Age-related changes in X-ray photographs of the skull. Lesions and pseudo-lesions of the bones of the cranial vault: Differential diagnosis and illustrated review of pathological conditions manifested by focal lesions of the cranial vault

Studies devoted to the study of radiological features of the skull in children with natal injuries spinal cord, we did not find either in domestic or in available foreign literature. Typically, X-ray examination of the skull is carried out only in isolated cases for birth injuries of newborns in case of suspected fracture of the bones of the cranial vault. Thus, E. D. Fastykovskaya (1970) developed in detail the issues of artificial contrasting of the vessels and sinuses of the brain during labor intracranial injuries newborns. Interpretation of skull radiographs in children is very difficult. An interesting study in this direction was carried out by M. Kh. Faizullin (1971) and his students.

The point of our research in this direction is that the presence of a natal spinal cord injury in a child does not exclude the possibility of simultaneous, albeit less severe, natal brain damage. Under these conditions, the cerebral lesion can easily be viewed. That is why in those of our patients where, along with spinal symptoms, some signs of craniocerebral inferiority were detected, we considered a craniographic examination mandatory.

In total, the skull was examined radiographically in 230 of our patients with birth injuries spinal cord. Radiography was carried out according to generally accepted methods, taking into account radiation protection measures for the subjects. The study was prescribed strictly according to clinical indications, minimum quantity pictures, as a rule, two pictures in lateral and frontal projections (Fig. 70, 71). A feature of the photographs taken in direct projection in newborns and children of the first years of life is that they had to be x-rayed not in the frontal-nasal position, as in older children, but in the occipital position. Special placements were prescribed only after studying two radiographs and only if they did not solve the diagnostic problem. On a regular lateral radiograph of the patient (Fig. 72, 73), one can only assume a fracture of the skull bones based on the superposition of fragments (“plus” shadow) in the frontal hand. This served as an indication for x-rays of the skull with a tangential beam, and then a significant depressed fracture became completely obvious. frontal bone associated with the application of obstetric forceps.

Rice. 70. X-ray of the skull in the lateral projection of patient Sh., 9 months.

Fig. 71. X-ray of the skull in a direct projection (occipital position) of the same patient Sh., 9 months. IN occipital bone transverse suture, “inca bones”.

Rice. 72. X-ray of the skull in the lateral projection of a newborn I., 13 days. In the frontal bone there is linear shading (“plus” shadow), the parietal bone overlaps the occipital bone, small shadows at the level of the lambda.

Rice. 73. A special radiograph of the same patient’s skull, produced by the “tangential” path of the X-ray beam. Depressed fracture of the squama of the frontal bone.

When evaluating radiographs of the skull in our patients, we paid special attention to the following details: configuration of the skull, the presence of digital impressions, the condition of sutures, fontanelles, the existence of intercalary bones, diploic canals, grooves venous sinuses, structure of the base of the skull, areas of bone structure restructuring. Of course, the results of radiological studies were carefully compared with clinical data. Some pathological findings on radiographs were found in 25% of patients.

Analysis of the obstetric anamnesis and birth history in our patients with changes identified on craniograms reveals a high frequency of births in breech, as well as in the front and transverse. All researchers note an unfavorable course of labor in breech presentation, large percentage birth injuries in these children, typically a combination of spinal and cerebral injuries. The frequency of delivery operations also deserves attention. Thus, manual assistance was provided in 15 of 56 births, vacuum extraction in 10, exit forceps were applied in three births, two births ended in cesarean section. There were twins in two births, protracted labor were noted in four women in labor, rapid births in five, and one woman had a narrow pelvis.

For lately growing in all countries of the world specific gravity births with a large fetus, fraught with the threat of complications associated with the discrepancy between the sizes of the fetus and the mother’s pelvis. Among our patients with pronounced changes in craniograms, delivery of a large fetus (over 4500 g) was noted in 20 of 56 observations. All this shows that there were many reasons for the occurrence of cranial complications in this group of newborns.

The greatest difficulty in assessing craniograms in our patients was caused by the severity of digital impressions, since an increase in the pattern of digital impressions can be a sign of pathology, for example, with an increase in intracranial pressure, and a reflection of the normal anatomical and physiological state in children and adolescents. We regarded the pattern of digital impressions as a sign of pathology only in comparison with other signs of increased intracranial pressure (dehiscence of sutures, increase in the size of the skull, thinning of the diploe, tension of the fontanelles, parts of the sella, flattening of the base of the skull, increased pattern of vascular grooves).

Naturally, we always assessed radiological data in comparison with the results clinical trials. Taking into account all of the above, in 34 patients, radiographic changes in the skull were regarded as signs of increased intracranial pressure. At the same time, we did not focus only on enhancing the pattern of finger impressions for the reason that the pattern of the skull bones can be poorly visible (“blurred” pattern) in case of external or mixed dropsy, when fluid in the outer parts of the brain is retained x-rays and creates a false impression of the absence of signs of intracranial pressure (Fig. 74).

Rice. 74. X-ray of the skull of patient K., 3 years old. Brain skull prevails over the facial one, the large fontanel is not fused, continues along the metopic suture. The bones of the skull are thinned, there are intercalary bones in the lambdoid suture and large fontanel. The base of the skull, including the sella turcica, is flattened.

In addition, digital impressions were pronounced in another 7 patients without other signs of increased intracranial pressure, which made it possible to interpret them as a sign of the age norm. The appearance of a pattern of digital impressions depends on periods of intensive brain growth and, according to I. R. Khabibullin and A. M. Fayzullin, can be expressed at the age of 4 to 13 years (and in children from 4 to 7 years - mainly in the parietal -temporal region, and in children from 7 to 13 years old - in all departments). We fully agree with the opinion of these authors that during the growth of the brain and skull, digital impressions can have different localization and intensity.

When the fetal head passes through birth canal the skull is temporarily deformed due to displacement individual bones in relation to each other. Radiologically, the parietal bones overlap the occipital, frontal or protrusion of the parietal bones. These changes in most cases undergo reverse development, without consequences for the fetus. According to E.D. Fastykovskaya, “the displacement of the parietal bones in relation to each other is more alarming,” since such a configuration of the fetal head can be accompanied by damage to the meningeal vessels, up to the superior longitudinal sinus. In our material, the overlap of the parietal bones onto the frontal or occipital bones was observed in 6 patients and only in the first 2 - 3 months of life (Fig. 75).

