Neuroradiology 15, 229-246 (1978)
© by Springer-Verlag 1978
Abstracts of the 16th Annual Meeting of the American Society of Neuroradiology 1978 1
Balloon Catheter Occlusive Techniques Grant B. Hieshima6, C. Mark Mehringer, Verity S. Grinnell, Anton N. Hasso, Neil H. Siegel, and Henry F. Pribram Harbor General Hospital, Loma Linda University Medical Center, Veterans Administration Hospital, Torrance, Loma Linda, and Long Beach, California Several types of balloon devices have been placed via catheters by previous investigators to treat arterial hemorrhage, arteriovenous malform-ations, vascular tumors and carotid cavernours fistulae. Three cases of balloon occlusion will be presented including two examples of the Use of a new detachable balloon which is inflated with water soluble contrast, flow directed, and detached by advancing a larger catheter in a coaxial system over the neck of the balloon. We will demonstrate occlusion of a traumatic carotid cavernous fistula and a traumatic vertebral jugular fistula in two different patients. Balloon techniques are most useful in the treatment of large fistulae which could not be occluded with the other embolic materials we have used including Gelfoam, Ivalon sponge and silastic spheres. 2
Clinical Experience with a Detachable and Perfusion Micro-Balloon Catheter System
Embolization of vascular abnormalities has received considerable attention as a definitive therapeutic technique or as an adjunct to surgery utilizing a variety of occluding agents. In review of the technique, it is immediately apparent that the most important factors in catheter selection are 1) safety during all phases of the embolization procedure, 2) superselectivity during catheterization, 3) occluding the nidus of the lesion and not merely the feeding pedicle, 4) prevention of distal migration of the emboli to the venous side or beyond it. With these four main factors in mind, we conducted a trial of the effectiveness of various single and double lumen balloon catheters in accomplishing a safe, supraselective embolization of the nidus of vascular abnormalities without distal migration of the embolizing agent. Technical variables encountered in embolization with different materials such as: dry compression polyvinyl alcohol foam (Ivalon) where it is critical to have non-tapered catheters, and fluid agents such as silastic fluid where the temporary obstruction of flow prevents the distal migration of the fluid silastic allowing a longer working time. Our experimental experience utilizing silastic fluid with catheters of very small I. D. will be described. Acrylate materials (IBC) have a very short working time and the risk of glueing the catheter to a vessel is a major disadvantage. We will describe the detachable balloon technique as an aid to overcome this disadvantage when high flow fistulous communications are treated with these fast polymerizing acrylics (IBC).
Paul H. Pevsner* Medical College of Virginia, Richmond, Virginia Twenty-eight patients with angiomas, carotid-cavernous fistulae, and other neoplasms underwent catherization with a detachable or perfusion micro-balloon catheter developed by the author. The angiomas were treated by vascular occlusion using a detachable balloon or elastomer perfusion. The other neoplasms were treated with BCNU perfusion. Patients were evaluated with interval angiography at three and six months post-embolizations. The tumor patients were followed with interval computed tomography. The clinical indications, results, and complications will be presented. 3
Catheter and Material Selection for Transarterial Embolization Alex Berenstein, Irvin I. Kricheff* Joseph P. Lin, and Norman E. Chase New York University Medical Center, New York, New York
Simplified Solid Particles Embolization with a new Introducer lrvin I. Kricheff* and Alex Berenstein New YorkUniversity Medical Center, New York, New York A new and simple introducer for the easy and reliable placement of various solid embolic particles is described. Its use with two embolic materials (barium inpregnated silastic spheres and polyvinyl alcohol foam) is described in detail. The advantages of the introducer are that it: 1) is simple and reliable for the introduction of materials, 2) considerably shortens the length of the procedure, 3) reduces the amount of fluids required, and 4) makes keeping count of the number and size of emboli simpler.
Hydrophilic Polyurethane Spheres: A new Embolic Material R. Gold, A. Fox*, J. Allcock, E. Wong, and L. Carey University of Western Ontario Hospital, London, Ontario and Ontario Research Foundation, Mississauga, Ontario Hydrophilic polyurethane spheres have been developed which increase in diameter by about 30% following wetting. These spheres can be made in various sizes appropriate for catheter embolization. This embolic material as well as conventional silicone spheres were eombolized into renal arteries of dogs in vivo via catheter. 27 vessels were occluded with polyurethane emboli and 13 with silicone. After two weeks, the dogs were sacrificed. Gross and histologic examinations of the embolized vessels were performed. There was no significant intimal reaction or granulation tissue with polyurethane emboli. Some reactive arteritis was seen with silicone beads. The polyurethane spheres caused some thinning of the arterial wall. This was attributed to the diameter increase of the embolus following its introduction. These spheres allow a somewhat larger embolus to result from that introduced. Since emboli can be seen to move further along following embolization, these spheres should be relatively more immobile than the silicone spheres. Clinical use of the expanding polyurethane spheres has begun with embolization of two patients with cerebral AVM's.
Polyvinyl Alcohol Foam: Prepackaged Emboli for Therapeutic Embolization Charles W. Kerber*, William O. Bank, Ziad Deeb, Burton P. Drayer, E. Ralph Heinz, and Arthur E. Rosenbaum University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Angiographers have developed many ingenious ways to block blood vessels deliberately. Experimentally, balloons and tissue adhesives are fashionable, but practically, silicone spheres and gelfoam particles have found the widest use. Both latter materials have disadvantages: silicone spheres excite almost no intraarterial tissue reaction and are expensive; gelfoam is not permanent. Foamed polyvinyl alcohol is a compromise. It is inexpensive, is radiopaque, and excites a modest inflammatory response. It is, however, difficult to prepare and introduce into the patient, having a high coefficient of friction with polyethylene. We discovered that in all of our embolizations an inordinate amount of time during the procedure was spent just preparing and introducing the embolic material no matter what type we used. This problem was solved by preparing batches of polyvinyl alcohol foam in a high shear blender, sorting them with graded sieves, and heat sterilizing aliquots of emboli in bottles. The angiographer thus has a ready supply of graded emboli and can spend his time on the important part of the case: monitoring the patient's well-being and the progression of the occlusion. We will demonstrate the technique, preparation, and use of this material.
