Age-related changes in x-ray images of the skull. Lesions and Pseudolesions of the Bones of the Skullcap: Differential Diagnosis and an Illustrated Review of Pathological Conditions Manifested by Focal Lesions of the Skullcap

Studies devoted to the study of radiographic features of the skull in children with natal injuries spinal cord, neither in the domestic nor in the available foreign literature, we found. Usually, X-ray examination of the skull is carried out only in isolated cases with birth injuries of newborns in case of suspected fracture of the bones of the cranial vault. So, E. D. Fastykovskaya (1970) elaborated in detail the issues of artificial contrasting of the vessels and sinuses of the brain during childbirth. intracranial injuries newborns. Interpretation of radiographs of the skull in children presents great difficulties. An interesting study in this direction was carried out by M. Kh. Fayzullin (1971) and his students.

The meaning 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 focus can easily be viewed. That is why in those of our patients, where, along with spinal symptoms, some signs of craniocerebral inferiority were revealed, we considered a craniographic study to be obligatory.

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

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

Fig. 71. Roentgenogram of the skull in direct projection (occipital position) of the same patient Sh., 9 months old. IN occipital bone transverse seam, "Inca bones".

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

Rice. 73. A special radiograph of the skull of the same patient, produced by the "tangential" course of the x-ray beam. Depressed fracture of the scales of the frontal bone.

When assessing skull radiographs in our patients, we paid special attention to the following details: skull configuration, presence of digital impressions, condition of sutures, fontanelles, existence of intercalations, diploic canals, furrows venous sinuses, the structure of the base of the skull, areas of restructuring of the bone structure. Of course, the results of x-ray studies were carefully compared with clinical data. These or other pathological findings on radiographs were found in 25% of patients.

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

Behind Lately growing all over the world specific gravity childbirth with a large fetus, fraught with the threat of complications associated with a mismatch in the size of the fetus and the mother's pelvis. Among our patients with pronounced changes on craniograms, delivery with a large fetus (over 4500 g) was noted in 20 out of 56 cases. All this shows that there were many reasons for the occurrence of cranial complications in this group of newborns.

The greatest difficulty in evaluating 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. The pattern of finger impressions as a sign of pathology was regarded by us only in comparison with other signs of increased intracranial pressure (divergence of sutures, an increase in the size of the skull, thinning of the diploe, tension of the fontanelles, details of the saddle, flattening of the base of the skull, increased pattern of vascular sulci).

Naturally, we always evaluated radiographic data in comparison with the results clinical research. In view of the foregoing, 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 strengthening the pattern of digital impressions, for the reason that the pattern of the skull bones can be poorly traced (“blurred” pattern) with external or mixed dropsy, when the fluid in the outer parts of the brain retains 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 front, a 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, a large fontanelle. The base of the skull, including the Turkish saddle, is flattened.

In addition, digital impressions were pronounced in 7 more 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 finger impressions depends on periods of intensive brain growth and, according to I. R. Khabibullin and A. M. Faizullin, can be expressed at the age of 4 to 13 years (moreover, in children from 4 to 7 years old - 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.

As the fetal head passes through birth canal the skull is temporarily deformed due to displacement individual bones in relation to each other. X-ray at the same time, the occurrence of the parietal bones on the occipital, frontal or protrusion of the parietal bones is noted. These changes in most cases undergo reverse development, without consequences for the fetus. According to E. D. Fastykovskaya, “the displacement of the parietal bones relative to each other is more alarming,” since such a configuration of the fetal head may be accompanied by damage to the meningeal vessels, up to the upper longitudinal sinus. On our material, the overlapping of the parietal bones on the frontal or occipital was noted in 6 patients and only in the first 2-3 months of life (Fig. 75).

Rice. 75. Fragment of the X-ray of the skull of V., 2 months old. The occurrence of the parietal bones on the occipital in the region of the lambda.

One of the indirect signs of a birth injury of the central nervous system may be cephalohematoma. Usually cephalohematoma persists up to 2 - 3 weeks after birth, and then undergoes reverse development. With a complicated course, the reverse development does not occur in the usual time frame. According to E. D. Fastykovskaya (1970), in such cases, an additional sclerotic rim is revealed at the base of the cephalohematoma due to the deposition of calcium salts in the hematoma capsule. Flattening of the underlying bone may also occur. We've been watching long-term preservation cephalohematoma 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 in the form of small islands of osteoporosis at the site of cephalohematoma was noted (Fig. 77).

