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Until a few years ago, conventional X-rays were the osseous fragments of the skull; (2) indirect fractures
imaging standard for cranio-cerebral and facial trau- identified as opacification of the paranasal sinuses and
mata. Today, however, computed tomography (CT) has soft tissue emphysema. For the facial skeleton, the
become the primary imaging method, along with sig- semi-axial view of the midface is required either in
nificant technical improvements, especially with the occipito-mental or occipito-frontal projections, while
development of multislice CT. fractures of the mandible require the panoramic and the
Conventional X-rays are relatively sensitive to cra- Clementschitsch view.
nial vault fractures, but insensitive to fractures of the The sensitivity of the different exposures for frac-
skull base and facial skeleton. CT enables a precise tures varies depending on fracture type. Some simple
diagnosis of all kind of fractures of the facial skeleton fractures can be well displayed on dedicated X-ray pro-
and skull base, and additionally delivers information jections. On the other hand, complex fractures can only
about intracranial bleeding and injuries to the cere- be partially evaluated because of the overlap of the vari-
brum. In the multi-traumatized patient, CT can be ous structures in the craniofacial skeleton, the complex-
extended to the cervical spine as well as the trunk if ity of which demands considerable expertise in evaluation
necessary. A complete body check for traumatic lesions (Figs. 2.12.6).
can be done within a few minutes, including the brain,
spine, bone, and organs. Thus, conventional X-rays of
the skull are no longer used in the case of head traumas
or polytraumatized patients; CT is widely accepted as 2.2 Computed Tomography
the primary imaging method of choice. Nevertheless,
the following provides an overview of all imaging CT is an X-ray imaging method where the X-ray source
methods, including conventional X-rays. rotates around the patient, giving information about the
densitiy of the tissues (attenuation profiles) in the slice
within the X-ray beam. The attenuation profiles of the
2.1 Conventional X-Rays slice are Fourier transformed into a matrix of digital
values representing a digital image of the slice. Every
The standard X-ray exposures for the skull are summa- pixel of the image represents a small volume element
rized in Table 2.1. Standard projections are the anterior/ (voxel) in the patient. There is density averaging within
posterior (AP) and the lateral view of the whole skull. the voxels (partial volume effects), but no superimposi-
These images are sensitive to skull fractures, which fall tion of structures. The thinner the slice, the lesser are
under two general categories: (1) direct fractures identi- partial volume effects and density averaging. CT per-
fiable as fracture lines, fracture gaps and dislocation of mits the analysis of the anatomical structures within the
patient without superimposition of structures, and with
a relatively good tissue density characterization, which
Contributed by Thomas Treumann, Kantonsspital Luzern (CH),
1 can even be improved by the injection of intravenous
Central Institute of Radiology, Luzern, Switzerland. contrast material (CM).
Fig. 2.1 Skull fracture on standard X-ray radiographs. Sharp lucent line without sclerotic margins in left frontal bone, distant to
sutures and vascular channels (arrow)
a b
**
Fig. 2.2 Blow-out fracture of the orbital floor. (a) Indirect fracture sign: total opacification of the right maxillary sinus (asterisks).
(b) Coronal CT reformatting: depression fracture of the central part of the orbital floor with hematosinus (arrow)
2.2 Computed Tomography 17
To cover larger parts of the body, multiple adjacent body segments can be scanned within a few seconds
volumes are acquired. Scanning is done by continuous with a submillimeter resolution in all three dimen-
movement of the patient through the CT gantry in com- sions. The scanners become more powerful from year
bination with continuous rotation of the X-ray tube, to year, with an increase in the number of simultane-
resulting in spiral scanning. This technique is called ously acquired slices and in the volume per rotation.
