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1161

Skull Base–related Lesions at
Routine Head CT from the Emer-
gency Department: Pearls, Pitfalls,
and Lessons Learned
Hernan R. Bello, MD
Joseph A. Graves, MD
Saurabh Rohatgi, MD
Mona Vakil, MD
Jennifer McCarty, MD
Rudy L.Van Hemert, MD
Stephen Geppert, MD
Ryan B. Peterson, MD
Abbreviations: ASB = anterior skull base,
CCJ = craniocervical junction, CPA = cerebello-­
pontine angle, CSB = central skull base,
CSF = cerebrospinal fluid, IIH = idiopathic
intracranial hypertension, MCF = middle cra-
nial fossa, PCF = posterior cranial fossa, PNS =
paranasal sinuses, PPF = pterygopalatine fossa,
SIH = spontaneous intracranial hypotension,
TMJ = temporomandibular joint
RadioGraphics 2019; 39:1161–1182
https://doi.org/10.1148/rg.2019180118
TRAUMA/EMERGENCY RADIOLOGY
Routine non–contrast material–enhanced head CT is one of the
most frequently ordered studies in the emergency department.
Skull base–related pathologic entities, often depicted on the first or
last images of a routine head CT study, can be easily overlooked in
the emergency setting if not incorporated in the interpreting radi-
ologist’s search pattern, as the findings can be incompletely imaged.
Delayed diagnosis, misdiagnosis, or lack of recognition of skull base
pathologic entities can negatively impact patient care. This article
reviews and illustrates the essential skull base anatomy and com-
mon blind spots that are important to radiologists who interpret
nonenhanced head CT images in the acute setting. The imaging
characteristics of important “do not miss” lesions are emphasized
and categorized by their cause and location within the skull base,
and the potential differential diagnoses are discussed. An interpre-
tation checklist to improve diagnostic accuracy is provided.
©
RSNA, 2019 • radiographics.rsna.org

Content Codes:

From the Department of Radiology and Im-

aging Sciences, Emory University School of Introduction
Medicine, Emory University Midtown Hos-
pital, 550 Peachtree Rd, Atlanta, GA 30308
Non–contrast material–enhanced CT of the head is the primary
(H.R.B., J.A.G., M.V., R.B.P.); Department of imaging modality used to evaluate patients with neurologic deficits
Radiology, University of Massachusetts Medi- who present to the emergency department. Routine head CT often
cal School, Worcester, Mass (S.R.); Department
of Diagnostic and Interventional Imaging, Uni- includes images of portions of the skull base, extracranial spaces, and
versity of Texas Health Science Center at Hous- upper cervical spine. Skull base anatomy is complex, and pathologic
ton, Houston, Tex (J.M.); and Department of
Radiology, University of Arkansas for Medi- conditions in this region can be subtle and easily overlooked. There-
cal Sciences, Little Rock, Ark (R.V.H., S.G.). fore, all radiologists working in the acute care setting must have a
Presented as an education exhibit at the 2017
RSNA Annual Meeting. Received March 30,
thorough knowledge of normal skull base anatomy at CT and the
2018; revision requested June 21 and received wide spectrum of disease that may manifest in this area.
July 17; accepted July 24. For this journal-based
SA-CME activity, the authors, editor, and re-
viewers have disclosed no relevant relationships.
Address correspondence to J.A.G. (e-mail:
Joseph.graves@emory.edu).
©
RSNA, 2019

SA-CME LEARNING OBJECTIVES

After completing this journal-based SA-CME
activity, participants will be able to:
■■Discuss the complex anatomy of the
skull base.
■■Characterize easily missed skull base
lesions on nonenhanced head CT images
in the acute setting.
■■Identifyclinical or imaging red flags
that may necessitate further workup.
See rsna.org/learning-center-rg.
1162  July-August 2019 radiographics.rsna.org
TEACHING POINTS
■■ If there is discordance between the imaging findings and the
clinical history, a more detailed investigation of the electronic
medical record or a direct conversation with the clinician or
consultation service members should be performed.
■■ Any time that facial pain or paresthesia (in a trigeminal nerve
distribution) manifests, the radiologist should interrogate the
PPF for evidence of abnormal soft tissue replacing the normal
fatty contents, which could indicate extraosseous extension
of metastatic disease and compression of the pterygopalatine
ganglion.
■■ The frontal sinus has bony dehiscences, structural abnor-
malities that can channel the spread of infection. Patients can
present with headaches, photophobia, seizures, or focal neu-
rologic signs. Complications include subdural and epidural
empyema, cerebritis, brain abscess, and meningitis, which are
often neurosurgical emergencies.
■■ If there is any suggestion of temporal bone injury, evaluating
nonenhanced lung-window CT images of the head may allow
identification of extra-axial pneumocephalus, which is a find-
ing highly suggestive of injury.
■■ When one encounters mastoid effusions (especially a unilat-
eral effusion), the soft tissues along the eustachian tube and
within the nasopharynx should be thoroughly investigated to
exclude an underlying obstructive mass.
In addition, using a systematic search pattern
and having an overall awareness of the neurologic
manifestations of a skull base lesion can aid in
increasing the diagnostic yield for the interpreting
radiologist. These neurologic manifestations are
often referred to as red flags and include cranial
nerve deficits, strokelike symptoms that are atypi-
cal for a specific vascular territory, and progres-
sive and/or recurrent onset of symptoms. Delayed
diagnosis, misdiagnosis, or lack of recognition
of skull base conditions can negatively impact
patient care, highlighting the importance of using
a mental checklist when interpreting studies of
the skull base, especially the first few images of
the study.
In this article, we review and illustrate the es-
sential skull base anatomy and the common blind
spots important to radiologists interpreting a
nonenhanced head CT study in the acute setting.
We review the imaging characteristics of impor-
tant “do not miss” lesions at the skull base on the
basis of their anatomic location and manifesta-
tions. An interpretation checklist to help improve
diagnostic accuracy is provided.
Imaging Parameters
According to the practice parameter for the per-
formance of head CT developed by the American
College of Radiology, the American Society of
Neuroradiology, and the Society for Pediatric Ra-
diology (1), contiguous or overlapping axial images
should be acquired with a section thickness of no
greater than 5 mm. Studies have shown the supe-
riority of depicting findings on thinly collimated
spiral CT images (2). Obtaining thin-section im-
ages of 3 mm or less is recommended in the setting
of trauma, as use of thick-section images has been
found to miss a significant number of linear frac-
tures and skull base lesions, particularly when the
images are obtained in the horizontal plane (3,4).
In addition to obtaining directly acquired axial
images, high-resolution multiplanar reformatted
images, including those obtained in the coronal
and sagittal planes, may be constructed from the
axial dataset to increase sensitivity in the acute
setting (2,5). At our trauma center, in addition to
obtaining CT images with 5-mm section thick-
ness, we routinely obtain 0.625-mm thin-section
images by using a bone algorithm with sagittal
and coronal reformatted images for all trauma
head CT protocols, thereby enhancing the depic-
tion of complex skull base anatomy.
Anatomy Review
The anatomy depicted on the first few images of a
routine nonenhanced head CT study can be cat-
egorized as being located in the skull base, cranio-
cervical junction (CCJ), or extracranial soft tissues.
Skull Base
The skull base separates the intracranial and
extracranial compartments. It is formed from
portions of the frontal, ethmoid, sphenoid, paired
temporal, paired parietal, and occipital bones
(Fig 1). Arteries, veins, and multiple cranial
nerves traverse the skull base through a constel-
lation of canals and foramina. The bones and
foramina of the skull base can be segmented into
three main components: anterior, middle, and
posterior (Figs 2,3) (6–9).
The ASB is formed by the ethmoid, frontal, and
sphenoid bones. Laterally, the ASB is composed of
the orbital plates of the frontal bones and antero-
medially by the cribriform plate, crista galli, and
fovea ethmoidalis of the ethmoid bone. Posteri-
orly, the flat surface of the planum sphenoidale
separates the sphenoid sinus from the intracranial
contents. The line dividing the anterior and middle
skull base can be drawn along the posterior aspect
of the lesser sphenoid wing and along the posterior
aspect of the planum sphenoidale, which (depend-
ing on the source used) typically does not include
the anterior clinoid processes (6–9).
The CSB is formed predominantly by the
sphenoid and temporal bones. Anteriorly, the
sphenoid tuberculum sellae, anterior clinoid
processes, and greater sphenoid wings define the
CSB. Laterally, the temporal bone squamosal
portion and parietal bone confine the CSB. The
petrous ridge of the petrous temporal bone seg-
RG  •  Volume 39  Number 4 Bello et al  1163