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

Rice. 77. Fragment of an X-ray of the skull of patient K., 5 months old. In the posterior-upper square of the parietal bone, there are small areas of enlightenment - "trophic osteolysis".

The etiology and pathogenesis of the formation of defects in the bones of the skull in children after trauma has not yet been studied. There are isolated reports in the literature (Zedgenidze OA, 1954; Polyanker 3. N., 1967). According to O. A. Zedgenidze, osteolysis of bone tissue and restructuring of the bone structure are trophic in nature and result from a fracture with damage to the hard meninges. 3. N. Polyanker believes that the features of the reaction of the bones are most prominently found in the remote 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. With cephalohematomas, after the use of 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 found in six patients. In addition to the thinning of the bones, in five other cases, on the contrary, limited areas of thickening of individual bones of the skull, more often the parietal ones, were revealed. When studying the history of these 11 births, it turned out that in three cases exit forceps were applied, in the remaining eight cases there was a vacuum extraction of the fetus, followed by the development of cephalohematoma. The relationship between these obstetric manipulations and the changes found on the craniograms is beyond doubt.

Skull asymmetry was noted by us on craniograms in nine newborns. Given the nature of the injury, the obstetric interventions used, and the typical X-ray picture, these changes were regarded by us as post-traumatic.

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

Rice. 78. Fragment of an X-ray of the skull of patient M., 7 months old. Linear crack of the parietal bone with transition to the opposite side.

More severe damage to the bones of the skull during childbirth is also possible. So, in one of our observations, the child was born from an urgent delivery, in the breech presentation with the allowance according to Tsovyanov. The condition was very heavy, the handles hung along the torso. Immediately, an X-ray examination of the cervical spine and skull was made, 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 non-permanent sutures - the metopic and the wisdom suture (Sutura mendosa). Metopic suture in adults occurs in 1% of cases (M. Kh., Faizullin), and in the study of children, A. M. Faizullin found this suture in 7.6% of cases. Usually, the metopic suture fuses by the end of the 2nd year of a child's life, but may persist up to 5-7 years. We found a metopic suture in 7 patients, all of whom were older than 2.5 years. Distinctive feature metopic suture from the crack is a typical localization, serration, sclerosis, no other symptoms of linear fractures (symptoms of "lightning" and bifurcation).

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

The transverse suture divides the scales 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 the remains of the transverse suture in two patients, and in two more it was preserved along the entire length of the scales 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 found in our patients only in one case.

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

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

In children, x-rays of the skull along the edges of the sutures may show sclerotic edging. We detected sclerosis around the coronal suture in 6 children older than 7 years. 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 sulci, lacunae, emissaries, and pits of pachyon granulations. Diploic canals were found 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 (squeezing) 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 signs.

When studying the shapes and sizes of the Turkish saddle, measuring the basal angle in our patients with natal spinal cord injuries, no pathology was detected.

Summarizing the data on the radiological 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 manifested most often as intracranial hypertension, x-ray symptoms of a former cephalohematoma, and changes in the configuration of the skull. Often there are symptoms of pathological restructuring of the bone structure at the site of cephalohematoma, 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 brain and spinal cord injury, craniographic findings were more common. An analysis of the obstetric anamnesis and birth histories showed that the births in all these cases took place with complications, with the use of obstetric benefits. Noteworthy is the frequency of births in breech presentation in the mothers of our patients, 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 of the spine and spinal cord, with the slightest suspicion of a combined skull injury, should be considered mandatory. In combination with neurological data, it makes it possible to judge the involvement of the skull in the process, to suspect damage to cerebral structures, and to form a clearer and more complete picture of a sick child.

X-ray of the skull is a method of instrumental diagnostics that allows you to assess the condition of the bones of the skull. It's not the best 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 the medical tactics, control the effectiveness of the treatment process with symptoms of brain damage.

The essence of the method

X-ray of the head is based on the different ability of tissues to absorb x-rays. X-ray tube sends a beam of x-rays to photosensitive element, in this case, 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 an obstacle for them.

The brain, which is 90% water, also transmits rays well.

Thus, internal organs form shadows of varying intensity. The darker the shadow, the brighter it looks in the picture, 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 be seen?