16th Annual Meeting of the American Society of Neuroradiology Using dogs as their experimental model, the authors have studied the short term and long term effects of vascular occlusion with gelfoam, silastic, silicone, lyophylized dura mater, and isobutyl 6-cyanoacrylate. Angiographic evaluations were performed immediately following embolization and at 8 days, 15 days, and 30 days to demonstrate the level and quality of arterial occlusion. Particular attention was paid to secondary recanalization of the occluded vessels, retrograde thrombosis, and the development of collateral circulation or ischemia. Gross and histopathological evaluation of the animals was performed at 8, 15, or 30 days to demonstrate the short and long term sequelae of embolization (congestion, inflammation, necrosis, sclerosis, and involution). The data obtained in this study provides a solid experimental foundation for choice of embolic material in clinical cases.
Factors Governing Stray Emboli in the Embolic Treatment of Cerebral Arteriovenous Malformations S. M. Wolpert* Tufts-New England Medical Center, Boston, Massachusetts Emboli injected into the cerebral arteries as a preoperative aid in the management of intracerebral arteriovenous malformations (AVMs) frequently lodge in normal arteries. In 56 embolization procedures (32 patients), this occurred on 39 occasions (68%). Clinically apparent neurological sequelae occurred immediately on 19 occasions, but in only two patients were the complications permanent. Development of immediate collaterals appears to be the main factor in the low incidence of permanent complications. To further investigate the dynamic factors affecting the flow of the emboli and the ultimate sites at which they lodged, a study was made of the ratios of the diameters of the feeding arteries to the AVM to the diameters of the adjacent normal arteries. The AVMs were divided into three groups: 1) Middle but no anterior cerebral artery supply - 27 procedures 2) Anterior and middle cerebral artery supply - 20 procedures 3) Posterior cerebral artery supply - 9 procedures. Groups 1 and 2 were embolized via the carotid artery; Group 3 via the vertebral artery. In Group 3, the ratios of the posterior cerebral artery on the side of the AVM to that on the opposite side were also analyzed. Conclusions a) Group 1 AVMs have a high safety margin if the ratio if 4.5 : 1 or greater b) In Group 3, posterior cerebral: posterior cerebral ratios of 4 : 1 or larger will probably ensure that the emboli injected into the vertebral artery will not go astray c) In Group 2, the precise factors preventing emboli lodging in normal vessels are difficult to determine.
A Variable Stiffness Guide Wire (VSGW) for Angiography
A Comparative Study of the Short and Long Term Effects of Different Materials for Embolization
James V. K. Willson* University of South Alabama Medical School, Mobile, Alabama
Claude Manelfe*, Jean-Francois Bardet, and Jean Fabre Centre Hospitalier Universitaire de Purpan, National Veterinary School, Toulouse, France
The author has developed a new angiographic guide wire which has variable controllable stiffness. The wire can be instantly changed from very floppy to very stiff or to any degree of stiffness
16th Annual Meeting of the American Society of Neuroradiology in between. The stiffness is under operator control at all times and can be changed at will from one state to the other without moving the guide wire from its position in the arteries. While the VSGH has many applications in angiography, it is primarily intended for catheterization of tortuous brachiocephalic arteries. It has been used in over 200 cases. Catheterization of tortuous vessels is faster, and in many extremely tortuous vessles we have succeeded with the VSGW when other techniques have failed. This report will utilize a short movie to illustrate the action of the variable stiffness guide wire. The construction of the wire, some of its applications, and the techniques for using it will be described.
Specialized telev&ion and physiologic patient monitoring equipment. Particularly successful techniques will be demonstrated. Utility of function is not enough in the design of modern radiologic rooms. Thoughtful attention to architectural and aesthetic details provides conditions which gain greater patient acceptance while radiologic operative procedures are being performed. Concomitantly a working environment is created for radiologic personnel to use and maintain with pride.
Microvascular Patterns in Central Nervous System Tumors 10
New Design Considerations in Neuroangiographic and CT Suites Arthur E. Rosenbaum*, Robert A. Zeman, Michael A. Stuhldreher, William F. Kennedy, Joseph H. Marcy, and Bertram R. Girdany University of Pittsburgh School of Medicine, Philips Medical Systems, Alfred Reid Associates, Pittsburgh, Pennsylvania The planning of optimal neuroradiologic facilities is increasingly hampered by the rising costs of specialized equipment and construction while hospital funds are decreasing. Compounding these planning difficulties are the frequent absence of detailed schema from the radiologist and insufficient consultation with non-physician special procedure functionaries. Moreover, in many parts of the world, governmental approval(s) must be won on the basis of regional need and a budget which may prove unalterable. This communication will deal with subjects to which only scant attention has been paid: Specialized lighting requirements and variations. Designs must provide for the ambient and fluoroscopic needs within the radiologic practice. Lighting patterns or grids should be to maximize the capacity for flexible or inflexible controls and illuminations. Color choices. Most colors, textures and finishes selected for walls and cabinetry reflect the tastes of the interior designer, the institution, or simply those which are in vogue. Many color choices do not prove restful for ill patients. Moreover, the color can potentiate the patient's negative perception of the examination, such as the feeling of warmth during angiography. Deeper tones of blue especially have a decidedly cooling effect and are recommended particularly over such warm colors as orange or red which augment warm feelings. Technologist's area. How does one provide for a control room with fully coordinated and functional instrumentation? Has ample space been achieved to accommodate both radiologic and nonradiologic personnel? Can observers be better dealt with elsewhere when the technologist must integrate numerous functions and techniques without significant distraction? Zoning of personnel work patterns. Departmental confinement of patient and personnel traffic paths have been eloquently articulated by European and North American Departmental planners. However, equal attention has not been paid to zoning the activities which occur within the individual diagnostic room. Directing the flow of personnel within the room by equipment positioning and lighting can further enhance the working environment and allow for greater order during examinations. Automatic accesses. This inexpensive solution to improve the intradepartmental movements of the film magazine and receiver laden technologist and the sterile gloved physician during special procedures proves highly valuable.
