Epidural fat, 584, 584f, 586f, 596f Epidural space, 28f–30f Epiglottis, 314f–316f, 448f–450f, 454f–460f, 504f–506f, 548f–552f pathologic process in, 458 Epitympanic recess, 318f Epitympanum, 402f–406f, 412f–416f Erector spinae muscle, 484f–486f, 533f, 584f–596f Esophageal muscles, 314f–315f Esophagus, 314f–315f, 484f–488f, 494f–496f, 504f–506f, 572f, 574f, 576f cervical, 480f–484f Esthesioneuroblastoma, 178 Ethmoid air cells, 49f–50f, 52f–54f, 62f–66f, 176f–178f, 322, 344f–346f anterior, 48f–52f, 54f–56f, 322, 324f–330f, 342f–344f posterior, 52f–54f, 326f–330f, 342f–344f, 346f–348f Ethmoid bone, 324f–328f, 342f–348f cribriform plate, 312f–313f crista galli of, 312f–313f, 324f–326f, 340f–348f lamina papyracea of, 328f–330f, 340f–342f middle nasal concha, 309f–310f orbital plate, 309f–311f perpendicular plate of, 309f–310f, 330f–332f, 338f–342f, 344f–348f Ethmoid bulla, 340f–342f Ethmoid sinus, 322 Eustachian tube, 394f–396f, 408f–410f opening of, 60f–62f, 332f–334f, 422f–424f External acoustic meatus, 318f External auditory canal, 384f–386f, 408f–410f, 412f–416f, 466f–469f External capsule, 10f–11f, 36f–40f, 74f, 76f, 132f–142f, 156f–164f diagnostic consideration of, 140 normal anatomy of, 126 External carotid artery, 316f–317f, 430f–438f, 472f–476f, 490f–494f, 540f, 542f–544f, 546f, 548f branch of, 94f cervical segment, 79f–80f left, 80f–84f branch of, 76f–78f right, 74f–76f, 90f–92f branch of, 72f–74f External oblique muscle, 533f Extraperitoneal fascia, 533f Extreme capsule, 10f–11f, 38f–40f, 74f–80f, 132f–136f, 140f–142f diagnostic consideration of, 140

Facial artery, 313f–314f, 316f–317f Facial colliculus, 11f–12f, 250, 250f–252f, 252 Facial nerve (CN VII), 6f–7f, 222f–224f, 246f–254f, 252, 256f–258f, 260f–264f, 282f–284f, 313f–314f, 318f, 400 anatomy of, 252, 260 geniculum (geniculate ganglion) of, 12f injury of, 120 labyrinthine segment of, 402, 402f–404f mastoid segment of, 406f–410f, 416f–418f anatomy of, 410 normal anatomy of, 120 pathologic process in, 402 right, 82f–84f in stylomastoid foramen, 120f–122f tympanic segment of, 404f–406f, 414f–416f Facial nerve tract (CN VII), 250f–252f Facial nodes buccinator, 317f–318f nasolabial, 317f–318f Facial nucleus, 12f, 250f–252f Facial vein, 313f–314f, 388f–390f, 446f–448f False vocal cord, 476f–478f, 488f–489f, 504f–506f Falx, 166f–168f Falx cerebelli, 7f–8f Falx cerebri, 6f–8f, 18f–52f, 62f–98f, 126f–132f, 274f–276f, 290f–292f Fasciculus, medial longitudinal, 11f–12f FDI dental notation system. See Fédération Dentaire Internationale (FDI) dental notation system Fédération Dentaire Internationale (FDI) dental notation system, 388 Field H1 of Forel, 222f–224f Fissula ante fenestram, 406 Flocculus, 236f–238f, 254f–256f, 266f–268f Follum, 292f–293f Foramen cecum, 314f–315f Foramen lacerum, 311f–312f Foramen magnum, 60f–62f, 88f–92f, 450f–452f, 536f–538f Foramen of Luschka, 8f–9f, 236f–238f, 258f–260f Foramen of Magendie, 8f–9f, 11f–12f, 270f–271f Foramen of Monro, normal anatomy of, 90 Foramen ovale, 70f–72f, 310f–311f, 352f–353f mandibular nerve in, 408f–410f transmitting V3, 72f–76f trigeminal nerve (CN V) in, 384f–386f Foramen rotundum, 208f–210f, 326f–328f, 348f–350f, 376f–378f transmitting V2, 66f–68f Foramen spinosum, middle meningeal artery in, 384f–386f, 408f–410f Foramen transversarium, 526f–527f body spicule dividing, 526f–527f septated, 526f–527f Foramina of Luschka, 285f–286f Foramina of Magendie, 284f–286f, 292f–293f Fornix, 34f–38f, 98f–100f, 126f–128f, 138f–142f, 150f–152f, 156f–160f, 166f–170f, 190f–192f, 214f–216f, 274f–276f, 296f–300f, 304f–305f

610 tahir99-VRG & vip.persianss.ir

Index Fornix (Continued) body of, 4f–5f, 8f–9f, 11f–12f, 80f–84f, 86f–88f, 148f–150f, 160f–164f column of, 4f–5f, 10f–11f, 38f–40f, 42f–44f, 85f–86f crus of, 4f–5f, 10f–11f, 144f–145f, 164f–166f normal anatomy of, 150 Fossa of Rosenmüller, 58f–62f, 332f–334f, 394f–396f, 422f–424f, 424 Fourth cervical vertebra, anterior view of, 526f–527f Fourth ventricle, 8f–9f, 11f–12f, 48f–52f, 88f–92f, 98f–104f, 166f–170f, 224f–228f, 234f–238f, 246f–250f, 257f–258f, 282f–284f, 290f–293f, 304f–305f, 401f–402f and cerebellum, 11f–12f median sagittal section, 11f–12f posterior view, 11f–12f and choroid plexus, 4f–5f taenia of, 11f–12f Fovea, inferior, 11f–12f Fracture, of lamina papyracea, 328 Frontal bone, 18f–38f, 40f–48f, 62f–64f, 66f–72f, 74f, 98f–102f, 104f–123f, 309f–312f, 322f–326f, 338f–348f anatomy of, 338 foramen cecum, 312f–313f frontal crest, 312f–313f glabella, 309f–311f groove for anterior meningeal vessels, 312f–313f groove for superior sagittal sinus, 312f–313f orbital surface, 309f–310f superior surface of orbital part, 312f–313f supraorbital notch (foramen), 309f–311f Frontal horn, pathologic process of, 278 Frontal lobe, 3f–4f, 29f–36f, 38f–44f, 62f–72f, 74f, 76f, 78f, 80f–82f, 84f–86f, 98f–123f, 126f–136f, 148f–150f, 188f–190f, 300f–304f, 364f–368f Frontal operculum, 3f–4f Frontal pole, 3f–4f Frontal sinus, 44f–48f, 104f–110f, 314f–315f, 322, 322f–326f, 338f–342f Frontobasal (orbitofrontal) artery, medial, 9f–10f Functional endoscopic sinus surgery, 178, 340 Fusiform gyrus, 170f–172f

G

Ganglia, 10f–11f Ganglion (gasserian), and trigeminal nerve (V), 12f Gasserian ganglion, 330 Geniculate ganglion, 401f–402f, 412f–414f and facial nerve (VII), 12f and trigeminal nerve (V), 12f trigeminal nerve (V) and, 12f Genioglossus muscle, 98f–106f, 314f–315f, 392f–396f, 432f–436f, 438f–446f, 454f–460f Geniohyoid muscle, 314f–315f, 392f–396f, 438f–446f, 454f–460f Glands, specialized, of head and neck, 474 Glenoid fossa, 70f–74f, 76f–80f mandibular condylar head within, 56f–58f of temporal bone, 410f–412f with TMJ articular cartilage, 74f–76f Globe, 62f–64f, 108f–114f, 118f–120f, 176f–178f, 180f–182f Globus pallidus, 8f–9f, 38f–40f, 76f–84f, 108f–110f, 128f–136f, 140f–142f, 150f–152f, 156f–160f, 170f–173f, 190f–192f, 300f–304f

Glossopharyngeal nerve (CN IX), 6f–7f, 12f, 236f–238f, 264f–270f, 313f–314f, 316f–317f anatomy of, 264, 266 and tract, 266f–268f Gracile fasciculus, 11f–12f Gracile tubercle, 11f–12f GRASS (3D SPGR) sequence, in transverse sinus and cortical vessels, 122 Great cerebral vein (of Galen), 4f–8f, 11f–12f, 92f–94f, 98f–104f, 130f–134f, 166f–168f, 276f–278f, 290f–292f cistern of, 277f–278f normal anatomy of, 90, 134 and straight sinus, junction of, 94f–96f Greater sciatic foramen, 531f–532f Gyrus rectus, 44f–48f

H

Habenula, 10f–11f, 38f–40f normal anatomy of, 38 Habenular commissure, 4f–5f, 11f–12f Habenular trigone, 11f–12f Haemophilus influenzae, type B vaccine, 458 Hard palate, 62f–66f, 98f–108f, 228f–230f, 314f–315f, 438f–442f Head, lymph vessels and nodes of, 317f–318f Hearing pathway, 400 Hippocampal head, 80f–84f crenulations of, 84f–86f Hippocampus, 40f–42f, 84f–88f, 140f–144f, 172f–173f body of, 114f–116f, 144f–145f, 170f–172f diagnostic consideration in, 86 and fimbria, 10f–11f fimbria of, 4f–5f, 8f–9f normal anatomy of, 154, 160, 170 pathologic process of, 162 Horizontal fissure, 260f–264f Hyoepiglottic ligament, 314f–315f Hyoglossus muscle, 392f–396f, 432f–436f, 444f–446f, 456f–462f Hyoid bone, 314f–316f, 396f–397f, 436f–437f, 454f–460f, 504f–512f, 550f–552f greater cornu, 462f–464f muscle of, 382 Hypoglossal canal, 414f–416f fat in, 58f Hypoglossal nerve (CN XII), 6f–7f, 270f–271f, 313f–314f, 316f–317f damage to, 270 diagnostic consideration for, 270 Hypoglossal nucleus, 12f Hypoglossal trigone, 11f–12f Hypopharynx, 456f–458f axial, 471f coronal, 471f imaging technique consideration in, 504 post-cricoid cartilage, 476f–480f posterior wall of, 472f–473f sagittal, 471f Hypophysis, 4f–7f, 298, 454f–458f Hypothalamic sulcus, 4f–5f, 11f–12f Hypothalamus, 8f–9f, 42f–44f, 76f–88f, 140f–142f, 152f–154f, 156f–158f, 168f–170f functions of, 76 normal anatomy of, 76 Hypotympanum, 412f–416f