Rice. 75. Fragment of a radiograph of V.’s skull, 2 months. The overlap of the parietal bones onto the occipital bone in the lambda region.

One of the indirect signs of birth trauma to the central nervous system there may be a detected cephalohematoma. Typically, cephalohematoma persists until 2 - 3 weeks after birth, and then undergoes reverse development. With a complicated course, reverse development does not occur in the usual time frame. According to E.D. Fastykovskaya (1970), in such cases, an additional sclerotic rim is detected at the base of the cephalohematoma due to the deposition of calcium salts into the hematoma capsule. Flattening of the underlying bone may also occur. We watched long-term preservation cephalohematomas in 5 patients (Fig. 76). In some children, the course of cephalohematoma was complicated by trophic disorders due to detachment of the periosteum and its possible rupture (in all these cases, exit forceps were used during childbirth). Radiographically, uneven thinning of the skull bones was noted in the form of small islands of osteoporosis at the site of the cephalohematoma (Fig. 77).

Rice. 76. X-ray of the skull of patient N., 25 days. Unresolved cephalohematoma in the parietal region.

Rice. 77. Fragment of a radiograph of the skull of patient K., 5 months. In the postero-superior quadrate of the parietal bone there are small areas of clearing - “trophic osteolysis”.

The etiology and pathogenesis of the formation of defects in the bones of the skull in children after trauma have not yet been studied. There are isolated reports in the literature (Zedgenidze O. A., 1954; Polyanker Z. N., 1967). According to O. A. Zedgenidze, osteolysis of bone tissue and restructuring of bone structure are trophic in nature and arise as a result of a fracture with damage to the hard meninges. 3. N. Polyanker believes that the peculiarities of bone reaction are most clearly revealed in long-term periods of traumatic brain injury. The occurrence of trophic changes in the bones of the skull in children is associated with the peculiar structure of the bones of the vault. In case of cephalohematomas, after using forceps and a vacuum extractor, there is a high possibility of damage and detachment of the periosteum, which leads to trophic changes.

Restructuring of the bone structure in the form of thinning and resorption bone elements We identified it in six patients. In addition to thinning of the bones, in five other cases, on the contrary, limited areas of thickening of individual bones of the skull, most often the parietal ones, were identified. When studying the history of these 11 births, it turned out that in three cases exit forceps were applied, in the remaining eight there was vacuum extraction of the fetus with the subsequent development of cephalohematoma. The relationship between these obstetric manipulations and the changes found on craniograms is beyond doubt.

We noted skull asymmetry on craniograms in nine newborns. Considering the nature of the injury, the obstetric interventions used, and the typical x-ray picture, we regarded these changes as post-traumatic.

It should be remembered that clinical manifestations Skull asymmetries in children injured during childbirth are even more common. At the same time, only one child had a linear crack (Fig. 78).

Rice. 78. Fragment of a radiograph of the skull of patient M., 7 months. Linear crack of the parietal bone with transition to the opposite side.

More severe damage to the skull bones during childbirth is also possible. So, in one of our observations, a child was born from urgent labor, in a breech presentation with the Tsovyanov manual. The condition was very serious, the arms were hanging along the body. An X-ray examination of the cervical spine and skull was immediately performed, which revealed an avulsion fracture of the occipital bone (Fig. 79). As one of the age-related features of the skull bones in children, sometimes simulating a violation of the integrity of the bones, it should be noted the presence of unstable sutures - the metopic and wisdom suture (Sutura mendosa). A metopic suture in adults occurs in 1% of cases (M. Kh., Faizullin), and in a study of children, A. M. Faizullin found this suture in 7.6% of cases. Typically, the metopic suture fuses by the end of the 2nd year of the child’s life, but can persist up to 5–7 years. We found a metopic suture in 7 patients, and all of them were older than 2.5 years. Distinctive feature The metopic suture from the crack is typical localization, serration, sclerosis, absence of other symptoms of linear fractures (symptoms of “zipper” and bifurcation).

Rice. 79. X-ray of the skull and cervical spine of newborn G., 7 days. Avulsion fracture of the occipital bone (explanation in the text).

A transverse suture divides the squama of the occipital bone at the level of the occipital protrusions. By the time of birth, only the lateral sections are preserved, called the suture of wisdom (sutura mendosa). According to G. Yu. Koval (1975), this suture synostoses at the age of 1 - 4 years. We found remains of a transverse suture in two patients, and in another two it was preserved throughout the entire length of the squama of the occipital bone (Fig. 80), which is also evident from the presence of large interparietal bones (Inca bone). A rare variant of the parietal bone, when it is formed from two independent sources of ossification, was identified in only one case in our patients.

Rice. 80. Fragment of a radiograph of the skull of patient K., 3 years 8 months. The preserved transverse suture of the occipital bone is the “wisdom” suture.

Traumatic injuries to the skull can be simulated by intercalary bones in the fontanelles and sutures - we found them in 13 patients. Some researchers associate the appearance and preservation of intercalary bones with birth trauma and the use of forceps. Thus, according to A.M. Faizullin, in 17 out of 39 children with intercalary bones detected, forceps were used during childbirth. Among our 13 patients, vacuum extraction was used in seven, and obstetric forceps in one case.

In children, on radiographs of the skull, a sclerotic border may be observed along the edges of the sutures. We identified sclerosis around the coronal suture in 6 children over 7 years of age. According to M. B. Kopylov (1968), this may be one of the signs of stabilization of cranial hypertension. According to our data, in three cases sclerosis around the coronal suture was accompanied by moderate signs intracranial hypertension.

When studying the vascular pattern of the skull, we paid attention to diploic canals, venous grooves, lacunae, emissaries, and pits of pachyonic granulations. Diploic canals were detected in 20 patients out of 56. Sphenoparietal and transverse sinuses are often found in healthy children. We identified these sinuses in four patients. Intensification of the pattern of diploic vessels and expansion (constriction) of the venous sinuses, in our opinion, in isolation from other symptoms cannot be considered as a sign of intracranial hypertension. They acquire meaning only in combination with other features.

When studying the shapes and sizes of the sella turcica and measuring the basal angle in our patients with natal spinal cord injuries, no pathology was identified.