C. L. Rumbaugh*, W. C. Schoene, and R. Utsunomiya Peter Bent Brigham Hospital, Boston, Massachusetts The textbook description of tumor vasculature is well known. When a tumor possesses this pattern, there usually is no difficulty in establishing the diagnosis by angiography. However, when the vascular pattern is atypical or very few or no tumor vessels can be identified, it may be much more difficult to establish the diagnosis. In an effort to improve tumor diagnosis in these difficult diagnostic problem cases, the authors have developed an experimental animal brain tumor model in the rat for studying tumor vessels, especially the smaller vessels in the periphery of the tumor, bordering normal brain. A few clinical examples of the problem will be discussed. Examples of micropaque and India ink animal studies will be presented, along with correlating histological studies. Some of our preliminary observations regarding the central nervous system tumor microvascular pattern in these experimental brain tumors will be demonstrated.
Anatomic Variations of the Ophthalmic and Middle Meningeal Arteries and their Relation to the Embryonic Stapedial Artery Domenico Dilenge* Centre Hospitalier Universitaire de Sherbrooke, The Neurological Institute of New York, Sherbrooke, Quebec, and New York, New York Forty-two cases of anomalous ophthalmic and middle meningeal arteries were studied by selective carotid angiography. The various anomalous patterns are interpreted in relation to the anomalies of the embryonic stapedial artery. Twelve of these cases were selected to illustrate a proposed classification for anomalies of the ophthalmic and middle meningeal arteries. The variations include the following: 1) Anomalies within the orbit involving connection or assimilation of the supraorbital branches of the stapedial artery with the dorsal ophthalmic artery. 2) Anomalies in which the ophthalmic and middle meningeal arteries arise from the extradural portion of the carotid siphon. 3) Anomalies in which the stapedial artery persists partially or completely. A fourth category includes other very rare anomalous origins of the ophthalmic artery from the middle cerebral, posterior communicating, or external carotid arteries, and of the middle meningeal from the basilar artery as previously reported, which, of course, are unrelated to the development of the stapedial artery.
16th Annual Meeting of the American Society of Neuroradiology
thrombosis, even to the point of complete obliteration of the fistula, can be followed by serial angiograms. In fact, sinus thrombosis occasionally appears to be accelerated by the angiography. The frequently confusing clinical course and the radiologic findings of several cases of carotid-cavernous sinus fistula and sinus thrombosis "in evolution" will be presented. The probable mechanism of inception of the thrombosis will be discussed. Correct angiographic technique and interpretation are essential for proper patient management, particularly in regard to proper selection of patients for a conservative management of expectant waiting rather than surgical therapy or embolization procedures.
Variations in the Angiographic Aspects of the Intratympanic Arteries P. Lasjaunias*, J. Moret, and C. Manelfe Centre Hospitalier et Universitaire de Bicetre, Fondation Ophthalmologique Adolphe de Rothschild, Centre Hospitalier Universitaire de Purpan, Kremlin Bic6tre, Paris, and Toulouse, France After the presentation of the embryological and normal angiographic aspects of the intratympanic vessels (including the supply of the V l l t h nerve in its canal), the authors present three different types of "abnormal course" of arteries through the tympanic cavity: Internal carotid artery Stapedial artery Pharyngotympanomeningeal artery Their embryological significance will be discussed with their radioanatomical aspects.
Cerebral Revascularization: An Analysis of Preand Post-Operative Angiographic Studies and Correlation with Clinical Results Richard E. Latchaw*, James I. Ausman, and Myoung C. Lee University of Minnesota Hospitals, Minneapolis, Minnesota
Dural Venous Network of the Tentorium and the Middle Cranial Fossa (A Normal Anatomic and Phlebographic Study) J. P. Braun* Hrpital Pasteur Colmar, France This anatomo-phlebographic study is based on 27 specimens of the tentorium cerebelli and 250 carotido-vertebral angiographies. The venous system of the tentorium is formed by: 1) The medial dural sinuses situated on each side of the midline and the lateral dural sinuses located on the distal position of the transverse sinus 2) The venous tributaries are subdivided into: the supra-tentorial veins: inferior temporal and occipital veins, and the infratentorial veins: inferior vermian, paravermian and hemispheric cerebellar veins. Topographic variations of these tributaries are demonstrated. Histological examination of the wall structure of the dural sinuses and tentorial veins are compared with ordinary venous tissue. Intradural venous network of the middle cranial fossa is demonstrated in opacified venous specimen and phlebographic study. Practical value of retrograde jugular phlebography in neuroradiological investigation of the middle and posterior fossae.
Carotid-Cavernous Sinus Fistulae and Venous Thrombosis Joachim F. Seeger*, Trygve O. Gabrielsen, Steven L. Giannotta, and Preston R. Lotz University of Michigan Medical Center, Ann Arbor, Michigan It is well known that spontaneous and traumatic carotid-cavernous sinus shunts may progress to partial or complete clinical remission or cure. It is less well known that clinical improvement or deterioration may be associated with partial or complete thrombosis of the ipsilateral and/or contralateral cavernous sinus and associated sinuses as well as venous tributaries. Although these venous thromboses have been demonstrated by orbital venography, we have usually been able to diagnose the fistula itself as well as sinus and venous thrombosis by cerebral angiography. Evolution of the
Pre- and post-operative angiographic studies have been analyzed in 40 patients undergoing superficial temporal (STA) to middle cerebral artery bypass. Anastomotic patency in the immediate post-operative period is found in 89% of patients, increasing to 97% on subsequent studies. The causes and implications of apparent occlusion of the STA on the initial studies will be discussed. The change in size of the STA post-operatively over sequential angiograms has been determined and found to correlate well with the degree of clinical improvement. The degree of intracranial filling through the anastomosis has also been quantitated angiographically. As the anastomotic filling increases, flow through leptomeningeal collateral channels decreases. Increasing function of the hemisphere contralateral to the revascularized side suggests revascularization diminishes intracranial steal. The correlation between the clinical results as measured by the standard neurological examination and the degree of intracranial filling is less than that with the change of STA. The need to perform extensive neuropsychological testing as an adjunct to the neurological examination in assessing clinical improvement is stressed.