Figure 1.  Basic skull base anatomy. (a) Axial three-

dimensional reconstructed CT image with color-coded
overlay shows the skull base sections. Blue = central skull
base (CSB), purple = posterior skull base, teal = anterior
skull base (ASB). (b) Axial CT image with color-coded
overlay shows the skull base bones. Blue = temporal
bones, fuchsia = nasal bones, green = ethmoid bone,
light pink = vomer, purple = occipital bones, teal = sphe-
noid bone, yellow = zygomatic bones. (c) Axial CT image
with color-coded overlay shows the extracranial spaces.
Blue = masticator space, dark yellow = parotid space,
fuchsia = parapharyngeal space, green = nasal cavity, light
yellow = maxillary sinus, pink = carotid space, purple =
perivertebral space, red = spinal canal and spinal cord,
teal = nasopharynx.

ment forms the posterior extent of the CSB. The
sella turcica, posterior clinoid processes, and the
body of the sphenoid all reside centrally.
The CSB shapes the MCF, which houses the
anterior temporal lobes, pituitary gland, cavern-
ous sinuses, and the exiting cranial nerves II
through VI. The optic canal traverses the sphe-
noid and houses the canalicular segment of the
optic nerve. This osseous canal courses medially
to the optic struts and inferomedially to the ante-
rior clinoid processes (6–9).
The posterior skull base is formed by the tem-
poral, sphenoid, and occipital bones. The anterior
margin begins at the temporal bone petrous ridge
and the dorsum sellae. Posteriorly, the occipital
bone forms the bulk of the posterior skull base
and creates the foramen magnum, which houses
the cervicomedullary junction. The cerebellar
hemispheres sit atop the posterior portions of the
occipital bone. The other foramen and canals in-
cluded in the posterior skull base are the internal
auditory canal and its internal opening, the porus
acusticus externus, as well as the jugular fora-
men and the hypoglossal canal. The jugular spine
splits the jugular foramen into the pars nervosa
and pars vascularis (6–9).
CCJ and Upper Cervical Spine
Segments of the CCJ and the upper cervical spine
are depicted on every routine nonenhanced head
1164  July-August 2019 radiographics.rsna.org

Figure 2.  Detailed skull base anatomy. (a) Coronal CT image: 1 = anterior clinoid process, 2 = optic canal, 3 = planum
sphenoidale, 4 = sphenoid sinus, 5 = foramen rotundum, 6 = vidian canal, 7 = middle cranial fossa (MCF), 8 = nasal cavity.
(b) Axial CT image: 1 = superior orbital fissure, 2 = sphenoid sinus, 3 = greater sphenoid wing, 4 = squamosal temporal
bone, 5 = MCF, 6 = internal auditory canal, 7 = clivus, 8 = facial nerve canal, 9 = petrous apex, 10 = tympanic cavity, 11 =
mastoid air cells, 12 = posterior cranial fossa (PCF). (c) Axial CT image: 1 = inferior orbital fissure, 2 = sphenoid sinus, 3 =
foramen ovale, 4 = foramen spinosum, 5 = foramen lacerum, 6 = carotid canal, 7 = clivus, 8 = jugular foramen, 9 = PCF.
(d) Coronal CT image: 1 = orbital plate, 2 = cribriform plate, 3 = fovea ethmoidalis, 4 = ethmoid sinus, 5 = lamina papy-
racea, 6 = maxillary sinus, 7 = orbit, 8 = nasal cavity, 9 = anterior cranial fossa.

CT study, the extent of which varies depending
on the patient’s positioning and the CT protocol.
The C1 (atlas) and C2 (axis) vertebrae of the cer-
vical spine form the CCJ in conjunction with the
occipital bone and a multipart ligamentous com-
plex. Often, only a small portion of the C1 and
C2 vertebrae are in the field of view, but because
the CCJ houses the cervicomedullary junction,
vertebral arteries, and various veins, these spinal
structures are critically important to evaluate.
Anteromedially, the occipital basion contrib-
utes to the cranial portion of the CCJ. Pos-
teriorly, the occipital opthision is the midline
osseous cranial landmark. Laterally, the occipital
condyles articulate with the lateral masses of the
C1 vertebra, forming the atlanto-occipital joints.
The lateral masses of the C1 and C2 vertebrae
articulate to form the atlantoaxial joints (7–9).
The ligamentous complex of the CCJ can be
directly identified on CT images by using sagittal
RG  •  Volume 39  Number 4 Bello et al  1165

Figure 3.  Detailed skull base anatomy. (a) Axial CT image: 1 = infratemporal fossa, 2 = orbit, 3 = ethmoid
sinuses, 4 = sphenoid sinuses, 5 = foramen ovale, 6 = temporomandibular joint (TMJ), 7 = external auditory
canal, 8 = foramen magnum and medulla. (b) Sagittal CT image: 1 = cribriform plate, 2 = planum sphenoidale,
3 = sella, 4 = basion, 5 = opthision, 6 = posterior arch of C1, 7 = sphenoid, 8 = dens, 9 = anterior arch of C1, 10 =
basion-dental interval.

reformatted images and if they have been win-
dowed correctly. In addition, secondary findings
of ligamentous injury such as atlanto-occipital or
atlantoaxial joint space widening, ventral spinal
canal collection and/or hematoma, or prevertebral
effusion can be depicted on nonenhanced head
CT images. Any suspicious direct or secondary
signs of CCJ trauma should be followed up with
nonenhanced MRI of the cervical spine, which is
the optimal modality to evaluate these injuries.
Extracranial Soft Tissues
Portions of the orbits, paranasal sinuses (PNS),
nasal cavity, and several suprahyoid neck spaces
abut the skull and are included at routine head
CT in varying degrees (Fig 1).
The orbit contains the globe, extraocular
muscles, lacrimal gland, superior ophthalmic vein,
ophthalmic artery, optic nerve sheath complex,
and cranial nerves II, III, IV, VI, and V1. Cranial
nerve II traverses through the optic canal, while
cranial nerves III, IV, V1, V2 , and VI all converge in
the cavernous sinus, just lateral to the sella turcica.
The soft-tissue spaces of the suprahyoid neck
continue from the skull base to the hyoid bone
and are partially included on routine head CT
images (10). The pharyngeal mucosal space,
masticator space, parotid space, retropharyngeal
space, danger space, and carotid space are the
most commonly encountered. The danger space
is further posterior to the true retropharyngeal
space and extends further caudally through the
posterior mediastinum all the way to the dia-
phragm—an ominous potential route for the
spread of infection.
Proposed Head CT Checklist
The radiologist’s job in the emergency setting does
not end after eliminating or confirming a diagnosis
of acute intracranial abnormalities on head CT
images. It is very important not to succumb to sat-
isfaction of search errors and to ensure adequate
evaluation of the visualized portions of the skull
base, CCJ, and extracranial soft-tissue structures.
In this section, we provide a proposed checklist
and guide for evaluating the skull base (Table).
Bony sagittal reformatted images are great for
evaluating the sella turcica, clivus, and CCJ on
bone-window CT images. Use soft-tissue win-
dows in the sagittal plane to evaluate the mid-
line structures, including the foramen magnum,
prepontine cistern, third and fourth ventricles,
cerebellar tonsils, and upper cervical epidural
space. Coronal reformatted images may be help-
ful in assessing the included portions of the orbits
and reevaluating the ASB.
Clinical and Imaging Red Flags
Patients with primary skull base conditions can
present to the emergency department with symp-
toms such as focal neurologic deficits, altered
mental status, or headache. These symptoms are
entirely nonspecific and are often attributed to
more common diagnoses such as a cerebrovascu-
lar accident, intracranial trauma, hemorrhage, or
uncomplicated infectious sinus conditions.
1166  July-August 2019 radiographics.rsna.org