Summarizing the data on the X-ray features of the skull in children with natal spinal cord injuries, it can be noted that changes were detected in a quarter of all examined and they most often manifested themselves as intracranial hypertension, X-ray symptoms of a former cephalohematoma, and changes in the configuration of the skull. Symptoms of pathological restructuring of the bone structure at the site of a cephalohematoma are common after the use of forceps and a vacuum extractor. We emphasize once again that only children with suspected cerebral pathology were examined craniographically. Skull fractures were found in isolated cases. In the group of patients with combined damage to the brain and spinal cord, craniographic findings were more common. Analysis of obstetric history and birth histories showed that childbirth in all these cases occurred with complications, with the use of obstetric aids. The frequency of breech births in the mothers of our patients is noteworthy, with more than half of the newborns born weighing more than 4.5 kg.

Thus, an X-ray examination of the skull in children with birth injuries to the spine and spinal cord at the slightest suspicion of a combined skull injury should be considered mandatory. In combination with neurological data, it allows us to judge the involvement of the skull in the process, suspect damage to cerebral structures and get a clearer and more complete picture of the sick child.

X-ray of the skull is an instrumental diagnostic method that allows you to assess the condition of the bones of the skull. This is not the most informative method, but it is indispensable in cases where there is little time for examination and more accurate methods are not available. With the help of radiography, you can make an accurate diagnosis, determine treatment tactics, monitor the effectiveness of the treatment process for symptoms of brain damage.

The essence of the method

X-rays of the head are based on the different ability of tissues to absorb X-rays. An x-ray tube sends a beam of x-rays to photosensitive element, in this case – photographic film. Some of them freely reach the film, and some are absorbed internal structures. The denser the fabric, the less rays it transmits. For example, bone is a very dense tissue, almost impenetrable to X-rays. Cavities containing air are not a barrier for them.

The brain, consisting of 90% water, also transmits rays well.

Thus, internal organs form shadows of varying intensity. The darker the shadow, the brighter it looks in the photo, and vice versa - the lighter it is, the darker the spot looks. This is due to the fact that the x-ray is essentially a negative.

What can you see?

X-ray allows you to visualize three groups of skull bones - vault, base, facial skeleton. All the bones of the skull are connected to each other using sutures - a fixed gear joint. The only exception is the lower jaw - it is attached using a joint. By taking several photographs in different projections, you can examine the shape of the bones and assess their integrity.

X-ray of the skull allows you to diagnose congenital defects, changes in the sella turcica - increase, destruction, decrease in bone density. All of them occur at elevated pressure in the corresponding zone. Most often these are benign and malignant tumors of the pituitary gland.

Also, an X-ray of the head will show signs of severe intracranial hypertension - finger-like impressions on the inner plate of the bones, arising due to high blood pressure on them the brain. Defects inside the bones indicate previous osteomyelitis. Calcifications inside the skull indicate chronic subdural hemorrhage, a focus of toxoplasmosis, or cysticercosis. A head X-ray diagnoses meningiomas or oligodendrogliomas of the brain, which often become calcified. The calcified pineal body is normally located in the midline and is clearly visible on cranial radiographs. Its displacement to the side indicates a tumor process in the brain on the side opposite to the displacement. In addition, x-rays of the skull show bone changes due to metabolic diseases such as Paget's disease.

Indications for the study

Considering the diagnostic capabilities of the method, the indication for radiography is a suspicion of one of the following diseases:

• open and closed craniocerebral injuries;

• pituitary tumor;
• congenital anomalies development;
• pathology of ENT organs, in particular paranasal sinuses nose

If making a preliminary diagnosis is difficult, a skull x-ray is indicated in the following situations:

• persistent headaches;
• dizziness;
• disturbances of consciousness;
• symptoms of hormonal imbalance.

These symptoms indicate a possible brain disease and require a detailed examination of the patient.

Technique of the procedure

No special preparation is needed for the study. The procedure is explained to the patient and warned that several images will be taken.

The patient is also asked to remove all metal jewelry in the head and neck area - they have high ability reflect X-rays and may obscure important areas of radiographs.

Depending on the patient’s condition, he is seated in a chair or placed on an x-ray table. To ensure reliable immobilization, the patient’s head is fixed using bandages, sand bags, and pads made of synthetic materials.

To obtain the maximum amount of useful information, photographs are taken in the following projections:

• right lateral;
• left side;
• anterior-posterior;
• posterior-anterior;
• axial

Before the patient leaves the office, the images are developed and their quality assessed.

Describing the result of the x-ray, the doctor assesses the shape and size of the skull, the thickness and integrity of the bones, and the condition of the sutures. The paranasal sinuses are also examined. The features of the vascular pattern are studied.

Depending on the indications, the doctor may not prescribe an X-ray of the head as a whole, but a targeted examination of the area of ​​interest - the lower jaw, nose, orbits, sella turcica, zygomatic bone, mastoid processes, temporomandibular joint.

Features of the procedure in children

The indications for X-rays of the skull in a child are the same as in adults. The most common of them are injuries, including birth injuries. However, research is resorted to only in the most extreme cases, when it is impossible to find a replacement, and the expected benefit clearly prevails over the likely side effects. This is due to the fact that all organs and tissues of children are actively growing, including brain cells. The more active the growth processes, the more susceptible the cells are to the negative effects of X-rays.

Before taking pictures, the child wears protective equipment - a lead apron and collar.

To minimize movement, the baby is securely restrained. So that he does not worry, relatives are allowed to be in the office. If the child is small or very restless, he is given sedatives.

Study safety

Not so long ago, doctors actively used the term “extremely permissible dose exposure." He determined maximum dose exposure for patients of different categories. Today, head x-rays are prescribed only when indicated. Therefore, it will be carried out as many times as necessary to make a diagnosis and monitor the effectiveness of treatment. On average, for one x-ray examination of the skull, the patient receives 4% of the annual radiation exposure from natural sources. A person who spends an hour in the open sun receives approximately the same amount.

For many patients, repeated x-ray examinations cause fear and doubt. In part, they are justified - frequent irradiation of actively growing cells increases the likelihood of mutations and development malignant diseases. However, studies are carried out even on young children and pregnant women - when the patient’s life is at stake, the doctor uses everything necessary methods diagnosis and treatment. Don’t be afraid to ask a specialist any questions you may have. Having discussed all the pros and cons together, you can come to a decision that will be optimal.

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X-ray of the skull and spine.