I

Idiopathic intracranial hypertension, 180 Iliac crest, 531f–532f

Iliac spine posterior inferior, 531f–532f posterior superior, 531f–532f Iliac wing, 586f, 588f–596f Iliolumbar ligament, 531f–532f Incisive canal, 314f–315f Incisor central, 388f–390f, 428f–430f lateral, 388f, 428f–430f Inconspicuous anterior tubercle, 526f–527f Incus, 318f, 406f–408f, 414f–416f Inferior alveolar artery and lingual branch, 316f–317f mental branch of, 316f–317f mylohyoid branch of, 316f–317f Inferior articular facet, 526f–527f, 529f–530f, 532f–533f for C3, 525f–526f for T1, 526f–527f Inferior articular process, 525f–527f, 529f–533f Inferior colliculi, 154f–156f, 166f–170f Inferior colliculus, 4f–5f, 11f–12f, 42f–46f, 90f–92f, 202f–206f, 232f–234f, 278f–282f, 292f–293f Inferior constrictor muscle, 476f–480f, 494f–496f Inferior deep lateral cervical (scalene) node, 317f–318f Inferior endplate, 578f–580f Inferior extent, maxillary sinus, 228f–230f Inferior frontal gyrus, 120f–122f opercular part, 3f–4f orbital part, 3f–4f triangular part, 3f–4f Inferior frontal sulcus, 3f–4f Inferior labial artery, 316f–317f Inferior longitudinal band, of cruciate ligament, 528f–529f Inferior meatus, 65f–66f, 334f–336f, 342f–350f nasolacrimal duct opening, 332f–334f Inferior medullary velum, 4f–5f, 268f–270f Inferior nasal concha, 309f–310f, 313f–314f Inferior oblique muscle, 62f–64f Inferior olivary nucleus, 264f–266f Inferior ophthalmic vein, and branches, 362f–364f Inferior orbital fissure, 309f–311f, 326f–330f Inferior parietal lobule angular gyrus, 3f–4f parietooccipital sulcus, 3f–4f supramarginal gyrus, 3f–4f Inferior pharyngeal constrictor muscle, 315f–316f Inferior rectus muscle, 54f–56f, 62f–66f, 110f–118f, 178f–180f, 186f–190f, 192f–196f, 198f–200f, 240f–242f, 356f–362f, 368f–374f, 390f–392f, 438f–442f tendons of, 374f–376f Inferior salivatory nucleus, 266f–270f Inferior temporal gyrus, 3f–6f Inferior temporal sulcus, 3f–6f Inferior thyroid artery, 316f–317f Inferior turbinate, 332f–336f, 340f–350f, 384f–386f Inferior vena cava, 533f Inferior vertebral notch, 529f–531f Inferior vestibular nerve (CN VIII), 240f–242f, 254f–258f, 260f–264f Inferior vestibular nerve tract (CN VIII), 256f Inferior vestibular nucleus, 256f Infrahyoid neck axial, 471f coronal, 471f sagittal, 471f

611 tahir99-VRG & vip.persianss.ir

Index Infraorbital artery, 316f–317f Infraorbital canal, 332f–334f, 342f–346f, 390f–392f Infraorbital foramen, 309f–310f Infraorbital groove, 309f–310f Infraorbital nerve, 384f–386f Infratemporal fossa, 310f–311f Infundibular recess, 8f–9f Infundibulum, 44f–48f, 74f–76f, 100f–102f, 154f–156f, 176f–178f, 200f–206f, 286f–288f, 292f–293f, 301f–305f, 362f–364f normal anatomy of, 74 Inner table, of skull, 62f, 64f, 66f–72f, 74f, 76f, 78f, 80f–82f, 84f, 86f, 88f, 90f, 92f–94f, 96f, 98f–102f, 104f–108f, 110f, 112f–116f, 118f, 120f, 122f Insula, 128f–144f, 156f–160f Insula (island of Reil), 10f–11f central sulcus, 3f–4f circular sulcus, 3f–4f limen, 3f–4f long gyrus, 3f–4f short gyri, 3f–4f Insular cortex, 34f–38f, 76f–88f normal anatomy of, 34 Insular lobe, 150f–152f, 170f–172f, 296f–303f Interarticular part, 525f–526f Intercalated node, 317f–318f Intercavernous sinuses, anterior and posterior, 6f–8f Intercostal muscle, 484f–486f Interhemispheric fissure, 28f–36f, 40f–46f, 136f–138f, 286f–288f, 296f–298f Intermediate nerve (of Wrisberg), 6f–7f Internal acoustic meatus, 318f Internal auditory canal, 260f–264f, 400f–406f, 414f–416f Internal capsule, 8f–9f, 68f–88f, 136f–139f, 172f–173f anterior limb of, 10f–11f, 34f–40f, 132f–136f, 139f–142f, 150f–152f, 274f–276f, 296f–304f genu of, 10f–11f, 38f–40f, 132f–136f, 150f–152f, 156f–158f normal anatomy of, 126 posterior limb of, 10f–11f, 34f–40f, 132f–136f, 142f–144f, 150f–152f, 158f–162f, 222f–224f, 274f–276f retrolenticular part of, 10f–11f Internal carotid artery, 6f–7f, 9f–10f, 46f–49f, 52f–54f, 58f–60f, 114f–116f, 158f–160f, 260f–264f, 282f–284f, 286f–288f, 313f–314f, 316f–317f, 362f–364f, 386f–390f, 400f–408f, 422f–438f, 450f–452f, 472f–476f, 536f, 538f, 540f, 542f–544f, 546f, 548f, 554f, 556f, 570f–572f cavernous segment of, 48f–50f, 73f–74f, 106f–108f, 140f–142f, 198f–200f, 278f–280f, 296f–304f, 378f–379f left, 74f–76f, 82f–84f, 228f–230f, 256f–258f cavernous segment of, 69f–70f distal cervical segment of, 60f–62f, 76f–82f petrous segment of, 76f, 78f–82f supraclinoid segment of, 71f–72f, 200f–206f petrous segment of, 384f–386f, 396f–397f, 406f anterior genu of, 114f–116f horizontal, 54f–56f vertical, 56f–58f, 116f–118f precavernous segment of, 50f–52f, 106f–110f, 356f–362f

612

Internal carotid artery (Continued) right, 68f–69f, 74f, 110f–114f, 208f–214f, 224f–228f, 234f–236f, 240f–242f, 258f–260f, 270f–271f, 284f–286f aberrant turn in, 76f–78f cavernous segment of, 70f–72f, 104f–106f distal cervical segment of, 78f–82f petrous segment of, 76f–82f, 110f–114f supraclinoid segment of, 70f–72f supraclinoid segment of, 73f–76f, 154f–156f, 176f–178f, 280f–282f, 298f–302f, 378f–379f, 382f–384f terminal portion of, 74f–76f Internal cerebral vein, 274f–276f Internal jugular vein, 56f–62f, 114f–118f, 260f–264f, 313f–314f, 318f, 388f–390f, 422f–438f, 450f–452f, 472f–484f, 474, 494f–498f, 512f–516f, 536f, 538f, 540f, 542f–544f, 546f, 548f, 550f–554f, 556f Internal oblique muscle, 533f tendon of, 533f Interpeduncular cistern, 42f–46f, 84f–86f, 98f–102f, 142f–144f, 154f–156f, 160f–162f, 202f–206f, 278f–282f, 280, 292f–293f pathologic process of, 44 Interspinal ligament, 562f–564f Interspinous ligament, 531f–533f, 574f–576f, 578f–580f, 596f–598f Interthalamic adhesion, 4f–5f, 10f–12f, 142f–144f, 292f–293f Interthalamic adhesion, 3rd ventricle and, 8f–9f Interventricular foramen (of Monro), 4f–5f, 11f–12f, 36f–38f, 88f–92f left, 8f–9f white arrow in, 8f–9f normal anatomy of, 90 pathologic process of, 36 Intervertebral discs, 530f–533f C2-C3, 527f–528f C3-C4, 527f–528f Intervertebral foramen, 530f–533f, 556f–558f, 574f–576f Intraorbital muscles, anatomy of, 370 Intraparietal sulcus, 3f–4f Intrinsic lingual muscles, 444f–448f, 454f–462f Ischial tuberosity, 531f–532f Ischium, spine of, 531f–532f Island of Reil. See Insula (island of Reil) Isthmus, of thyroid gland, 482f–484f, 504f–506f

J

J coupling, 114 Jugular foramen, 6f–8f, 414f–418f pars nervosa, 409f–410f pars vascularis, 409f–410f Jugular lymph node chain, 474 imaging technique consideration in, 488 Jugular spine, 264 Jugular trunk, 317f–318f Jugular tubercle, 84f–86f Jugulodigastric lymph node, 474 Jugulodigastric node, 317f–318f Juguloomohyoid node, 317f–318f

K

Kidney, 533f

L

L1 dorsal root ganglion, 600f–602f inferior articular process, 598f–600f intervertebral foramen, 600f–602f lamina, 596f–600f pedicle, 600f–602f spinous process, 596f–598f superior articular process, 600f–602f transverse process, 602f–605f vertebral body, 596f–604f L1-L2 intervertebral disc, 600f–602f annulus fibrosus of, 596f–598f nucleus pulposus of, 596f–598f L1 vertebra, 524f–525f, 530f–531f body of, 531f–532f spinous process of, 533f L2 dorsal root ganglion, 600f–602f inferior articular process, 598f–600f intervertebral foramen, 600f–602f lamina, 599f–600f pedicle, 600f–602f superior articular process, 600f–602f transverse process, 602f–605f vertebra, 530f–531f body of, 533f superior view of, 530f–531f vertebral body, 596f–604f L2-L3 intervertebral disc, 600f–602f annulus fibrosus of, 598f–600f nucleus pulposus of, 598f–600f L3 inferior articular process, 598f–602f intervertebral foramen, 600f–602f pars interarticularis, 602f–604f pedicle, 600f–602f superior articular process, 600f–604f transverse process, 604f–605f vertebra, 530f–531f posterior view of, 530f–531f spinous process of, 530f–531f vertebral body, 596f, 598f–604f L3-L4 intervertebral disc, 600f–602f L4 dorsal ramus of spinal nerve, 586f–588f inferior articular process, 584f–590f, 598f–604f lamina, 596f–598f pars interarticularis, 600f–604f pedicle, 600f–604f spinal nerve dorsal root ganglion, 584f–586f spinous process, 584f–586f, 596f–598f superior articular process, 602f–604f transverse process, 604f–605f ventral ramus of spinal nerve, 586f–588f vertebra, 530f–531f posterior view of, 530f–531f vertebral body, 596f–604f L4-L5 facet joint, 584f–588f, 600f–602f L4-L5 intervertebral disc, 600f–602f L5 dorsal nerve root, 598f–600f dorsal root ganglion, 602f–604f inferior articular process, 594f–596f, 598f–600f, 602f–604f intervertebral foramen, 602f–604f lamina, 588f–594f, 596f–598f pars interarticularis, 600f–602f, 604f–605f pedicle, 588f–592f, 602f–605f spinal nerve, 600f–602f spinal nerve dorsal root ganglion, 592f–596f spinal nerve root, 584f–588f spinous process, 586f–598f

