Although it may seem a rash, even ill-conceived, undertaking to devote a mono graph to cerebral angiography at a time when CT seems to be the most important neuroradiologic procedure, this is definitely not the case. Moreover, the authors are aware of the necessity of taking these new techniques into account. Cerebro-arterial occlusive diseases are frequently the cause of acute and chro nic neurologic disturbances. The authors' aim in preparing this book was to demonstrate the value of neuroradiology in the diagnosis of these conditions. They have accomplished their purpose, and above all, they have succeeded in demonstrating how angiography and CT complement each other. They point out the absolute necessity of high quality in angiographic imaging; indeed, arterial occlusive diseases may have a very capricious and unexpected evolution that can be followed-up by iterative CT examinations - for instance once a week - but angiography, which is performed only once, must be as perfect and informative as possible. Both authors received part of their training in the Neuroradiologic Depart ment of the University Hospital in Strasbourg. I am thus very pleased to find in this book both the perfection I was accustomed to seeing in G. B. BRADAc's iconography and the sound judgement I always appreciated in R. OBERSON. Therefore, it is with great satisfaction that I write this foreword. It is my wish that both authors achieve the recognition they rightfully deserve in the Univer sities of Berlin and of Lausanne."

It is amazing to discover how little importance has been attached to narrow lumbar canal syndromes up to now. Though H. VERBIEST gave a very accurate description in 1949, the neurologist's and neurosurgeon's preoccupations were mainly focused on discal pathology, disregarding the problem of an exclusively bony origin in canalar stenosis. A. WACKENHEIM and E. BABIN have the merit of becoming aware of the impor tance and originality of this problem; they organized in the beautiful surround ings of the Bischenberg near Strasbourg, a postgraduate course, in which the most eminent European specialists in this field participated. I am very honored to have been asked to write the introduction to this mono graphy, which contains all the studies reported and commented on during this meeting. Before considering the problem from the various radiologic points of view, it is in my opinion indispensable to define the term "stenosis." We could not do so more accurately than by assuming the definition proposed by A. WACKENHEIM and E. BABIN and unanimously confirmed by all those who attented the session."

Radiology, the youngest of the major medical sciences, has undergone an extraordinary technical evolution since the discovery of X-rays. It began with the development of the different types of tomography and the adoption of many contrast agents, then proceeded rapidly to serioscopy, subtraction of images, direct enlargement, echography, thermography, and xerography. Today, even before all these innovations have come into common use, another branch of radiologic technology has evolved: computerized (axial) tomography. More than just an innovation, its true dimensions are unfore seeable. Radiology has become in less than a century an indispensable adjunct to the practice of medicine. The development of radiology as a speciality followed its technical advances, which varied greatly from country to country. This rapid development led quickly to subspecialization, even the very early development of radiotherapy and radiodiagnostics as separate entities. However, the entry of radiology into the university has preserved it a single branch of medicine, avoiding the frequent tendency toward auto nomy of the branches of a speciality. Today the fourth generation of radiologists is faced with another deci sion: whether to become technologists subjugated to their machinery, to become sub specialists with a single skill, or to remain doctors. The vast majority of this fourth generation has rejected becoming an accessory to a master technique and rather has specialized according to the hippocratic concept of medicine."

Master of all endocrine activity and executive organ of one's quality of life, the pituitary gland is tightly lodged in the" turkish saddle. " As a bony container, the sella turcica is to the hypophysis what the skull is to the brain; it can therefore be looked upon as a little vault within the cranial vault. Just as the cranium is moulded by the growth of the brain, so is the sella fashioned by its content. It becomes locally enlarged in response to expanding intrasellar lesions, and it tends to return to its original size and shape upon their removal or destruction. Pituitary adenomas have in the past been diagnosed upon enlargement of the sella turcica. In the past decade, as a direct result of interdisciplinary coopera- tion, we have learned that tiny adenomas, the immediate cause of some cases of acromegaly, amenorrhea-galactorrhea syndrome, or Cushing's disease, can exist with minimal or no observable effect on the size of the sella. The break- through started when radioimmunoassay, as a new method of accurately measur- ing specific hormonal output, indicated selective pituitary oversecretions in pa- tients with normal-sized sellae. Neurosurgeons highly skilled in the transsphenoi- dal approach with the surgical microscope were obliged to operate on some of these patients and confirmed the presence of tiny oversecreting adenomas in their pituitary glands.