multislice spiral CT (MSCT). The resulting slices are The primary imaging plane of CT images is axial, but
put together to form a stack, which in turn can be ana- many structures are more easily analyzed in other imag-
lyzed image by image or by reformatting for interactive ing planes. For the evaluation of the facial skeleton, axial
analysis in arbitrary imaging planes. and coronal images are mandatory. Until a few years
MSCT scanners cover up to 40 mm of patient vol- ago, before the MSCT era, the facial skeleton had to be
ume in one rotation, split into up to 128 slices, with scanned twice, in the axial and coronal direction sepa-
slices as thin as 0.5 mm or less. Using MSCT, large rately, resulting in a double dose of radiation. In MSCT,
a b
Fig. 2.7 Comparison of direct paracoronal scanning of the images, tooth artifacts superimpose relevant structures (b). Axial
midface (a, b) to coronal reformations from thinslice spiral CT thin-section CT scanning allows comfortable patient positioning
datasets (c, d). Direct paracoronal scanning has been abandoned and scanning without gantry tilt (c). Artifacts remain in the plane
with introduction of multislice spiral CT scanners. In direct para- of the teeth and do not go across relevant structures (d). There is
coronal scanning, patient positioning is uncomfortable because no image quality loss between reformatted images and original
reclination of the head is required. Furthermore, the CT gantry paracoronal images (b, d)
has to be tilted leaving less space for the patient (a). In the
2.4 Ultrasonography 19
only a single dataset in the axial plane is required. The a high-magnetic-field chamber so as to localize the
coronal images and any other planes are reconstructed origin of the radiowaves within the patients body.
from the axial images by multiplanar reformatting (MPR) Before placing the patient in the chamber, any metal has
on a computer workstation. A workstation can be a CT to be removed from the patient. Cardiac pacemakers and
workstation or a picture archiving and communication other implanted electronic devices are contraindications
system (PACS) workstation. PACS is the electronic for MRI. Anesthetic monitoring requires dedicated
image database system with which most hospitals are equipment with special medical devices, where all metal
equipped today. The image quality of the reconstructed elements are manufactured out of nonmagnetic materi-
coronal images is similar to that of directly acquired cor- als. These devices are expensive and may not be avail-
onal images. MPR analysis is routinely used to detect or able in every hospital or MR unit. MR scanning is more
exclude fractures of the skull base, optic canal, orbital time-consuming than CT scanning, and is much less
floor, maxilla, palate, and mandible, as well as to mea- effective in imaging bone than CT.
sure the extent of dislocations (Fig. 2.7). Because of these limiting characteristics, CT is used
In addition to MPR, three-dimensional views of the rather than MRI when initially examining a trauma
scanned object can be calculated using shaded surface patient. However, MRI may be used in evaluating post-
display (SSD) or volume rendering (VR) algorithms. operative complications, inasmuch as it lends itself for
VR images are color coded and give an impressive view easy detection of shearing injuries of the brain in the
of the anatomy. The three-dimensional (3D) perspec- posttraumatic period, which must be suspected when
tives are valuable for the analysis and visualization of neurologic recovery of the patient is delayed. MRI may
complex fractures. They give an overview over the main be also used to look for cerebrospinal fluid (CSF) leaks,
fragments and relevant dislocations, from which conclu- which are a diagnostic problem after skull base injuries.
sions about the trauma mechanism can be drawn. On The best, but difficult and invasive, method to localize a
modern computer workstations, 3D views can be calcu- CSF leak is to inject contrast medium (CM) intrathe-
lated within a few seconds, making 3D visualization a cally and to perform CT scans before and after CM
practicable routine diagnostic add-on. administration. MRI is noninvasive, but less sensitive
In the case of foreign body penetration injuries, CT because detection is based on indirect signs, such as
sensitivity is variable. Whereas glass and metal are seen fluid in the ethmoid cells or sphenoid sinus. In most
very well and detected without prior knowledge of their cases, a noncontrast-enhanced low-dose CT of the para-
presence, wood and plastic are difficult to detect and nasal sinuses and skull base will be sufficient to identify
special attention must be given for their possible pres- osseous skull base defects, which should be explored by
ence. Wood appears like air and plastic materials have the surgeon.
different density. A rare complication of skull base trauma is a
Intraoperatively, CT datasets can be used for naviga- carotid-cavernous sinus fistula. In this case, MRI and
tion. For this purpose, the primary axial CT images are MR angiography are helpful in making the diagnosis.
loaded into a computer program which displays the CT Additional treatment is provided by interventional
findings at the site or during surgery (Hassfeld et al. angiography and coil placement (Fig. 2.8).
