One could easily argue that, when imaging head and neck malignancy, evaluation of possible perineu-ral spread is more important than identifying the primary tumor or finding metastatic nodes. In almost every case, the clinician has already identified the primary lesion and has made a good estimate of the margins. The location and size of the primary tumor determine the treatment of lymph nodes at least as much as does the imaging assessment. Perineural spread, on the other hand, can be unsuspected and can carry a tumor beyond the region that is to be treated by either surgery or radiation. If the extent of perineural spread is not correctly identified, the pa-tient will likely undergo significant morbidity without hope of cure. Assessment of perineural spread is therefore a key concept in head and neck imaging. The radiologist absolutely must understand the con-cept and be comfortable with its assessment. The article by Chang et al in this issue of the AJNR presents a series of patients with malignant mela-noma exhibiting perineural spread. More specifically, they write that a particular subtype, the desmoplastic melanoma, has a particular propensity for following nerves. Presentation of this material affords an op-portunity to examine several points, some controver-sial, related to perineural spread. By far the most important issue to an imager is how to look for per-ineural spread and that is the main point of this editorial. At our institution, we avoid fat suppression at the skull base. Before discussing imaging, however, a comment regarding the basic concept and a word about terminology is appropriate as an introduction.
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