It is with great pleasure and, much interest that I accepted to write the foreword to this book by Paul Doury, Yves Dirheimer, and Serge Pattin on the subject of "algodystrophy." First, because I know the extent of their personal experience, from which they have selected the best for this book. Second, because it seemed to me that their detailed analysis of the numerous works on the subject, works which have been published all over the world and which provide diverse physiopathologic interpretations, would provide a comprehensive study meeting a real need. Algodystrophy, to adopt the term used by the authors, merits rheumatolog ists' careful attention. It is indeed a frequent condition and, as is now well known, occurs in the most varied etiologic circumstances; it is not solely posttraumatic, a notion on which diagnosis had long been based. This variable etiology suggests the complexity of algodystrophy's pathogenic mechanism."

In 1932 there appeared the work of SCHMORL and JUNGHANNS, Die gesunde und kranke Wirbelsiiule im Rontgenbild, which laid the foundations of diagnostic radiology of the spine. Since that time the discipline has been extended and refined in a systematic manner and our knowledge has been greatly enriched by the large number of monographs in which leading experts have assembled additional data. An encyclopedic treatment of all that is currently known requires not only that reference be made to all work published since 1932 in order to reveal the problems that remain but also that a serious attempt be made to contribute to the solution of such problems. For this reason, Professor TONDURY and Professor THEILER of Zurich, who know more than anyone else about the ontogeny of the spine, have been invited to display their erudition in this field. Should contra dictions or divergent opinions on certain points be revealed through this confrontation with radiologically obtained findings, so much the better; the effect of this could only be to spur workers in both disciplines on to more advanced research. We have only to recall how in Goethe's time the premaxilla was still the subject of controversy, yet this great man pursuing his studies in comparative anatomy and anthropology was able to prove its existence beyond all doubt. Mainz, May 1974 L. DIETHELM Inhaltsverzeichnis - Contents A. Die normale Wirbelsliule . . . . . . . . . . . . . . . . . . . . 1 1 I. Phylogenetische Entwicklung des Achsenskelets. Von K. THEILER 1 1. Die Bogenelemente. . . . . . . . . . . . . . . 2. Die Chorda dorsalis . . . . . . . . . . . . . ."

It is a privilege and pleasure to write a foreword to this work. Who, twenty years ago, would have thought that a whole book could be devoted to the veins of the posterior fossa? Even today the standard text-books of anatomy only give a paragraph to the subject. Thanks to the dedicated work of rather a few neuroradiologists our knowledge has now reached a very sophisticated level. The careful correlation of anatomical dissection with the angiographic image has achieved this, but without the aid of subtraction (discovered by a world figure in neuroradiology - Professor ZIEDSES DES PLANTES) the subject would not be as advanced as it is. The authors are to be congratulated not only for presenting the most up to date anatomical information but also for showing how wide the applications are in the clinical field by the careful analysis of displacements of veins, many of which were quite unrecognised only a very few years ago. Drs W ACKENHEIM and BRAUN are in the forefront of this discipline to which they and the French school have contributed so much. Also it was their great enthusiasm and drive which led to the birth of the European Society of Neuroradiology, the first meeting of which was held in Colmar in September 1969. The Society has flourished under their guidance and very successful annual meetings have been held for nearly a decade.

Technical advances in the field of mammography and better interpretation of the photographs have led recently to a more precise and reliable means of diagnosis, especially for findings which are difficult to analyse. With the help of numerous pathological and control cases the authors explain both the step-by-step procedure in diagnosis and the advantages of mammography as the choice of examination in particular patients. This book guides the reader to an exact interpretation of mammograms. The book is directed at radiologists, gynaecologists and general practitioners. Interdisciplinary collaboration and diagnosis in the preclinical stage are especially important for furthering the prevention of breast cancer.