Blood Flow Variation in Orbital Anastomoses after STA-MCA Surgical Anastomosis J. Moret*, A. N. Hasso, and G. Austin Fondation Ophthalmologique Adolphe de Rothschild, Loma Linda University Medical Center, Paris, France, and Loma Linda, California The authors reviewed a material of 124 cases of STA-MCA anastomosis. After a selection based upon tile radiological projection, the magnification, the injected arteries, and the angiographic parameters, 26 cases are evaluated in order to study the influence of the STA-MCA anastomosis on the physiological orbital anastomosis. Impressions: the lacrymal ramus of the anterior deep temporal artery is the more efficient anastomosis between the external carotid artery and the ophthalmic artery. the posterior branch of the superficial temporal artery has to be used when possible. the surgica STA-MCA anastomosis increases the blood flow through the physiological orbital anastomosis.
16th Annual Meeting of the American Society of Neuroradiology
Evaluation of Superficial Temporal-Middle Cerebral Anastomosis
A Clinical Comparison between Emission and Transmission Computerized Tomography
Mokhtar Gado*, Robert Ratcheson, Robert Grubb, Thomas Naidich, and Marcus Ralchle Washington University School of Medicine, Saint Louis, Missouri
Mokhtar Gado*, Marcus Raichle, Robert Grubb, Thomas Naidich, and Michael Ter-Pogossian Washington University School of Medicine, Saint Louis, Missouri
Fourteen patients with cerebrovascular occlusive disease were surgically treated by superficial temporal-middle cerebral anastomosis. In one case, the surgery was done on both sides. All patients were studied by angiography, cerebral blood flow measurement and metabolic studies. The examinations were done before surgery, soon after surgery and six months later. Results: 1) The angiographic findings demonstrate changing phenomena in the patterns of flow and collateral flow as a result of the anastomosis. a) When the anastomosis is efficient, a stenosed cerebral artery may become functionally redundant and is occluded. b) Insufficiency of the anastomosis may cause flow in collateral channels that were hitherto nonfunctioning. 2) The demands put upon the anastomosis may influence its apparent patency on angiography. An angiographically inadequate anastomosis may become angiographically adequate at a later study after a stenosis occurred in the contra-lateral carotid artery which had been supplying flow through the circle of Willis. 3) The angiographic hemodynamic changes will be correlated with ciinical findings and results of cerebral flow and metabolism studies.
Introduction Emission transaxial tomography depends in principle upon the reconstruction of an image of the distribution of radioactive material in a slice of the organ examined. Depending on the tracer used, the distribution of activity will reflect different physiological phenomena. The three isotopes used in this clinical study are a3NNH3, 150-CO and 68Ga EDTA. Material Thirty patients with cerebral infarction or neoplasms are included in this study. Each patient was studied both with emission and transmission computerized transaxial tomography. Preliminary Results 1. The distribution of activity in the as0-CO image reflects the blood volume and is not related to contrast enhancement on CT. 2. The distribution of activity in the ~3N-NH3 image reflects to a certain extent cerebral perfusion and showed a negative zone in many cases of infarction. There were instances however, in which the appearance of the ~3N-NH3 image was misleading. 3. The pattern of the activity on the 68Ga image reflects the defect in the blood brain barrier and showed remarkable correspondence with contrast enhancement on CT.
Xenon Enhanced Cranial Computed Tomography 19
Comparison of the Cerebral Physiologic Data Provided by Xenon Inhalation Studies and Images of the Distributions of Positron-Emitting Radionuclides Robert H. Ackerman*, Thanos Gouliamos, John A. Correia, Nathaniel M. Alpert, and Juan M. Taveras Massachusetts General Hospital, Boston, Massachusetts This report presents a comparison of the types of clinical data that may be provided by two non-invasive methods for monitoring cerebral physiology-measurements of CBF by clearance of inhaled xenon and imaging of cerebral circulation and metabolism using short-lived positron-emitting radionuclides. The M G H Cerebral Blood Flow Laboratory uses a heavily collimated xenon-inhalation system that appears to provide relevant regional CBF data despite regional count rates of 150-350 each second. Investigations with positron-emitting radionuclides have been made primarily with two dimensional images on the M G H positron camera. At this time, the xenon inhalation technique is a more practical procedure, can be repeated easily on subsequent days, and provides quantitative regional cerebral blood flow data for each hemisphere so that change and rate of change in CBF can be assessed readily. The two-dimensional positron studies provide qualitative information on both circulation and metabolism (although the potential for regional quantitation has been demonstrated). Inhalation of CX5°2 to equilibrium, for example, provides an index of CBF, and inhalation of 15°2 to equilibrium gives an index of oxygen uptake. Correlation of the positron scintigrams on 60 subjects with clinical and other neurodiagnostic data suggests that the method provides unique visual information, including images that permit identification of perfused hut metabolically depressed tissue.