1998; Gellrich et al. 1999, 2003). The images have to
be loaded in DICOM format from a CD, DVD, or online
from the PACS archive, which is the standard format
used in medicine (DICOM, digital image communica- 2.4 Ultrasonography
tion in medicine). Postoperatively, CT can be used to
check and document the repositioned fracture frag- Ultrasonography is not applicable for adult patients with
ments and the position of the osteosynthesis material. trauma to the head and face, but may be the method of
choice for evaluation in children. Sonographic imaging
of the brain in young children is possible through the fon-
2.3 Magnetic Resonance Imaging (MRI) tanels, which are still open. Also, the high spatial resolu-
tion of ultrasound allows skull fractures to be detected.
MR tomography (MRI, MRT) is an imaging method As for the facial skeleton, CT is a necessity for treatment
that uses radiowaves, rather than X-rays, to gain infor- decision, thus rendering ultrasound imaging a waste of
mation from the patient. The patient has to be placed in time (Fig. 2.9).
20 2 Radiology of Craniofacial Fractures
Fig. 2.8 Illustration of the high sensitivity of MRI for shearing small foci of low intensity representing hemorrhage in shearing
injuries and SDH. (a-c) CT after head trauma demonstrating fis- injuries (arrow). (f) Coronal FLAIR image shows distincly a
sural fracture of right orbital roof (arrow) with frontal sinus small SDH covering both frontal lobes (arrow)
involvement and pneumatocele. (d, e) MRI demonstrates multiple
a b
2.5 Diagnostic Algorithm and hard tissue damage is reliably demonstrated and a
first fast overview of the images can be done to iden-
tify relevant lesions requiring immediate surgery, such
2.5.1 General Considerations as intracranial hemorrhage or splenic rupture. The CT
datasets can then be analyzed thoroughly in an off-
Conventional X-ray is no longer the standard in radio- line situation at the computer workstation, while the
logical imaging for cranio-facial trauma detection; patient is brought to the operating room or otherwise
this is now carried out by CT imaging. CT is widely managed by the trauma team. MRI is not the primary
available and allows fast scanning of the patient. Soft imaging modality after trauma, although it is sensitive
2.5 Diagnostic Algorithm 21
for the detection of shearing injuries to the brain, albeit of elevated ICP? Elevated ICP is indicated by narrow-
this question is raised later after trauma. Shearing inju- ing or absence of the external and internal CSF spaces.
ries are of little significance in the primary posttrau- Narrow spaces may be physiological in young patients.
matic situation (Yokata et al. 1991). However, absent spaces are never normal, especially if
The first important issue to be resolved after cranio- the basal cisterns are not visible. Diffuse brain damage
facial trauma is to exclude space-occupying intracranial must be suspected if the basal ganglia and cortical
hemorrhage or increased intracranial pressure (ICP) structures have the same density as the white matter.
requiring neurosurgical intervention. This includes evac- This is referred to as absence of the normal medullo-
uation of hematoma, craniectom, or ICP monitoring. cortical differentiation.
The second point is to assess bone injury (Schneider and Cerebral hemorrhage usually occurs at the polar
Tlly 1984; Bull et al. 1989; Lehmann et al. 2001; Bowley areas of the brain and at the brain surface. Typical
2003), identifying and classifying fractures. locations are the frontal and temporal poles, the lateral
Technically, the primary CT after trauma is done as contours of the temporal lobes, and the basal surfaces
noncontrast-enhanced (NECT) scanning. Intravenous of the frontal and temporal lobes. In these regions, the
contrast administration is contraindicated since it can brain collides with the bone or glides over the rough
obscure small intraparenchymal hemorrhages. Contrast- skull base or over the edge of the temporal bone during
enhanced CT is added only if, based on the NECT scan, deceleration.
an intracranial tumor is suspected or if significant suba- Hemorrhagic contusions are usually small in the
rachnoid hemorrhage is detected and a cerebral artery initial CT, but nonetheless always indicate significant
aneurysm must be excluded. CM is injected, however, for brain injury and bear the risk of delayed bleeding, the
CT of the cervical spine and trunk; first NECT scanning so-called blooming-up of contusional hemorrhages.
of the head, followed by scanning other parts of the body. As a further complication, brain swelling can develop.