These exercises are meant for students and practitioners who wish to familiarize themselves with the normal and pathologieal computerized tomographie radioanatomy of the abdomen. The iconography is suffieiently characteristic to be read without the help of clinical or biological data. It comprises both normal and pathologie findings. Analysis of scans is comprised of two steps. The first part consists of the detailed study of normal scans, whieh serve as a reference. For this, eight main slice levels have been considered necessary and sufficient: neces sary since a certain number of slices are indispensable for the exploration of the abdomen; sufficient because a larger number of slices would risk rendering memorization difficult. The second part involves a study of the pathologie findings, organ by organ. Acknowledgements. Appreciation is extended to all those who have helped in realizing this study and, more particularly, to our friends and colleagues, J. L. DIETEMANN, C. Roy, J. L. BURGUET, M. VOUGE, and J. W. SOUITER. We would also like to thank Dr. J. WIECZOREK for his friendly assistance and advice in the planning and presentation of figures and schemata. 1 Technical Note Computerized tomography of the abdomen begins with an initial image called "scout view". This numbered radio graph of the abdomen is an analogous representation of the information and allows the location of the eight selected slice levels; these are represented by horizontallines. The slices are 10 mm thick and are taken at intervals of 2.5 cm.

This book, the seventh in the series Exercises in Radiological Diagnosis, deals with sonography, an imaging procedure in which the ability of the radiologist plays an exceptionally important role. The author, Catherine Roy, has very extensive experience in the clinical use of sonography. She has selected the images, which are of excellent quality, with great care to illustrate a wide range of conditions and has supplemented them by commentaries and discussions which are easy to comprehend. The systematic use of schematic drawings to interpret the images makes it possible for the reader to follow the author's approach without any difficulty. Schematic drawings are par ticularly important in sonography because the relationship be tween the details in the images and the anatomy may be very weak. Images, schematic drawings, and text (both commentaries and interpretations) are three didactic elements which Cathe rine Roy has skill-fully combined in these exercises into an excellent whole. A. WACKENHEIM v Contents Introduction . . . . . . . . . . . . . . . . . . 1 Iconography, Commentary with Corresponding Schemata. . 2 Subject Index 203 VII Introduction Ultrasound imaging of the abdomen has now become a routine investi gation. It has brought about changes in the procedure of additional investigations and even rendered part of conventional radiology redun dant, particularly that concerning the bile ducts. These exercises are meant for students or physicians who already have basic knowledge of ultrasound diagnosis. It has not been possible to cover the entire spectrum of abdominal pathology, especially trauma, with 114 cases.

Osteoarticular pathology is a very frequent motive for consultation. Very often, the diagnosis relies upon symptomatology, and the physi cian requires confirmatory radiological investigations. Whatever the clinical indication, the interpretation of radiological data must be very rigorous. On the basis of a complete description of the radiographic images, according to a systematic analysis plan, a certain number of diagnostic hypotheses may be proposed. Selection of the most likely hypothesis requires the correlation of clinical, biological, and radiological data, and may sometimes necessi tate additional investigations, such as tomograms, scintigrams, and computed tomography (CT). 1 Part One Iconography 3 3 1 2 4 5 5 6 6 7 8 b a 8 a 9 10 11 12 10 13 14 11 15 a b 12 a c 13 17 b a c 14 15 c 16 17 23 21 a 22 b 18 19 20 21 22 23 33 34 24 25 37 38 26 27 40- 43 28 29 46 30 48 47 31 49 50 32 33 52 a b c 34 53 a b d c 35 54 a b 36 37 55 a 38 55 b c 39 56 57 40 58 41 60 61 42 43 63 64 44 65 66 45 67 68 46 69 a b 47 70 71 48 73 49 74 75 50 76 77 51 78 79 52 80 a b c 53 81 82 54 83 84 55 85 86 S6 87 88 57 89 90 58 91 92"