Proposed Checklist for Evaluating the Skull Base

Structures
Skull Base
Segment and Specific Osseous Foramen, Canals, and Adjacent
Imaging Tips Bones Components Traversing Structures Structures
Anterior: Look Ethmoid, Cribriform plate Cribriform plate: CN I olfactory Nasal cavity, sep-
for fractures, frontal, Crista galli fibers tum, bony arch
osseous ero- sphenoid Lateral lamella Foramen cecum, emissary vein Orbital contents
sions, dehis- Orbital walls Anterior ethmoid foramen, ante- PNS
cence, and Fovea ethmoidalis rior ethmoid artery and vein Premalar and
opacification Planum sphenoidale Posterior ethmoid foramen, pos- retroantral fat
of the PNS. Lesser wing of the sphenoid terior ethmoid artery and vein pads
Middle: Turn Sphenoid, Tuberculum sellae Optic canal, CN II PPF, CN V2,
to the lung temporal, Optic strut Superior orbital fissure, CN pterygoid gan-
window to parietal Anterior clinoid processes III, IV, V1, VI; superior and glion
look for subtle Sella turcica inferior ophthalmic veins Masticator space
pneumocepha- Posterior clinoid processes Inferior orbital fissure, CN V2, Parotid space
lus. Evaluate Dorsum sellae infraorbital artery and vein Carotid space
the middle ear Squamosal temporal bone Foramen rotundum, CN V2 TMJ, mandible
for bony ero- Petrous temporal bone, pe- Vidian canal, vidian nerve and Middle and exter-
sion, abnormal trous apices artery nal ear, ossicles
fluid, or soft Tympanic plates Foramen ovale, CN V3 Cavernous sinuses
tissue. Greater wings of the sphenoid Foramen spinosum, middle Meckel cave
Pterygoid plates meningeal artery
Sphenoparietal recess Carotid canal, ICA
Posterior: Look Sphenoid, Mastoid temporal bone Internal auditory canal, CNs VII Mastoid air cells
for lytic or temporal, Clivus and VIII Nasopharynx and
sclerotic bony occipital Occipital condyles Jugular foramen, pars nervosa retropharynx
lesions. (CN IX, Jacobson nerve, Included portions
inferior petrosal sinus), pars of the CCJ
vascularis (CNs X and XI, Jugular fossa
jugular bulb, posterior menin- CPA
geal artery)
Hypoglossal canal, CN XII
Foramen magnum, medulla,
anterior and posterior spinal
arteries
Note.—CN = cranial nerve, CPA = cerebellopontine angle, ICA = internal carotid artery, PPF = pterygopala-
tine fossa.

Sometimes the clinical picture does not co-
incide with the imaging findings for these more
common conditions. If there is discordance
between the imaging findings and the clini-
cal history, a more detailed investigation of the
electronic medical record or a direct conversa-
tion with the clinician or consultation service
members should be performed. Special atten-
tion should be directed toward the clinical time
course of the symptoms, a detailed neurologic
examination should be performed, and past
medical history including any prior imaging
should be reviewed. There are a number of clini-
cal scenarios or red flags in which the radiologist
should consider performing a detailed inspec-
tion of the skull base to include or exclude an
alternative diagnosis.
Positional Headaches and/or
Multiple Cranial Nerve Deficits
If a patient presents with positional headaches
and/or multiple cranial nerve deficits, a diagnosis
of spontaneous intracranial hypotension (SIH)
should be excluded (Fig 4). Although infrequent
(the annual incidence is five per 100 000 patients),
this diagnosis can be easily missed by a trainee or
radiologist who is unfamiliar with the condition,
which can delay treatment. Symptoms of SIH
include nausea, vomiting, neck pain, visual and/
or hearing disturbances, or vertigo, likely result-
ing from the tension of the cranial nerve owing to
brain sagging (11).
Sagittal imaging can improve the sensitivity
for identifying SIH; however, all trainees and
any radiologist reviewing neurologic images
RG  •  Volume 39  Number 4 Bello et al  1167

Figure 4.  SIH in a young woman who presented with dizziness. (a, b) Axial nonenhanced head CT images show crowding at
the foramen magnum (arrowheads in a) and diffuse effacement (arrowheads in b) of the basal cisterns. (c) Axial T2-weighted
MR image obtained at follow-up shows bilateral subdural collections (arrowheads). (d) Axial T1-weighted MR image ob-
tained after the administration of contrast material (postcontrast) shows diffuse pachymeningeal enhancement (arrowhead).
(e) Sagittal postcontrast T1-weighted MR image shows effacement of the prepontine cistern (arrowhead), sagging of the brainstem,
and cerebellar tonsillar ectopia.

from the emergency department should be fa-
miliar with the findings on axial cross-sectional
images. Routine nonenhanced imaging find-
ings that should raise the possibility of an SIH
diagnosis include (a) bilateral subdural hemor-
rhages or subdural hygromas; (b) effacement of
the skull basal cisterns, especially the suprasellar
and prepontine cisterns; (c) engorgement of the
dural venous system; (d) sagging of the brain
parenchyma, including abutment of the optic
apparatus on the sella turcica or cerebellar ton-
sillar ectopia; and (e) inferior orientation of the
splenium of the corpus callosum.
Additional evaluation with contrast-enhanced
MRI can confirm SIH, and its imaging features
include diffuse non-nodular pachymeningeal
enhancement, decreased fluid in the optic nerve
sheaths, engorgement of the pituitary gland, and
any of the previously noted signs of brain sagging.
Strokelike Symptoms with Nonacute Time
Course or Facial Pain and/or Paresthesia
The time frame for the onset of a patient’s
symptoms can be unclear, especially if there is
a history of prior cerebrovascular events and a
lack of reliable past clinical history or imaging. In
1168  July-August 2019 radiographics.rsna.org
these settings, a focal neurologic deficit related
to a skull base lesion can be mistaken for a new
vascular ischemic stroke.
A key example is an osseous metastasis or
primary osseous tumor (eg, chordoma) close
to skull base foramina, specifically the Dorello
(cranial nerve VI) or the hypoglossal (cranial
nerve XII) canals. In these situations, patients
may present with the inability to laterally abduct
one or both eyes or with tongue deviation, a
finding reflecting cranial nerve compression and
associated muscular atrophy. Also, any time that
facial pain or paresthesia (in a trigeminal nerve
distribution) manifests, the radiologist should
interrogate the PPF for evidence of abnormal
soft tissue replacing the normal fatty contents,
which could indicate extraosseous extension of
metastatic disease and compression of the ptery-
gopalatine ganglion.
If the clinical time frame is in question or if
facial pain manifests, the radiologist should pay
special attention to the mineralization pattern
of the skull base and investigate any additional
signs of metastatic disease outside the brain
or interrogate the medical record. If there are
additional questions, further evaluation with
contrast-enhanced MRI or skeletal scintigraphy
may be considered.
In addition, infectious processes of the skull
base can occur as an unusual acute strokelike
manifestation. Infection or inflammation of the
petrous apex in the setting of acute otomastoid-
itis can present with a unilateral cranial nerve VI
palsy known as Gradenigo syndrome, first de-
scribed in 1904. The classic triad of symptoms
comprises acute suppurative otitis media, severe
temporoparietal pain, and paresis or paralysis of
the ipsilateral abducens nerve.
Often, in addition to abducens nerve palsy,
ipsilateral facial pain owing to involvement of
the adjacent dura and trigeminal nerve in the
Meckel cave may manifest. Nonenhanced im-
ages should depict opacities in the tympanic
cavity, mastoid air cells, and pneumatized
petrous apex, usually with lysis of the thin bony
septa. Contrast-enhanced MRI is more sensitive
for the evaluation of dural or leptomeningeal
enhancement, and it aids in imaging of compli-
cations such as adjacent cerebritis, intracranial
abscess, and cavernous sinus thrombosis (12).
Blurry Vision with Headaches
Acute or subacute changes in vision should
always prompt an investigation with MRI, un-
less there is an acceptable alternative diagnosis
such as migraine. However, the first emergent
examination usually performed is nonenhanced
head CT to exclude a subarachnoid hemorrhage
or intracranial mass. If the patient is a woman
of childbearing age and is obese, idiopathic
intracranial hypertension (IIH) should be the
preemptive diagnosis, especially if papilledema
is noted at physical examination or the patient
reports pulsatile tinnitus.
Another CT finding of IIH includes en-
largement of the skull base foramina (Fig 5).
Although there are few imaging findings of
IIH identified at CT, an empty and expanded
sella turcica has been described in patients
with IIH and can indicate underlying increased
intracranial pressure. The diagnosis is usually
confirmed by the results of a lumbar puncture,
but additional findings can be seen at MRI,
including increased cerebrospinal fluid (CSF)
in the optic nerve sheaths, intraocular protru-
sion at the optic disc, optic nerve tortuosity or
enhancement, flattening of the posterior globes,
transverse dural venous sinus stenosis, and slit-
like ventricles (13).
New Seizures, Facial Swelling,
or Acute Change in Mental Status
A diagnosis of an occult skull base encephalo-
cele or CSF leak should be strongly considered
if there is an acute change in mental status or
new seizures and a remote history of traumatic
brain injury or evidence of frontotemporal
traumatic encephalomalacia. Protrusion of brain
parenchyma through an osseous or dural defect
from prior trauma typically occurs at the ante-
rior cranial fossa (cribriform plate) and MCF
(tegmen tympani or tegmen mastoideum), dam-
aging the underlying protruding brain paren-
chyma and resulting in an epileptogenic focus.
These defects can also predispose a patient to
CSF leaks that can result in meningitis or cere-
britis, leading to seizure activity. Visualization of
the defect is often difficult on axial images, so if
there is concern, coronal images should be re-
viewed as they are key to making the diagnosis.
Traumatic cavernous carotid fistulas or pseu-
doaneurysms can occur immediately following
or soon after significant traumatic skull base
fractures. If there is any periorbital erythema or
new altered mental status, radiologists and clini-
cians need to have a low threshold for perform-
ing vascular imaging such as CT angiography.
In addition, a cavernous sinus thrombus can
manifest in a similar fashion in the setting of
more subacute trauma or infectious processes
like invasive sinus disease. In such cases, spe-
cial attention should be paid to exclude any
asymmetric bulging of the cavernous sinuses or
enlargement of the superior ophthalmic vein,
which can be seen with a cavernous carotid
fistula, pseudoaneurysm, or thrombus.
RG  •  Volume 39  Number 4 Bello et al  1169