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

X-ray of the skull allows you to diagnose congenital malformations, changes in the Turkish saddle - an 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 that occur due to high blood pressure on them brain. Defects inside the bones indicate past osteomyelitis. Calcifications inside the skull indicate chronic subdural hemorrhage, focus of toxoplasmosis, cysticercosis. X-ray of the head diagnoses meningiomas or oligodendrogliomas of the brain, which often calcify. The calcified pineal body is normally located in the midline and is well visualized on radiographs of the skull. Its displacement to the side indicates a tumor process in the brain from 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

Given the diagnostic capabilities of the method, an 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, an X-ray of the skull is indicated in such 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.

Procedure technique

Special preparation for the study is not needed. The patient is explained the course of the procedure and is warned that several images will be taken.

Also, the patient is 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 condition of the patient, he is seated in a chair or placed on an x-ray table. To ensure reliable immobilization, the patient's head is fixed with bandages, sandbags, pads made of synthetic materials.

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

right side;
left side;
anterior-posterior;
posterior-anterior;
axial.

Before the patient leaves the office, the images are developed and evaluated for quality.

Describing the result of radiography, the doctor assesses the shape and size of the skull, the thickness and integrity of the bones, 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 prescribe not an X-ray of the head as a whole, but a targeted study of the area of interest - the lower jaw, nose, eye sockets, Turkish saddle, zygomatic bone, mastoid processes, temporomandibular joint.

Features of the procedure in children

Indications for an x-ray of the skull in a child are the same as in adults. The most common of these are injuries, including birth. However, research is resorted to only in the most extreme cases when it is impossible to find a replacement, and the expected benefit clearly outweighs 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 the cells are exposed to the negative effects of X-rays.

Before taking pictures, the child is put on protective equipment - a lead apron and a collar.

To minimize movement, the baby is securely fixed. 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 allowable dose irradiation." He determined maximum dose exposure for patients of different categories. To date, X-rays of the head are prescribed only according to indications. 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 norm of exposure from natural sources. Approximately the same amount is received by a person who stays in the open sun for an hour.

In many patients, multiple 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, even small children and pregnant women are being researched - when a patient's life is at stake, the doctor uses everything necessary methods diagnosis and treatment. Do not be afraid to ask the specialist questions of interest. Having discussed all the pros and cons together, you can come to a decision that will be optimal.

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Radiography of the skull and spine.

X-ray of the skull is used for intracranial diseases, head injuries, diseases of the bones of the skull, X-ray of the spine - for pathological changes in the vertebrae, their joints, ligamentous apparatus.
Pictures are taken in two projections - frontal 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), the development of vascular furrows, the severity of digital impressions, the contours of the Turkish saddle, sphenoid processes, pyramid of the temporal bone, adnexal cavities of the nose. When analyzing craniograms, take into account age features the structure of the bones of the child's skull (Fig. 62).
The thickness of the bones of the skull in children is less than in adults. A completely large fontanel closes by 1 year 4 months. The bones of the skull are malleable and plastic. The younger the child, the more pronounced the compliance of the bones. Finger impressions (imprints of convolutions) in children under the age of 1 year are absent. They appear after a year. Strengthening the pattern of finger impressions and vascular furrows is observed with an increase in intracranial pressure.
Establish with the help of a craniogram birth defects skull bones, early divergence or fusion of cranial sutures, brain deformities, hydrocephalus, microcephaly, traumatic injuries, calcifications, with neurinomas of the VIII nerve - expansion of the internal auditory canal, with pituitary tumors, craniopharyngioma - destruction of the Turkish saddle.
X-rays of the spine reveal congenital anomalies in the development of the spine: cervical ribs, non-fusion of the vertebral arches - spina bifida (more often in area I sacral vertebra), destruction of the 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.

children younger age which are difficult to fix, before craniography, an enema is made from a 2% solution of chloral hydrate at an age dose. Before radiography of the lower thoracic, lumbar, sacral spine, a cleansing enema is performed.

Contrasting research methods.