X-rays of the skull are used for intracranial diseases, head injuries, diseases of the skull bones, X-rays of the spine are used for pathological changes in the vertebrae, their joints, and ligaments.
Pictures are taken in two projections - front and profile. On the craniogram, attention is paid to the contours and dimensions of the skull, cranial sutures (divergence, calcification), fontanelles (early or late closure), development of vascular grooves, severity of digital impressions, contours of the sella turcica, sphenoid processes, pyramid of the temporal bone, paranasal cavities. When analyzing craniograms, take into account age characteristics structure of the bones of the child’s skull (Fig. 62).
The thickness of the skull bones in children is less than in adults. The large fontanelle closes completely by 1 year 4 months. The bones of the skull are malleable and plastic. The younger the child, the more pronounced the flexibility of the bones. There are no fingerprints (prints of convolutions) in children under 1 year of age. They appear after a year. An increase in the pattern of digital impressions and vascular grooves is observed with increased intracranial pressure.
Using a craniogram, they establish birth defects skull bones, early divergence or fusion of cranial sutures, brain deformities, hydrocephalus, microcephaly, traumatic injuries, calcifications, with neuromas of the VIII nerve - expansion of the internal auditory canal, with pituitary tumors, craniopharyngioma - destruction of the sella turcica.
X-rays of the spine reveal congenital anomalies of the spine: cervical ribs, nonfusion of the vertebral arches - spina bifida (usually in area I sacral vertebra), destruction of vertebral bodies in tuberculous spondylitis. With deforming spondyloarthrosis, growth is determined articular surfaces, with osteochondrosis - proliferation of cartilaginous surfaces.

Rice. 62 X-rays of the skull in frontal (a) and lateral (b) projections.


Rice. 63. Scheme of pneumoventriculogram.

For children younger age who are difficult to fix, before craniography, an enema is given from a 2% solution of chloral hydrate in an age-related dose. Before radiography of the lower thoracic, lumbar, and sacral spine, a cleansing enema is performed.

Contrast research methods.

Contrast research methods are widely used in the clinic to clarify the diagnosis in various diseases brain and spinal cord. Contrast research methods include pneumoencephalography, ventriculography, myelography and angiography.
Pneumoencephalography is valuable diagnostic method research in diseases of the nervous system. Air introduced into the subarachnoid space of the spinal cord fills the cerebrospinal fluid gaps, cisterns, and ventricles, which become visible on craniograms. X-ray images of the subarachnoid spaces and ventricles of the brain have been well studied. In diseases of the brain accompanied by displacement of brain tissue (tumor, abscess, hematoma, tuberculoma, gumma), the topography and shape of the ventricles of the brain change, which is revealed on a pneumoencephalogram (Fig. 63).
Before pneumoencephalography, a cleansing enema is prescribed the night before. Phenobarbital is given in the evening and morning in a dose appropriate for age. In the morning, an enema is given from a 2% solution of chloral hydrate (for children under 1 year - 10 - 15 ml, then adding 5 ml per year of life, but not more than 50 - 60 ml for older children).
In some cases, young children are given anesthesia instead of a chloral hydrate enema. For adults and older children, pneumoencephalography is performed in a sitting position with the head slightly tilted forward and the knees and knees bent. hip joints feet. A conventional lumbar puncture is performed with two needles between the spinous processes of the vertebrae (L2-L3 and L-4-L5). Cerebrospinal fluid is removed through the lower needle, and air is introduced through the upper one. After measuring the pressure of the cerebrospinal fluid, slowly release it from the lower needle using a mandrel, and collect it in a special graduated tube to measure the total amount. To prevent liquorodynamic disturbances, the fluid is removed in fractional portions. After removing 5 - 10 ml of liquid, 10 - 15 ml of air is slowly introduced, then the liquid is removed again and air is introduced; repeat this in the specified sequence up to 3-4 times. Cerebrospinal fluid is removed 10 - 20 ml less than air injected. Older children are given up to 70-80 ml of air, younger children - up to 40-50 ml, adults - 100-120 ml.
For children early age pneumoencephalography can be performed in a horizontal position of their body with one needle. Take the first portion of cerebrospinal fluid (3 - 4 ml) and slowly introduce 7 - 10 ml of air through the same needle, then repeat everything. During pneumoencephalography for uniform distribution air through the subarachnoid spaces and cavities, the child’s head is bent forward, then backward, left and right:
Pneumoencephalography without removal of cerebrospinal fluid is performed in cases of high intracranial pressure caused by a volumetric process, or if a hematoma is suspected after a traumatic brain injury. The patient should be seated in front of the X-ray screen in vertical position. A lumbar puncture is performed and, without releasing the cerebrospinal fluid, 1 ml of air is injected over a minute - a total of 5 - 7 ml. Then they do x-rays, after which 6-8 ml of air are slowly introduced again and pictures are taken again. In total, up to 25 ml of air can be introduced. Usually four x-rays are taken.
During the production of pneumoencephalography, there may be headache different intensity; Sometimes nausea and vomiting appear. When vomiting, caffeine is injected subcutaneously. If pallor, a stunned state, pulse arrhythmia and respiratory distress occur, then pneumoencephalography is stopped. The patient is given oxygen and administered cordiamine. During the first 3 to 5 days after pneumoencephalography, headache, drowsiness, and fever up to 39 ° C may be observed. In these cases, dehydration therapy is used (diuretics - parenterally, hypertonic solutions intravenously), antipyretics (amidopyrine, analgin orally and intramuscularly).
Indications for pneumoencephalography: tumors, abscesses, cysts, tuberculomas, gummas, echinococci; epilepsy, especially traumatic; consequences inflammatory processes brain and its membranes (arachnoiditis) without symptoms of cerebrospinal fluid duct occlusion.
Contraindications to pneumoencephalography: blockade of the cerebrospinal fluid passages (in which pneumoencephalography can lead to severe complications due to herniation of the brainstem into the foramen magnum or the foramen of the cerebellar tentorium); localization of the tumor and other pathological processes in the posterior cranial fossa; occlusive form of hydrocephalus; tumors temporal lobe; increased intracranial pressure with secondary symptoms of brainstem displacement; sharp decrease in vision (0.1 and below).
Ventriculography is based on the injection of air or contrast agents directly into the ventricles of the brain. Craniograms produce an image of only the ventricles of the brain.
Angiography- radiography of cerebral vessels after the introduction of a contrast agent into them (Fig. 64). Angiography is an important diagnostic research method. The purpose of angiography is to clarify the localization of the pathological focus, to find out its nature and character. Using angiography, various vascular lesions of the brain, anomalies in the development of cerebral vessels, angiomas, aneurysms, and tumors are diagnosed. The essence of the method is that a contrast agent (thorotrast, diotrast, urotrast, verotrast, etc.) is injected into the arterial bed, which, as it passes through the vessels, makes them visible on the craniogram. Angiography allows you to study the image of arteries, veins, venous sinuses, their location, lumen, state of collateral circulation, and the speed of passage of the contrast agent.
Serial radiography allows you to capture several stages of the passage of the contrast agent through the vascular system of the brain. The first angiogram shows the projection of the arteries, the second - the capillaries, and the third - the veins and venous sinuses. Pictures are usually taken in two projections - profile and front.
Normal arteriograms are characterized by a certain vascular pattern. The anatomical and physiological characteristics of the newborn’s vascular system should be taken into account; the caliber of his arteries is greater than the caliber of his veins. For young children it is 1:1, for older children and adults the caliber ratio is 1:2.
Among the pathological changes during angiography, displacement of blood vessels, their straightening, changes in shape and caliber, and neoplasms of blood vessels are most often detected. Displacement of blood vessels is observed in tumors, abscesses, cysts, and tuberculoma. As these formations grow, they displace the blood vessels in the brain. In some cases, a straightening of the usual vascular bend is observed, in others, on the contrary, it is more pronounced. Changes and displacements of blood vessels depend on the location, direction of growth and size of the space-occupying formation. Thus, with tumors of the frontal lobe, compression of the branches of the anterior and middle cerebral arteries is characteristic. With tumors of the temporal lobe, displacement and straightening of the middle cerebral artery often occurs. Tumors of the parietal lobe, located parasagittally, change the direction of the branches of the anterior cerebral artery, convexital tumors - the middle cerebral artery. Diffuse straightening of blood vessels indicates the presence of a sharp internal hydrocephalus. Limited straightening of blood vessels is more common with tumors and cysts.