Figure 5.  IIH in a woman with obesity who presented with eye pain. (a, b) Axial nonenhanced head CT images
show an enlarged foramen ovale (arrowhead in a) and an empty sella (arrowhead in b). (c) Axial T2-weighted MR
image shows increased CSF (arrowheads) in the optic nerve sheaths. (d) Axial postcontrast T1-weighted MR image
shows stenosis (arrowheads) of the transverse venous sinuses bilaterally.

Pathologic Entities of the Skull Base
Anterior Skull Base
Common pathologic conditions in the ASB in-
clude intracranial extension of sinonasal malignan-
cies and infections, as well as congenital lesions
and conditions secondary to trauma (6,14,15).
Neoplasms of the nasal cavity and PNS can
involve the ASB, with many of these aggressive le-
sions demonstrating overlapping imaging features,
which are discussed in the section on the “Sinona-
sal Region.” The role of the radiologist interpret-
ing the initial CT study is to identify the presence
of an extracranial lesion and recommend further
imaging with enhanced brain MRI to determine
the full extent of involvement from a resectability
and staging standpoint (6,14,15).
Sinonasal infections caused by bacteria such
as Pseudomonas aeruginosa or invasive fun-
gal agents like Aspergillus or Zygomycetes are
commonly diagnosed in immunocompromised
patients (15,16). CT is often the first modality
performed to diagnose bony involvement and
intracranial extension (15,17), which can result
either from direct extension or by valveless com-
municating veins. In addition, the frontal sinus
has bony dehiscences, structural abnormalities
that can channel the spread of infection (16,17).
Patients can present with headaches, photo-
phobia, seizures, or focal neurologic signs (16).
Complications include subdural and epidural
empyema, cerebritis, brain abscess, and men-
ingitis (Fig 6), which are often neurosurgical
emergencies (16). Osteomyelitis of the frontal
bone can spread outward and form a subgaleal
abscess described as Pott puffy tumor (16,17).
Polyposis with secondary fungal infections can
erode into the ASB, which can develop into
meningitis or cause CSF leaks (15,18).
During an acute trauma assessment, the radi-
ologist is at the forefront of interpreting injuries
of the face and ASB, as performing a physical
1170  July-August 2019 radiographics.rsna.org

Figure 6.  Invasive bacterial and/or fungal sinusitis in an immunocompromised woman who presented with headache
and facial pain. (a) Axial nonenhanced head CT image shows opacification throughout the PNS and osseous erosions
(arrowheads). (b) Axial postcontrast T1-weighted MR image obtained at follow-up shows abnormal sinus wall en-
hancement, with extrasinus extension (white arrowhead), and an enhancing extra-axial collection (black arrowhead) in
the left CPA, a finding compatible with an abscess.

examination alone is insufficient (19). Craniofacial

injuries are frequently associated with fractures
of the ASB, and fractures of the facial bones and
sinus walls can lead to CSF leak, dural laceration,
and herniation, with the ASB being the most com-
mon location for traumatic CSF leak (6,14).
In the pediatric population, normal sutures, ac-
cessory or variant sutures, and wormian bones can
mimic calvarial fractures in both accidental and
nonaccidental trauma (20). Coup or contrecoup
traumatic intraparenchymal contusions commonly
occur along the inferior frontal and anterior tem-
poral lobes where the brain has the greatest chance
of impact against the rigid bone (20,21).
Meningoencephaloceles are a congenital
herniation of meninges and brain parenchyma,
which are further subdivided as sincipital or
basal, dependent on the site of herniation (6,14).
MRI is performed to delineate the extent of the
Figure 7.  Schwannoma in a young man who presented with
lesion, but high-resolution CT with multiplanar right-sided facial numbness. Axial nonenhanced CT image of
reformatted images helps delineate bony anat- the head shows marked asymmetric expansion of the right
omy and differentiate meningoencephaloceles foramen ovale (red arrowhead) when compared with that of
the normal left foramen ovale (white arrowhead). There are
from other congenital masses such as nasal der-
no overlying erosions to suggest an aggressive process. The
moids, sinus cysts, and nasal gliomas (6,14,15). findings on MR images (not shown) were compatible with a
Pitfalls in the ASB include areas of arrested trigeminal (V3) schwannoma.
pneumatization in the basisphenoid, which are
incidental “do not touch” findings that are often
mistaken for malignancy. These are nonexpansile include unossified frontal, nasal, and ethmoid
fat-containing geographic lesions with calcifica- bones, which can be mistaken for skull base de-
tion and sclerotic margins (6). Additional pitfalls fects, especially in infants (14).
RG  •  Volume 39  Number 4 Bello et al  1171
Middle Cranial Fossa
The MCF is an easily overlooked segment of the
skull base on nonenhanced CT images and has a
close anatomic relationship with temporal bone
and CSB entities. The main structures in this re-
gion are the temporal lobe with its accompanying
dura and the sphenoparietal dural venous sinus
along the lesser wing of the sphenoid bone.
Subtle traumatic injury in this region can be
easily obscured at imaging by significant beam-
hardening artifacts from the adjacent dense
bone. Lung windows may help identify punctate
extra-axial pneumocephalus, which can suggest
underlying injury. Extra-axial hematomas (epi-
dural and subdural) are common in this loca-
tion, with 10.5% localized to the MCF (22). A
venous epidural hematoma is an entity specific
to this location. It is likely the result of trauma
to the sphenoparietal sinus, often following a
benign clinical course as compared with that of
an arterial epidural hematoma, and does not re-
quire surgical intervention. Coup or contrecoup
traumatic intraparenchymal contusions are also
frequent owing to the underlying rough contour
of the temporal and sphenoid bones.
Neoplastic processes in this region usually fol-
low a benign course. The differential diagnosis of
a mass in the MCF region includes meningioma
and epidermoid cysts, which usually arise in the
CPA but can arise from the parasellar region in
10%–15% of cases and extend into the MCF
(23). Epidermoid cysts can be easily mistaken
for arachnoid cysts and can be differentiated on
MR images, where epidermoid cysts demonstrate
marked restricted diffusion at imaging.
Central Skull Base
The anatomy of the CSB is complex and com-
pact. As previously stated, using thin-section
bone algorithms and obtaining coronal or sagit-
tal reformatted images are useful for identify-
ing subtle skull base conditions (2). Important
structures are housed in the CSB, including the
pituitary gland, cavernous sinuses, and basal
foramina, which contain an array of vital neuro-
vascular structures (6–9). Neoplastic, infectious,
inflammatory, and traumatic processes can af-
fect the CSB.
Slow-growing tumors such as schwannomas
can expand the skull base foramina (Fig 7).
However, more aggressive tumors will demon-
strate a destructive process. Tumors affecting the
cavernous sinus may cause neurologic symptoms
related to the neurovascular structures involved,
including trigeminal nerve dysfunction (eg, facial
numbness or pain), visual field deficits owing to
compression of the optic nerve, ischemic deficits
owing to carotid artery compression, and ocular
motor deficits (eg, ptosis, diplopia, anisocoria, or
ophthalmoplegia) (24).
Patients with tumors of the anterior clivus
often present with signs and symptoms related
to local invasion (Fig 8). These include cranial
nerve palsies, brainstem compression, or hydro-
cephalus (25). Clival metastases are often aggres-
sive soft-tissue masses and usually manifest in
patients with a known history of malignancy.
Chordomas of the skull base are uncommon
but malignant. They can arise at the midline cli-
vus and are typically well-circumscribed expans-
ile soft-tissue masses that may contain irregular
intratumoral calcifications. The differential
diagnosis for clival and spheno-occipital lesions
includes chondrosarcomas, metastases, and plas-
macytomas (26).
Pituitary adenomas are benign lesions and can
vary in size and location. Usually macroadeno-
mas manifest with symptoms owing to local mass
effect. They arise from the anterior lobe of the
pituitary gland and are the most common cause
of sellar masses from 20 years of age, but they
account for only up to 10% of all intracranial
neoplasms (27,28).
Care should be taken not to overlook inflam-
matory or infectious processes, as they can spread
rapidly and have deadly consequences. Involve-
ment of the CSB can occur from the extension of
sinusitis from the sphenoid sinus and can infil-
trate the cavernous sinus, leading to cavernous
sinus thrombosis (16).
Trauma in the region of the CSB is not usually
an isolated finding but is typically seen with ASB
or temporal bone trauma. Important structures to
evaluate in the traumatic setting include the carotid
canals (for which performing CT angiography may
be warranted), sphenoid bone (for assessing for
CSF leak), and pterygoid plates (for assessing for
Le Fort–type fractures). It is important to recog-
nize CSB trauma, as performing additional imag-
ing, including facial CT, temporal bone CT, CT
angiography, and/or MRI, may be warranted.
Temporal Bone
Similar to the CSB, the temporal bone is a
complex region that houses many of the cranial
nerve foramina, the auditory apparatus, and
carotid vascular inflow, and it articulates with
the CSB and mandible. The crucial techniques
used to identify pathologic conditions in this
region involve evaluating symmetry (eg, com-
paring the side with the finding to the contralat-
eral temporal bone) and using thin-section bone
algorithms with reformatted images. Pathologic
conditions in this region can be categorized
as having traumatic, neoplastic, infectious, or
inflammatory causes.
1172  July-August 2019 radiographics.rsna.org