Index L5 (Continued) superior articular process, 584f–590f, 600f–604f transverse process, 588f–594f traversing nerve root, 590f–592f ventral nerve root, 598f–600f vertebra, 524f–525f, 530f–531f body of, 531f–532f vertebral body, 586f–596f, 598f–604f L5-L6 intervertebral disc, 601f–602f L5-S1 annulus fibrosus of, 596f–600f facet joint, 592f–596f, 602f–604f intervertebral disc, 600f nucleus pulposus of, 596f–600f Labyrinthine (internal acoustic artery), 9f–10f Lacrimal bone, 309f–311f, 330f–332f Lacrimal gland, 46f–52f, 62f–64f, 120f–122f, 360f–368f anatomy of, 366 function of, 366 Lacrimal sac, fossa for, 309f–311f Lambdoid suture, 28f–44f, 46f–50f, 52f, 54f–58f, 92f–98f, 104f–114f, 116f–123f Lamina, 526f–527f, 529f–533f Lamina papyracea, 52f diagnostic consideration for, 328 of ethmoid bone, 328f–330f, 340f–342f Lamina terminalis, 4f–6f, 11f–12f Laryngeal inlet (aditus), 314f–315f Laryngeal ventricle, 454f–458f, 504f–506f Laryngeal vestibule, 490f–494f, 504f–512f Laryngopharynx, 314f–315f Larynx axial, 471f coronal, 471f sagittal, 471f Lateral aperture, left, 8f–9f Lateral frontobasal (orbitofrontal) artery, 9f–10f Lateral funiculus, 11f–12f Lateral geniculate body, 5f–6f, 9f–12f, 40f–42f Lateral geniculate nucleus (LGN), 184, 184f–186f Lateral incisor, 388f–390f, 428f Lateral lemniscus, 206f–208f Lateral mass, 525f–526f Lateral occipitotemporal gyrus, 4f–5f Lateral pterygoid muscle, 58f–62f, 66f–72f, 74f–78f, 116f–120f, 228f–230f, 238f–240f, 313f–314f, 382, 384f–388f, 392f–397f, 422f–426f, 446f–450f, 462f–466f anatomy of, 394 Lateral pterygoid plate, 313f–314f, 332f–334f, 350f–352f Lateral recess, 11f–12f left, 8f–9f Lateral rectus muscle, 48f–54f, 62f, 64f–66f, 114f–120f, 178f–182f, 186f–190f, 192f–198f, 278f–280f, 324f–326f, 360f–364f, 368f–374f, 382f–384f, 390f–392f Lateral sacrococcygeal ligament, 531f–532f Lateral semicircular canal, prominence of, 318f Lateral sulcus (of Sylvius), 5f–6f anterior ramus, 3f–4f ascending ramus, 3f–4f posterior ramus, 3f–4f Lateral ventricle, 9f–11f, 30f–32f, 136f–145f, 148f–150f, 168f–170f, 214f–216f, 260f–264f, 292f–293f anterior body of, 286f–288f atrium of, 36f–42f, 108f–116f, 170f–172f atrium/trigone of, 150f–154f, 166f–168f body of, 126f–130f, 156f–166f, 242f–244f, 274f–276f, 288f–290f, 304f–305f

Lateral ventricle (Continued) choroid plexus of, 8f–11f frontal horn of, 32f–40f, 66f–80f, 83f–84f, 130f–132f, 148f–150f, 274f–276f, 296f–304f left, 84f–92f atrium of, 92f–96f central part of, 8f–9f frontal horn of, 8f–9f, 70f–72f, 74f, 76f, 78f, 80f–82f occipital (posterior) horn of, 8f–9f temporal (inferior) horn of, 8f–9f occipital (posterior) horn of, 10f–11f posterior horn of, 32f–34f, 42f–44f with choroid plexus, 35f–36f right, 8f–9f temporal horn of, 79f–84f temporal horn of, 44f–48f, 85f–86f, 108f–118f, 154f–156f, 166f–168f, 278f–282f, 288f–290f, 362f–363f diagnostic consideration for, 46 inferior, 8f–9f trigone of, 128f–136f, 172f–173f, 276f–278f, 290f–292f Lateral vestibular nucleus, 256f Latissimus dorsi muscle, 533f Left anterior cerebral artery, 68f–70f A1 segment, 200f–202f pericallosal branch of, 68f–72f Left cerebellar hemisphere, 46f–54f, 58f–60f inferior, 54f–58f Left innominate vein, 486 Left internal jugular vein, 80f–82f, 84f–88f, 228f–230f Left middle cerebral artery branch of, 214f–216f M1 segment, 200f–202f Left optic strut, 69f–70f Left posterior cerebral artery, 204f–206f, 216f–218f Left vertebral artery, 82f, 190f–192f, 214f–218f, 228f–230f, 284f–286f V3, 84f–88f V4, 86f Leiomyosarcoma, 452 Lens, 50f–52f, 114f–118f, 176f–178f, 180f–182f, 360f–364f anatomy of, 360 separating anterior and posterior compartments, 53f–54f Lentiform nucleus, 8f–11f, 136f–140f globus pallidus, 10f–11f normal anatomy of, 128 putamen, 10f–11f Lesser sciatic foramen, 531f–532f Levator labii superioris alaeque nasi muscle, 384f–386f Levator labii superioris muscle, 384f–388f Levator palpebrae muscle, 112f–116f, 178f–180f, 186f–188f Levator palpebrae superioris muscle, 192f–196f, 364f–372f, 390f–392f Levator scapulae muscle, 432f–438f, 472f–484f, 498f–504f, 514f–518f Levator veli palatini muscle, 58f–60f, 238f–240f, 313f–316f, 386f–388f, 394f–397f, 448f–450f Ligamentum flavum, 527f–528f, 531f–533f, 573f–574f, 576f–580f, 584f, 586f, 588f–595f, 597f–600f Ligamentum nuchae, 527f–528f, 564f–566f Limbic system, 147–174

Lingual artery, 316f–317f Lingual gyrus, 4f–5f Lingual tonsil, 314f–315f, 396f–397f, 454f–456f Locus caeruleus, 11f–12f Longissimus capitis muscle, 476f–484f Longissimus cervicis muscle, 500f–502f, 512f–514f Longitudinal cerebral fissure, 5f–6f Longitudinal esophageal muscle, 315f–316f cricoid attachment of, 315f–316f Longitudinal pharyngeal muscles, 315f–316f Longus capitis muscle, 58f, 60f–62f, 74f, 76f–78f, 228f–230f, 313f–314f, 386f–388f, 396f–397f, 422f–436f, 461f–462f, 472f–476f, 563f–564f, 566f–568f Longus colli muscle, 236f–238f, 460f–464f, 476f–484f, 494f–496f, 537f–540f Lower deep cervical group, 317f–318f Lumbar artery, 602f Lumbar curvature, 524f–525f Lumbar spinal nerve, 533f Lumbar vertebra, 524f–525f body of, 532f–533f left lateral view of, 530f–531f Lumbosacral spine axial, 535f imaging technique consideration in, 596 normal anatomy of, 584, 596, 600, 604 pathologic process in, 586 sagittal, 535f Lunate sulcus (inconstant), 3f–4f Lung, 484f–488f, 498f–504f, 510f, 512f–519f Lymph nodes of neck, 474 diagnostic consideration in, 510 metastatic, 498 of superior parotid gland, 384f–386f

M

Macroadenoma, 300 Major alar cartilage, 313f–314f Malar bone, 118f–120f Malleolar ligament, anterior, 412f–414f Malleus, 406f–408f head, 318f, 404f–406f diagnostic consideration for, 406 Mammillary body, 4f–6f, 8f–9f, 42f–44f, 82f–84f, 98f–102f, 140f–142f, 152f–154f, 158f–160f, 168f–170f, 184f–186f, 232f–234f, 304f–305f, 364f–366f normal anatomy of, 42 Mammillary process, 530f–531f Mammillothalamic fasciculus, 4f–5f Mandible, 116f–118f, 314f–315f, 330f–332f, 348f–353f, 381–398, 388f–390f, 436f–444f, 464f–466f anatomy of, 384 axial, 381f–390f body, 309f–311f condylar process of, 58f–62f, 73f–74f condyle, 410f–412f coronal, 381f, 390f–397f coronoid process of, 58f–60f, 238f–240f, 310f–311f, 313f–314f, 332f–334f, 384f–386f head of condylar process, 310f–311f mandibular notch, 310f–311f mental foramen, 309f–311f mental protuberance, 309f–310f mental tubercle, 309f–310f neck of, 238f–240f, 313f–314f, 332f–334f oblique line, 310f–311f

613

Index Mandible (Continued) ramus of, 60f–62f, 66f–76f, 309f–311f, 332f–338f squamous cell carcinoma of, 390 subcoronoid process of, 60f–62f Mandibular condyle, 118f–122f, 326f–330f, 378f–379f, 386f–388f Mandibular nerve (V3), 6f–7f, 231f–232f, 408f–410f Mandibular nodes, 317f–318f Mandibular ramus, 394f–396f, 552f–556f Manubrium, 504f–512f of sternum, 578f–580f, 582f–584f Marginal sulcus, 4f–5f Massa intermedia, 34f–36f, 98f–100f Masseter muscle, 60f–62f, 64f–72f, 120f–123f, 228f–230f, 238f–240f, 313f–314f, 382, 384f–390f, 392f–397f, 422f–434f, 442f–450f, 466f–468f anatomy of, 382 Masseteric artery, 316f–317f Mastoid air cells, 50f–60f, 84f–88f, 313f–314f, 410f–412f, 560f–562f labyrinthian canals and, 116f–118f Mastoid antrum, 400f–404f, 416f–419f Mastoid nodes, 317f–318f Maxilla, 58f–62f, 438f–440f alveolar process, 309f–311f anterior nasal spine, 309f–311f frontal process, 310f–311f, 326f–328f incisive fossa, 311f–312f infraorbital foramen, 309f–311f infratemporal surface of, 310f–311f intermaxillary suture, 311f–312f orbital surface, 309f–310f palatine process, 311f–312f tuberosity of, 310f–311f zygomatic process, 309f–312f Maxillary antra, 322 Maxillary artery, 316f–317f Maxillary bone, 313f–314f, 328f–348f zygomatic process of, 56f–58f Maxillary nerve (V2), of trigeminal nerve (CN V), 6f–7f, 208f–214f, 244f–246f, 300f–304f, 326f–328f, 348f–350f Maxillary sinus, 54f–66f, 108f–118f, 313f–314f, 322, 328f–336f, 343f–348f, 356f–358f, 384f–388f, 422f–426f, 438f–444f, 460f–466f Maxillary teeth, 98f–102f, 104f–110f alveolar roots of, 346 diagnostic consideration for, 108 Meatus, inferior, 62f–64f Meckel’s cave (trigeminal cave), 224f–228f, 234f–236f, 244f–246f, 296f–298f containing gasserian ganglion, 74f–76f containing trigeminal ganglion, 77f–78f normal anatomy of, 52 Meckel’s ganglion, 330 diagnostic consideration for, 240 in pterygopalatine fossa, 240f–242f Medial dorsal nucleus, 142f–144f Medial eminence, 11f–12f Medial frontal gyrus, 4f–5f Medial frontobasal (orbitofrontal) artery, 9f–10f Medial geniculate body, 5f–6f, 9f–12f, 40f–42f Medial lemniscus, 236f–238f, 252f–254f, 266f–268f, 292f–293f decussation of, 284f–286f Medial longitudinal fasciculus, 220f–222f, 252f–254f Medial occipitotemporal gyrus, 4f–5f, 260f–264f