Burton P. Drayer*, Sidney Wolfson, Jr., Manfred Boehnke, Manuel Dujovny, Eugene Cook, and Arthur E. Rosenbaum University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Xenon freely diffuses across the blood-brain barrier and thus may be used to evaluate cerebral perfusion and cerebral blood flow (CBF). Brain enhancement with non-radioactive Xenon is readily demonstrated with the improved image resolution permitted by cranial computed tomography (CT). Following clearance of nitrogen with oxygen inhalation, anesthetized baboons inspired commercial Xenon via a closed, controlled ventilation apparatus. Xenon inhalation was then abruptly discontinued and successive CT scans were performed at 90 second intervals. A Xenon clearance curve was then generated from the changes (decreased enhancement) in CT attenuation coefficient. Both a fast and slow component of CBF were defined by compartmental analysis. Stochastic methodology also provided an accurate estimation of CBF consistent with the findings reported in nonhuman primates by other techniques. The sensitivity of the Xenon CT method was affirmed by measuring CBF during hypocapnia, normocapnia, and hypercapnia. The morphologic nature of CT should provide for improved regional specificity of CBFmeasurements with advancing scanner technology.
Dynamic Computed Tomography David Norman*, Walter Berninger, Douglas Boyd, Victor Levin, and Thomas H. Newton University of California, San Francisco, California
16th Annual Meeting of the American Society of Neuroradiology
A five second rapid venous injection of iodinated contrast agent followed ~;y 4.8 second scans in rapid sequence permits visual demonstration of blood distribution. Scan data can be further segmented into 2.8 second periods. Digital analysis of the data provides quantitative information related to blood flow. This technique is useful in (1) basic physiological research, (2) tumor blood flow and enhancement dynamics, and (3) the evaluation of cerebrovascular occlusive disease. Details of the technique as well as clinical series are presented.
4) Extensive thinning of the sellar cortex - An apparent complete loss of sellar cortex does not necessarily imply a breakthrough of tumor into the sinus. Surgical inspection usually showed a paper thin and occasionally fractured cortex. 5) Sloping floors - An obliquely oriented cortex may not be seen on tomography. This problem is simply solved by triangulating the area of suspected cortical loss with the comparison frontal or lateral section.
Cerebrovascular and Blood Flow Response to Prolonged Transfusion Therapy in Children with Sickle Cell Disease
The Normal and Pathologic Jugular Tubercles
H. I. Goldberg*, Marie O. Russell, Robert A. Zimmerman, Larissa T. Bilaniuk, and Reena Banka Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
The jugular tubercles are two small ovoid protruberances that arise from the concave inferolateral margins of the clivus and project posterosuperiorly over the hypoglossal canals. In contrast to their better-known neighbours, the jugular foramina, the jugular tubercles have received scant attention in the radiological literature. In order to delineate the normal appearance of the jugular tubercles, 50 dried skulls were examined. AP and submentovertex hypocycloidal t0mograms were obtained at the levels of the jugular foramina and petro-occipital fissures. The contours of the jugular tubercles and adjacent structures were mapped on tracing paper. Two cadaver heads were frozen in dry ice, sectioned coronaUy at 5 mm intervals, photographed immediately, and then fixed in formalin. Specimen microradiographs were obtained and were compared to 1 mm AP hypocycloidal tomograms obtained in 25 normal patients. The gross and radiographic anatomy of the jugular tubercles will be described, emphasizing the spectrum of their normal tomographic appearance. A variety of pathological processes affecting the jugular tubercles will also be presented.
Twenty-two children with homozygous sickle cell disease and recent strokes were serially studied with cerebral angiography to determine the effect of prolonged transfusion therapy on their cerebrovascular disease. Ten patients were evaluated in addition with Xenon 133 cerebral blood flow studies. Those children not transfused had recurrent strokes and progression of their cerebrovascular disease. The children put on the transfusion therapy program had a variety of changes develop in their vascular disease. In some with mild disease there was complete clearing. In others with more severe involvement, there was partial to complete resolution of some of the disease and a change in character in other diseased vessels. The blood vessel alterations in the acute stage, soon after the stroke, had characteristic changes which differed from those observed while on chronic transfusion therapy. Cerebral blood flow in involved areas was elevated above normal adult values even in the face of severe vascular disease. Flow however was reduced in the involved hemisphere when compared to the contralateral side.
Anne G. Osborn* and W. Robert Brinton University of Utah College of Medicine, Salt Lake City, Utah
Pitfalls in the Diagnosis of Erosive Changes in Expanding Lesions of the Pituitary Fossa Michael S. Tenner*, Michael Sacher, Imre Weitzner, Gwendolyn Hotson, and Lewis Rothman State University of New York Downstate Medical Center, Brooklyn, New York In a review of the tomographic findings in 32 patients in a two-year period who have subsequently undergone transsphenoidal hypophysectomy for expanding intracellar masses, we have encountered a group of changes that have led to confusion in assessing the presence of or significance of erosive changes of the pituitary fossa. These changes can be categorized into five groups: 1) Pattern of aeration of the sphenoid sinus - There is a constant relationship of the density of the sellar cortex to the underlying aerated or non-aerated sinus. 2) Septal attachments - A change of density and contour of the sellar cortex occurs at the site of sphenoid sinus septum attachment. 3) Sphenoid sinus mucous membrane thickening - This was found in approximately half of our patients, and when it approximated an area of ballooning of the sella could mimic complete erosion and tumor breakthrough.
Uniformity, Linearity, and Reproducibility of CT Numbers Irvin I. Kricheff*, R.T. Bergeron, J. Schimpt, C. Marshall, and Mokhtar Gado New York University Medical Center, Washington University School of Medicine, New York, New York, and Saint Louis, Missouri Computed Tomography (CT) offers the radiologist the ability to accurately quantitate radiation attenuation of various tissues. This information may in fact become the most valuable data obtained by CT. Before the radiologist can accept attenuation figures, one must insure that the scanner used will yield CT numbers which vary in a linear (or known) fashion with the linear attenuation coefficient, that the CF numbers will be reproducible over timer (will not drift), and that they will be reasonably uniform throughout the matrix. A head size water filled phantom with teflon ring was used which permitted the insertion of plastic cylinders of varying absorption. Scans of the phantom were obtained over several weeks utilizing an EMI Head Scanner, EMI Body Scanner (5005), Delta Scanner (50), Philips Tomoscan (200), Pfizer (0200FS), Delta 25, and General Electric (CT/T). The uniformity, linearity, and reproducibility of the scanners and CT number conversion factors will be discussed.