Figure 8.  Metastatic disease in a middle-aged man with no significant medical history who presented
with isolated tongue deviation. (a) Axial nonenhanced CT image of the head shows a focal lytic lesion (ar-
rowhead) in the left aspect of the clivus near the hypoglossal nerve canal. (b) Axial CT image of the neck
obtained at follow-up shows fatty atrophy (arrowhead) of the left base of the tongue owing to hypoglossal
nerve involvement. The patient was later diagnosed with metastatic prostate cancer.

Approximately 18%–22% of patients with major
head trauma have involvement of the temporal bone
(29). Patients will often present with stark clinical
signs of focal trauma such as Battle sign, postau-
ricular ecchymosis, vertigo, or hearing loss. Physi-
cal findings include facial nerve palsy, otorrhagia,
hemotympanum, tympanic membrane perforation,
stroke, and nystagmus. Subtle nondisplaced tem-
poral bone fractures can be easily missed. However,
if there is soft-tissue swelling overlying the temporal
bone and hyperattenuating fluid in the mastoid air
cells and tympanic cavity, a close interrogation of
the temporal bone at thin-section imaging should
be repeated.
As described previously, if there is any sugges-
tion of temporal bone injury, evaluating nonen-
hanced lung-window CT images of the head may
allow identification of extra-axial pneumocephalus,
which is a finding highly suggestive of injury.
When a temporal bone fracture is identified, the
extent and distribution of the fracture can predict
morbidity and prognosis. Classically, a temporal
bone fracture is described as either longitudinal
(most common) or transverse but can be a combi-
nation (described as mixed, complex, or commi-
nuted) (29). A newer classification system uses the
involvement of the otic capsule (otic capsule–spar-
ing vs otic capsule–violating fracture) (30). The
involvement of the ossicular chain, PNS, tegmen
tympani and/or mastoideum, carotid canal, and
cranial nerve foramina can help explain and/or
predict facial nerve palsies and various types of
hearing loss, as well as help guide management.
Management examples include further evalua-
tion with CT angiography if the carotid canal is
involved or treatment with antibiotics to prevent
meningitis if the fracture crosses the PNS or tem-
poral bone tegmen.
One fracture that is often overlooked is the
tympanic plate fracture involving the posterior
wall of the glenoid fossa of the TMJ. With direct
injury to the jaw, either by motor vehicle collision
or ground-level fall onto the chin, the energy is
either transmitted to the mandibular condyle or
transferred to the tympanic plate. The tympanic
plate fracture can be incorrectly identified as a
normal adjacent squamotympanic fissure and
can lead to misdiagnosis, external auditory canal
atresia, and subsequent conductive hearing loss,
unless bolstered by packing material by a trauma
or otorhinolaryngology surgeon.
There is a plethora of neoplastic processes that
can involve the temporal bone region, includ-
ing paraganglioma, schwannoma, neurofibroma,
endolymphatic sac tumor, and metastasis.
Infectious or inflammatory involvement of
the temporal bone can include disease processes
that appear masslike such as cholesteatomas and
petrous apex cholesterol granulomas (Fig 9)
or infiltrative such as petrous apicitis and otitis
media. Fluid accumulation in the mastoid air
cells is among the first findings of infection in
RG  •  Volume 39  Number 4 Bello et al  1173

Figure 9.  Cholesterol granuloma in a patient who presented with tinnitus and left facial pain. (a) Axial nonenhanced
CT image of the head shows an expansile well-marginated lesion (arrowheads) in the left petrous apex. Note the nor-
mally pneumatized right petrous apex (arrows). (b) Axial T2-weighted MR image shows a focal lesion (arrowhead) with
high signal intensity. (c) Axial postcontrast T1-weighted MR image shows no significant enhancement of the lesion
(arrowhead). (d) Coronal T2-weighted MR image shows T2-hyperintense debris (arrowhead) with a sedimentation
level (arrow).

this region. When one encounters mastoid effu-
sions (especially a unilateral effusion), the soft
tissues along the eustachian tube and within the
nasopharynx should be thoroughly investigated
to exclude an underlying obstructive mass. In
addition, complications of a temporal bone in-
fection should be excluded, including coalescent
otomastoiditis; associated dural venous sinus
dehiscence or thrombosis; and subperiosteal,
sternocleidomastoid muscular, or intraparenchy-
mal brain abscess.
Posterior Cranial Fossa
The PCF is the most posterior aspect of the skull
base and is home to the brainstem and cerebel-
lum, as well as other important extra-axial struc-
tures (eg, dural venous sinuses, internal acoustic
meatuses, foramen magnum, jugular foramina,
hypoglossal canals, and the vestibular aqueducts)
(6–9). Owing to bone-induced beam-hardening
artifacts depicted on images, the evaluation of the
PCF is often compromised.
The most common neoplasms in the PCF are
CPA tumors, which are almost all benign. Ves-
tibular schwannomas are by far the most common
CPA tumor, accounting for over 85% of all CPA
tumors, followed by meningiomas (31,32). The
key to visualizing an isoattenuating CPA mass is to
carefully evaluate the CPA cistern for effacement
and asymmetry, abnormal soft-tissue opacification,
or expansion of the internal auditory canal.
Vascular abnormalities can be easily overlooked
owing to the limitations of imaging the PCF.
Posterior inferior cerebellar artery aneurysms
can sometimes be visualized on nonenhanced
CT images if they are large, partially calcified,
or hyperattenuating. Dural arteriovenous fistulas
are an uncommon collection of conditions that
share arteriovenous shunts from dural vessels
(Fig 10). Diagnosing dural arteriovenous fistulas
can certainly be challenging at nonenhanced CT,
but a red flag should be raised if the intracranial
hemorrhage pattern is in an unusual location or
is visualized in a patient outside the typical age of
manifestation (33).
Dural venous thrombosis is a critical diagno-
sis that could have dire consequences if missed.
Classically, patients with dural venous sinus
1174  July-August 2019 radiographics.rsna.org