614

Medial pterygoid muscle, 58f, 60f–62f, 66f–72f, 74f–78f, 116f, 118f–120f, 238f–240f, 313f–316f, 382, 384f–386f, 388f–390f, 392f–397f, 426f–432f, 446f–450f, 460f–466f anatomy of, 394 Medial rectus muscle, 48f–54f, 62f, 64f–66f, 178f–182f, 186f–190f, 192f–196f, 278f–280f, 324f–326f, 360f–364f, 368f–374f, 382f–384f, 390f–392f anatomy of, 370 tendons of, 374f–375f Medial vestibular nucleus, 256f Median aperture (foramen of Magendie), 8f–9f, 11f–12f Medulla, 56f–58f, 86f–88f, 168f–170f, 236f–238f, 284f–286f, 292f–293f, 422f–426f Medulla oblongata, 4f–5f, 11f–12f, 58f–60f, 258f–260f, 268f–270f, 304f–305f, 313f–314f Medullary pyramid, 236f–238f, 270f–271f, 284f–286f Medullary velum inferior, 11f–12f superior, 11f–12f, 166f–168f Meningioma, 108 Mesencephalic nucleus, of trigeminal nerve (CN V), 12f, 232, 232f–234f Mesencephalon, 42f–44f Mesentery, 533f Mesial temporal sclerosis, 162 Mesotympanum, 412f–416f Microadenoma, 300 Midbrain, 44f–46f, 86f–88f, 152f–156f, 160f–166f, 168f–170f, 184f–186f, 232f–234f, 280f–282f, 304f–305f, 382f–384f Middle concha, 58f–60f Middle frontal gyrus, 3f–4f Middle meatus, 330f–332f, 342f–350f Middle meningeal artery, 6f–7f, 316f–317f in foramen spinosum, 384f–386f, 408f–410f Middle pharyngeal constrictor muscle, 315f–316f Middle septum, 59f–60f Middle temporal gyrus, 3f–4f Middle turbinate, 330f–332f, 342f–348f Modiolus, 404f, 412f–414f Molar 1st, 388f–390f, 428f–430f 2nd, 388f–390f 3rd, 388f–390f Motor nucleus, of trigeminal nerve (V), 12f Mouth, mucosa over roof of, 62f–66f Multifidus muscle, 436f–438f, 472f–484f, 500f–504f Muscles, of mastication, 381–398 anatomy of, 382 axial, 381f–390f coronal, 381f, 390f–397f Mylohyoid muscle, 230f–232f, 314f–315f, 392f–397f, 432f–438f, 440f–446f, 454f–460f diagnostic consideration in, 442

N

Nasal bone, 309f–311f, 326f–332f, 338f–340f Nasal cavity, 328f–344f Nasal choanae, 60f–62f Nasal septal cartilage, 313f–314f Nasal septum, 54f–58f, 60f–66f, 250f–252f, 314f–315f, 326f–342f, 348f–350f, 422f–426f

Nasal vestibule, 313f–314f Nasion, 309f–310f Nasolacrimal canal, 358f–362f Nasolacrimal duct, 330f–332f inferior meatus opening into, 333f–334f opening into inferior meatus, 332f–333f Nasopharyngeal lumen, 376f–379f, 446f–448f Nasopharynx, 6f–7f, 60, 60f–62f, 66f–72f, 238f–240f, 296f–300f, 314f–315f, 318f, 332f–336f, 350f–353f, 392f–397f, 454f–460f anatomy of, 336 diagnostic considerations for, 60 pathologic process, 424 Neck anatomy of nerve roots of, 498 imaging technique consideration in, 488 infrahyoid axial, 471f coronal, 471f sagittal, 471f lymph vessels and nodes of, 317f–318f suprahyoid anatomy of, 422 axial, 421f coronal, 421f diagnostic consideration in, 450, 466 pathologic process in, 430 sagittal, 421f Nerve roots, cervical, 498 Neural foramen, 530f–531f, 584f–586f Neural foramina, 568f–570f cervical, 510 normal anatomy of, 510 Neurohypophysis, 304 Nodulus, 257f–260f, 290f–292f Nucleus accumbens septi, 138f–140f Nucleus ambiguus, 12f, 266f–270f Nucleus pulposus, 530f–531f, 584f–588f

O

Obex, 11f–12f, 292f–293f Obliquus capitis inferior muscle, 430f–436f, 460f–466f, 567f–568f Obliquus capitis superior muscle, 460f–466f Occipital artery, 316f–317f and sternocleidomastoid branch, 316f–317f Occipital bone, 32f, 34f–44f, 46f–52f, 54f–60f, 88f, 90f, 92f–94f, 96f–102f, 310f–311f, 412f–414f asterion, 310f–311f basilar part of, 311f–313f, 315f–316f, 527f–528f clivus of, 250f–252f, 312f–313f condylar canal and, 311f–312f condyle, 312f–313f foramen magnum, 311f–312f groove for inferior petrosal sinus, 312f–313f groove for occipital sinus, 312f–313f groove for posterior meningeal vessels, 312f–313f groove for superior sagittal sinus, 312f–313f groove for transverse sinus, 312f–313f hypoglossal canal, 311f–312f inferior nuchal line, 311f–312f occipital condyle, 311f–312f occipital crest external, 311f–312f internal, 312f–313f occipital protuberance external, 310f–312f internal, 312f–313f pharyngeal tubercle of, 311f–312f, 314f–315f superior nuchal line, 311f–312f

Index Occipital condyle, 60f–62f, 80f–88f, 108f–110f, 536f–538f, 556f–560f, 568f–570f superior articular facet of lateral mass for, 525f–526f superior articular surface for, 525f–526f Occipital lobe, 3f–4f, 32f–42f, 44f–52f, 96f–99f, 102f–116f right, 49f–50f Occipital nodes, 317f–318f Occipital pole, 3f–4f Occipital sinus, 7f–8f Occipitomastoid suture, 560f–562f Occipitotemporal gyrus lateral, 4f–6f medial, 4f–6f Occipitotemporal sulcus, 4f–6f Oculomotor nerve (CN III), 6f–7f, 12f, 138f–140f, 154f–156f, 200, 200f–220f, 208, 244f–246f, 286f–290f, 300f–304f, 362f–364f, 378f–379f anatomy of, 200, 208, 216 fibers for, 200 pathologic process of, 202 pathway, 200f–202f unilateral palsy of, 370 Oculomotor nerve palsy, 202 Oculomotor nucleus, 12f, 200f–202f origin of, 200 Odontoid process, 304f–305f, 556f–560f, 564f–566f base of, 540f–542f, 562f–564f junction, with body C2, 542f–544f pathologic process in, 540 diagnostic consideration in, 556 tip, 538f–540f Olfactory bulb, 5f–6f, 48f–50f, 64f–66f, 176f–178f Olfactory groove, anatomy of, 344 Olfactory nerve (CN I), 16, 176, 178f–180f, 186f–188f, 192f–196f anatomy of, 176 imaging technique for, 178 Olfactory recess, 326f–328f Olfactory sulcus, 5f–6f, 194f–196f Olfactory tract, 4f–6f, 189f–190f “Omega” (Ω) sign, 24 denoting precentral gyrus, 22f–26f Omohyoid muscle, 396f–397f Operculum frontal lobe covering insula, 87f–88f parietal lobe covering insula, 86f–88f temporal lobe covering insula, 86f–88f Ophthalmic artery, 192f–194f, 196f–198f, 362f–376f branch of, 368f–374f Ophthalmic nerve (V1), trigeminal nerve (CN V), 6f–7f, 208f–214f, 244f–246f, 300f–304f, 378f–379f Ophthalmic vein, superior, 6f–7f, 64f, 368f–376f Opisthion, 102, 562f–564f Optic canal, 348f–350f, 376f–378f foramen, 309f–310f Optic chiasm, 4f–7f, 44f–46f, 74f–76f, 102f–104f, 156f–158f, 168f–170f, 182, 182f–184f, 244f–246f, 280f–282f, 286f–288f, 298f–305f normal anatomy of, 74 Optic nerve (CN II), 4f–7f, 46f–52f, 102f–104f, 108f–114f, 138f–140f, 176f–184f, 186f–190f, 192f–200f, 278f–280f, 324f–326f, 362f–364f, 368f–370f, 372f–376f, 382f, 390f–392f anatomy of, 182, 198, 368 diagnostic consideration for, 180, 186, 196

Optic nerve (Continued) entering chiasm, 73f–74f left, 64f–72f entering chiasm, 72f intracanalicular portion, 66f–68f origin of, 198 prechiasmatic, 208f–212f, 296f–298f, 378f–379f Optic sheath, 176f–182f, 186f–190f, 192f–200f Optic strut, 66f–69f, 376f–378f anatomy of, 376 Optic tract, 5f–6f, 8f–10f, 76f–82f, 102f–104f, 140f–142f, 152f–154f, 182f–186f, 184, 190f–192f, 212f–218f, 232f–234f, 364f–366f anatomy of, 184 Oral cavity, 314f–315f axial, 421f coronal, 421f diagnostic consideration in, 442 imaging technique consideration for, 438 sagittal, 421f Orbicularis oculi muscle, 382f–384f, 390f–392f Orbicularis oris muscle, 390f–392f, 424f–426f, 428f–430f, 432f–436f, 454f–458f Orbit, 438f–440f Orbital fat, retrobulbar, 358f–360f Orbital gyri, 5f–6f Orbital operculum, 3f–4f Orbital sulci, 5f–6f Orbits, 355–380 axial, 355f–368f coronal, 355f, 369f–379f imaging technique of, 368 Oropharyngeal lumen, 336, 544f–546f Oropharynx, 72f–74f, 314f–315f, 336f–338f, 388f–390f, 396f–397f, 428f–430f, 472f–473f anatomy of, 336 normal anatomy, 428 Osteomeatal unit, 342f–344f anatomy of, 342 function of, 342 obstruction of, 342 Otitis media, 408 Otosclerosis, 406 Outer table, of skull, 62f, 64f, 66f–72f, 74f, 76f, 78f, 80f–82f, 84f, 86f, 88f, 90f, 92f–94f, 96f, 98f–102f, 104f–108f, 110f, 112f–116f, 118f, 120f, 122f