The usual trauma algorithms for CT respect this issue. In order not to miss these complications, CT should be
The initial CT scan is usually focused on the neuro- repeated 624 h after trauma. The risk of continuing
cranium and usually covers the region from the foramen hemorrhage and significant hematomas is high in
magnum to the apex of the skull. The maxilla is not patients on anticoagulant drugs. In these patients, the
completely included, and the mandible is usually CT should be repeated earlier, usually after 46 h. The
excluded. However, if significant trauma to the facial need for ICP monitoring by a surgically placed probe
skeleton is suspected, the CT technician should be depends on the initial CT findings and is managed by
advised to scan the head completely from the chin to the the neurosurgeon. Brain swelling may require immedi-
apex. This is not a problem with modern CT systems. ate or delayed decompression by craniectomy. Also,
Fractures of the cervical spine must be excluded in large hematomas or massive cerebellar swelling in the
any major cranio-facial trauma. The cervical spine can posterior fossa can result in obstruction of the fourth
be scanned immediately after the NECT scan of the ventricle and cause hydrocephalus, and may require
head without repositioning the patient. It is, however, ventricular drainage (Fig. 2.10).
advisable to apply i.v. CM to exclude dissection of a The second thing to look for is extracerebral hemor-
vertebral artery. In polytraumatized patients, CT is rhage. There may be epidural or subdural hematomas
extended to the thorax and the abdomen, also carried (SDHs). Large hematomas with a significant mass effect
out with i.v. CM injection. require immediate surgery. Subarachnoid hemorrhages
(SAH) may be present, but almost never require inter-
vention since they generally resolve spontaneously. Still,
one should be aware that a SAH may be caused by a
2.5.2 Craniocerebral Trauma ruptured cerebral artery aneurysm, and the rupture of the
aneurysm can be the cause for the trauma. If there is
2.5.2.1 The Initial CT After Trauma significant spread of the SAH in the typical regions
around the basal arteries in the basal cisterns, a contrast-
The primary structure of observation in the initial head enhanced arterial phase CT should be added to look for
CT is the brain. Is there parenchymal bleeding? Are cerebral aneurysms. If there is no aneurysm on CT, cere-
there signs of diffused brain damage? Are there signs bral angiography should be discussed. In the long term,
22 2 Radiology of Craniofacial Fractures
Fig. 2.10 Signs of brain swelling after severe trauma. Compression of the external CSF spaces especially in the tentorial area.
Little subarachnoid hemorrhage in the insular cisterne on the left side
SAH may cause CSF malresorption and hydrocephalus 1224 h has already been mentioned. The need for fur-
weeks to months after trauma and require ventricular ther follow-up CTs will depend on the patients clinical
drainage. Multiple or combined hemorrhages in differ- course (Figs. 2.112.15).
ent areas indicate semi-severe to severe cranio-cerebral The third thing to look for is fractures. Singular
trauma. The need for a second look CT scan after undisplaced skull fractures are of little clinical
2.5 Diagnostic Algorithm 23
Fig. 2.12 Large supraorbital EDH (arrow) after complex left cranio-orbito-zygomatic fracture
a b c
d e f
Fig. 2.13 Major burst fracture of the skull after compression of the frontal bone continues through the planum sphenoidale,
injury. Large right-anterior craniofacial skull fragment. (a) right ethmoid and orbit (arrow) into the anterior wall of the right
Large right-anterior craniofacial skull fragment (b) Left fron- maxillary sinus (f) Postoperative result after craniotomie (left)
toparietal skull impression fracture. (c,) Left subdural hematoma and zygomatico-orbital osteosynthesis (right)
(SDH) (arrow) with midline shift to the right (d, e) The fracture
significance unless they cause epidural hematomas Calvarial bones (frontal, temporal, parietal, occipital)
(EDH). Depressed and displaced fractures with gaps Anterior and/or posterior wall of the frontal sinus
and steps between fragments may require surgery. Ethmoid (roof, lateral wall)
In describing a fracture, the first step is to define the Sphenoid sinus, sphenoid wing, optic canal and
affected bone structures: clivus
24 2 Radiology of Craniofacial Fractures
Fig. 2.15 Typical hemorrhagic contusions in both frontal lobes (arrow) after midface trauma. Fracture of the left zygomatic arch
and lateral zygomatico-maxillary complex
Orbit (roof, medial wall, lateral pillar, orbital floor, Maxillary sinus (anterior and lateral walls, orbital
optic canal) floor)
Nasal bone Maxilla (alveolar process, teeth, pterygoid process)
Zygoma and zygomatic arch and palate
2.5 Diagnostic Algorithm 25
Craniocerebral trauma
History
Course of accident
Unconsciousness
Vertigo
Vomitting
Clinic
Pupils
Reaction to light
Reaction to pain
Neurology
Normal Pathological
Increased intracranial
pressure?