Figure 10.  Dural arteriovenous fistula in a patient who

presented with altered mental status experienced while
driving. (a) Axial nonenhanced CT image of the head
shows enlargement and tortuous course of the left mid-
dle meningeal artery (arrows), arising from the foramen
spinosum. (b) Axial nonenhanced CT image of the head
shows multiple intraosseous vascular structures (arrow-
heads), with pitting of the inner table. (c) Time-resolved
MR angiogram obtained at follow-up shows a Borden
type III dural arteriovenous fistula (arrowheads). Note
the prominent middle meningeal artery (arrow).

thrombosis will present with headache, with or

without neurologic deficits. On nonenhanced
CT images, the affected sinuses or vein will be
hyperattenuating, with or without venous hem-
orrhage or infarction. This has been described as
the “dense cord” or “dense vein” sign.
The results of a study by Buyck et al (34)
show that sinus attenuation more than 62 HU
and a Hounsfield unit to hematocrit ratio greater
than 1.52 support a diagnosis of cerebral venous
sinus thrombosis. If this diagnosis is suspected,
CT venography should be performed for confir-
mation (34). In the setting of trauma, skull base
fractures involving the dural venous sinus place
the patient at risk for dural venous thrombosis,
and CT venography should be considered.
The PCF houses a number of neurovascular
structures. Radiologists must inspect the internal
auditory canals and hypoglossal canals for masses
like schwannomas along cranial nerves VII, VIII,
and XII, respectively. The jugular foramen is an
important landmark that can be divided into the
pars nervosa and the pars vascularis. Although the
foramen can be asymmetric in size, it is important
to make sure the walls are well corticated.
Craniocervical Junction
The extent of the CCJ depicted on routine head CT
images can vary. Pathologic conditions involving the
CCJ and included portions of the cervical spine are
most often caused by trauma. However, incidental
findings of upper cervical spine neoplasms, includ-
ing metastatic disease, should not be overlooked. It
is important to identify primary or secondary find-
ings that indicate cervical spine injury, as the next
step would include spine surgery consultation and
performing CT and/or MRI of the cervical spine to
assess for brainstem, cord, and ligamentous injury.
Craniocervical dissociation or atlanto-occipital
dissociation refers to subluxation, distraction, or
complete dislocation at the atlanto-occipital joint,
RG  •  Volume 39  Number 4 Bello et al  1175
which is primarily stabilized by the tectorial mem-
brane and paired alar ligaments. Atlanto-occipital
dissociation results from the disruption of these
ligaments, usually caused by extreme hyperexten-
sion and lateral flexion in high-velocity trauma.
These injuries are often associated with severe
neurologic deficits and high mortality, particularly
from vascular and brainstem injuries (2,35).
The basion-dens interval should be assessed
on sagittal images. A basion-dens interval greater
than 10 mm as measured on the sagittal plane is
highly suggestive of atlanto-occipital dissociation
(5). Secondary findings include occipital condyle
fractures and subarachnoid or subdural hemor-
rhage, which should be included on the radiolo-
gist’s imaging checklist.
Occipital condyle fractures are often visualized
on routine head CT images and are classified
into three types: (a) isolated impaction fracture
(type I), (b) skull base fractures that extend into
the occipital condyles (type II), and (c) alar liga-
ment avulsion fractures (type III) that extend
into the foramen magnum. Type I and II injuries
are stable, and type III injuries are potentially
unstable, dependent on the degree of fracture
fragment displacement (2,35,36).
Injuries associated with occipital condyle
fractures include cervical spine or facial fractures,
as well as vascular trauma to the vertebral or
carotid arteries (36). Lower cranial nerve palsies
may also be diagnosed, most commonly of the
hypoglossal nerve, if there is fracture extension
through the hypoglossal canal (35).
Atlas fractures account for one-fourth of CCJ
injuries and are often associated with C2 ver-
tebra fractures. Fractures are divided into five
types according to their location: (a) posterior
arch (type I), (b) anterior arch (type II), (c) an-
terior and posterior arches (type III or Jefferson
burst fracture), (d) lateral masses (type IV), and
(e) avulsion injuries (type V) (27). On coronal
images, the displacement of the lateral masses
of C1 in relation to the lateral aspect of C2 is an
indicator of atlas fracture (2).
Odontoid fractures account for over one-half
of C2 fractures, with a greater prevalence in the
older population. They can be divided into three
types, dependent on location: (a) tip of dens
fracture from avulsion of the alar ligament (type
I), (b) junction of the odontoid process and body
of C2 (type II), and (c) extension into the body
(type III) (36). Fractures of the odontoid process
are best depicted on coronal and sagittal refor-
matted images. It is important not to mistake an
unfused os odontoideum or the subdental basilar
synchondrosis with a dens fracture.
The atlanto-dens interval should always be
assessed on sagittal images. Widening of the in-
terval that is greater than 3 mm in adults suggests
atlantoaxial dissociation, with injury to the trans-
verse ligament (2). A transverse ligament injury
is usually associated with a C1 or dens fracture
but can occur in isolation or with nontraumatic
causes such as rheumatoid arthritis. Atlantoaxial
dissociation may result in the posterior displace-
ment of the C2 vertebra and compression of the
spinal cord between the dens and the posterior
arch of the C1 vertebra.
Various causes can result in craniocervical
extra-axial hemorrhage, most commonly trauma,
including the various fractures described previ-
ously. Additional causes include aneurysmal and
nonaneurysmal subarachnoid hemorrhage, dural
arteriovenous fistula, and extension of epidural or
intrathecal hemorrhage from the cervical spine.
The most common intramedullary spinal cord
lesion is ependymoma, although its CT appear-
ance is nonspecific. The differential diagno-
sis includes astrocytoma, hemangioblastoma,
metastasis, lymphoma, or myelitis. Spinal cord
tumors typically expand the spinal cord and are
isoattenuating or slightly hyperattenuating on
nonenhanced CT images, especially if hemor-
rhage is present. A syrinx is any cavity within the
cord with CSF attenuation that may or may not
communicate with the central canal. This can be
congenital, most commonly from Chiari malfor-
mations (Fig 11), or acquired from trauma or
spinal cord tumors obstructing the normal flow
of CSF. Extramedullary intradural lesions typi-
cally have a CSF cleft between the lesion and the
spinal cord and may result in cord compression.
Meningiomas and nerve sheath tumors make up
a majority of intradural lesions and can be dif-
ficult to distinguish at CT.
Osseous metastasis may be osteoblastic,
osteolytic, or mixed and should be considered in
the differential diagnosis for any bone lesion in a
patient over 40 years of age. The most common
lytic vertebral body metastases include those
found in the breast, lung, renal cells, and thyroid,
(although metastases in the breast and lung may
have a mixed appearance), as well as melanoma
and lymphoma. The prostate and bladder are the
most common sites of sclerotic metastasis. Multi-
ple myeloma manifests as diffuse osseous infiltra-
tion, with multiple well-defined lytic lesions.
Pathologic Entities of the
Extracranial Structures
Masticator Space
The masticator space contains the mandible,
TMJ, muscles of mastication (temporalis, masse-
ter, medial pterygoid, and lateral pterygoid), and
V3 branch of the trigeminal nerve (10).
1176  July-August 2019 radiographics.rsna.org

Figure 11.  Chiari malformation in a young woman with recurrent headache. (a) Axial nonenhanced CT image of
the head shows crowding (arrowheads) at the foramen magnum. (b) Sagittal T2-weighted MR image of the brain ob-
tained at follow-up shows a peglike configuration of the cerebellar tonsils with downward displacement (line) through
the foramen magnum, resulting in crowding of the medulla. Note the decreased CSF level at the foramen magnum
(arrowhead), resulting in mild hydrocephalus.