P

Palate hard, 438f–442f soft, 442f–448f, 454f–456f, 458f Palatine bone, 334f–336f, 346f–348f greater palatine foramen, 311f–312f horizontal plate, 311f–312f lesser palatine foramina, 311f–312f orbital process of, 309f–310f posterior nasal spine, 311f–312f pyramidal process, 311f–312f Palatine glands, 314f–315f Palatine tonsils, 314f–315f, 426f–434f, 446f–450f Palatomaxillary suture, 311f–312f Palatopharyngeus muscle, 315f–316f Pallidum, 36f–38f Pancoast tumor, 498 Pancreas, 533f Paracentral lobule, 4f–5f, 20f–22f, 104f–106f, 122f–123f

Paracentral sulcus, 4f–5f Paraglottic space, 488f–492f Parahippocampal gyrus, 4f–6f, 8f–9f, 84f–88f, 142f–144f, 152f–156f, 160f–168f, 172f–173f, 288f–290f Paranasal sinuses, 321–354 anatomy of, 322 axial, 321f–338f coronal, 321f, 338f–353f diagnostic consideration of, 326 magnetic resonance imaging of, 326 roles of, 326 Parapharyngeal fat, 538f Parapharyngeal space, 388f–390f, 394f–396f Pararenal fat, 533f Parietal bone, 16f, 18f–36f, 38f–42f, 44f–46f, 76f, 78f, 82f, 84f, 86f, 88f, 90f, 92f–102f, 104f–123f, 309f–312f, 346f–348f groove for middle meningeal, 312f–313f inferior temporal line, 310f–311f mastoid angle, 312f–313f superior temporal line, 310f–311f temporal fossa, 310f–311f vessels (parietal branches), 312f–313f Parietal lobe, 3f–4f, 28f–36f, 38f–44f, 70f–72f, 76f, 78f, 80f–81f, 84f, 86f, 88f–102f, 104f–116f, 126f–128f, 148f–150f Parietal operculum, 3f–4f Parietooccipital sulcus, 3f–5f, 98f–110f Parotid duct, 388f–390f Parotid gland, 58f, 70f–86f, 120f–123f, 313f–314f, 318f, 386f–390f, 396f–397f, 424f, 426f–433f, 450f–452f, 466f–469f deep lobe, 60f–62f diagnostic considerations for, 60 superficial lobe, 60f–62f superior, lymph nodes of, 384f–386f Pars compacta, substantia nigra, 204f–206f Pars interarticularis, 530f–531f Pars nervosa, 408f–410f glossopharyngeal nerve (CN IX) in, 284f–286f Pars reticularis, 154f–156f Pars vascularis, 408f–410f right jugular bulb in, 284f–286f Pedicle, 525f–527f, 529f–533f Periaqueductal gray matter, 144f–145f Pericallosal cistern, 142f–144f Perimesencephalic cistern, 154f–156f, 160f–166f Perineural invasion, sign of, 240 Periodontal disease, 108 Perirenal fat, 533f Peritoneum, 533f Petropharyngeus muscle, 315f–316f Petrosal sinus inferior, 6f–8f superior, 6f–8f, 120f–122f Petrosal vein, 6f–7f Pharyngeal aponeurosis, 315f–316f Pharyngeal constrictor muscles, 314f–315f Pharyngeal raphe, 314f–316f Pharyngeal recess, 313f–314f Pharyngeal tonsil, 314f–316f, 454f–456f Pharyngeal tubercle, 315f–316f, 527f–528f Pharyngobasilar fascia, 315f–316f Pharyngoepiglottic fold, 315f–316f Pharynx anatomy of, 428, 454 axial, 421f

615

Index Pharynx (Continued) coronal, 421f diagnostic consideration in, 456 median section, 314f–315f muscles of, 315f–316f sagittal, 421f Phrenic nerve, 316f–317f Pia mater, 8f–9f Pineal body, 4f–5f, 10f–12f Pineal cyst, 36f–38f Pineal gland, 38f–40f, 100f–102f, 134f–136f, 144f–145f, 164f–166f, 168f–170f, 276f–278f, 292f–293f diagnostic consideration for, 122 p.v., 88f–90f Pineal recess, 8f–9f Pineal region, 304f–305f Pinna, 56f–58f Piriform sinus, 472f–476f, 492f–494f Pituitary apoplexy, 304 Pituitary gland, 4f–7f, 46f–50f, 140f–142f, 202f–208f, 210f–214f, 218f–222f, 244f–246f, 286f–288f, 292f–293f, 298f–304f anterior, 168f–170f, 304f–305f lesion within, 300 normal anatomy of, 74 pathologic process in, 304 posterior, 168f–170f, 304f–305f posterior bright spot of, 98f–100f in sella turcica, 70f–76f, 98f–102f Pituitary lesion diagnostic considerations for, 298 pathologic process of, 300 Platysma muscle, 392f–397f, 454f–466f Pleomorphic adenoma, 60 Pons, 4f–5f, 11f–12f, 48f–50f, 52f–54f, 82f–88f, 98f–104f, 142f–145f, 162f–164f, 168f–170f, 216f–218f, 224f–228f, 234f–236f, 240f–244f, 246f–258f, 282f–284f, 288f–290f, 304f–305f, 450f–452f middle, 104f–106f p.v., 80f–81f Pontine arteries, 9f–10f Pontine reticular formation, 220f–222f Pontomedullary junction, 54f–56f, 304f–305f Pontomesencephalic junction, 46f–48f Porus acousticus, 401f–402f Post-cricoid cartilage hypopharynx, 476f–480f Postcentral gyrus, 3f–4f, 20f–26f, 112f–118f Postcentral sulcus, 3f–4f Posterior arch, 525f–526f Posterior articular facet, for transverse ligament of atlas, 525f–526f Posterior auricular artery, 316f–317f Posterior clinoid process, 154f–156f, 200f–202f, 204f–208f Posterior commissure, 4f–5f, 11f–12f Posterior cricoarytenoid muscle, 315f–316f Posterior ethmoidal foramina, 309f–310f Posterior lateral choroidal artery, 9f–10f Posterior lateral superficial cervical (spinal accessory) nodes, 317f–318f Posterior longitudinal ligament, 528f–529f, 531f–533f, 572f, 575f–580f, 584f–600f Posterior medial choroidal artery, 9f–10f Posterior perforated substance, 222f–224f in interpeduncular fossa, 5f–6f Posterior sacrococcygeal ligament, 531f–532f Posterior sacroiliac ligament, 531f–532f Posterior spinal artery, 9f–10f Posterior superior alveolar artery, 316f–317f Posterior tubercle, 525f–527f Pre-epiglottic space, 454f–456f, 458f–460f, 506f–510f

616

Precentral gyrus, 3f–4f, 20f–22f, 112f–118f Precentral sulcus, 3f–4f, 117f–118f Precrural cistern, 44f–46f Precuneus, 4f–5f Predental space, 538 Prefrontal artery, 9f–10f Premedullary cistern, 264f–266f Premolar 1st, 388f–390f, 428f–430f 2nd, 388f–390f, 428f–430f Preoccipital notch, 3f–4f Prepontine cistern, 100f–104f, 168f–170f, 226f–228f, 242f–244f, 246f–248f, 256f–258f, 282f–284f, 288f–290f, 292f–293f, 304f–305f normal anatomy of, 52 Pretracheal fascia, 314f–315f Prevertebral fascia, and anterior longitudinal ligament, 314f–315f Primary fissure, 292f–293f Primary hypopharyngeal squamous cell carcinoma, 474 Promontory, 318f Proton-density (PD) sequences, 132 Prussak’s space, 404f–408f, 414f–416f pathologic process in, 414 Pseudotumor cerebri, 180 Psoas major fascia, 533f muscle, 533f Psoas major muscle, 604f–605f Pterion, 310f–311f Pterygoid canal, 352f–353f Pterygoid plate lateral, 58f–60f, 66f–68f medial, 58f–60f, 66f–68f Pterygomaxillary fissure, 310f–311f Pterygopalatine fossa, 58f–62f, 238f–240f, 310f–311f, 328f–332f, 348f–350f, 384f–386f anatomy of, 330 vessels and nerves in, pathologic process of, 58 Pterygopalatine ganglion, 330 Pulmonary sulcus tumor, 498 Putamen, 8f–9f, 34f–40f, 68f–82f, 108f–112f, 128f–136f, 140f–144f, 150f–152f, 156f–162f, 170f–173f, 190f–192f, 222f–224f, 242f–244f, 274f–276f, 286f–288f, 296f–304f third, 83f–84f Pyramidal eminence, 406f–408f Pyramidal tract, 220f–222f, 254f–256f, 266f–268f

Q

Quadrangular lobule, posterior portion, 260f–264f Quadratus lumborum fascia, 533f muscle, 533f Quadrigeminal cistern, 154f–156f, 164f–166f, 168f–170f, 278f–282f, 290f–293f, 304f–305f Quadrigeminal plate, 11f–12f Quadrigeminal plate cistern, 40f–46f, 92f–96f, 152f–154f

R

Rectus capitis anterior muscle, 313f–314f Rectus capitis posterior major muscle, 92f–96f, 430f–432f, 452f–454f Rectus capitis posterior minor muscle, 92f–94f, 428f–430f