Contrast methods of research are widely used in the clinic to clarify the diagnosis in various diseases brain and spinal cord. Contrast methods of research 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 liquor-bearing gaps, cisterns, and ventricles, which become visible on craniograms. The X-ray image of the subarachnoid spaces and ventricles of the brain is well studied. In diseases of the brain, accompanied by a displacement of the brain tissue (tumor, abscess, hematoma, tuberculoma, gumma), the topography and shape of the brain ventricles change, which is detected on the pneumoencephalogram (Fig. 63).
Before pneumoencephalography the night before, a cleansing enema is prescribed. In the evening and in the morning they give phenobarbital in a dose corresponding to age. In the morning, an enema is made from a 2% solution of chloral hydrate (children under 1 year old - 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 bent at the knees and 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, air is introduced through the upper needle. After measuring the pressure of the cerebrospinal fluid, slowly release it from the lower needle using a mandrin, and collect it in a special graduated tube to measure the total amount. To prevent liquorodynamic disturbances, the liquid is withdrawn in fractional portions. After removing 5-10 ml of liquid, 10-15 ml of air is slowly introduced, then the liquid is again removed and air is introduced; repeat this in the indicated sequence up to 3-4 times. Cerebrospinal fluid is removed 10-20 ml less than air is introduced. Older children are injected with up to 70-80 ml of air, younger children - up to 40-50 ml, adults - 100-120 ml.
children early age pneumoencephalography can be performed in the horizontal position of their body with one needle. They take the first portion of cerebrospinal fluid (3-4 ml) and slowly inject 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 anteriorly, then backwards, left and right:
Pneumoencephalography without removal of cerebrospinal fluid is performed in cases of high intracranial pressure due to 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 cerebrospinal fluid, 1 ml of air is injected per minute - only 5-7 ml. Then do x-rays, after which 6-8 ml of air is slowly injected again and pictures are taken again. In total, up to 25 ml of air can be injected. Usually four x-rays are taken.
During the production of pneumoencephalography, it may occur headache different intensity; sometimes there is nausea, vomiting. When vomiting, caffeine is injected subcutaneously. If blanching, stunned state, arrhythmia of the pulse and respiratory failure occur, then pneumoencephalography is stopped. The patient is given oxygen and administered cordiamine. During the first 3-5 days after pneumoencephalography, headache, drowsiness, fever up to 39 ° C can be observed. In these cases, dehydration therapy is used (diuretics - parenterally, hypertonic solutions intravenously), antipyretics (amidopyrine, analgin inside and intramuscularly).
Indications for pneumoencephalography: tumors, abscesses, cysts, tuberculomas, gummas, echinococci; epilepsy, especially traumatic; consequences inflammatory processes the brain and its membranes (arachnoiditis) without symptoms of occlusion of the CSF tract.
Contraindications to pneumoencephalography: blockade of the cerebrospinal fluid (in which pneumoencephalography can lead to severe complications due to wedging of the brain stem into the foramen magnum or opening of the cerebellar tenon); 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 displacement of the brain stem; a sharp decrease in vision (0.1 and below).
Ventriculography is based on the introduction of air or contrast agents directly into the ventricles of the brain. Craniograms show 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. With the help of 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 lies in the fact that a contrast agent (thorotrast, diotrast, urotrast, verografin, etc.) is injected into the arterial bed, which, at the time of passage through the vessels, makes them visible on the craniogram. Angiography allows you to study the image of arteries, veins, venous sinuses, their location, lumen, the state of collateral circulation, the speed of passage of the contrast agent.
Serial radiography allows you to catch several stages of the passage of a contrast agent through the vascular system of the brain. On the first angiogram, the projection of the arteries is fixed, on the second - capillaries, on the third - veins and venous sinuses. Pictures are usually taken in two projections - profile and face.
Normal arteriograms are characterized by a certain vascular pattern. Anatomical and physiological features of the vascular system of the newborn should be taken into account; the caliber of the arteries is greater than the caliber of the veins. In young children it is 1:1, in older children and adults the ratio of calibers is 1:2.
Among the pathological changes in angiography, displacement of vessels, their straightening, changes in shape and caliber, neoplasms of vessels are most often detected. Vessel displacement is noted in tumors, abscesses, cysts, tuberculoma. As they grow, these formations displace the vessels of the brain. In some cases, there is a straightening of the usual vascular bend, in others, on the contrary, it is more pronounced. Changes and displacements of vessels depend on the location, direction of growth and size of the volumetric formation. So, 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, there is more often a displacement and straightening of the middle cerebral artery. Tumors of the parietal lobe, located parasagittally, change the direction of the branches of the anterior cerebral artery, convexital - the middle cerebral artery. Diffuse straightening of the vessels indicates the presence of a sharp internal hydrocephalus. Limited straightening of blood vessels is more common with tumors, cysts.