rice. 64 Angiography schemes

New vascular formation on craniograms is manifested by the expansion of the lumen of blood vessels and the pathological development of the collateral network. These changes are observed more often with tumors of the meninges. The most typical ones are crimped, like a looped ball, small vessels, resembling the head of a jellyfish. At the same time, there is a significant dilation of the diploe veins. Changes in the shape of blood vessels, which may be associated with injury or disease vascular wall, found in aneurysms and angiomas.
During carotid angiography, a contrast agent is injected into the vascular bed of the common carotid artery or separately into the external and internal carotid arteries on the side of the lesion. There are two methods of administration: closed puncture (transcutaneous), i.e., by puncture of vessels through the skin, and open, by exposing the arteries surgically.
In pediatric practice, the closed puncture method is most often used. For young children, angiography is performed under anesthesia through a mask or intratracheally, for older children and adults under local anesthesia. The contrast agent Thorotrast is injected into the arterial bed in a dose appropriate for age, i.e. 10 - 15 ml. The timing of contrast agent administration is extremely important for the success of angiography. It must be coordinated in time with the production of photographs. The entire amount of contrast agent is injected continuously at a rate of approximately 3 ml per minute. After introducing % of the total amount of contrast mass, the first picture is taken, while the contrast agent is continued to be injected. After 2 s, a second photo is taken, and after 2 - 3 s, a third one is taken. After angiography, bed rest is prescribed for 3 to 5 days. Heavy, but very rare complications angiography includes transient paresis, paralysis, and short-term convulsions.
Indications for angiography: tumors, abscesses, cysts, brain tuberculomas, aneurysms and congenital malformations of cerebral vessels of various origins, late period traumatic brain injury, when there is a mixing of blood vessels due to cicatricial changes with the formation of cysts.
Contraindications to angiography: general severe condition of the child, tumors of the ventricles of the brain.
For topical diagnostics Contrast myelography is used for diseases of the spinal cord and its membranes. The essence of the method is to determine the blockade of the subhirutinous space of the spinal cord by introducing various contrast agents- mayodil, etc. Recently, isotope myelography (133Xe) has been successfully introduced into practice. Using myelography, it is possible to determine the level of spinal cord damage and differentiate tumor diseases from other spinal cord lesions. Myelography is rarely used in pediatric practice.

Using this method, both general and local changes in the bones of the skull are detected in case of brain tumors.

General changes in the bones of the skull develop as a result of a long-term increase in intracranial pressure, which is observed with brain tumors. The nature and extent of development of these changes mainly depend on the location of the tumor and its relationship to the cerebrospinal fluid pathways and the great cerebral vein of Galen.

When a rapidly growing tumor is located along the cerebrospinal fluid tract (III ventricle, Sylvian aqueduct, IV ventricle), secondary occlusive hydrocele gradually develops and, as a consequence, changes appear in the vault and base of the skull. On a number of radiographs taken in the same patient over several weeks or months, a gradually developing thinning of the bones of the cranial vault (general osteoporosis), flattening of its base, smoothing of the basal angle, as well as shortening and thinning of the back of the sella turcica, up to complete its destruction. The bottom of the sella turcica deepens, sometimes its destruction is observed. The sinus of the main bone is compressed. Along with these changes, osteoporosis is detected, and sometimes destruction of the anterior and posterior wedge-shaped processes.

With a slowly developing increase in intracranial pressure, a mostly symmetrical expansion of the normally preformed openings of the skull base is determined, namely the optic nerves, round, oval and torn holes, internal auditory canals. Thinning of the edge of the foramen magnum is also often observed. In an advanced stage of the disease, especially with subtentorial tumors, osteoporosis of the apices of both pyramids is noted. The development of osteoporosis at the apex of only one pyramid on the side of the tumor is observed when it is located at the base of the temporal lobe of the brain.

With pronounced phenomena of increased intracranial pressure in young people and especially in children, divergence of cranial sutures is also detected; they are stretched and gaping. As a result of the increased pressure of the cerebral convolutions on the cranial vault, the pattern of digital impressions and ridges intensifies. These changes are mostly found in subtentorial tumors. With large supratentorial tumors located in the midline, pronounced general signs increased intracranial pressure from the bones of the vault with the phenomena of significant divergence of cranial sutures.