16th Annual Meeting of the American Society of Neuroradiology
Modification of a CT Body Scanner for the Demonstration of Intra- and Extramedullary Lesions on Plain CT
Coronal and Sagittai Reconstructions in Computerized Tomography
R. Ethier*, D. Melancon, G. Belanger, S. Taylor, and Christopher Thompson Montreal Neurological Institute, Montreal, Quebec Since the introduction of the EMI CT 5000 Body Scanner, we have been interested in imaging the intraspinal contents, especially by the spinal cord. At first, software changes were made to obtain a "zoomed down" view of the spine and surrounding tissues. Interesting results were achieved, but the cord remained difficult to visualize. With the support of the company, hardware changes were made to the system in order to double the number of readings per traverse. Additional changes in the software were carried out in order to handle the data. At present, if the 32 cm mode ist used, a 16 cm view of the spinal canal can be seen, and if the 24 cm mode is used, a 12 cm picture of the canal is obtained. Using these facilities, we have been successful in imaging the spinal canal and demonstrating quite clearly the presence of cavitation in the cord associated either with hydromyelia or cystic tumours. We have also the facility of repeating slices at the same level and averaging these slices. This facility, with the possibility of filtering the data obtained, can produce very good delineation of the intraspinal contents without having to inject intrahecal contrast medium. This "zoom" technique can be applied to the head as well, especially in pediatric cases and in cases where additional information is required about the posterior fossa, the sella turcica, and the orbits. Normally, the 13 mm collimator is used, but a 5 mm collimator can be added to push the information further. Illustrative cases will be presented and discussed.
Evaluation of a Low Noise Screen in Complex Blurring Movement Tomography M. S. Tenner* State University of New York Downstate Medical Center, Brooklyn, New York Complex blurring movement tomography has inherent resolution loss in large part due to the elongated paths of the radiographic tube and film. It was felt that a high absorption screen would be beneficial in this situation because of the decrease in noise that results. A yellow dye is incorporated in the screen's phosphor structure which increases light absorption and lowers the conversion efficiency of the screen. The increased photon statistics decreases the quantum mottle and affords a "silky" reasonably noise free background which enhances the low resolution image produced by complex blurring movement tomography. Modulation transfer functions of a high speed screen (Dupont hi-plus) and the low noise screen showed little difference between the two. Wiener spectrum analysis however showed a definite reduction in quantum noise with the low noise screen. Trispiral tomography using a 3 mm focal spot and i mm thickness sections were performed of the petrous bones of a skull phantom at 60 kV with the low noise screen and a high speed screen (Dupont hiplus). The resultant images showed a definite improvement with the low noise screen.
Robert D. Boroff* and H. F. W. Pribram Veterans Administration Hospital, Long Beach, California Conventional computerized tomograms are presently displayed in the axial projection. The scans are obtained with degrees of head angulation that vary from patient to patient. This makes accurate localization of masses extremely difficult. It is not even possible sometimes to decide whether a mass is above or below the sylvian fissure. A temporal lobe mass may elevate the sylvian fissure and on the axial tomogram appear to be above the sylvian fissure. Conventional neuroradiological studies have demonstrated that the lateral projection, in most instances, is the most valuable to the neurosurgeon. The need, therefore, for presenting the data in coronal and sagittal planes has been felt for some time. Slice thicknesses of three millimeters furnish sufficient data to obtain sagittal and coronal reconstructions. The latter have been found invaluable in the assessment of orbital tumours, pituitary tumours, pontine tumours, acoustic neuromas, colloid cysts, and metastatic disease, in particular solitary metastases. These applications will be discussed in detail.
Computer Reconstructed Sagittal and Coronal CT Scans: Clinical Experience Kenneth R. Maravilla* and Jan T. Diehl University of Texas Health Science Center at Dallas, Dallas, Texas Utilizing data manipulation techniques, images can be reconstructed in sagittal and coronal planes from the axial plane CT scan data. A technique is described which utilizes thin nonoerlapping scans of 3 mm slice thickness to reconstruct the orthogonal plane images. The advantages of this technique in decreasing partial volume averaging and providing better resolution of the subsequent sagittal and coronal pictures will be discussed. Multiple plane CT evaluation has proven a valuable adjunct to axial plane CT scanning in our hands. The clinical usefulness of this technique will be discussed together with illustrative cases. Some limitations of this method together with some advantages over direct coronal scanning with a body scanner will also be presented.
Direct Sagittal Scanning in Cranial Computed Tomography Anne G. Osborn* and Robert E. Anderson University of Utah Medical Center, Salt Lake City, Utah While pleuridirectional CT scans generated from axial scan data have been reported, the geometric resolution in reconstructed sections is much less than in the horizontal plane. Most coronal and sagittal reconstruction techniques have utilized multiple thin partly overlapping cuts to reduce noise level. However, the improved resolution is also obtained at the expense of significantly increased patient radiation dose. Even with this technique, sagittal sections generated from the horizontal scan data provide less than optimal delineation of the intracranial and facial structures. We have constructed an accessory table for use in conjunction with the wide-aperture Varian head/body scanner that permits satisfactory comfortable positioning of the patient for direct sagit-
16th Annual Meeting of the American Society of Neuroradiology
tal scans of the head. These true non-reconstructed scans have spatial and density resolution equal to that obtainable in the standard axial plane. We will describe the current table configuration and demonstrate the utility of this new scan modality in delineating lesions of the nose and paranasal sinuses. The normal CT anatomy of the face in the sagittal plane will be presented and compared to both gross anatomical section s, specimen microradiographs, and plain film tomograms. Representative pathological lesions will be discussed.