rice. 64 Angiography charts

Neoplasm of vessels on craniograms is manifested by the expansion of the lumen of the vessels and the pathological development of a network of collaterals. These changes are observed more often in tumors of the meninges of the brain. The most typical are twisted, like a looped ball, small vessels resembling the head of a jellyfish. At the same time, there is a significant expansion of the veins of the diploe. Change in the shape of the vessels, which may be associated with damage or disease vascular wall found in aneurysms and angiomas.
With carotid angiography, a contrast agent is injected into the vascular bed of the common carotid artery or separately external and internal carotid arteries on the side of the focus. There are two methods of administration: closed puncture (transcutaneous), i.e., by puncturing vessels through the skin, and open, when arteries are surgically exposed.
In pediatric practice, the closed puncture method is most often used. For younger 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 at a dose appropriate for age, i.e. 10-15 ml. The timing of the injection of the contrast medium is critical to the success of the angiography. It must be coordinated in time with the production of photographs. The entire amount of contrast agent is continuously injected at a rate of approximately 3 ml per minute. After the introduction of % of the total amount of contrast mass, the first picture is taken, while continuing to inject a contrast agent. After 2 s, a second shot is taken, after 2 - 3 s - the third. After angiography, bed rest is prescribed for 3 to 5 days. To heavy, but very rare complications angiography includes transient paresis, paralysis, short-term convulsions.
Indications for angiography: tumors, abscesses, cysts, brain tuberculomas, aneurysms and congenital malformations of cerebral vessels of various origins, late period craniocerebral injury, when there is a mixture of vessels due to cicatricial changes with the formation of cysts.
Contraindications to angiography: general serious condition of the child, brain ventricular tumors.
For topical diagnostics diseases of the spinal cord and its membranes, contrast myelography is used. The essence of the method is to determine the blockade of the subhyrutinal space of the spinal cord by introducing various contrast agents- Mayodil, etc. Recently, isotope myelography (133Xe) has been successfully introduced into practice. With the help of myelography, it is possible to determine the level of damage to the spinal cord, differentiate neoplastic diseases from other spinal cord injuries. In pediatric practice, myelography is rarely used.

With the help of this method, both general and local changes in the bones of the skull are revealed in brain tumors.

General changes in the bones of the skull develop as a result of a prolonged increase in intracranial pressure, which is observed in brain tumors. The nature and degree of development of these changes mainly depend on the location of the tumor and its relationship to the CSF pathways and the great cerebral vein of Galen.

When a rapidly growing tumor is located along the CSF pathways (III ventricle, Sylvian aqueduct, IV ventricle), secondary occlusive dropsy gradually develops and, as a result, changes appear on the side of the vault and base of the skull. On a number of radiographs made in the same patient over several weeks or months, there is 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 Turkish saddle, up to complete its destruction. The bottom of the Turkish saddle 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 sphenoid processes.

With a slowly developing increase in intracranial pressure, a mostly symmetrical expansion of the normally preformed openings of the skull base, namely the optic nerves, round, oval and torn holes, internal auditory canals. Often there is also a thinning of the edge of the large occipital foramen. In the advanced stage of the disease, especially with subtentorial tumors, osteoporosis of the tops of both pyramids is noted. The development of osteoporosis of 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, a divergence of the 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 is enhanced. These changes are mostly found in subtentorial tumors. With large supratentorial tumors located along the midline, pronounced common features increased intracranial pressure from the bones of the arch with the phenomena of a significant divergence of the cranial sutures.

As a result of tumor-induced disturbances in the cerebral circulation in the skull, it is often noted diffuse expansion diploe vein channels. It is sometimes evenly expressed in both halves of the skull. Wide canals of diploic veins on radiographs are revealed in the form of slightly tortuous, short furrows heading towards one center. The pits of pachyon granulations and venous graduates also change their appearance in case of difficulty in blood circulation. They expand and deepen significantly.

Revealed in pictures general changes skull bones in case of suspected brain tumor confirm its presence, but do not give indications of localization.

For topical diagnostics importance has the identification on radiographs of local changes caused by the 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 on radiographs are detected in the form of local hyperostosis, usuration, foci of pathological calcification inside the tumor or along its periphery and increased development of vascular furrows involved in the blood supply to the tumor.