I am proud that this study of the hand appears in the series Exercises in Radiological Diagnosis founded by A. WACKEN HEIM. From time eternal, man has tried to explain the numerous configurations and lines of the hand in order to reveal the true character of a person and to display his life. The importance of the symbolism of the hand is reflected in its role in the cultural life of the old world. Therefore, it is not astanishing that the first book about the hand, by Johannes Hartlieb, was devoted to Chiromancy, and that it was so successful that it went through four editions since the second half of the fifteenth century. When Wilhelm Rontgen in 1895 asked his wife to lay her hand on a photographic plate covered with black paper and exposed it to the radiation he had just discovered, it marked the beginning of radiology. Today the study of the hand concerns only 2%-4% of the activity of radiology. It nevertheless reveals an amazing quantity and variety of pathology. That is the reason for this work. - The authors wishes to thank his friends Y. DIRHEIMER, rheumatolog1st, J. C. DoscH, traumatologist, and G. Fou CHER, surgeon, who provided some of the material for the illustrations. P. BouRJAT VII Contents Part One: Iconography . . . . . . . . . . . . . . . . 1 Part Two: Commentary with Corresponding Schemata 117 Subject Index . . . . . . . . . . . . . . . . . . 203 . . ."

Marcelle Megret has assembled a comprehensive collection of radiographie images during her work in the field of com puted tomography of the cranial skeleton. This collection and her experience have made it possible for her to prepare these exercises in radiological diagnosis concerned exclusively with craniofacial tomodensitometry. The viewer will appreciate the choice of original docu ments of the highest quality, and also note the delicacy of execution of the diagrams, all drawn by the author herself. Marcelle Megret, like most of my students, conceives and carries out the schematas herself. The requirements concern ing certainty, strictness, precision, and objectivity would lead her to agree with Ludwig Wittgenstein's observations that since certain things cannot be said they must be shown, and that rules are insufficient when there are no examples. I should like this book to be successful. It inaugurates Marcelle Megret's career as an author and is an honor to the University of Geneva.

Like my first book of exercises in radiological diagnosis con- cerning the vertebrae in adults, the first part of this book consists of an atlas of images ready for immanent reading. The images are numbered, each number corresponding to a case. The second part comprises the corresponding comments, critical interpretations, and drawings (using the same num- bers as the corresponding radiographs in the first part). I hope that this second booklet will be as appreciated as was the first, which was published in four languages (Radio- diagnosis of the Vertebrae in Adults. Springer, Berlin Hei- delberg New York 1983). My own documentation having proved deficient in some fields, I had recourse to the didactic collections oimy collea- gues, friends, and students. Special thanks are due to Prof. J. F. Bonneville, and to Drs. J. L. Dietemann, Y. Dirheimer, J. C. Dosch, and J. Vignaud. AUGUSTE WACKENHEIM VII Contents Introduction ...1 Part One: Iconography 5 Part Two: Commentary with Corresponding Schemata. 107 References . . 189 Subject Index 191 IX Introduction The analysis or the reading of an X-ray picture proceeds from struc- turalistic rules, such as the immanence, the synchronism, the significa- tion (signifiant and signifie of a sign), first from the semeiologic and then from the semantic point of view. In a simpler way, one can say that it is necessary to distinguish the signifiant, the signiGBPie, the comment, the interpretation, and the radiobioclinical confrontation. The signifiant or character is a normal or pathological "characteris- tic" part of the image.

This volume is the latest in the series Exercises in Radio logical Diagnosis, launched by the Strasbourg School of Radio logy. Further volumes on the facial bones, senology, and abdominal tomography are in preparation. Jean-Louis Dietemann has over a decade's experience of radiodiagnosis of the skull, and has already proven his talents as a teacher with his earlier books on the sella turcica and on carotid angiography. The present volume will assuredly be a great success and will enhance the series. Professor A. W ACKENHEIM Hospices Civils de Strasbourg Centre Hospitalier Regional Service de Radiologie I Strasbourg v Contents Part One: Iconography . . . . . . . . . . . . .. . . 1 . Part Two: Commentary with Corresponding Schemata. 85 References . . 165 Subject Index 167 VII Part One Iconography 1 1 a b 3 2 a b 4 3 4 5 6 6 a b 7 7 8 8 a b 9 9 10 10 11 a b 11 12 13 a b 13 a b 14 b 15 16 17 16 17 20 18 21 a b 19 22 a b 20 21 24 a b 22 b 23 26 27 24 a 25 26 29 27 31 32 28 33 34 29 35 36 30 37 a b 31 38 39 32 40 41 33 42 43 34 44 a b 35 44 c 45 a 36 45 b ~----~------~~ c 37 46 47 38 48 49 39 50 a b 40 41 52 53 a 42 53 b 54 a 43 54 b 55 44 56