Cerebral edema?
Space consuming hemorrhage?
Compression fracture?
Foreign body?
Cerebral pressure monitoring
Surgical decompression
an occipital fracture can radiate down into the foramen cause hemorrhage in the mastoid cells and tympanon.
magnum. Anterior head trauma can result in complex Clinical symptoms are otic hemorrhage, otic liquor-
fractures of the frontal skull base and ethmoid bone rhea and hearing loss.
and may extend into the roof of the sphenoid sinus, the Another mechanism leading to skull base fractures
clivus and the sella. Temporal bone fractures can radi- is the indirect energy transmission from the mid-face
ate into the petrous bone and mastoid process and to the skull base through the main vertical pillars. This
2.5 Diagnostic Algorithm 27
History - Clinic
CT
CT Frontal sinus - axial 2 mm Rhinoliquorrhea ?
mainly affects the temporal skull base and the ethmoid. 2.5.4 Midface Fractures
Not associated with mid-face fractures are skull base
fractures after axial head trauma from the vertex with For midface fractures, CT images in the axial and cor-
fractures in the region of the foramen magnum and the onal planes are obligatory to differentiate fracture
risk of a burst fracture of the first cervical vertebra types and to define the extent of the fracture. The sagit-
(atlas ring burst fracture). tal plane may be helpful to assess dislocations in the
There are direct and indirect signs of skull base frac- anterior-posterior direction (nasion, maxilla). Oblique
tures. Direct signs are fracture lines, fracture gaps and sagittal images parallel to the optic nerve or parallel to
steps between fragments. Indirect signs are intracranial the inferior rectus muscle of the orbit may be helpful to
air collections and liquorrhea. Intracranial air collections visualize muscle entrapment in fractures of the orbital
can be demonstrated in 2530% of skull base fractures floor. The required series of images should be gener-
(Probst and Tomaschett 1990). Small air collections are ated by the CT technician. In addition, analysis can be
regularly seen with fractures of the temporal bone and done interactively in a PACS viewer, if available.
sphenoid sinus. Vast air collections (pneumocephalus) CT permits a differentiated fracture assessment and
occur after destructive fractures of the frontal sinus and provides evidence of injury in anatomically difficult
ethmoid roof. In the CT dataset, the primary axial images areas, e.g., the orbits, the naso-orbito-ethmoidal com-
are most helpful to detect skull base fractures and must plex, the peri- and retroorbital skull base and the retro-
be analyzed thoroughly. To exclude undisplaced skull maxillary region (Terrier et al. 1984; Schwenzer and
base fractures, MPR is required. MPR is also required Pfeifer 1987; Schneider and Tlly 1984; Manson et al.
for analysis of the extent of displacement of skull base 1990; Whitaker et al. 1998; Rother 2000).
fractures. Coronal images should be routinely recon- Classification of midface fractures, according to the
structed from the axial image set by the CT technicians classification systems outlined in Chap. 3, surgical plan-
team (Fig. 2.17). ning and intraoperative navigation are based on CT.
28 2 Radiology of Craniofacial Fractures
Midface fractures
Computed tomography
Roentgenograms
- p.a./occipito-mental/occipito-frontal views
- Clementschitsch view
- Lateral view
- Axial view
- Orthopantomogram
Bone trauma
CT obligatory
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