Local changes in the bones of the skull (hyperostoses, foci of destruction) are most often observed in arachnoid endotheliomas. The detection of these changes in the bones of the skull is important not only for determining the exact localization of the tumor; in some patients, these changes make it possible to judge its probable histological structure.

BG Egorov out of 508 patients with arachnoidendotheliomas in 50.2% of them revealed various local changes in the bones of the vault and base of the skull. KG Terian with arachnoid endotheliomas found the presence of hyperostoses directly at the site 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 arachnoid endotheliomas. Our data show that with a thorough x-ray examination of the skull, local changes in its bones are determined in 70-75% of patients with arachnoid endotheliomas, especially when they are localized at the base of the skull.

Hyperostoses of the skull bones (endostoses, exostoses) on radiographs are revealed in the form of various shapes and sizes of limited seals. They are often determined in the small wings of the main bone, in the region of which arachnoidendotheliomas are often localized. Sometimes hyperostoses are also found in the region of the tubercle of the Turkish saddle and the olfactory fossa. Severe hyperostoses in the form of needle periostitis are detected mainly in arachnoidendotheliomas of the cranial vault and can spread to fairly large areas of the bone.

In the presence of hyperostoses and usurs in differential diagnosis, one should keep in mind not only arachnoid endotheliomas, 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 far 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 brain appendage. We observed them in 97.3% of 355 patients with pituitary tumors. With intrasaddle tumors, these changes are expressed in a cup-shaped expansion of the Turkish saddle, destruction of its bottom, straightening of the back, its destruction, elevation and undermining of the anterior sphenoid processes. The presence of the bypass of the bottom of the Turkish saddle usually indicates uneven growth of the tumor.

The greater narrowing of one of the halves of the sphenoid sinus, which is detected on sighting images and tomograms of the sella turcica, indicates the predominant direction of tumor growth in this direction.

A detailed study of some features of pathological changes in the bone skeleton of the Turkish saddle makes it possible to presumably speak in favor of one or another histological structure intrasternal tumor.

With eosinophilic adenomas, accompanied mostly by acromegalic syndrome, the sella turcica is usually cupped, deepened and enlarged in the anteroposterior size. Its back is sharply straightened, deflected backwards and sharply sparse. Along with this, there is also a significant increase in the size of the respiratory sinuses of the skull and their increased pneumatization. Such changes in the sella turcica and adnexal nasal cavities were observed by us in 82% of patients with eosinophilic pituitary adenomas. With chromophobic and basophilic adenomas, only those expressed in varying degrees destructive changes of the Turkish saddle.

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.

According to the nature of the destruction of the Turkish saddle, one can also presumably judge the suprasatella, near-saddle, behind-saddle, and anterior-saddle localization of the tumor.

With a suprasellar tumor, the back of the Turkish saddle is tilted anteriorly, destroyed and shortened. The anterior sphenoid processes are deflected downward and destroyed. The bottom of the Turkish saddle is compressed, the lumen of the sinus of the main bone is reduced.

With a perisedial tumor (tumor of the temporal lobe, tumor of the membranes), there is predominantly one-sided destruction of the Turkish saddle on the side where this tumor is located. In these cases, the destruction of the dorsum of the sella turcica is often determined on craniograms, which is sometimes combined with unilateral destruction of the anterior sphenoid process.

With a posterior saddle tumor, the back of the Turkish saddle is pushed forward. The posterior sphenoid processes are shortened and destroyed. Sometimes there is destruction of the Blumenbach clivus. With further tumor growth, as a result of compression of the Sylvian aqueduct and the development of hydrocephalus, secondary changes in the sella turcica appear, which are characteristic of a chronic increase in intracranial pressure.

Anterior seat tumors cause destruction of the anterior sphenoid processes and destruction of the Turkish saddle of one kind or another. These tumors are detected on radiographs due to the presence of hyperostoses in the region of the olfactory fossa or the region of the small wings of the sphenoid bone.

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

Lime deposition is one of the most important local radiographic features of brain tumors. The presence of this sign makes it possible not only to establish the localization of the tumor, but sometimes correctly determine its histological nature. It is known that such normally preformed formations as the pineal gland, choroid plexus lateral ventricles, large falciform process, dura mater, pachyon granulations, in some people they also calcify under physiological conditions. Especially often, not less than 50-80% healthy people calcification of the pineal gland is observed. Its displacement by a brain tumor is of great diagnostic value. Under the influence of tumor growth, the calcified pineal gland, as a rule, shifts from the midline in the opposite direction from the tumor.

