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Waleed F. Mourad MD, Kenneth S. Hu MD, Louis B. Harrison MD

This document provides guidance on contouring the cranial nerves (CN) IX through XII for radiation treatment planning. It describes in detail: - The anatomical routes of CNs IX-XI through the jugular foramen and CN XII through the hypoglossal canal as they exit the skull base. - Recommendations to contour the intracranial portions of these structures and follow them through the carotid sheath down to the lower border of C3 vertebrae. - Landmarks for beginning and ending contouring, including the jugular foramen, hypoglossal canal, internal carotid artery, and bifurcation of the common carotid artery.

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60 views16 pages

Waleed F. Mourad MD, Kenneth S. Hu MD, Louis B. Harrison MD

This document provides guidance on contouring the cranial nerves (CN) IX through XII for radiation treatment planning. It describes in detail: - The anatomical routes of CNs IX-XI through the jugular foramen and CN XII through the hypoglossal canal as they exit the skull base. - Recommendations to contour the intracranial portions of these structures and follow them through the carotid sheath down to the lower border of C3 vertebrae. - Landmarks for beginning and ending contouring, including the jugular foramen, hypoglossal canal, internal carotid artery, and bifurcation of the common carotid artery.

Uploaded by

Jaime AC
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Waleed F. Mourad MD, Kenneth S. Hu MD, Louis B.

Harrison MD
Department of Radiation Oncology

Beth Israel Medical Centers (BIMC)


St. Luke's-Roosevelt Hospital (SLRH)
Continuum Cancer Centers of New York (CCCNY)
Montefiore Medical Center
Albert Einstein College of Medicine (Einstein)

Due

to anatomical nature of CNs IX, X and XI, they


were grouped as one structure while CN XII was
contoured individually.

XII

CN emerges from the ventrolateral aspect of the


MO and enters the hypoglossal canal and then exits
from skull base.

It

proceeds to run behind the X CN, and then between


the internal jugular vein (IJV) and internal carotid
artery (ICA) until the lower border of C3.

At

this level it travels lateral to the bifurcation of the


common carotid and loops anteriorly above the greater
horn of the hyoid bone to run on the lateral surface of
the hyoglossus muscle (Figures B 1-3).

Medical illustration of the cranial


nerves (CNs) IX-XII routes via skull
base and upper neck.

CNs

IX-XI emerge from the lateral aspect of the MO


and pass through the jugular foramen (JF).

After

their exit from the JF they pass vertically down


the neck within the carotid sheath, lying between the
IJV and ICA as far as the upper border of the thyroid
cartilage (i.e. at the level of lower border of C4)
(Figures A 1-14).

For

the sake of ease we recommend stop all CN IX-XII


contouring at the upper border of hyoid bone or lower
border of C3 (i.e. bifurcation of the carotid artery).
Medical illustration of the cranial
nerves (CNs) IX-XII routes via skull
base and upper neck.

Developing contouring atlas

CT simulation (IV contrast) while head in neutral position and immobilized with extended
thermoplastic mask.
CT slice thickness should be 2.5 mm
Use a 3 mm contouring brush.
Identify, contour, and follow the space in the JF (green) and hypoglossal canal (yellow).
CNs IX-XI OAR in green and CN XII OAR in yellow.
For CN XII identify and follow the hypoglossal canal (yellow).
For CN IX, X, and XI: identify and follow the JF (green).
Of note, the JF has 2 foramina the pars nervosa contains the CN IX (dark green) and the pars
venosa contains the CN X and XI.
All CNs (IX-XII) exit skull base and lie within the carotid sheath, between the IJV and ICA.
From that level contour the ICA with 3 mm margin expansion to ensure including the carotid
sheath, CN IX-XII, and the anterior portion of the IJV.
Continue to contour the CNs following the ICA down to the bifurcation of the common
carotid, or lower border of C3. We dont recommend the upper border of hyoid bone as
landmark as it moves with swallowing.

Start contouring at that level of intracranial opening of jugular foramen (JF); identify and follow
the 2 foramina; the anteromedial foramen (pars nervosa-smaller foramen) contains the CN IX
(green) and the posterolateral foramen (pars venosa-wider foramen) contains the CN X and XI
(lemon green).

Contour the CN IX-XI (green) following the JF and internal carotid artery (ICA) down to the
lower border of C3 (i.e. bifurcation of the common carotid artery -CCA)

The 2 foramina meet and form the JF at which all IX-XI merge and exit skull base.
keep contouring the CN IX-XI (green) along the ICA sheath down to the lower border of C3.

At the level of intracranial opening of hypoglossal canal start contouring the CN XII (yellow)
down to the lower border of C3 where CN XII follows the lingual artery course.

Internal carotid artery (ICA=red), internal jugular vein (IJV=blue), CN IX-XI (green),
and CN XII (yellow). The intracranial portion of the CN XII (yellow) emerges from the
brainstem, enters the hypoglossal canal (yellow), and then exits the skull base and joins
the CN IX-XI in the carotid sheath (arrow).

ICA (red), IJV (blue), CN IX-XI (green), and CN XII (yellow) all lie within the carotid sheath.
Notice the contours are expanded few mm to include the anteriomedial potion of the IJV (arrow).

ICA (red) at the level of CCA bifurcation (arrow), CN XII (yellow) travels lateral to the
bifurcation of the CCA, following the lingual artery, and loops anteriorly above the greater horn
of the hyoid bone to run on the lateral surface of the hypoglossus muscle.
At that level (i.e. Lower border of C3) the CN IX-XII contouring ends.

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