As a result of tumor-induced disturbances in cerebral circulation in the skull, diffuse expansion vein channels diploe. It is sometimes evenly expressed in both halves of the skull. Wide channels of diploic veins on radiographs are revealed in the form of poorly tortuous, short grooves directed towards one center. The pits of pachyonic granulations and venous outlets also change their appearance when blood circulation is difficult. They expand and deepen significantly.

Revealed in photographs general changes If a brain tumor is suspected, skull bones confirm its presence, but do not give indications of location.

For topical diagnostics important has the identification on radiographs of local changes caused by contact of the tumor directly with the bones of the skull or the deposition of calcareous inclusions in it.

Local changes in the bones of the vault and base of the skull in brain tumors are revealed on radiographs in the form of local hyperostoses, usurs, foci of pathological calcification inside the tumor or along its periphery and increased development of vascular grooves involved in the blood supply to the tumor.

Local changes in the bones of the skull (hyperostosis, foci of destruction) are most often observed in arachnoidendotheliomas. Detection of these changes in the bones of the skull is important not only for determining the exact location of the tumor; in some patients these changes make it possible to judge its probable histological structure.

B. G. Egorov, out of 508 patients with arachnoidendotheliomas, identified various local changes in the bones of the vault and base of the skull in 50.2% of them. K. G. Terian, with arachnoidendotheliomas, discovered the presence of hyperostoses directly at the point of contact of these tumors with the bones of the skull in 44% of patients. I. Ya. Razdolsky observed local changes in the bones of the skull in 46% of patients with arachnoidendotheliomas. Our data show that with a thorough X-ray examination of the skull, local changes in its bones are detected in 70-75% of patients with arachnoidendotheliomas, especially when they are localized at the base of the skull.

Hyperostoses of the skull bones (endostoses, exostoses) are revealed on radiographs in the form of various shapes and sizes of limited compactions. They are often detected in the small wings of the main bone, in the area of ​​which arachnoidendotheliomas are often localized. Sometimes hyperostoses are also found in the area of ​​the tubercle of the sella turcica and the olfactory fossa. Severe hyperostoses in the form of needle periostitis are detected mainly in arachnoidendotheliomas of the calvarium and can spread to fairly large areas of the bone.

In the presence of hyperostoses and usurs, in the differential diagnosis one should take into account not only arachnoidendotheliomas, but also diseases of the skull bones themselves, such as benign and malignant tumors, localized fibrous dysplasia, syphilis and tuberculosis.

Local bone changes are not detected on craniograms when arachnoidendotheliomas are located away from the vault and base of the skull. Local destructive changes in the bones of the skull are most often found in tumors of the cerebral appendage. We observed them in 97.3% of 355 patients with pituitary tumors. With intrascidal tumors, these changes are expressed in a cup-shaped expansion of the sella turcica, destruction of its bottom, straightening of the back, its destruction, elevation and undermining of the anterior wedge-shaped processes. The presence of double contour of the bottom of the sella turcica usually indicates uneven tumor growth.

A greater narrowing of one of the halves of the main sinus revealed on targeted images and tomograms of the sella turcica indicates a preferential direction of tumor growth in this direction.

A detailed study of some features of pathological changes in the bony skeleton of the sella turcica makes it possible to presumably speak in favor of one or another histological structure intrascidal tumor.

With eosinophilic adenomas, most often accompanied by acromegalic syndrome, the sella turcica is usually cup-shaped, widened, deepened and increased in anteroposterior size. Its back is sharply straightened, deviated posteriorly and sharply sparse. Along with this, there is also a significant increase in the size of the air sinuses of the skull and their increased pneumatization. We observed such changes in the sella turcica and paranasal cavities in 82% of patients with eosinophilic pituitary adenomas. In chromophobe and basophilic adenomas, only those expressed in varying degrees destructive changes in the sella turcica.

Differential diagnosis between these two groups of tumors cannot be carried out without analyzing the clinical picture of the disease and studying the fundus, field and visual acuity of the patient under study.

By the nature of the destruction of the sella turcica, one can also presumably judge the suprascidal, parascidal, posterior sciatic, and anterior sciatic localization of the tumor.

With a supraschillar tumor, the back of the sella turcica is tilted anteriorly, destroyed and shortened. The anterior wedge-shaped processes are deflected downwards and destroyed. The bottom of the sella turcica is compressed, the lumen of the sinus of the main bone is reduced.

With a peri-saddle tumor (tumor of the temporal lobe, tumor of the membranes), predominantly unilateral destruction of the sella turcica is observed on the side where this tumor is located. In these cases, craniograms often reveal destruction of part of the dorsum of the sella turcica, which is sometimes combined with unilateral destruction of the anterior sphenoid process.

With a posterior sciatic tumor, the dorsum of the sella turcica is pressed anteriorly. The posterior wedge-shaped processes are shortened and destroyed. Sometimes destruction of the Blumenbach clivus is observed. With further growth of the tumor as a result of compression of the Sylvian aqueduct and the development of hydrocephalus, secondary changes in the sella turcica appear, characteristic of a chronic increase in intracranial pressure.

Anterior sphenoid tumors cause destruction of the anterior sphenoid processes and destruction of the sella turcica of one type or another. These tumors are detected on radiographs due to the presence of hyperostoses in the area of ​​the olfactory fossa or the area of ​​the small wings of the sphenoid bone.

In some cases, tumors develop in the sinus of the main bone and grow into the sella turcica from below. With this localization of tumors, the cavity of the sella turcica sharply narrows, its bottom either bends upward or collapses. The lumen of the sinus of the main bone is not differentiated. Most often, craniopharyngiomas develop in this area - tumors arising from Rathke's pouch, and malignant tumors of the skull base. Characteristic of craniopharyngiomas is the deposition of lime in the tumor shell or inside its cystic contents.

Lime deposits are one of the most important local radiological signs of brain tumors. The presence of this sign makes it possible not only to establish the location of the tumor, but sometimes to correctly determine its histological nature. It is known that such normally preformed formations as the pineal gland, choroid plexuses lateral ventricles, greater falciform process, dura mater, pachyonic granulations, and in some people calcify under physiological conditions. Especially often, no less than 50-80% healthy people, calcification of the pineal gland is observed. Its displacement by a brain tumor is of great diagnostic importance. Under the influence of tumor growth, the calcified pineal gland, as a rule, shifts from the midline in the direction opposite to the tumor.