Various physiological calcifications must be differentiated from lime deposits in brain tumors. Intratumoral deposits of lime may be homogeneous. Sometimes they come to light in the form of linear shadows, separate amorphous lumps or fine inclusions. In some tumors, for example, in arachnoid endotheliomas, lime is deposited only in their shell, which gives a certain idea of the size of these neoplasms. Sometimes, with prolonged observation of the patient, it is possible to see the growing calcification of the tumor on x-rays.

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

A characteristic lime deposition is seen 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 various sizes of amorphous lumps. The presence of this kind of calcifications, taking into account their localization, allowed us to establish the correct diagnosis in 28 out of 32 patients with craniopharyngiomas. In differential diagnosis, it should be borne in mind that a similar nature of calcification can also be observed with cholesteatoma.

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

The deposition of lime, as a rule, is 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 of the vascular pattern of the bones of the skull in some cases is a pathognomonic sign of brain tumors. In arachnoidendotheliomas, crannograms often reveal a peculiar pattern of furrows of the branches of the meningeal arteries, characteristic of these tumors, that participate in their nutrition. In these cases, in a limited area of the cranial vault, unevenly expanded, short, intertwining vascular grooves are revealed. On technically well-executed radiographs in these cases, it is sometimes possible to trace the furrow of the arterial trunk that feeds the tumor into this tangle.

In intracerebral tumors, predominantly on the side of the tumor, diffuse expansion of the diploic veins of the skull bones is sometimes observed, resulting from venous stasis.

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

The most characteristic craniographic sign of a tumor in the region of the cerebellopontine angle is the destruction of the apex of the pyramid. Its destruction is observed in both benign and malignant tumors of this area. At malignant neoplasms the destruction of the top 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 determined in cholesteatoma and glioma of the cerebellum.

In those patients in whom the data clinical examination and craniography data are insufficient for the diagnosis of a brain tumor and its localization, they resort to a contrast X-ray examination of the cerebrospinal fluid spaces of the brain and its vessels.

In X-ray diagnostics of diseases of the skull, along with a deep knowledge of the basics of X-ray anatomy, it is necessary to take into account its age, gender and constitutional features, as well as anatomical variants and anomalies in the development of bone elements and cranial sutures: intercalary - Wormian - bones, tiled 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 overlook the initial pathological changes in those cases where they actually exist.

X-ray analysis of pathological changes in the skull consists in 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 size.

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

2. The thickness of the bones of the skull, 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 in different people normally varies within a fairly wide range (from 2 to 10 mm). Pathological thinning and osteoporosis individual sections bones (cranial vault, Turkish saddle) may appear as a result of atrophy from pressure on the bone of 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 in syphilis (Fig. 12) and actinomycosis.

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

At endocrine disorders, for example, acromegaly (see), along with an increase in the Turkish saddle and thinning of its elements due to pressure from the pituitary tumor, there is a thickening of the bones of the cranial vault, protrusion superciliary arches and occiput, prognathism of the mandible and unusual development of the paranasal sinuses.

Changes in the contours, thickness and structure of the bones of the skull can be observed in various types of primary and metastatic bone tumors(see Bone tissue, radiodiagnosis of tumors of bone tissue). For example, in cancer, multiple myeloma, osteoclastic cancer metastases separate parts of the bone can 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 cranial vault; 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; enlightenment in its place has a fairly regular rounded shape, clear contours and is devoid of any structure. Almost identical radiographic symptoms can be observed in tuberculosis, eosinophilic granuloma, cholesteatoma (Fig. 13, b). In these cases, in the differential diagnosis special meaning acquire a clinical picture and anamnesis. Rounded solitary foci of enlightenment in the bones of the cranial vault, which have a regular stellate structure, are typical for hemangioma. The X-ray picture of osteoblastic metastases of cancer in the bones of the cranial vault, which are intense round foci of darkening of various sizes, is very characteristic.

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

The nature of the internal relief of the bones of the skull in comparison with the external one seems to be more complex due to the X-ray image on the survey images of the skull of digital impressions, vascular sulci, canals and sinuses, pachyon pits, openings of graduates, etc. Therefore, when assessing it, it is necessary to take into account both numerous anatomical variants, as well as a specific picture of the disease and age-related features of the skull. Pronounced changes in the internal relief of the bones of the cranial vault are observed, in particular, in various forms of hydrocephalus (see). open molds hydrocephalus are distinguished by a smoothing of the internal relief, while closed ones are characterized, on the contrary, by an increase in digital depressions, furrows of the venous sinuses, meningeal arteries and pachyon fossae.