This book is intended for beginners and for those who want to refresh their knowledge of the elementary radioanatomy of the vertebrae, particularly their pathological radioanatomy. I do not pretend, as does Roger Martin du Gard's hero, that one always must begin with a radiographic examination, but I do believe that a student, especially one interested in radiology, must be able to apprehend an image isolated from its clinical context. To optimize memorization of the image I have selected unmistakable cases with marked, well-evolved lesions. This will enable the studentlater to recognize less distinct images of the same kind. The first section of the book is exclusively iconographic. After studying an image, the reader will find in the second section, under the appropriate reference number, a commen tary illustrated with a realistic drawing by my friend Dr. Csaba Hethalmi. Attention to the following points will assist a fruitful reading: 1. Cases 1-5 involve normal subjects; all other cases are pathological. 2. The reader must imagine that he is conducting a routine examination and draw on his resources to make a practical analysis of an image. As a matter of fact, all the films (except that in case 46, which is the radiograph of a specimen) were -indeed taken under routine conditions using standard pro jections. 3. The cases are in no systematic or nosological order. Each case is illustrated with one, two, or (rarely) three images.

In this book are published papers presented at the first meeting about tomodensito metry (Computer Tomography) which the CEPUR organized in Luxembourg in March 1977. CEPUR (College d'enseignement post-universitaire de Radiologie) is an international medical association having as its main aim the promotion of courses in advanced radiology. Several sections deal with the subspecializations, one of which is Com puter Tomography. Thanks to the fruitful cooperation of several University Hospitals (Ancona, Leuven, Montpellier, Bruxelles, Strasbourg), the two-day meeting organized by Dr. Capesius in Luxembourg covered a certain number of aspects of clinical tomodensitometry in the brain as well as in the trunk. We hope that this volume will be the first of a series dealing with the actual problems in clinical radiology. Leuven/Bruxelles/Strasbourg A. BAERT L. JEANMART A. WACKENHEIM Contents I. Introduction to the Technology of Computer Tomography K. Ungerer. With 18 Figures ... 2 II. Head Sellar Region: Normal and Pathologic Conditions. U. Salvolini, F. Menichelli, and U. Pasquini. With 40 Figures ...... 14 Empty Sella and Pituitary Gland. J.L. Dietemann and A. Wackenheim. Wi th 3 Figures . . . . . .... . ., 38 Midline Lesions. D. Baleriaux-Waha, L.L. Mortelmans, M. Dupont, and L. Jeanmart. With 17 Figures ....... .. 39 Ventriculocisternal Pathology in Children. D. Touitou. With 9 Figures . . . . . . . . . . . . . . .. ....... 47 Endocranial Calcifications. J.H. Vandresse, G. Cornelis, and A."

It was with great pleasure that I accepted Professor Wackenheim's invitation to write the preface of this most interesting monograph. During the international course on neuroradiology in Obernai, organized by Professor Wackenheim in 1978, an entire day was devoted to discussions about various aspects of stenosis of the lumbar vertebral canal. As Professor Wackenheim and his group, in particular Dr. E. Babin, had thorough. ly studied this field, it was an excellent occasion for the exchange of views through personal contact. Their support of basic views such as attributing the cause of stenosis to a developmental disturbance of growth of the neural element - the vertebral arc- and spontaneous agreement about essentials in classification and nomenclature facili tated this exchange. Reading the present monograph made me think back to 1949 when I wrote my first publication on stenosis of the lumbar vertebral canal in a French volume that com memorated my teacher in neurosurgery, Professor Clovis Vincent. During the following years it was impossible to publish a more detailed paper on the subject in international journals since their editorial boards did not believe in its occurrence. My first English papers were published in the Journal of Bone and Joint Surgery (1954, 1955), but it was only during the 1970s that this form of stenosis became more universally recog nized."