Various physiological calcifications must be differentiated from lime deposits in brain tumors. Intratumoral lime deposits can be homogeneous. Sometimes they appear in the form of linear shadows, individual amorphous lumps or small dotted inclusions. In some tumors, for example in arachnoidendotheliomas, lime is deposited only in their membrane, which gives a certain idea of ​​​​the size of these tumors. Sometimes, during long-term observation of the patient, it is possible to see increasing calcification of the tumor on radiographs.

Most often, lime is deposited in arachnoidendotheliomas. It is determined in them in the form of linear calcifications bordering their periphery, and sometimes in the form of point inclusions located inside the tumor. Much less often, calcareous inclusions are detected in intracerebral tumors of neuroectodermal origin. Most often we found them in oligodendrogliomas. Lime in these tumors occurs in the form of linear formations, in places merging with each other. The same form of calcification is occasionally observed in astrocytomas. Therefore, it is usually not possible to distinguish them from oligodendrogliomas by the nature of calcification.

Characteristic calcareous deposition is observed in craniopharyngiomas. Along the periphery of these tumors, lime is deposited in the form of linear or lamellar formations, and in the thickness of the tumor - in the form of amorphous lumps of varying sizes. The presence of this kind of calcification, taking into account their localization, allowed us to establish the correct diagnosis in 28 out of 32 patients with craniopharyngiomas. When making differential diagnoses, it should be taken into account that calcifications of a similar nature can also be observed with cholesteatomas.

It should be borne in mind that lime deposition is determined not only in tumors, but also in pathological processes of a non-tumor nature, for example, brain cysticerci, brain scars and long-term inflammatory foci. Differential diagnosis in these cases between tumor and non-tumor diseases of the brain based on craniography data is difficult.

Lime deposits, as a rule, are also observed in Sturge-Weber disease. The characteristic pattern of thin double strips of lime located on the surface of the brain, in its cortex, makes it easy to distinguish these calcifications from those observed in various brain tumors.

Strengthening the vascular pattern of the skull bones in some cases is a pathognomonic sign of brain tumors. With arachnoidendotheliomas, cranograms often reveal a peculiar pattern of grooves in the branches of the meningeal arteries, characteristic of these tumors, involved in their nutrition. In these cases, in a limited area of ​​the cranial vault, unevenly expanded, short, intertwined vascular grooves are revealed. On technically well-performed radiographs in these cases, it is sometimes possible to trace the groove of the arterial trunk entering this tangle that feeds the tumor.

With intracerebral tumors, predominantly on the side of the tumor, diffuse dilation of the diploic veins of the skull bones is sometimes observed, resulting from venous stagnation.

For tumors of the posterior cranial fossa(subtentorial) important radiological signs that contribute to their recognition are expansion of the internal auditory canal, osteoporosis, destruction of the apex of the pyramid, as well as the identification of intratumoral calcifications. Uniform expansion of the internal auditory canal is most often observed with neuroma auditory nerve. When assessing this symptom, it should be taken into account that the expansion of the ear canal is also observed in non-tumor processes, for example internal dropsy and limited arachnoiditis.

The most characteristic craniographic sign of a tumor in the cerebellopontine angle region is destruction of the apex of the pyramid. Its destruction is observed in both benign and malignant tumors of this area. At malignant neoplasms destruction of the apex of the pyramid occurs more quickly and is more pronounced than in benign tumors.

A valuable craniographic sign of cerebellar tumors is the thinning of the edge of the foramen magnum on the side of the tumor.

Topical diagnosis of subtentorial tumors is facilitated by calcifications sometimes detected in them on radiographs. Foci of lime are most often detected in cholesteatomas and cerebellar gliomas.

In those patients who have data clinical examination and craniography data turn out to be insufficient for the diagnosis of a brain tumor and its localization, they resort to contrast X-ray examination of the cerebrospinal fluid spaces of the brain and its vessels.

When X-ray diagnostics of diseases of the skull, it is necessary, along with a thorough knowledge of the basics of X-ray anatomy, to take into account its age, gender and constitutional characteristics, as well as anatomical variants and anomalies in the development of bone elements and cranial sutures: intercalary - Wormian - bones, imbricated arrangement of bone scales in the lambdoid suture (Fig. 11 ,6) areas of thinning of the bones of the arch (foramina parietalia permagna), pneumatization of the wings of the main bone, etc. This is necessary, on the one hand, in order to avoid overdiagnostic conclusions, and on the other hand, not to view the initial pathological changes in cases where they actually exist.

X-ray analysis of pathological changes in the skull consists of studying the state of the following main anatomical elements that form the X-ray picture of the skull as a whole.
1. General form and skull dimensions.

Various deformations of the skull are observed with craniostenosis (see) due to premature fusion of cranial sutures.

2. The thickness of the skull bones, their contours and structure, the relief of the outer and inner surfaces.

The thickness of the bones of the cranial vault in its various parts different people normally varies within a fairly wide range (from 2 to 10 mm). Pathological thinning and osteoporosis individual plots bones (cranial vault, sella turcica) can appear as a result of atrophy from pressure on the bone from pathological formations, such as tumors, etc., as well as due to inflammatory processes in any part of the bone (Fig. 10, a). Often, destructive processes accompanied by bone atrophy can be combined with reparative changes leading to its thickening - hyperostosis, which, in particular, is observed with syphilis (Fig. 12) and actinomycosis.

Rice. 12. Syphilis of the frontal bone. Marginal destructive foci in the scales of the frontal bone, at the border with which the bone is thickened and compacted.

At endocrine disorders, for example, acromegaly (see), along with an increase in the sella turcica and thinning of its elements due to pressure from the pituitary tumor, there is a thickening of the bones of the cranial vault, protrusion brow ridges and occipital protuberance, prognathism of the lower jaw and unusual development of the paranasal sinuses.

Changes in the contours, thickness and structure of the skull bones can be observed with various types of primary and metastatic bone tumors(see Bone tissue, X-ray diagnosis of bone tissue tumors). For example, in cancer, multiple myeloma, osteoclastic cancer metastases individual areas of the bone may appear as defects completely devoid of bone structure (Fig. 13, a).

Rice. 13. Large defects in the bones of the skull: a - osteoclastic metastases cancerous tumor in the bones of the cranial vault; b - cholesteatoma in the calvarium; a large defect of the parietal bone with wavy, clear contours.

