CT procedure of neck, Avinesh Shrestha
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This presentation discusses briefly about the anatomy of neck and about different protocols used for CT examination of neck. Also, some pathology are shown in the presentation.
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CT procedure of neck, Avinesh Shrestha
- 2. Anatomy In general , neck is the part of a person’s or animal’s body connecting the head to the rest of the body. Here, neck is the part extending from the mandible to the thoracic inlet anteriorly and from the base of the skull to the scapulae posteriorly. 5/15/2017 2
- 3. Contd... Clinically, Neck is divided into different areas which are: Anterior Triangle Posterior Triangle Also all triangles mentioned here are paired i.e. they will appear on the left and the right side of the neck. 5/15/2017 3
- 4. Contd... Anterior triangle: The anterior triangle is situated at the front of the neck. It is bounded: Superiorly – Inferior border of the mandible (jawbone) Laterally – Medial border of the sternocleidomastoid Medially – Imaginary sagittal line down midline of body 5/15/2017 4
- 5. Contd... Contd... The muscles in this part of the neck are divided as to where they lie in relation to the hyoid bone, which are: Suprahyoid Muscle: Stylohyoid Digastric Mylohyoid Geniohyoid Infrahyoid Muscle: Omohyoid Sternohyoid Sternothyroid Thyrohyoid 5/15/2017 5
- 8. Contd... Anterior triangle is further divided into following parts: Carotid triangle Submental triangle Submandibular triangle Muscular triangle 5/15/2017 8
- 9. Contd... Carotid triangle: The carotid triangle of the neck has the following boundaries: Superior: Posterior belly of the digastric muscle. Lateral: Medial border of the sternocleidomastoid muscle. Inferior: Superior belly of the omohyoid muscle. The main contents of the carotid triangle are the common carotid artery (which bifurcates within the carotid triangle into the external and internal carotid arteries), the internal jugular vein, and the hypoglossal and vagus nerves. 5/15/2017 9
- 10. Contd... Submental triangle: It is bounded: Inferiorly – Hyoid bone. Medially – Imaginary sagittal midline of the neck. Laterally – Anterior belly of the digastric. The submental triangle is situated underneath the chin. Its main content is the submental lymph nodes, which filter lymph draining from the floor of the mouth and parts of the tongue. 5/15/2017 10
- 11. Contd... Submandibular triangle: The submandibular triangle is located underneath the body of the mandible. It contains the submandibular gland (salivary), and lymph nodes. The facial artery and vein also pass through this area. The boundaries of the submandibular triangle are: Superiorly: Body of the mandible. Anteriorly: Anterior belly of the digastric muscle. Posteriorly: Posterior belly of the digastric muscle. 5/15/2017 11
- 12. Contd... Muscular triangle: This area actually have four boundaries. It doesn’t contain vessels, It however contain some muscles and organs – the infrahyoid muscles, the pharynx, the thyroid and parathyroid glands. The boundaries of the muscular triangle are: Superiorly: The hyoid bone. Medially: Imaginary midline of the neck. Supero-laterally: Superior belly of the omohyoid muscle. Infero-laterally: Inferior portion of the sternocleidomastoid muscle. 5/15/2017 12
- 13. Contd... Posterior triangle: The posterior triangle of the neck is an anatomical area located in the lateral aspect of the neck. Its boundaries are as follows: Anterior: Posterior border of the SCM. Posterior: Anterior border of the trapezius muscle. Inferior: Middle 1/3 of the clavicle. 5/15/2017 13
- 14. Contd... Structures in posterior triangle are vertebral muscles, external jugular vein, subclavian vein ,cervical plexus etc. Posterior triangle is divided into two divisions by the omohyoid muscle, which are: Occipital triangle: the larger, superior part Subclavian triangle: the inferior part 5/15/2017 14
- 15. Contd... For imaging purposes, the boundaries of the neck are Mandible and the Mylohyoid muscles anterosuperiorly The base of the skull posterosuperiorly The scapulae posteroinferiorly, and The thoracic inlet centrally in the inferior aspect. 5/15/2017 15
- 16. Contd… Neck Spaces Another approach to the anatomy of the neck is the so-called 'spatial approach’. The ‘neck space’ concept is a commonly used method in radiology in organizing the neck and establishing appropriate differential diagnosis for pathology discovered within a specific space of the neck. The hyoid bone is used as a landmark to divide the neck into the suprahyoid and infrahyoid. 5/15/2017 16
- 17. Contd… Suprahyoid neck parapharyngeal space parotid space pharyngeal mucosal space masticator space buccal space danger space 5/15/2017 17 Infrahyoid neck anterior cervical space posterior cervical space visceral space Supra and Infrahyoid neck carotid space retropharyngeal space perivertebral space Subligual space Submandibular space
- 21. Lymph nodes The neck has an extensive lymphatic network containing more than one third of the body's total number of lymph nodes. Typically, as many as 75 lymph nodes are located on each side of the neck 5/15/2017 21
- 22. Lymph nodes They are classified into following groups according to its location: Level I:Submental & Submandibular nodes Level II: Upper Internal Jugular Vein nodes Level III: Middle Internal Jugular Vein nodes Level IV: Lower internal Jugular Vein nodes Level V: Posterior Triangle nodes(Spinal accessory, Transverse cervical, Supraclavicular) Level VI: Anterior Triangle nodes(Paratracheal, Pretrachial, Visceral) 5/15/2017 22
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- 35. Indications Inflammatory, nodal and tumoral diseases including lymphoma and metastases. Thyroid diseases Pharyngeal lesions Salivary glands pathologies Detection /confirmation of lesions Follow-ups Baseline scans Trauma 5/15/2017 35
- 36. Contra-indications Hypersensitivity to iodinated contrast media Pregnancy(relative) Renal diseases 5/15/2017 36
- 37. Patient Preparation Clear history should be taken along with reports of previous investigations. Pregnancy needs to be ruled out. Radiopaque materials should be removed from FOV. Proper information and instruction about the procedure. NPO for 4-5 hours prior to procedure for CECT. 5/15/2017 37
- 38. Patient Preparation Blood creatinine levels should be in its normal limit (M=0.6 to 1.5,F=0.5-1.2 mg/dl) and Blood urea level should range between 9 to 42 mg/dl Signed informed consent from patient or his/her close relatives. Irritable/uncooperative and Pediatric patients should be sedated. Neck should be in neutral position. The patient should be instructed to avoid swallowing movements. 5/15/2017 38
- 39. Routine Neck protocol Patient positioning Head first, supine with arms by the sides of the trunk with hands tucked under the hips. Head rest/support can be applied to restrict the neck movement. Topogram position/Landmark: lateral; level of forehead Mode of scanning: Helical with single breath-hold technique Scan orientation Cranio-caudal Starting location:Base of the skull End location :Arch of the aorta Cranio-caudal orientation reduces artifacts at the level of the thoracic inlet caused by the beam-hardening effects of the contrast agent. 5/15/2017 39
- 40. Routine Neck protocol FOV: Just fitting the ROI. Gantry tilt To make the plane of the scanning parallel to the hard palate or perpendicular to the plane of larynx. Contrast administration: Intravenous and monophasic Volume of contrast: 80-100 ml Rate of injection of contrast: 2-3 ml/sec Scan delay: 30-40 sec 5/15/2017 40
- 41. Routine Neck protocol Slice thickness in reconstruction 3-5 mm Slice interval in reconstruction 1.5-2.5 mm Reconstruction algorithm/kernel Medium smooth for soft tissue. Sharp for cartilage, bone and lung parenchyma in the scan range. 3D-Reconstructions MPR MIP 5/15/2017 41
- 42. Routine Neck TUTH Protocol Patient positioning : Head first, supine with arms by the sides of the trunk, Head rest preferred Topogram position/Landmark: lateral; level of forehead Mode of scanning: Helical Scan orientation Cranio-caudal Starting location: Base of the skull End location :Arch of the aorta Slice Acquisition: 0.6x128 Recon Slice Thickness: 0.75mm Recon Interval:0.7mm 5/15/2017 42
- 43. Routine neck TUTH Protocol FOV: Just fitting the ROI. Gantry tilt: Nil Volume of contrast: 80-100 ml Rate of injection of contrast: 2-3 ml/sec Scan delay:35-40 sec Recon Algorithm: b31s medium smooth 3D recon: MPR Window Setting: W/L: 250/50 Filming: 3mmx3mm Axial: Plane + Contrast film Coronal and Sag MPR film 5/15/2017 43
- 44. Protocol for Larynx and Hypopharynx Indications Screening for inflammatory or tumoral diseases of the larynx and hypopharynx. Preoperative baseline scan Post-surgery or post-chemotherapy follow-ups. Patient positioning Head first, supine with arms by the sides of the trunk with hands tucked under the hips. Head rest/support can be applied to restrict the neck movement. 5/15/2017 44
- 45. Protocol for Larynx and Hypopharynx Topogram position/Landmark lateral; level of forehead Mode of scanning Helical with single breath-hold technique Scan orientation Cranio-caudal Starting location: Base of the skull End location : Arch of the aorta FOV Just fitting the ROI. 5/15/2017 45
- 46. Protocol for Larynx and Hypopharynx Gantry tilt: To make the plane of the scanning parallel to the hard palate or perpendicular to the plane of larynx. Contrast administration: Intravenous , monophasic Volume of contrast: 80-100 ml Rate of injection of contrast: 2-3 ml/sec Scan delay: 30-40 sec Slice thickness in reconstruction : 3-5 mm Slice interval in reconstruction : 1.5-2.5 mm 5/15/2017 46
- 47. Protocol for Larynx and Hypopharynx Reconstruction algorithm/kernel Medium smooth for soft tissue. Sharp for cartilage, bone and lung parenchyma in the scan range. 3D-Reconstructions MPR MIP Virtual endoscopy Dynamic maneuvers phonation (for a better visualization of the laryngeal ventricle) modified Valsalva (for a better visualization of the pyriform sinuses and upper airway). 5/15/2017 47
- 48. CT Carotid Angiography Indications Suspected occlusion of the carotid arteries, their aneurisms, dissections. Preoperatively for head /neck tumors to detect the origin of their feeding vessels for the purpose of ligation. The goals of CTA for cervicocranial vascular evaluation can be summarized as follows: to accurately measure stenosis of the carotid and vertebral arteries and their branches to evaluate the circle of Willis for completeness using three-dimensional reformations of cerebral vasculature in relation to other structures, and to detect other vascular lesions, such as dissections or occlusions. Patient positioning Head first, supine with arms by the sides of the trunk with hands tucked under the hips. Head rest/support can be applied to restrict the neck movement.5/15/2017 48
- 49. CT Carotid Angiography Topogram position/Landmark: lateral; level of forehead Mode of scanning: Helical with single breath-hold technique Scan orientation :Caudo-Cranial Starting location: Arch of the aorta End location : 2-3 cm above the sella FOV: Just fitting the ROI. Gantry tilt: Nil Contrast administration: Intravenous , monophasic, Saline chasing(half the volume of NS w.r.t the volume of contrast administration is given immediately after contrast administration, which reduces contrast volume, streak artifact and gives better and consistent enhancement) 5/15/2017 49
- 50. CT Carotid Angiography Volume of contrast: 80-100ml Rate of injection of contrast: 4-5 ml/sec Scan delay: 10-15 sec Slice thickness in reconstruction : 1.0-1.5 mm Slice interval in reconstruction : 0.5-0.75 mm Reconstruction algorithm/kernel: smooth 3D-Reconstructions MIP VRT (preferably after bone subtraction) 5/15/2017 50
- 51. Carotid Angio TUTH Protocol Patient positioning : Head first, supine with arms by the sides of the trunk, Head rest preferred Topogram position/Landmark:lateral; level of forehead Mode of scanning: Helical Scan orientation: Caudo-Cranial Starting location: Base of the skull End location :2-3 cm above the sella Slice Acquisition: 0.6x128 Recon Slice Thickness: 0.75mm Recon Interval:0.7mm 5/15/2017 51
- 52. FOV: Just fitting the ROI. Gantry tilt: Nil Volume of contrast: 80-100 ml Rate of injection of contrast: 4-5ml/sec Bolus Tracking(ROI: Arch of aorta), Post Threshold Delay:5 sec Window Setting: W/L: 800/90 Recon Algorithm: b30f medium smooth 3D recon: MIP, VRT(with subtraction) 5/15/2017 52 Carotid angio TUTH Protocol
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- 57. Spaces and pathologies 5/15/2017 57 Jugular vein thrombosis
- 60. Spaces and pathologies 5/15/2017 60 Sarcoma
- 61. References CT and MRI protocol- a practical approach, Satish K Bhargava. CT and MRI of whole body, Fifth edition, Johan R. Hagga. Anatomy for Diagnostic Imaging, second edition Sectional Anatomy for Imaging Professionals, ed 2, LORRIE L. KELLEY www.radiologyassistant.nl 5/15/2017 61
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Hinweis der Redaktion
- Laryngeal prominence (Adam's apple) in the midline formed by the thyroid cartilage at approximately C4. Inferiorly the ring of the cricoid cartilage may be palpated at C6. The tips of the transverse processes of C1 are more prominent than those of other cervical vertebrae and can be palpated in the parotid space bilaterally between ramus of the mandible and mastoid process. The hyoid bone: Its body is at the level of C3. It has lesser and greater horns bilaterally. The thyroid cartilage lies at the levels of C4 and C5. The laryngeal prominence is Adam's apple in the male. The thyroid cartilage is composed of 2 lateral laminae with superior and inferior horns. The inferior horns articulate with the cricoid cartilage. The cricoid cartilage is at C6. The upper end of the trachea is palpable in the midline from the cricoid cartilage to the superior border of the manubrium. The thyrohyoid membrane is pierced by the internal laryngeal nerve and vessels. The cricothyroid membrane may be used for a high tracheostomy. *The preferred site of tracheotomy is at tracheal cartilages 2-4 (below cricoid cartilage and isthmus of the thyroid gland). Craniovertebral Joints Atlanto-occipital joint: joint between atlas (vertebra C1) and occipital bone; movements - flexion - extension of the neck (nodding the head in "yes" movement). Atlanto-axial joint: joint between atlas (C1) and axis (C2); movement: lateral rotation of atlas on axis (shaking head in "no" movement) Ligaments of joint - stabilize joints and protect medulla and spinal cord; some prevent excessive movement; some are extensions of ligaments of spinal column