Recurrent artery of Heubner, 9f–10f Red nucleus, 5f–6f, 12f, 40f–46f, 152f–156f, 162f–164f, 168f–170f, 184f–186f, 200f–206f, 232f–234f Renal fascia (anterior and posterior layers), 533f Retina, 358f–366f Retrobulbar orbital fat, 358f–360f Retromandibular triangle (retromolar trigone), 430 Retromandibular vein, 313f–314f, 424f–430f, 432f–434f, 436f–438f Retromolar trigone (retromandibular triangle), 430 Retropharyngeal lymph node, 424 Retropharyngeal space, 314f–315f Rhinal sulcus, 4f–6f Rhomboid muscle, 482f–486f, 512f–519f Rib first, 482f–484f, 512f–519f, 570f–572f second, 484f–486f, 500f–504f, 582f–584f third, 582f–584f fourth, 582f–584f fifth, 582f–584f sixth, head of, 582f–584f seventh, 529f–530f neck of, 582f–584f eighth, neck of, 582f–584f twelfth, 602f, 604f head, 572f–574f tubercle of, 572f–574f Right alveolar vein, artery, and nerve, inferior, 66f–67f Right basilar artery, 258f–260f Right cerebellar hemisphere, 46f–48f, 50f–54f, 57f–60f, 88f–96f inferior, 54f–57f superior, 48f–50f Right inferior orbital nerve, 64f–66f Right internal jugular vein, 80f–82f, 84f–86f, 116f, 258f–260f Right mandibular vein, 119f–122f Right middle cerebral artery, 288f–290f Right orbit, frontal and, 309f–310f Right posterior cerebral artery, 80f–84f, 200f–204f, 206f–208f, 214f–216f, 218f–220f, 280f Right retromandibular vein, 118f, 120f, 122f–123f Right sigmoid sinus, 258f–260f Right superior cerebral artery, 80f–84f, 202f–204f Right vertebral artery, 80f–86f, 104f–106f, 108f, 110f–116f, 190f–192f, 268f–271f V3, 82f, 84f, 86f–88f V4, 86f–88f Rosenmüller, fossa of, 332f–334f, 394f–396f, 422f–424f, 424 Round (cochlear) window, 318f

S

Sacral ala, 594f–596f Sacral curvature, 524f–525f Sacral foramina, 602f anterior, 603f–604f Sacral vertebra articular facet for, 530f–531f auricular surface of, 531f–532f Sacroiliac ligament, posterior, 531f–532f Sacrospinous ligament, 531f–532f Sacrotuberous ligament, 531f–532f

Index Sacrum, 601f–602f, 604f–605f S1, 596f–600f, 602f–604f dorsal nerve root, 598f–600f nerve root, 590f–594f spinal nerve root, 594f–596f superior articular process, 592f–596f ventral nerve root, 598f–600f S1-S5, 524f–525f, 531f–532f S2, 598f–600f Sagittal sinus inferior, 6f–8f, 66f–96f, 98f–102f, 126f–130f superior, 6f–8f, 16f–50f, 62f–104f, 102 diagnostic consideration for, 96, 102 Sagittal suture, 16f–28f, 76f, 78f, 80f–82f, 84f, 86f, 88f, 90f, 92f–94f, 96f Salivatory nuclei, superior and inferior, 12f Salpingopharyngeus muscle, 315f–316f Scala tympani, 318f Scalene muscle anterior, 316f–317f, 450f–452f, 466f–468f, 478f–486f, 494f–496f, 514f–518f medial, 480f–484f middle, 316f–317f, 496f–500f, 514f–519f posterior, 482f–484f, 496f–502f Sciatic foramen greater, 531f–532f lesser, 531f–532f Sclera, 358f–366f Scutum, 414f–416f Second cranial nerve (CN II), 180 Sella, 298 Sella turcica, 48f–50f, 103f–104f, 314f–315f coronal, 295f dorsum sellae, 312f–313f hypophyseal fossa, 312f–313f posterior clinoid process, 312f–313f sagittal, 295f tuberculum sellae, 312f–313f Semicircular canal, 52f–54f anatomy of, 282 dehiscence, 416 horizontal, 282f–284f, 414f–418f posterior aspect of, 418f–419f lateral, 401f–402f, 404f, 414f–418f normal anatomy of, 52 posterior, 400f–402f, 406f–408f, 416f–419f superior, 400f–402f, 414f–418f coronal MR images of, 416 Semicircular ducts, 318f Semilunar lobule inferior portion, primary white matter tract, 260f–262f superior portion, 260f–262f Semispinalis capitis muscle, 92f–98f, 426f–428f, 430f–438f, 452f–454f, 460f–464f, 472f–480f Semispinalis cervicis muscle, 436f–438f, 452f–454f, 460f–464f, 472f, 474f–484f, 500f–504f, 512f–519f Sensory nucleus, principal, of trigeminal nerve (V), 12f Septated foramen transversarium, 526f–527f Septum pellucidum, 4f–5f, 8f–11f, 32f–36f, 68f–80f, 126f–132f, 136f–144f, 156f–164f, 274f–276f, 296f–300f, 302f–304f Serratus posterior inferior muscle, 533f Seventh cervical vertebra anterior view of, 526f–527f superior view of, 526f–527f Sigmoid sinus, 7f–8f, 88f–94f, 116f–123f, 257f–258f, 260f–264f, 400f–406f, 452f–454f continuation of transverse sinus, 6f–7f and internal jugular vein, right, junction of, 86f–88f loop of, 401f–402f, 410f–412f and transverse sinuses, junction of, 92f–94f

Sinus surgery, functional endoscopic, 340 Sinus tympani, 406f–408f Skin, 62f, 64f, 66f–72f, 74f, 76f, 78f, 80f–82f, 84f, 86f, 88f, 90f, 92f–94f, 96f, 98f–102f, 104f–108f, 110f, 112f–116f, 118f, 120f, 122f Skull, sectioned horizontally, superior view of, 6f–7f Small intestine, air in, 584f–586f, 596f Soft palate, 98f–108f, 228f–230f, 314f–315f, 392f–397f, 442f–448f, 454f–460f Solitary tract nucleus, 12f, 266f–270f Sound reception, pathway of, 318f SOV. See Superior ophthalmic vein (SOV) Sphenoethmoidal recess, 62f–64f, 344f–348f Sphenoid body, 326f–330f, 352f–353f Sphenoid bone, 46f–49f, 66f–68f, 313f–314f, 322f–324f, 384f–386f anterior clinoid process, 348f–350f body, 312f–313f jugum, 312f–313f prechiasmatic groove, 312f–313f sella turcica, 312f–313f carotid groove, 312f–313f clivus, 312f–313f foramen ovale, 311f–312f foramen spinosum, 311f–312f greater wing of, 309f–313f, 324f–330f, 346f–353f, 382f–384f groove for middle meningeal vessels (frontal branches), 312f–313f orbital surface of, 309f–310f infratemporal crest, 310f–311f lateral plate of pterygoid process, 310f–311f lesser wing, 309f–310f, 312f–313f anterior clinoid process, 312f–313f orbital surface of, 309f–310f pterygoid hamulus, 310f–311f pterygoid process hamulus, 311f–312f lateral plate, 311f–312f medial plate, 311f–312f pterygoid fossa, 311f–312f scaphoid fossa, 311f–312f pterygoid process of, 330f, 334f–336f, 348f–350f spine, 311f–312f Sphenoidal sinus, 6f–8f, 52f–56f, 66f–74f, 100f–108f, 136f–142f, 176f–178f, 188f–190f, 208f–214f, 296f–302f, 314f–315f, 322, 324f–330f, 350f–352f, 356f–362f, 376f–379f, 392f–394f, 446f–448f anatomy of, 324 bony septum of, 66f–74f Sphenooccipital synchondrosis, 314f–315f Sphenopalatine artery, 316f–317f Sphenopalatine foramen, 310f–311f Sphenoparietal sinus, 6f–7f Sphenosquamosal suture, 348f–353f Sphenozygomatic suture, 326f–328f Spinal accessory nerve, 268 Spinal artery of Adamkiewicz, 574 Spinal canal, 542f–543f Spinal cord, 498f–500f, 502f–504f, 543f–544f, 558f–560f, 562f–566f, 572f, 574f–576f, 578f–580f, 596f–599f central canal of, 8f–9f, 11f–12f cervical, 86f–88f, 428f–438f Spinal dura mater, 533f Spinal nerve C1, dorsal ramus of, 527f–528f C4, groove for, 526f–527f C7, groove for, 526f–527f L2, ventral ramus of, 531f–532f L4, 531f–532f

Spinal nucleus, of trigeminal nerve, 236 Spinal tract and spinal nucleus, of trigeminal nerve (V), 12f Spinalis cervicis muscle, 498f–500f Spine, 535–606 Spine of ischium, 531f–532f Spinous process, 502f–504f, 525f–526f, 529f–533f bifid, 526f–527f of C7 vertebra, 527f–528f Splenius capitis muscle, 94f, 96f–98f, 426f–438f, 452f–454f, 464f–468f, 472f–484f, 512f–514f Splenius cervicis muscle, 500f–504f Squamous cell carcinoma, of mandible, 390 Squamous suture, 42f, 44f, 74f–76f, 78f, 80f–82f, 84f, 86f, 88f, 90f Stapedius muscle, 406f–408f Stapes, 406f–408f, 414f–416f limbs of, 318f Stapes in oval (vestibular) window, base of, 318f Stenosis, cervical foramen, assessment of, 510 Stensen’s duct, 428f–432f Sternal angle, 578f–580f Sternocleidomastoid muscle, 426f–438f, 450f–452f, 466f–469f, 472f–488f, 492f–500f, 508f–519f Sternocleidomastoid nodes, 317f–318f Sternohyomastoid muscle, 382 Sternum, body of, 578f–580f Sternum, manubrium of, 314f–315f Straight gyrus, 5f–6f Straight sinus, 6f–8f, 34f–48f, 98f–104f, 130f–132f, 134f–136f Strap muscles, 474f–486f, 488f–494f Stria terminalis, 8f–9f Striae medullares, 11f–12f Striate artery, distal medial, 9f–10f Styloglossus muscle, 313f–314f, 392f–394f Stylohyoid muscle, 313f–316f Styloid, 554f Styloid process, 78f–80f, 313f–316f, 536f–540f Stylomastoid foramen, 410f–412f, 416f–418f Stylopharyngeus muscle, 315f–316f Subarachnoid space, 62f, 64f–66f Subcallosal gyrus, 4f–5f Subcallosal (parolfactory) area, 4f–5f Subclavian artery, 316f–317f, 486f–488f, 514f–519f Subclavian trunk, and node, 317f–318f Subcutaneous fat, 62f, 64f, 66f–72f, 74f, 76f, 78f, 80f–82f, 84f, 86f, 88f, 90f, 92f–94f, 96f, 98f–102f, 104f–108f, 110f, 112f–116f, 118f, 120f, 122f Subglottis, 488f–489f, 504f–508f Subiculum, 154f–156f, 160f–168f Sublingual gland, 230f–232f, 462f–464f Submandibular gland, 316f–317f, 392f–397f, 432f–438f, 444f–450f, 462f–464f, 472f–473f, 488f–496f Submandibular nodes, 317f–318f Submental artery, 316f–317f Submental nodes, 317f–318f Suboccipital nerve, 527f–528f Subparotid node, 317f–318f Subserous fascia, 533f Substantia nigra, 5f–6f, 40f–46f, 142f–144f, 160f–162f, 222f–224f, 280f–282f Subthalamic nucleus, 152f–154f, 160f–162f, 222f–224f Sulcus limitans, 11f–12f Superficial parotid nodes, 317f–318f Superficial temporal artery, 313f–314f, 316f–317f Superior anastomotic vein, 16