Traumatic abnormalities include mandibular Carotid Space

fracture and TMJ dislocation. These are often
clinically evident and easy to visualize at CT.
TMJ arthritis related to degenerative joint dis-
ease usually causes flattening and widening of the
mandibular condyle with peripheral osteophytes,
and periarticular erosions in rheumatoid arthritis
give rise to a characteristic “sharpened-pencil”
appearance of the mandibular condyle, often with
additional findings from secondary degenerative
joint disease.
Infectious and inflammatory conditions are
common in the masticator space, with infection
often arising from periodontal disease. Phleg-
mon and abscess can both manifest similarly,
with trismus or jaw pain. Loss of normal fat
planes and well-defined fluid collections are
obvious signs of infection, but it is important to
identify if the source of infection is from peri-
odontal abscesses or dental caries. The radiolo-
gist should evaluate for focal cortical break-
through or periosteal inflammation.
The most commonly encountered neoplas-
tic lesion in this region involves the mandibular
branch (V3) of the trigeminal nerve, which may
be affected by a primary nerve sheath tumor or
by perineural spread, either from an oropharyn-
geal malignancy or from an intracranial malig-
nancy. Clinically, patients often present with
neuropathy in the V3 distribution. Widening of
the mandibular foramen is the most important
diagnostic clue and should prompt a search for
the primary site of malignancy.
The carotid space is formed from all three layers
of cervical fasciae (superficial, middle, and deep),
and encases the carotid artery, jugular vein, sym-
pathetic plexus, lymph nodes, and cranial nerves
IX, X, XI, and XII (10).
Traumatic abnormalities in the space include
carotid dissection and pseudoaneurysm (Fig 12).
Both can cause patients to present with anterior
circulation strokelike symptoms. On nonenhanced
head CT images, carotid dissection can be seen
as a long segment luminal irregularity, an abrupt
change in caliber, or displacement of calcified
plaque in an atherosclerotic arterial wall. Occa-
sionally in acute dissection, there will be a hyperat-
tenuating crescentic mural hematoma. Pseudoan-
eurysm is often depicted along with dissection and
appears as focal dilatation of the vessel, usually
just proximal to the entrance to the carotid canal.
In practice, the two may be indistinguishable. The
dissection will frequently start in the proximal in-
ternal carotid artery, often below the field of view
on a head CT image, and usually stops before the
intracranial internal carotid artery.
The classic infectious abnormality to occur in
the carotid space is septic thrombophlebitis of
the internal jugular vein, also known as Lemierre
syndrome. Unlike noninfectious causes of throm-
bophlebitis, this commonly occurs in young
patients after being diagnosed with bacterial
pharyngitis. On nonenhanced head CT images,
the thrombosed vein will be enlarged and hyper-
attenuating, with surrounding soft-tissue edema.
RG  •  Volume 39  Number 4 Bello et al  1177

Figure 12.  Internal carotid artery pseudoaneurysm

in an older man with a recent history of trauma. Axial
nonenhanced CT image of the head shows a periph-
erally calcified mass, a finding suspicious for left in-
ternal carotid artery pseudoaneurysm (green arrow-
head), compared to the normal right internal carotid
artery (red arrowhead). The diagnosis was confirmed
at CT angiography (not shown).

The most common neoplastic lesions in
the carotid space are glomus tumors (carotid
body tumor and glomus vagale) and schwanno-
mas. Both manifest as mass lesions, but glo-
mus tumors are more likely to be pulsatile. On
nonenhanced CT images, they both appear as
soft-tissue masses similar in attenuation to that of
muscle. Schwannomas often displace the internal
carotid artery, whereas glomus vagale tumors
splay the internal carotid artery and the external
carotid artery. While both can be familial lesions,
glomus vagale tumors are more likely to be bilat-
eral and are often seen with glomus tympanicum
and glomus jugulare tumors. Performing a search
pattern that includes the contralateral carotid
space, jugular foramen, and middle ear could
help with differentiation.
Nasopharyngeal and
Retropharyngeal Spaces
The nasopharyngeal space includes the mucosal
surface, lateral pharyngeal recess (fossa of Ros-
senmüller), torus tubarius, constrictor muscles,
pharyngeal lymphatic tissue (adenoids of Waldeyer
ring), minor salivary glands, and the eustachian
tube openings (8–10). The retropharyngeal space
contains mostly fat. While the boundaries of these
spaces are indistinguishable at normal nonen-
hanced head CT, they may be elucidated by the
type and extent of the pathologic processes.
Traumatic injury in this region varies widely,
from gunshot wounds to embedded ingested for-
eign bodies, and it can be iatrogenic or idiopathic.
Lines and tubes can potentially cause iatrogenic
trauma or may be malpositioned and included in
the field of view on CT or scout CT images. Hem-
orrhage from trauma can spill into the pharynx,
inciting a risk of aspiration, or may distend the
retropharyngeal space.
Inflammatory and/or infectious processes range
from pharyngitis to retropharyngeal abscess. At im-
aging, pharyngitis will appear as ill-defined thick-
ening of the mucosal space. However, this finding
should raise a red flag when depicted in adults, as
benign nasopharyngeal inflammation can be dif-
ficult or even impossible to distinguish from early
stage primary nasopharyngeal carcinoma (37).
A further review of the patient’s history or direct
examination of the mucosa may be necessary.
Retropharyngeal edema is depicted as an area
of ill-defined low attenuation. In contrast, a retro-
pharyngeal abscess will appear well defined on im-
ages and often will distend the space to a greater
degree than that of an edema. Given that both ret-
ropharyngeal edemas and abscesses can continue
caudally to the T3 level, where the retropharyngeal
space ends, and owing to the potential for epidural
extension in the case of an abscess (10), perform-
ing additional imaging of this region is imperative.
Malignancies of the nasopharynx include na-
sopharyngeal carcinoma (Fig 13), non-Hodgkin
lymphoma, and minor salivary gland tumors. The
clinical presentations for these malignancies may
be vague. Nasopharyngeal carcinoma is a nonke-
ratinizing carcinoma that arises from the lateral
pharyngeal recess, and it is related to an Epstein-
Barr virus infection (38). Asymmetry, masslike
invasion of adjacent structures, and (potentially)
CSB destruction will clue the radiologist into
considering a nasopharyngeal carcinoma diagno-
sis. Radiologists should always be on high alert
if they encounter asymmetric nasopharyngeal
fullness and unilateral persistent tympanomastoid
effusion on CT images of the head in adults.
1178  July-August 2019 radiographics.rsna.org

Figure 13.  Nasopharyngeal carcinoma in a patient with no significant medical history who presented with arm
pain. (a) Axial nonenhanced CT image of the head shows an incidental asymmetric soft-tissue mass (white ar-
rowhead) in the right posterior nasopharynx, effacing the fossa of Rossenmüller. Note the normal left side (black
arrowhead), which contains an aerated eustachian tube (arrow). (b) Axial postcontrast fat-saturated T1-weighted
MR image obtained at follow-up shows a homogeneously enhancing mass (white arrowhead) in the right naso-
pharynx, compared to the normal left nasopharynx (black arrowhead).

