Cranial Base Dan Emergency Case

Cranial base
dan Emergency
case
Muhammad Erfansyah, S. Si, M. Tr. Kes
Cranial base
ANATOMY (Superior View)
ANATOMY (Inferior View)
PATHOLOGY
* Trauma capitis :A mechanical trauma that

directly or indirectly on the head and lead to
impaired neurological function
* Frakture
* Osteoma / osteosarkoma
Patient Preparation
• On examination of the orbit there is no special

preparation, because it does not use contrast media.
• Remove objects that are likely to be intrusive

radiographic like earrings, etc.
• Use apron or protective to the patients

Tools Preparation
- Plane x-ray (eksposi factors: kV, mA, S and condition
of the aircraft) and the place or the examination table.
- Tapes and films in accordance with the area to be
examined
- Marker (marker R: right, L: left)
- Fixation devices (preventing the movement of objects
such as sandbag, sponge, etc.)
- GRID / bucky, in order to obtain detailed images
clearer.
PROJECTION
1. Submentovertical projection (SCH-OLLER
METHOD)
2. Verticosubmental projection (SCH-OLLER

METHOD)
SUBMENTO VERTICAL projection
Position of patient (SCHÜLLER METHOD) -merrill-
• The success of the submentovertical (SMV) projection of the cranial base depends
on placing the IOML as nearly parallel with the plane of the IR as possible and
directing the central ray perpendicular to the IOML. The following steps are taken :
• 'Place the patient in the supine or the seated-upright position.
• When the patient is placed in the supine position, elevate the torso on
• firm pillows or a suitable pad to allow the head to rest on the vertex with the neck in
hyperextension.
• Flex the patient's knees to relax the abdominal muscles.
• Place the patient's arms in comfortable position, and adjust the shoulders to lie
in the same horizontal plane.
Position of part
• •With the midsagital plane of the patient's body centered to the
midline of the grid.
• • Extend the patient's neck to the greatest extent as can be achieved,
placing the IOML as parallel as possible to the IR
• • Adjust the patient's head so that the midsagital plane is
perpendicular to IR
Note : Patient's placed in the supine position for the cranial

base may have increased intracranial pressure. As a
result, they may dizzy or unstable for a few minutes
after having been ij this position. Use of the upright
position may alleviate some of this pressure
SUBMENTO VERTICAL projection
(SCHÜLLER METHOD)
CR : Directed throught the sella turcica perpendicular to

the IOML. The central ray enters the midsagital plane
of the throat between the angles of the mandible and
passes through a point¾ inch (1,9 cm) anterior to the
level of the EAM.
CP :At point ¾ inch (1,9 cm) anterior to the level of the
EAM.
Cassete : 24cm x 30cm, lengthwise
FFD : 120 cm
Exposure factors (KV, mA, and s) appropriate with
exposure factors tabel
Radiographic
criteria:
• The basic structure of the cranium looked good, indicating sufficient penetration.
• The same distance between the lateral head of the mandibular condyle with both sides
signaling cut no slope on the patient's head.
• Mental protuberance superposition with the anterior part os.frontal indicates full -
extension in the patient's neck Mandibular condyle in the anterior petrous pyramids.
• Petrousa symmetrical.
VERTICOSUBMENTAL PROJECTION
(SCHÜLLER METHOD) -MERRILL-
Position of patient:
• Prone on the examination table, mid sagital plane of the patient's body
centered to the midline of the examination table.
• Flex the patient's elbow, place the patient's arms in a comfortable
position, and adjust the shoulders to lie in the same horizontal plane.
Position of part:
• The patient's chin full extension on an examination table and set MSP
perpendicular to the cassete.
• Immobilize the patient's head.
CR : Perpendicular IOML, throught sella turcica. passes through a

point ¾ inch ( 1,9 cm) anterior to the level of the EAM.
FFD: 120 cm
• Image Reseptor : 24 x 30 lengthwise
• Expose when the patient holding his breath
Structure shown:
• Verticosubmental projection almost same with

submentovertical projection.
• Due to the increasing OID (Object Image receptor
Distance) & angle between basis cranii with cassette, the
structure of basis cranii slightly deflection and refraction
(distortion & magnification).
• Magnification & distortion can decrease by placing the
cassete in contact with the throat, because this projection
is used to evaluate the anterior skull base and sphenoid
sinuses.
VERTICOSUBMENT
AL PROJECTION
(SCHÜLLER
METHOD) -MERRILL-
Radiographic criteria :
1. Clearly visible structures of the cranial base,
2. Equal distance from lateral border of skull to mandibular condyles on both sides, indicating no tilt.
3. Mandibular condyles anterior to petrous pyramids.
4. Symmetric petrosae.
5. Superimposition of mental protuberance over anterior frontal bone, indicating full extension of neck..
Emergency
case
Anatomy Of Cranium
Cranium / cranial bone terdiri dari: Face bone :
1. Calvaria 2. Floor/base -2 tulang maxillary -2 tulang inferior nasal conchae

- Frontal - Right temporal -2 tulang zygomatic -2 tulangpalatine
- Right parietal - Left temporal -2 tulanglacrimal -1 vomer
- Left parietal - Sphenoid -2 tulangnasal -1 mandibula
- Occipital - Ethmoid
In Front view there are:
Frontal
• Squamous/ vertical portion
• Orbital/ horizontal portion
• On squamous there is sinus frontalis
• Jointed with right and left parietal bones, sphenoid and ethmoid
1. Parietal :
• Forms the lateral and superior walls of the head

• Square and concave in the interior
• Joint with the frontal, occipital, sphenoid and parietal
bones
2. Occipital :
• Forms a superior infero wall from the head