617

Index Superior articular facet, 526f–527f, 529f–530f of lateral mass, for occipital condyle, 525f–526f Superior articular process, 526f–527f, 529f–533f Superior articular surface, for occipital condyle, 525f–526f Superior cervical cardiac nerve, 316f–317f Superior colliculus, 4f–5f, 11f–12f, 40f–42f, 90f–92f, 144f–145f, 152f–154f, 168f–170f, 292f–293f of corpora quadrigemina, 5f–6f Superior deep lateral cervical (internal jugular) nodes, 317f–318f Superior endplate, 578f–580f Superior fovea, 11f–12f Superior frontal gyrus, 3f–4f, 20f–28f Superior frontal sulcus, 3f–4f Superior labial artery, 316f–317f Superior laryngeal artery, 316f–317f Superior laryngeal nerve, internal branch of, 315f–316f Superior lateral superficial cervical (external jugular) node, 317f–318f Superior limb, cerebellopontine fissure, 234f–236f Superior longitudinal band, of cruciate ligament, 528f–529f Superior meatus, 346f–348f Superior medullary velum, 4f–5f, 220f–222f, 226f–228f, 234f–236f, 246f–248f Superior mesenteric artery, 533f Superior mesenteric vein, 533f Superior muscle complex, 390f–392f superior rectus muscle and levator palpebrae superior muscle, 62f–66f Superior oblique muscle, 62f–66f, 178f–180f, 186f–190f, 192f–196f, 364f–366f, 368f–374f, 390f–392f anatomy of, 370 Superior ophthalmic vein (SOV), 65f–66f, 178f–180f, 186f–190f, 188, 192f–198f, 368f–376f and branches, 360f–374f enlargement of, 188 pathologic process, 364, 368 Superior orbital fissure, 309f–310f, 324f–326f Superior parietal lobule, 3f–4f Superior parotid gland, lymph nodes of, 384f–386f Superior pharyngeal constrictor muscle, 315f–317f, 388f–390f, 396f–397f Superior rectus/levator palpebrae superioris muscle complex, 196f Superior rectus muscle, 46f–48f, 110f–118f, 178f–180f, 186f–190f, 192f–196f, 198f–200f, 364f–374f, 390f–392f Superior sagittal sinus, 4f–5f, 274f–278f Superior temporal gyrus, 3f–4f, 376f–378f Superior temporal sulcus, 3f–4f Superior thoracic artery, 484f–486f Superior thyroid artery, 316f–317f Superior thyroid nodes, 317f–318f Superior turbinate, 188f–190f, 346f–348f Superior vermis, 382f–384f Superior vertebral notch, 529f–531f Superior vestibular nerve (CN VIII), 246f, 260f–264f cisternal segment, 252f–254f intracanalicular segment, 252f–254f Superior vestibular nerve tract (CN VIII), 256f Superior vestibular nucleus, 256f Supraclavicular nodes, 317f–318f Suprahyoid artery, 316f–317f

618

Suprahyoid neck anatomy of, 422 axial, 421f coronal, 421f sagittal, 421f Suprahyoid node, 317f–318f Supramarginal gyrus, 3f–4f Supraoptic recess, 4f–5f, 8f–9f Supraorbital artery, from ophthalmic artery, 316f–317f Supraorbital notch, 309f–310f Suprapineal recess, 8f–9f Suprasellar cistern, 70f–72f, 140f–142f, 154f–158f, 280, 280f, 286f–288f, 292f–293f, 300f–305f normal anatomy of, 44 pathologic process of, 280 Supraspinatus muscle, 500f–502f Supraspinous ligament, 527f–528f, 531f–533f, 578f–580f, 596f–598f Suprasternal space (of Burns), 314f–315f Supratrochlear artery, from ophthalmic artery, 316f–317f Sutural (wormian) bone, 310f–311f Sylvian cistern, 154f–156f, 280f–282f Sylvian fissure, 36f–38f, 40f–44f, 66f–90f, 118f–122f, 126f–145f, 156f–158f, 160f–168f, 276f–278f, 286f–288f, 296f–300f, 302f–304f, 366f–368f Sylvius, aqueduct of, 292 Sympathetic trunk, 313f–314f, 316f–317f Synovial cavities, 528f–529f

T

T1 lamina, 579f–580f pedicle, 581f–582f spinous process, 579f–580f vertebra, 524f–525f, 527f–528f inferior articular facet for, 526f–527f vertebral body, 570f–572f, 578f–582f T1-weighted imaging, of cerebrospinal fluid around brainstem, 60 T2 lamina, 578f–580f pedicle, 580f–582f spinous process, 578f–580f transverse process, 582f–584f T2-T3 facet joint, 580f–582f T2-T3 intervertebral disc, 578f–582f T2-weighted fluid-attenuated inversion recovery (FLAIR) images, 86, 144 T3 intervertebral foramen, 580f–582f superior articular process, 580f–582f transverse process, 582f–584f vertebral body, 578f–582f T4 lamina, 578f–580f spinous process, 578f–580f transverse process, 582f–584f vertebral body, 580f–582f T4-T5 intervertebral disc, 578f–582f T5 pedicle, 580f–582f transverse process, 582f–584f vertebral body, 578f–580f T5-T6 intervertebral disc, 580f–582f T6 inferior articular process, 580f–582f lamina, 578f–580f spinous process, 578f–580f superior articular process, 580f–582f transverse process, 582f–584f

T6 (Continued) vertebra lateral view of, 529f–530f superior view of, 529f–530f vertebral body, 580f–582f T6-T7 intervertebral disc, 578f–580f T7 intervertebral foramen, 580f, 582f–583f lamina, 578f–580f pedicle, 580f–582f spinous process, 572f–576f, 578f–580f vertebra, 529f–530f posterior view of, 529f–530f vertebral body, 578f–580f T7-T8 facet joint, 580f–582f T7-T8 intervertebral disc, 578f, 580f–582f T8 inferior articular process, 576f, 580f–582f intervertebral foramen, 582f–583f lamina, 574f–578f pedicle, 572f–574f, 580f–582f spinal nerve root, 572f–578f superior costal facet, 572f–574f transverse process, 572f–574f vertebra, 529f–530f posterior view of, 529f–530f vertebral body, 572f–576f, 580f–582f T8-T9 annulus fibrosus, 576f–578f T8-T9 facet joint, 576f–578f T8-T9 intervertebral disc, 579f–582f T8-T9 nucleus pulposus, 576f–578f T9 inferior articular process, 577f–578f intervertebral foramen, 580f–582f lamina, 579f–580f pedicle, 580f–582f superior articular process, 576f–578f transverse process, 582f–584f vertebra, 529f–530f posterior view of, 529f–530f vertebral body, 578f–580f, 582f–583f T9 rib head, 576f–578f T9-T10 facet joint, 582f–584f T9-T10 intervertebral disc, 578f–583f T10 inferior articular process, 580f–584f intervertebral foramen, 583f–584f lamina, 578f pedicle, 580f–582f spinous process, 578f vertebral body, 578f–580f, 582f–584f T10-T11 intervertebral disc, 578f–583f T11 inferior articular process, 580f–582f intervertebral foramen, 583f–584f lamina, 578f–580f pedicle, 582f–584f spinous process, 579f–580f superior articular process, 582f–584f vertebral body, 578f, 580f–584f T11-T12 facet joint, 580f–582f T11-T12 intervertebral disc, 578f, 580f–583f T12 inferior articular process, 580f–582f lamina, 578f–580f spinous process, 578f–580f superior articular process, 580f–584f vertebra, 524f–525f lateral view of, 529f–530f vertebral body, 578f–584f T12-L1 intervertebral disc, 578f–583f Tectal plate, anterior portion of, 88f–90f Tectal (quadrigeminal) plate, 4f–5f, 11f–12f Tectorial membrane, 562f–564f accessory part of, 528f–529f

Index Tectum, superior and inferior colliculi, 98f–104f Tegmen mastoideum, 416f–419f Tegmen tympani, 318f, 412f–416f Tela choroidea, of 3rd ventricle, 8f–9f Temporal bone, 38f, 40f–42f, 44f, 46f–50f, 52f, 54f–58f, 66f–72f, 74f, 76f, 78f, 80f–82f, 88f, 90f, 92f–94f, 309f–310f, 322f–324f, 468f–469f accessory muscle bundle from petrous part of, 315f–316f anatomy of, 400, 410, 412f–414f articular tubercle, 310f–312f axial, 399f carotid canal (external opening), 311f–312f coronal, 399f external acoustic meatus, 310f–312f fracture of, 404 glenoid fossa of, 410f–412f groove for posterior deep temporal artery, 310f–311f jugular fossa, 311f–312f lambdoid suture, 310f–311f mandibular fossa, 310f–312f mastoid canaliculus, 311f–312f mastoid foramen, 311f–312f mastoid notch, 311f–312f mastoid process, 310f–312f occipital groove, 311f–312f pathologic process in, 402 petrotympanic fissure, 311f–312f petrous part, 311f–312f arcuate eminence, 312f–313f groove for greater petrosal nerve, 312f–313f groove for lesser petrosal nerve, 312f–313f groove for sigmoid sinus, 312f–313f groove for superior petrosal sinus, 312f–313f trigeminal impression, 312f–313f petrous ridge of, 86f–88f round window of, 406f–408f squamous part, 310f–313f squamous portion of, 324f–326f, 348f–353f styloid process, 310f–312f stylomastoid foramen, 311f–312f supramastoid crest, 310f–311f tympanic canaliculus, 311f–312f zygomatic process, 56f–58f, 310f–312f, 390f–392f, 468f–469f Temporal gyrus inferior, 120f–123f middle, 120f–123f superior, 120f–123f, 376f–378f Temporal horn, 278 Temporal lobe, 3f–4f, 34f, 36f–38f, 42f–56f, 66f–74f, 76f–82f, 88f, 90f–92f, 114f–116f, 138f–140f, 154f–156f, 180f–182f, 248f–250f, 296f–304f, 356f–360f, 362f–368f, 382f–384f anterior, 110f–114f medial, 108f–110f right, 75f–76f, 81f–82f squamous portion of, 353f superior, 40f–42f Temporal operculum, 3f–4f Temporal pole, 3f–4f Temporalis muscle, 42f–58f, 64f–84f, 112f–123f, 382, 382f–388f, 390f–396f, 422f–426f, 440f–448f, 464f–468f anatomy of, 392 deep head of, 60f–62f Temporomandibular joint (TMJ) imaging technique consideration in, 396, 552 Tensor tympani muscle, 406f–410f, 412f–414f Tensor veli palatini muscle, 58f–60f, 238f–240f, 386f–388f, 394f–396f, 426f–428f