Differential diagnosis of solitary defects of the bones of the cranial vault is difficult in cases where the focus of destruction extends to all three plates of the bone; the clearing in its place has a fairly regular rounded shape, clear contours and is devoid of any structure. Almost identical radiological symptoms can be observed with tuberculosis, eosinophilic granuloma, cholesteatoma (Fig. 13, b). In these cases, differential diagnosis special meaning acquire a clinical picture and anamnesis. Round solitary foci of clearing in the bones of the calvarium, having a regular stellate structure, are typical for hemangioma. The X-ray picture of osteoblastic metastases of cancer in the bones of the calvarium is very characteristic, representing intense round foci of darkening of different sizes.

With benign tumors, in particular with osteomas, in contrast to most malignant ones, growth and thickening of the bone occurs at the site of the tumor. The contours of osteoma are always sharply defined, the structure is very dense and homogeneous. Unlike osteoma, with limited hyperostosis of the skull bones (see Osteodysplasia), there is no sharp transition from thickened bone tissue to normal.

The nature of the internal relief of the skull bones in comparison with the external one seems to be more complex due to the X-ray image on survey photographs of the skull of digital impressions, vascular grooves, canals and sinuses, pachyonic fossae, foramina, etc. Therefore, when assessing it, it is necessary to take into account both numerous anatomical options, as well as the specific picture of the disease and age-related characteristics of the skull. Pronounced changes in the internal relief of the bones of the cranial vault are observed, in particular, with various forms of hydrocephalus (see). Open forms hydrocephalus is characterized by a smoothing of the internal relief, while closed ones are characterized, on the contrary, by increased digital impressions, grooves of the venous sinuses, meningeal arteries and pachyonic fossae.

Changes in the bones of the cranial vault, accompanied by their thickening and characteristic restructuring of the bone structure, are observed in osteodystrophies (see) and osteodysplasias.

3. Openings and canals of the brain and facial parts of the skull.

Studying their condition often requires the use of special two-moment projections to compare the parts of the same name on the right and left sides. Sometimes minor destruction or relatively slight expansion of one of the canals may indicate the presence of a tumor of the corresponding nerve (see Brain, X-ray diagnosis of diseases). For example, with glioma optic nerve It is necessary to study in the Rese-Golvin projection (Fig. 4), and in case of a neuroma of the VIII nerve, expanding the internal auditory canal, in the projection of the pyramids according to Stenvers (Fig. 14).

Rice. 14. Neuroma of the right auditory nerve. X-ray of the pyramids temporal bones according to Stenvers. On the right, a sharp expansion of the internal auditory canal is determined.

Rice. 15 (right). Acute sinusitis. X-ray of the paranasal sinuses. Vertical position of the patient's head and the cassette. Horizontal levels of fluid are visible in the right frontal and right maxillary sinuses.

4. Air-bearing bones of the skull (frontal, ethmoid, sphenoid, maxillary, temporal) and air-bearing cells and sinuses.

The air spaces of the air bones in inflammatory diseases are filled with pathological contents (serous or purulent effusion, edematous mucous membrane, polyps, cysts, granulations) or the integrity of their walls is disrupted as a result of a fracture or destruction due to tumor lesions. In the sinuses, mainly in the frontal sinuses, sometimes for the first time it is possible to detect a radiologically benign tumor - osteoma. In all cases, replacing air with heavier contents gives a radiological symptom of darkening, the intensity of which depends on its quantity, atomic weight and volume of the sinus itself. Radiography with the patient's head and the cassette in a vertical position reveals a radiological symptom of a horizontal fluid level in it (Fig. 15). In doubtful cases, use the injection of iodolipol or mayodil into the sinus.

5. Foci of calcification of the skull.

X-ray examination of the skull often reveals intracranial calcifications, some of which are physiological (calcifications of the pineal gland, plexus chorioideus, dura mater, most often falx cerebri). The symptom of displacement of the shadows of the pineal gland and plexus chorioideus can be used to establish the diagnosis and localization of some brain tumors. Calcification of the falx cerebri in the image of the paranasal sinuses can be projected onto the frontal sinus and simulate osteoma.

Rice. 16. X-rays of the skull with a calcified hematoma: a - chin-nasal projection of the skull for examining the paranasal sinuses. The sinuses are airy, in the outer part of the left frontal sinus intense shadow detected; suspicion of sinus osteoma; b-right lateral view of the skull; in the parietal region the same shadow is visible: a calcified hematoma (after a childhood injury) of the right parietal lobe of the brain.

Rice. 17. Craniopharyngioma. A slight increase in the anteroposterior size of the sella turcica. Compaction and thickening of its walls. A landkarto-shaped area of ​​calcification above the sella turcica.

Pathogenic calcifications of the brain and its membranes are observed in extra- and intracerebral hematomas (Fig. 16, a and b), meningioma, craniopharyngioma (Fig. 17), Sturge-Weber disease, lime deposits in the walls of large arteries, cysticercosis and toxoplasmosis. Extracerebral calcifications are found in the nasal cavity (rhinolitis), in the salivary glands and their ducts (see Sialography), in the ears of boxers. The X-ray symptoms of many calcifications of the skull are very pathognomonic; great value Some of them can be determined by comparing data from X-ray and clinical studies.

6. Soft tissues of the head and mucous membranes of the accessory cavities.

X-rays of the skull clearly show the image of not only the bone skeleton, but also the soft tissues of the head. Shadow of a large upper lip in the photograph of the facial skull may overlap with clearings maxillary sinuses and simulate shadows of cysts; special “boneless” photographs of the eyeball are used to detect the smallest foreign bodies; on special radiographs shadows of triangular and alar cartilages can be seen in the nasal bones; to study the auricle, they use its “boneless” projection; against the background of the air column of the nasopharynx, the shadows of the elements are clearly visible soft palate, enlarged adenoids, tumors or choanal polyp. The shadow of a massive cheek tumor can simulate the darkening of the corresponding maxillary sinus.

Lesions of the bones and soft tissues of the skull and its air cavities, the recognition of which is based on the radiography method, are diverse. They are accompanied by various pathological changes in the bone structure (acromegaly, xanthomatosis, Paget's disease, mucocele of the sinuses, cholesteatoma of the ear, some malignant tumors, their metastases, osteopathies, etc.). System and endocrine diseases bones (Paget's disease, multiple myeloma, malignant tumors of the thyroid gland, adrenal gland, gonads, etc.) are sometimes discovered for the first time by x-ray examination of the skull.