Sinonasal Region immunocompromised patients to determine

The sinonasal region contains the nasal cavity
and PNS. Traumatic abnormalities in this region
include a host of facial fractures, including zy-
gomaticomaxillary complex, Le Fort, and naso-
orbitoethmoid fractures (Fig 14). Radiologists
should evaluate for skull base involvement, as
skull base fractures have the potential for com-
plications of CSF leaks and meningitis, as well as
other complications.
Inflammatory and infectious conditions include
sinusitis, granulomatosis with polyangiitis (GPA,
formerly known as Wegener granulomatosis), and
sarcoidosis. Sinusitis is a clinical diagnosis. Imag-
ing features can include mucosal thickening, frothy
secretions, and air-fluid levels as depicted in cases
of typical bacterial sinusitis; hyperattenuating ex-
pansile material in cases of allergic fungal sinusitis;
and the ominous invasive extrasinus soft tissue
depicted in cases of invasive fungal sinusitis. GPA
manifests with clinical features of chronic rhinitis
and renal failure and histologic features of granu-
lomatous necrotizing inflammation. Imaging may
show mucosal nodularity of the nasal cavity, septal
destruction, erosions, and osteoneogenesis (39).
Sarcoidosis may show similar nonspecific findings
on nonenhanced head CT images.
Special care should be taken to evaluate
the PNS on nonenhanced head CT images in
if there is any evidence of extrasinus exten-
sion or invasive features. Prompt diagnosis
and treatment are essential, as acute invasive
fungal sinusitis infection has a mortality rate of
50%–80% (40). Abnormal soft tissue or inflam-
mation in the premalar, retroantral, and PPF
fat and subtle erosions of the PNS wall or any
significant mucosal irregularities in the nasal
cavity can indicate an invasive fungal or aggres-
sive bacterial sinusitis. Early detection before
significant intracranial extension or vascular
compromise could result in improved outcomes.
Importantly, not all sinus low-attenuation
opacification represents secretions or sinusitis.
Patients with encephaloceles and CSF leaks
may have water-attenuation–filled isolated PNS
that abut the skull base at imaging. Multiplanar
reconstructions are invaluable in differentiating a
sinus entity from an intracranial entity protruding
into the sinuses.
Sinonasal cavity malignancies include squa-
mous cell carcinoma (SCC), lymphoma, sino-
nasal undifferentiated carcinoma, and esthesio-
neuroblastoma. The clinical symptoms of nasal
stuffiness, nasal discharge, and headache overlap
with the symptoms of benign sinonasal entities.
SCC is the most common sinonasal malignant
tumor and will manifest as a masslike destruc-
RG  •  Volume 39  Number 4 Bello et al  1179

Figure 14.  Axial nonenhanced CT images of the head show various traumas in four patients.
(a) Image shows a type III left occipital condyle fracture (arrowheads). (b) Image shows hyperattenuating
blood products (arrowhead) in the prepontine cistern in a patient with no other intracranial hemorrhage.
(c) Image shows a tympanic plate fracture (arrowhead). (d) Image shows a dislocated right mandibular
condyle (arrowhead) in a patient who was found unconscious. Note the normal position of the left man-
dibular condyle within the mandibular fossa.

tive soft-tissue lesion. Esthesioneuroblastoma is
a neuroectodermal neoplasm, most commonly
located in the nasal cavity olfactory recess,
which may be isolated to the nasal cavity. Its
findings include olfactory recess widening and
cribriform plate extension, which help differen-
tiate it from other benign nasal entities (41).
Juvenile nasopharyngeal angiofibromas are
benign locally aggressive tumors diagnosed in
adolescent boys that arise from the sphenopala-
tine foramen, with the propensity to reoccur. CT
images classically depict widening of the PPF and
sphenopalatine foramen, with anterior bowing of
the posterior maxillary sinus wall (Holman-Miller
sign). In addition, these masses can extend into
the orbit and MCF (14,15,42).
Olfactory groove meningiomas may extend
through the cribriform plate into the ethmoid si-
nuses and nasal cavity. On CT images, classic fea-
tures include depict hyperostosis, dural thickening,
1180  July-August 2019 radiographics.rsna.org
and bone remodeling (6,14,15). Benign osseous
lesions include fibrous dysplasia, a fibro-osseous
lesion that can affect any bone, can be mono- or
polyostotic, and can have a ground-glass appear-
ance at CT. Osteomas are slow-growing osteogenic
lesions composed of mature bone. They are hyper-
attenuating at CT and most commonly manifest
in the frontal and ethmoid sinuses (14,42,43).
Orbit
The contents of the orbit and the potential for
complications are extensive. Traumatic enti-
ties should not be missed at emergent imaging.
They include subtle traumatic globe rupture,
radiopaque or lucent ocular foreign bodies, lens
dislocation, intraorbital hemorrhage or detach-
ments (retinal, choroidal, or vitreous), retrobul-
bar hematomas, and orbital floor fractures.
Orbital infection is usually apparent clinically,
but the identification of postseptal extension or
subperiosteal abscess is extremely important,
although these can be difficult to visualize on
routine nonenhanced head CT images. Exophthal-
mos, PNS opacities, sinus wall thinning or dehis-
cence, and postseptal orbital fat inflammation are
findings that can help direct the identification of
these sometimes-thin abscesses and determine if
additional imaging is needed.
Acute manifestations of thyroid orbitopathy can
mimic periorbital cellulitis. Usually, the patient
has a clinical history of thyroid orbitopathy, and
nonenhanced head CT is performed for other
reasons. Therefore, it is important to avoid incor-
rectly diagnosing this population with cellulitis.
The radiologist should remember the mnemonic
for expected extraocular muscle involvement,
“I’M SLO,” with enlargement progressing from
the inferior rectus, medial rectus, superior rectus,
lateral rectus, and oblique muscles, in that order
(44). A normal muscle thickness ranges from 3 to
6 mm (45).
Orbital and ocular neoplastic processes include
primary neoplasms such as choroidal melanoma,
optic nerve sheath meningiomas, lacrimal gland
lymphoma, and adenoid cystic carcinomas.
Intraorbital metastasis should not be overlooked,
especially if the patient has been diagnosed with
basal cell or squamous cell skin cancer or breast or
renal carcinomas (44).
Orbital pseudotumor or immunoglobulin G4–
related orbitopathy classically manifests with pain-
ful exophthalmos. However, an incomplete patient
history or history of headaches can misguide the
radiologist. The appearance of orbital pseudotumor
can mimic other neoplastic processes of the orbit
but can be as understated as ill-defined soft tissue
at the orbital apex, which can easily be missed. Re-
viewing the clinical history and performing further
Figure 15.  Parotid gland mass in a patient who pre-
sented with seizure. Axial nonenhanced CT image of
the head shows an incidental small left parotid mass (ar-
rowhead), later diagnosed as a benign Warthin tumor.
evaluations with contrast-enhanced MRI of the
orbits are critical for a correct diagnosis.
Vascular lesions are common, accounting for
up to 20% of orbital masses (44). Most of these
are incidental slow-growing lesions, with a sub-
acute to chronic time course. The main vascular
lesions the radiologist should not overlook are
orbital varices or enlargement of the superior
ophthalmic vein from a cavernous carotid fistula
or cavernous sinus thrombosis.
Parotid Space
The parotid space houses the parotid gland,
lymph nodes, retromandibular vein, and cranial
nerve VII (7–10).
Parotid gland inflammation will appear as
an area of abnormal attenuation and indistinct
borders, with stranding of the adjacent fat planes
and possible thickening of the deep cervical fascia.
Parotitis has many possible causes, including
systemic infectious processes such as mumps (eg,
the epidemic form that most commonly manifests
in children), HIV infection, catscratch disease, and
syphilis. Often, this finding will be bilateral.
Acute bacterial sialadenitis is usually unilat-
eral and can be a result of sialoliths blocking the
gland’s ducts, which will appear dilated on CT
images. Parotid gland abscesses are hypoattenu-
ating fluid collections within the gland. Nonin-
fectious parotitis can be secondary to sarcoid-
osis, radiation therapy, and Sjögren disease. In
these chronic conditions, the gland may appear
atrophied and replaced by fat.
Parotid gland neoplasms are difficult to dif-
ferentiate on nonenhanced CT images (46).
RG  •  Volume 39  Number 4 Bello et al  1181
They include benign neoplasms such as pleo-
morphic adenoma (the most common salivary
gland tumors) and lymphomatous papillary
cystadenomas (Warthin tumor), a well-defined
heterogeneous solid and cystic lesion that can
be multifocal and bilateral in up to 20% of cases
(Fig 15). Malignant parotid neoplasms include
mucoepidermoid carcinoma and adenoid cystic
carcinoma, which may affect the intraparotid
facial nerve and cause perineural spread (46).
Purely cystic parotid gland lesions include
first branchial cleft cysts, simple sialocysts, and
benign lymphoepithelial lesions, commonly seen
in patients with HIV infection and in association
with cervical lymphadenopathy and adenoid tis-
sue enlargement.
Conclusion
Pathologic entities located in and around the
skull base can be easily overlooked on non-
enhanced head CT images in the emergency
department. Understanding the patient’s clini-
cal history and identifying discordant patient
symptoms or red flags can prompt the radiolo-
gist to rereview the first few images of a CT
examination. A systematic checklist will aid in
identifying alternative diagnoses related to the
skull base, and every attempt should be made to
incorporate this process into routine practice.
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