3-Dimensional Viewer for CT Scan Interpretation Robert E. Anderson*, Brent S. Baxter, and Steven A. Johnson University of Utah Medical Center, Salt Lake City, Utah Interpretation of computed tomography scans can be more difficult than interpreting conventional tomography because of the absence of any sort of "plain film" for orientation. Viewing a series of transparencies of CT scans, properly aligned in all three dimensions, provides a degree of spatial orientation. However, this method is tedious and very impractical. A prototype electronic viewing system has been built which shows the CT image planes in their proper perspective in all three dimensions, displaying an image containing true stereopsis and parralax depth cues of a real three dimensional object. Design features of this viewer will be enumerated. Images derived from the viewer will be demonstrated. Initial impressions suggest that this type of viewing system may aid in understanding anatomical features which are seen in several parallel planes perpendicular to the " Z " axis.
The Efficacy of Computerized Tomography (CT) of the Head in Changing Patient Care and Health Costs - A Retrospective Study Albert Lee Bahr* and Fred J. Hodges, III LDS Hospital, Johns Hopkins Hospital, Salt Lake City, Utah, and Baltimore, Maryland Detailed analysis of all neurological and neurosurgical admissions at Johns Hopkins Hospital for six months prior to and the second six months after installation of a CT head unit was undertaken in an attempt to identify the effect CT had on health care decisions, costs, and morbidity. Data showed decreased cost of over $ 2,000 per patient and shorter length of stay by 7 days in patients with extracerebral collections, and over $ 2,500 and 8 days reduction in patients with tumors after CT was in use. A group matched by computer for age, diagnosis, and physician showed decreased costs of over $ 2,000 and shortened stay by more than 3 days per hospitalization. Increased costs were shown in cerebral vascular disease patients after CT. Change in method of workup with fewer invasive studies was also demonstrated for all patients (p < 0.001) and significant increase in cost of diagnostic workup demonstrated (p < 0.001). Morbidity and mortality showed no change between the two groups. The data suggest that CT of the head may reduce cost and length of hospitalization in certain patient groups and frequently alters patient workup.
Cost Effective Study of CT Scanning in a System of Socialised Medicine K. Kaan*, W. D. Roberon, J. Tyhurst, R. Evans, L. V. Truitt, and R. Davidson Vancouver General Hospital, Vancouver, British Columbia Under our system of socialised medical care, health expenditures represent 25% of the provincial budget in British Columbia. Both the province and the hospital have to exercise cost restraints. Only one CT scanner (EMI 1005) is available to service a population of 21/2 million over an area larger than the combined area of California, Oregon, and Washington. The survey is a joint effort of Neuroradiology, Hospital Administration, and the Department of Economics of the University of British Columbia. A detailed cost analysis is made of the cost of hospital stay, CT scanning, and allied medical tests. A study is made of the utilisation of diagnostic tests and the change following introduction of CT scanning. Allowance is made for established trends. The hospital records of similar selected patients are compared before and after introduction of CT scanning. A questionnaire to patients and referring physicians of 1000 consecutive scans is being completed to study the effect on patient management from the Vancouver General Hospital and other referral hospitals. The result will be subjected to statistical analysis and will be presented.
Utilization and Cost Effectiveness of Cranial Computed Tomography at a University Hospital William A. Knaus, David O. Davis, Steven Young, and Amar Gulati* George Washington University Medical Center, Washington, D.C. The probability of cranial computed tomography (CCT) resulting in a positive and clinically significant diagnosis under various clinical circumstances was studied. 1,098 (35%) out of 3,070 CCT scans studied over a twelve-month period at the George Washington University Hospital were positive. Overall cost for a positive scan was $ 800.00. Cases were arranged into 25 categories depending upon patient's most specific signs and symptoms. The results varied from a high of 68% positives among patients in a coma to a low of 8% positives among patients with headaches as the only indication for scanning. There was, however, close agreement between the rank listing of the 25 indications for scanning compiled before and after scanning. 38
A Comparative Study on Management, Cost Effectiveness, and Treatment of lntracerebral Hematoma with and without CT Scanning B. Azar-Kia* and M. Fine Hines Veterans Administration Hospital, Loyola University Medical Center, Hines and Maywood, Illinois We are presenting our experience with 98 cases of intracerebral hematoma by CT scanning to compare the results in those patients treated medically and those treated surgically. We are also pre-
16th Annual Meeting of the American Society of Neuroradiology senting the effect of CT scan on management of patients and costs and outcome of treatment in 20 patients treated before CT and 20 patients treated after CT became available in our institution. The series is divided into hypertensive and non-hypertensive patients. We have not found CT of great value in determining an underlying vascular anomaly. Post-infusion CT did not yield much additional information. Forty-seven angiograms were performed on 38 normotensive and 9 hypertensive patients. In our institution, the CT scan has significantly changed the prognosis and management of intracerebral hematomas. We have shown that the prognosis depends on many factors including site, size, etiology, and presence of associated infarction. Our series has shown that a better prognosis can be expected with conservative therapy. For a better comparison of the results of medical and surgical treatment, we are demonstrating 12 hypertensive patients with comparable hematomas, six treated medically and six treated surgically.
237 Characterization. Finding suggesting that the mass was a neoplasm were present in 39% of skull films, 97% of computed tomograms, and 92% of angiograms. More specific and ultimately correct information regarding tumor histology was identified in 2% of skull films, 25% of computed tomograms, and 25% of angiograms. Analysis of these data suggests that plain skull radiography is no longer indicated as a screening examination prior to computed tomography. However, x-rays of the skull can provide valuable information (particularly in regards to the sella turcica) after computed tomography has indicated the presence of a mass. Similarly, computed tomography was significantly superior to cerebral angiography for the localization of intracranial tumors, but angiography provides information regarding blood supply which is not obtainable by CT.
Angiography and Pneumoencephalography: Their Role in the Era of CT Morton Jacobs* and D. Gordon Potts New York Hospital - Cornell Medical Center, New York, New York Two hundred patients who were referred for a computed tomographic scan of the head and who subsequently underwent angiography, pneumography, or angiography and pneumography were reviewed. The goal of this study was to determine how much further information, important for the management of the patient, was provided by these subsequent procedures that was not obtained from the CT scan. Two main groups of cases will be discussed: (1) where the diagnosis was missed on the CT scan but made from the subsequent procedure or procedures, and (2) where the subsequent procedure or procedures gave important additional information.