Tentorial artery, 6f–7f Tentorium, 290f–292f Tentorium cerebelli, 6f–8f, 220f–222f straight sinus in, 4f–5f Tentorium cerebellum, 88f–96f, 104f–122f Thalamostriate vein, superior, 8f–9f Thalamus, 8f–11f, 32f–40f, 80f–88f, 100f–108f, 125–146, 128f–136f, 150f–152f, 160f–166f, 168f–172f, 190f–192f, 242f–244f, 274f–276f, 304f–305f anterior nucleus of, 222f–224f pulvinar, 5f–6f, 9f–12f, 38f–40f, 88f–92f, 144f–145f stria medullaris of, 4f–5f 3rd ventricle, 4f–5f, 11f–12f ventral lateral nucleus of, 142f–144f Thecal sac, 584f–600f Third ventricle, 8f–12f, 130f–136f, 140f–144f, 156f–164f, 214f–216f, 276f–278f, 288f–290f, 292f–293f choroid plexus of, 8f–9f and interthalamic adhesion, 8f–9f tela choroidea of, 8f–9f Thoracic artery, superior, 484f–486f Thoracic curvature, 524f–525f Thoracic duct, 317f–318f Thoracic spine axial, 535f imaging technique consideration in, 572 normal anatomy of, 576, 578, 580 sagittal, 535f Thoracic vertebrae, 524f–525f Thoracolumbar fascia anterior layer, 533f middle layer, 533f posterior layer, 533f Thyroarytenoid gap, 478f–480f Thyroarytenoid muscle, 476f–478f, 488f–494f Thyrocervical trunk, 316f–317f Thyrohyoid membrane, 314f–316f Thyroid cartilage, 314f–315f, 454f–462f, 474f–480f, 488f–494f, 504f–512f pathologic process in, 480 superior horn of, 315f–316f Thyroid cartilage lamina, posterior border of, 315f–316f Thyroid gland, 314f–315f, 480f–484f, 490f–494f, 508f–512f isthmus, 482f–484f, 504f–508f Thyroid lobe, 512f–514f TMJ. See Temporomandibular joint (TMJ) Tongue, 66f–68f, 426f–432f, 462f–464f body of, 314f–315f dorsum of, 392f–394f intrinsic muscle of, 62f–66f, 98f–108f intrinsic muscles of, 394f–396f root of, 314f–316f Tonsillar artery, 316f–317f Torcular Herophili, 98f–104f Torus tubarius, 60f–62f, 332f–334f, 394f–396f, 424, 424f–426f Trachea, 314f–315f, 480f–488f, 490f–498f, 504f–508f anatomy of, 484 imaging technique consideration in, 504 Transversalis fascia, 533f Transverse arytenoid muscle, 314f–315f Transverse cervical chain of nodes, 317f–318f Transverse facial artery, 316f–317f Transverse foramen, 525f–526f, 540f–542f, 548f–550f, 554f Transverse fracture, of temporal bone, 404 Transverse ligament, 538f–542f

Transverse occipital sulcus, 3f–4f Transverse pontine fibers, 206f–208f Transverse process, 525f–527f, 529f–533f, 540f–542f Transverse sinus, 6f–8f, 50f–58f, 94f–98f, 104f–123f imaging technique consideration for, 122 Transversus abdominis muscle, 533f tendon of, 533f Trapezius muscle, 428f–438f, 464f–466f, 472f, 474f–486f, 498f–504f, 512f–519f Trigeminal fat pad, 60f transmitting V3, 56f–58f Trigeminal ganglion, 6f–7f, 330 appearance of, 244 Trigeminal nerve (CN V), 224, 286f–288f anatomy of, 188, 224, 228, 230, 232, 236 branches of, 224 cisternal segment, 84f–86f, 222f–226f, 242f–244f denervation of mandibular V3 branch of, 384 diagnostic consideration for, 244 in foramen ovale, 384f–386f mandibular division, 238f–240f and ganglion (gasserian), 12f and geniculate ganglion, 12f of inferior alveolar nerve, mandibular division (V3), 228f–230f main sensory nucleus, 234f–236f mandibular branch (V3) of, 72f–74f, 228, 230f normal anatomy of, 72 maxillary division (V2) of, 326f–328f, 348f–350f mesencephalic nucleus of, 12f, 234f–236f motor nucleus of, 12f, 234f–236f ophthalmic division (V1) of, 138f–140f, 378f–379f pathologic process, 384 principal sensory nucleus of, 12f root entry zone, 226f–228f, 234f–236f spinal nucleus, 236f–238f spinal tract and spinal nucleus of, 12f through foramen rotundum, maxillary division (V2), 240f–242f Trigeminal tubercle, 11f–12f Trigone, 276 Trochlear nerve (CN IV), 6f–7f, 11f–12f, 208f–214f, 218, 220f–224f, 244f–246f, 300f–304f, 370 anatomy of, 218 pathway, 218f–222f Trochlear nucleus, 12f, 218f–220f Troisier, sentinel lymph nodes of, 317f–318f True vocal cord, 478f–480f, 488f–489f, 504f–510f Tuber cinereum, 4f–6f Tubercle, for transverse ligament of atlas, 525f–526f Tumors, diagnostic consideration in, 452 Turbinate inferior, 62f–66f middle, 58f–66f, 102f–108f superior, 102f–106f Tympanic cavity, 318f Tympanic membrane, 318f, 408f–410f, 412f–416f pathologic process in, 408

U

Uncal notch, ambient gyrus, 156f–158f Uncinate fasciculus, 138f–140f

619

Index Uncinate process, 526f–527f, 556f–558f articular process of, 526f–527f left, area for articulation of, 526f–527f right, articular surface of, 526f–527f Uncovertebral osteophytes, 546 Uncus, 4f–6f Universal number system (dental), 388 Uvula, 68f–72f, 258f–260f, 315f–316f, 448f–450f, 454f–458f

V

Vagal trigone, 11f–12f Vagus nerve (CN X), 6f–7f, 12f, 236f–238f, 264f–268f, 313f–314f, 316f–317f anatomy of, 268 dorsal nucleus of, 12f and tract, 268f–270f Vallecula, 270f–271f, 458f–460f Vein of Labbé, 92f–94f Vein of Trolard, 16f–18f, 64f–66f, 90f–96f normal anatomy of, 16 Velum interpositum, cistern of, 142f–144f, 150f–152f Venous plexus, 562f–564f Ventral cochlear nucleus, 256f Ventral pons caudal aspect, 258f–260f infarcts of, 250 Ventral pontomedullary sulcus, 258f–260f Ventral ramus, of L2 spinal nerve, 531f–532f Ventricle temporal horn of, 206f–208f right lateral, 78f–84f third, 38f–44f, 76f–82f, 84f–86f, 88f–90f chiasmatic recess of, 98f–100f infundibular recess of, 98f–100f Ventricles and cerebrospinal fluid cisterns axial, 273f coronal, 273f imaging technique consideration for, 276 sagittal, 273f Ventricular system, anatomy of, 275 Vermis, 224f–226f, 236f–238f, 250f–252f, 258f–260f, 264f–266f, 268f–270f, 282f–284f superior, 382f–384f

620

Vertebra prominens, 526f–528f Vertebral artery, 9f–10f, 58f–60f, 82, 83f–84f, 106f–108f, 250f–252f, 266f–268f, 288f–290f, 386f–388f, 424f–438f, 452f–454f, 462f–464f, 472f–486f, 496f–498f, 527f–528f, 536f–538f, 540f, 542f–546f, 548f–551f, 554f–556f, 568f–572f confluence (origin of basilar artery) of, 82f–84f groove for, 525f–526f normal anatomy of, 82 proximal V4 segment, 60f–62f Vertebral body, 525f–527f, 529f–531f posterior surface of, 532f–533f Vertebral canal, 529f–531f Vertebral foramen, 525f–527f, 529f–531f Vertebral notch inferior, 529f–531f superior, 529f–531f Vertebral veins, internal, 100f–101f Vertebral venous plexus (of Batson), 7f–8f Vertex cranii diagnostic consideration for, 16 imaging technique consideration for, 16 Vestibular aqueduct, 402f–406f, 404 Vestibular area, 11f–12f Vestibular nerve, 318f Vestibular nuclei, 12f, 256 Vestibule, 318f, 401f–406f, 414f–418f laryngeal, 490f–494f, 504f Vestibulocochlear nerve (CN VIII), 6f–7f, 12f, 222f–224f, 248f–252f, 252, 254f–258f, 282f–284f, 318f, 400 anatomy of, 254, 256, 260 pathologic process, 262, 416 Vidian canal, 296f–298f, 352f–353f, 392f–394f vidian nerve in, 376f–378f Vidian nerve, 350f–352f anatomy of, 350 in vidian canal, 376f–378f VI/VII nerve complex, left, 86f–88f VII/VIII nerve complex, 52f–54f Virchow, sentinel lymph nodes of, 317f–318f Vitreous body, 358f–366f Vitreous humor, 52, 180f–182f normal anatomy of, 52

Vocal cord false, 476f–478f, 488f–489f, 504f–506f imaging technique consideration in, 478 pathologic consideration in, 476 pathologic process in, 490 true, 478f–480f, 488f–489f, 504f–506f Vocal fold, 314f–315f Vomer, 309f–314f, 384f–386f Vomer bone, 328f–338f, 340f–352f

W

White matter imaging technique consideration for, 144 normal anatomy of, 32

Z

Zygapophyseal joints C2-C3, 528f–529f C3-C4, 527f–528f C4-C5, 527f–528f C5-C6, 527f–528f capsule of, 532f–533f C2-C3, 528f–529f C3-C4, 527f–528f Zygoma, 392f–394f Zygomatic arch, 64f–66f, 356f–358f Zygomatic bone, 48f–50f, 52f–56f, 58f, 60f–64f, 311f–312f, 324f–334f, 342f–348f frontal process, 309f–310f orbital surface, 309f–310f temporal process, 309f–311f zygomatic arch, 310f–311f zygomaticofacial foramen, 309f–311f Zygomatic process, 59f–60f Zygomaticomaxillary suture, 56f–58f Zygomaticus major muscle, 384f–388f, 390f–392f Zygomaticus minor muscle, 386f–388f Zygomaticus muscle, 424f–432f