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

3. Holes and channels of the brain and facial parts of the skull.

The study of their condition often requires the use of special two-moment projections to compare the details of the same name on the right and left sides. Sometimes a slight destruction or a relatively small expansion of one of the channels may indicate the presence of a tumor of the corresponding nerve (see Brain, X-ray diagnosis of diseases). For example, in glioma optic nerve a study in the projection of Rese - Golvin (Fig. 4) is mandatory, and in case of neuroma of the VIII nerve, which expands the internal auditory meatus, the projection of the pyramids according to Stenvers (Fig. 14).

Rice. 14. Neurinoma of the right auditory nerve. X-ray of the pyramids temporal bones by Stanvers. On the right, a sharp expansion of the internal auditory canal is determined.

Rice. 15 (right). Acute sinusitis. X-ray of the paranasal sinuses. The vertical position of the patient's head and cassette. Visible horizontal levels of fluid in the right frontal and right maxillary sinus.

4. Air bones of the skull (frontal, ethmoid, main, maxillary, temporal) and air 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 violated as a result of a fracture or destruction in case of tumor lesions. In the sinuses, mainly in the frontal sinuses, sometimes for the first time it is possible to detect a radiographically benign tumor - an osteoma. In all cases, the replacement of air with heavier contents gives an x-ray symptom of darkening, the intensity of which depends on its amount, atomic weight and the volume of the sinus itself. Radiography in the vertical position of the patient's head and the cassette reveals a radiographic symptom of a horizontal level of fluid in it (Fig. 15). In doubtful cases, they use the introduction of yodolipol or mayodil into the sinus.

5. Foci of calcification of the skull.

An x-ray examination of the skull often reveals intracranial calcifications, some of which are physiological (calcifications of the pineal gland, plexus chorioideus, dura mater, more 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 falx cerebri in the picture of the paranasal sinuses can be projected onto the frontal sinus and simulate an osteoma.

Rice. Fig. 16. Radiographs of the skull with calcified hematoma: a - chin-nasal projection of the skull for the study of the paranasal sinuses. The sinuses are airy, in the outer part of the left frontal sinus intense shadow detected; suspected sinus osteoma; b-right lateral survey projection of the skull; the same shadow is visible in the parietal region: a calcified hematoma (after trauma in childhood) of the right parietal lobe of the brain.

Rice. 17. Craniopharyngioma. A slight increase in the anteroposterior size of the Turkish saddle. Thickening and thickening of its walls. Landcart shaped area of calcification above the Turkish saddle.

Pathogenic calcifications of the brain and its membranes are observed with extra- and intracerebral hematomas (Fig. 16, a and b), meningioma, craniopharyngioma (Fig. 17), Sturge-Weber disease, lime deposition in the walls of large arteries, cysticercosis and toxoplasmosis. Extracerebral calcifications are found in the nasal cavity (rhinoliths), in the salivary glands and their ducts (see Sialography), in the auricles of boxers. X-ray symptoms of many calcifications of the skull are very pathognomonic; great importance in the establishment of some of them has a comparison of data from X-ray and clinical studies.

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

On radiographs of the skull, the image of not only the bone skeleton, but also the soft tissues of the head is clearly visible. The shadow of a large upper lip in the picture of the facial skull can be superimposed on the enlightenment maxillary sinuses and simulate the shadows of cysts; special "boneless" pictures of the eyeball are used to detect the smallest foreign bodies; on special radiographs bones of the nose, you can see the shadows of the triangular and alar cartilages; 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 well marked soft palate, enlarged adenoids, tumors or choanal polyp. The shadow of a massive tumor of the cheek 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 method of radiography, are diverse. They are accompanied by various pathological changes in the bone structure (acromegaly, xanthomatosis, Paget's disease, sinus mucocele, ear cholesteatoma, some malignant tumors, their metastases, osteopathy, etc.). System and endocrine diseases bones (Paget's disease, multiple myeloma, malignant tumors of the thyroid gland, adrenal gland, sex glands, etc.) are sometimes detected for the first time by X-ray examination of the skull.