Dieses Aoebungsbuch richtet sich an Studenten, A"rzte und Radiologen, die sich mit der Auswertung von Computertomogrammen des Abdomens vertraut machen wollen. Die einzelnen FAlle zeigen zum einen Kontrollaufnahmen des Gesunden und zum anderen pathologische VerAnderungen, die organspezifisch klassifiziert sind. Der Leser wird im vorliegenden Band schrittweise an die systematische Interpretation der Computertomogramme herangefA1/4hrt.

Wie in unserem ersten Ubungsbuch zur Rontgendiagnostik der Wirbel des Erwachsenen, wird es hier zwei verschiedene Teile geben. Der erste Teil besteht nur aus Bildern, die immanent gelesen werden sollen. Die Bilder sind laufend numeriert; jede Nummer entspricht einem Fall. 1m zweiten Teil geben wir Kommentare, kritische Interpre tationen und Skizzen dieser Bilder unter den entsprechenden Nummern. Ich wiinsche diesem zweiten Biichlein den gleichen Erfolg wie dem ersten, das in 4 Sprachen erschienen ist. Da meine eigene lkonographie manchmal unvollsHindig war, habe ich auf die Lehrsammlungen meiner Kollegen, Freunde und SchUler zuriickgegriffen. Ich mochte hier den Herren Prof. Dr. J. F. Bonneville, Dr. J. L. Dietemann, Dr. Y. Dirheimer, Dr. J. C. Dosch und Dr. J. Vignaud fur ihre freundliche Mitarbeit herzlich danken. AUGUSTE W ACKENHEIM VII Inhaltsverzeichnis Einleitung ...... 1 1. Teil: R6ntgenbilder 5 2. Teil: Text und Schemata 107 Literaturverzeichnis 189 Sachverzeichnis 191 IX Einieitung Beim Lesen eines R6ntgenbildes mussen wir strukturalistische Regeln wie Immanenz, Synchronie, Signifikant und Signifikat eines Zeichens, berucksichtigen und uns zuerst in der Semiologie bewegen und dann in der Semantik. Vereinfacht k6nnte man sagen, daB wir folgende Begriffe zu unter scheiden haben: der Signifikant, das Signifikat des Zeichens, der Kommentar, die Interpretation und die radio-bio-klinische Gegenuber stellung. Der Signifikant, auch Charakter genannt, ist ein charakteristischer Bildteil (normal oder pathologisch). Beispiel: Sella turcica, Crista galli, Fraktur, Osteom, Aneurysma. Das Signifikat ist normal, spezifisch fUr eine Krankheitsgruppe oder pathognomonisch fur eine bestimmte Krankheit. Beispiel: normal: in diesem Fall sind Signifikant und Signifikat identisch."

Der Schwerpunkt dieses Buches liegt auf dem Erkennen und der Interpretation r-ntgenologischer Zeichen. Der Leser soll da- durch in die Lage versetzt werden, die Bildsprache einer R-ntgenaufnahme zu erkennen. Die r-ntgenologischen Zeichen werden jeweils in einem dreistufigen Informationsgang vorge- stellt. Die Autoren stellen jeweils die charakteristischen, die spezifischen und die pathognomonischen Zeichen vor und geben ihre diagnostische Wertigkeit an.

In the beginning after Dandy's publication in 1918, ventriculo- graphy and pneumencephalography were the main tools in the neuroradiographical examination of brain tumours. Later on, cerebral angiography after Egaz Moniz in 1927, has been more and more commonly used. Now it appears to be the most important neuroradiological examination in tumours of the great hemispheres. Up till some years ago, air studies were the predominant examinations in lesions of the brainstem and the contents of the posterior fossa. Gradually angiographic examination for lesions in these regions has been more frequently used. Nowadays angiographic examination of the mesencephalon proves to be of increasing importance. However, some neuro- radiologists feel inhibited. They fear difficulties when reading the angiogram, even if the subtraction method is applied. Like other workers in the field of neuroradiology and neuro- surgery they will be very pleased with the edition of Wacken- heim and Braun's monograph. These authors are already well known because of their excellent air studies in mesencephalic lesions. With this book they provide us with a most valuable and clear guide to the inter- pretation of normal and pathologic angiograms, including capillarograms, of the mesencephalic regions.