• There is a magnum foramen
• Joint with 2 parietal bones, 2 temporal bones, sphenoid
and atlas
PERSIAPAN ALAT SAAT PEMERIKSAAN
Pesawat Sinar-X
Film
Kaset
Marker L dan R
Apron
Grid
Alat Processing Film
Pesawat Sinar-X
Alat yang digunakan untuk melakukan diagnose medis yang
memanfaatkan sinar-x
1. Radiografi Umum 2. Digital Radiography

Film Kaset Marker L dan R
yang digunakan Selalu digunakan Suatu tanda yang
untuk Bersama dengan diberikan pada hasil foto
mengambil intensifying screen roentgen/radiograf.
gambar bagian didepan dan
dalam tubuh. dibelakang film. Apron
Melindungi Peralatan yang
(jika menggunakan
Digital Radiografi
intensifying screen digunakan sebagai
tidak perlu dari kerusakan dan bahan pelindung
menggunakan film debu. terhadap radiasi sinar-x.
dan kaset).
Untuk menyerap radiasi
hambur yang tidak
Grid
searah yang berasal dari
objek yang di eksposi.
Alat processing film
untuk merubah
gambaran laten
menjadi gambaran
radiograf yang
akan tampak.
Projection
• Lateral : Skull ( Trauma )

• AP and AP Axial: Skull (Trauma)
Lateral : Skull ( Trauma )
Patient position: Supine, without
removing cervical collar, if present.
With possible spinal injury, move Part position: Stabilize the neck
patient to back edge of table. (Do and head position as normal. CR = Horizontal to IR . FFD / SID = 102 cm/ 40 inches.
note levate or move patient’s head Ensure no rotation or tilt.
before cervical spine injurie shave
been ruled out).
IR = Horizontal beam CR (to

CP = (5 cm) superiorto EAM or (2 include entire skull) about 2,5 cm Cassette Size = 24 x 30 cm
Grid = Yes
cm) anterior to EAM. below tabletop and posterior skull landscape.
(move oating tabletop forward).
Exposur = Analog: 70 – 80 kV & Shielding = Shield radiosensitive

Digitas systems: 75 –85 kV tissues outside region of interest.
IF THE CONDITION IS THERE A FRACTURE:
1. Skull – Depressed fracture

• Displaced or depressed skull fractures may result in overlapping bone which causes white lines of increased density.
• Note: The sphenoid sinus is clear - however this does not exclude a basal skull fracture.
2. Sphenoid air-fluid level

• No fracture is visible.
• The air-fluid level seen in the sphenoid sinus is due to haemorrhage or CSF leakage due to basal skull fracture.
• The other paranasal sinuses also contain blood due to facial bone injury.
3. Scalp foreign bodies
A dedicated soft tissue X-ray taken at an appropriate angle clearly shows
several foreign body fragments in the scalp - glass in this case.
AP and AP Axial: Skull (Trauma)
Patient position: Patient carefully moved ontox-ray table in supine position. All projections performed as is, without
moving patient’s head. (With possible spine or severehead injuries, perform all projections AP without moving patient’s head
or without removing cervical collar unless requested to do so by physician).
Part position: Stabilize the neck and head position as normal. Ensure no rotation or tilt.
CR = 0o parallel to OML, or 15o cephalad to OML or 30o caudad to OML.
FFD / SID = 102 cm
CP = If AP 0ocentered to glabella, if 15o cephalad centered to nasion, if 30o caudad centered to (5 – 6 cm) above glabella.
IR = Centered to prejected CR
Cassette Size = 24 x 30 cmatau 10 x 12 inches portrait.
Grid = Yes
Exposur = Analog: 70 – 80 kV range & Digital systems: 80 – 85 kV range
Shielding = Shield radiosensitive tissues outside region of interest.
AP reverse Caldwell. CR
15o cephalad to OML,
centered to nasion.
AP-CR parallel to OML, AP Axial (Towne). CR 300 caudad to

centered to glabella OML, CR to (5-6 cm) above glabella.
IF THE CONDITION IS THERE A
FRACTURE:
1. Normal skull - AP
• Sutures have a saw-tooth appearance which
distinguishes them from fractures which form smooth
lines
2. Skull fractures - AP
• The black lines represent skull fractures
• These lines are too smooth to be sutures and do not
branch like the vascular markings of the skull.
THANK YOU

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Cranial base

* Trauma capitis :A mechanical trauma that

• On examination of the orbit there is no special

• Remove objects that are likely to be intrusive

• Use apron or protective to the patients

2. Verticosubmental projection (SCH-OLLER

Position of patient (SCHÜLLER METHOD) -merrill-

Note : Patient's placed in the supine position for the cranial

CR : Directed throught the sella turcica perpendicular to

CR : Perpendicular IOML, throught sella turcica. passes through a

• Verticosubmental projection almost same with

1. Clearly visible structures of the cranial base,

3. Mandibular condyles anterior to petrous pyramids.

Cranium / cranial bone terdiri dari: Face bone :

1. Calvaria 2. Floor/base -2 tulang maxillary -2 tulang inferior nasal conchae

• Forms the lateral and superior walls of the head

• Forms a superior infero wall from the head

1. Radiografi Umum 2. Digital Radiography

Alat processing film

• Lateral : Skull ( Trauma )

IR = Horizontal beam CR (to

Exposur = Analog: 70 – 80 kV & Shielding = Shield radiosensitive

1. Skull – Depressed fracture

2. Sphenoid air-fluid level

AP-CR parallel to OML, AP Axial (Towne). CR 300 caudad to

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