Evaluation of Neuroradiological Procedures for the Detection, Localization, and Characterization of Intracraniai Tumors Stephen A. Kieffer*, Jorge V. Esguerra, Eugene F. Binet, and David T. Thompson State University of New York Upstate Medical Center, Syracuse, New York The availability and widespread acceptance of computed tomography has called into question the usefulness of the more traditional components of the diagnostic workup of the patient with suspected intracranial tumor. In a retrospective review of 60 patients with intracranial tumors, the information provided by skull radiography, computed tomography, and cerebral angiography was analyzed from three aspects: Detection. The presence of an intracranial mass was suggested on 67% of plain skull films, 95% of computed tomographic studies, and 92% of cerebral angiograms. Localization. The tumor was partially localized in 35% of skull films, 96% of computed tomograms, and 94% of angiograms. Accurate delineation of tumor margins was possible in 2% of skull films, 80% of computed tomograms, and 48% of angiograms.
Reyes Syndrome: Computed Tomographic Documentation of Disordered Intracerebral Structure Eric J. Russell*, Robert D. Zimmerman, Joseph H. French, and Norman E. Leeds Montefiore Hospital and Medical Center, Bronx, New York Reyes Syndrome is a viral associated disease of unknown etiology affecting children, and is the 2nd leading cause of death from viral associated central nervous system disease in the U. S.. It is often rapidly fatal. CT in four cases reveals acute cerebral edema and residual change s of atrophy and cerebral degeneration. The pathologic anatomy as seen on CT adheres closely to known gross and microscopic pathologic findings and correlates well with the subsequent clinical course of the patients studied.
Computed Tomography in Herpes Encephalitis D. R. Enzmann*, B. Ransome, and D. Norman, and E. Talberth Stanford University Medical Center, University of California Medical Center, Stanford and San Francisco, California The most characteristic, early computed tomography (CT) scan finding in herpes simplex encephalitis (HSE) was a unilateral, low density lesion in the medial temporal lobe and/or insular cortex. This was seen on the initial CT scan in 10 of 13 patients with HSE and eventually in all patients as the disease progressed. This low density lesion associated with hemorrhage and streaked contrast enhancement (CE) added specificity to the CT scan but was seen in only 3 patients. Early in the course of HSE, focal CT scan findings although often subtle, localized the temporal lobe of greatest involvement in 12 of the 13 patients; one patient had a normal initial CT scan. The CT scan abnormalities progressed rapidly in concert with the disease; late, follow-up scans reflected the widespread destruction caused by this infection.
Computed Tomography and Herpes Simplex Encephalitis Robert D. Zimmerman*, Eric J. Russell, Norman E. Leeds, and David M. Kaufman Montefiore Hospital and Medical Center, Bronx, New York
238 Six patients with Herpes Simplex Encephalitis were evaluated with CT. The disease produced a highly characteristic although by no means pathognomic CT picture. In each case there was a mass lesion involving one temporal lobe with extension into the region of the island of Reil and lateral ganglionic region. There was always an abrupt transition to the normal density of the lenticular nucleus. Contiguous areas of involvement were present in the majority of cases, the most common site being superior contiguous involvement. The disease was unilateral in five of six cases. Non contrast scans always demonstrated low density lesions. There was no evidence of hemorrhage. Linear enhancement was noted in three of five cases and was seen as early as five days after the onset of symptoms. On follow-up examinations there was a decrease in mass effect, a decrease in enhancement, and an increasing focality of the lesions. At one month, most of the lesions appeared as low density lesions involving the temporal lobe and Island of Reil area only. These CT findings differ from the pathologic findings in this disease in two main respects: first, the disease is more diffuse pathologically than is demonstrable at CT, and second, areas of hemorrhage are common pathologically and yet are not demonstrated at CT.
16th Annual Meeting of the American Society of Neuroradiology 3) Fourth ventricle enlargement. 4) Definite enlargement of vermian and superior cerebellar cisterns. Four clinical categories were noted: 1) Patients with grand mat seizures and on long-term diphenylhydantoin (Dilantin) therapy. 2) Patients with cerebellar dystrophic or atrophic syndromes of probable congenital origin. 3) Known chronic alcoholics with predominantly cerebellar abnormalities. 4) Patients with prominent cerebellar abnormalities of obscure etiology, often as part of a generalized process. Excellent general correlation between CT and clinical findings was encountered and some specificity was noted in chronic alcoholism with cerebellar signs and with olivopontocerebellar degeneration,
CT Scan Findings in Psychiatric Disorders John Howieson*, Craig Karson, and Janice Stevens University of Oregon Health Sciences Center, Portland, Oregon
The Computed Tomography of Brain Abscesses Margaret A. Whelan* and Sadek K. Hilal The Neurological Institute of New York, New York, New York The diagnostic features of cerebral abscesses on computed tomography and their relationship to the clinical course were analyzed in 18 patients who had serial CF and extended clinical management with antibiotics and steroids. Unlike previously published material on cerebral abscesses, we have found that the abscess can present with a CT density greater than that of brain. In these cases, the distinction between a cerebra] abscess and a neoplasm becomes more difficult. The differential diagnosis will be discussed. A correlation between the CT density and pathological anatomical material was also carried out and will be presented. Most important in this presentation is an analysis of the correlation between the clinical course and the CT appearance. Unlike previous reports, we would like to stress the importance of CT not only as a follow-up method, but as a guide to active patient management. The influence of systemic steriod therapy on the CT appearance of brain abscess and its significance as to management will be discussed. The "false cure" diagnosis as a result of steroids suppressing the uptake of contrast medium is of great importance and will be analyzed in great detail.
Cerebellar Atrophy: CT-Clinical Correlation Joseph H. Allen*, J. True Martin, L. William McClain, and Joseph C. Jones Vanderbilt University Medical Center, