Skull Radiography

SKULL RADIOGRAPHY
INTRODUCTION
• In order to produce high-quality diagnostic images of the cranium
and minimize the radiation dose to the patient, the radiographer
must have a good understanding of the relevant anatomy,
positioning landmarks and equipment used for imaging.
• Skull images are recognized as one of the most difficult to interpret

due to the complexity of the bony construction with numerous
irregular bones forming a sphere joined by sutures.
LANDMARKS
• Outer canthus of the eye: the lateral point where the upper and lower eyelids meet.
• Nasion: the articulation between the nasal and frontal bones.
• Glabella: a bony prominence found on the frontal bone immediately superior to the
nasion.
• Vertex: the highest point of the skull in the median sagittal plane.
• External occipital protuberance (inion): a bony prominence found on the occipital
bone, usually coincident with the median sagittal plane.
• External auditory meatus (EAM): the opening within the ear that leads into the
external auditory canal.
PATIENT PREPARATION FOR SKULL
RADIOGRAPHY
• Ensure all metal/radio-opaque objects are removed from the patient, e.g. hair
clips or pins.
• Ponytails/bunches of hair often produce artefacts and thus should be loosened.
• If the area of interest includes the mouth, then false teeth containing metal or
metal dental bridges should be removed unless the patient has facial injuries as
they may be assisting retention of the airway.
• The patient should be provided with a clear explanation of the procedure.
GENERAL GUIDELINES
• Whenever possible, use an OF (occipito-frontal or PA) rather than an FO (fronto-

occipital or AP) technique as this greatly reduces the dose to the orbits.
• 24 × 30 cm CR cassettes are generally utilized for plain skull radiography or
appropriate collimation when using DDR.
• A grid, moving or stationary, should be used for skull radiography to ensure high
resolution and definition of fine detail in the bony anatomy of the skull.
• Any patient suffering a head injury or any severe trauma affecting the skull
should be referred for a CT scan if available rather than a skull x-ray.
Position of patient and image receptor
LATERAL ERECT• The patient sits facing the erect Bucky/receptor and the
head is then rotated such that the median sagittal plane
(MSP) is parallel to the Bucky/receptor and the
interpupillary line is perpendicular to the Bucky/ receptor.
• This projection can also be performed with the patient
prone on a floating-top table with a collimated vertical
beam., however, an air/fluid level in the sphenoid sinus
(an indicator for a base of skull fracture) will not be visible
Direction and location of the X-ray beam
• Center with a collimated horizontal beam midway
between the glabella and the external occipital
protuberance to a point approximately 5 cm superior and
posterior to the EAM.
Position of patient and image receptor
OCCIPITO-FRONTAL
• This projection may be undertaken erect or in the prone position.
The prone projection may be uncomfortable for the patient.
• The patient is seated facing the erect Bucky/receptor so that the
MSP is coincident with the midline of the IR and is also
perpendicular to it.
• The neck is flexed so that orbito-meatal line is perpendicular to the
IR. This can usually be achieved by ensuring the nose and forehead
are in contact with the Bucky/receptor.
• The collimated horizontal beam is directed perpendicular to the
Bucky/receptor along the median sagittal plane.
• The beam collimation should include the vertex of the skull
superiorly, the region immediately below the base of the occipital
bone inferiorly and the lateral skin margins.
• Occipito-frontal (OF) projections can be employed with different
degrees of caudal angulation (OF10°↓, OF15°↓, OF20°↓).
• Fronto-occipital (FO) projections of the skull will
FRONTO-OCCIPITAL
demonstrate the same anatomy as OF
projections. The orbits and frontal bone,
however, will be magnified as they are
positioned further from the image receptor.
• Such projections should only be undertaken
when the patient cannot be moved and must be
imaged supine. These projections result in an
increased radiation dose to the orbits and some
loss of resolution of the anterior skull structures
due to increased object-to-receptor distance.
• All angulations for FO projections are made cranially
(FO10°↑, FO15°↑, FO20°↑).
HALF AXIAL, FO
30°↓ (TOWNE’S Position of patient and image receptor
PROJECTION) • The patient lies supine on the X-ray table with the
posterior aspect of the skull resting on an IR/gridded CR
cassette.
• The head is adjusted to bring the MSP perpendicular to
the IR.
• The orbito-meatal line should be perpendicular to the IR.
• Direction and location of the X-ray beam
• The collimated vertical beam is angled caudally so it
makes an angle of 30° to the orbito-meatal plane.
• Collimation is set to ensure the lower border is
coincident with the superior-orbital margin and the
upper border includes the skull vertex. Laterally the skin
Correctly positioned Townes with sella turcica margins should also be included within the field.
seen within the foramen magnum.
SUBMENTO- Position of patient and image receptor
VERTICAL • The patient sits or lies supine and the neck is .
hyperextended to bring the vertex of the skull in
contact with the IR.
• The head is adjusted to bring the EAMs
equidistant from the image receptor.
• The MSP should be perpendicular to the IR and the
orbito-meatal line should be near parallel to the IR.
• The collimated perpendicular beam is directed
perpendicular to the orbito-meatal lines and
centered midway between them.
• An optimum projection will demonstrate the
mandibular angles clear of the petrous portions of
the temporal bone.

Skull Radiography

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SKULL RADIOGRAPHY

• Skull images are recognized as one of the most difficult to interpret

• Whenever possible, use an OF (occipito-frontal or PA) rather than an FO (fronto-

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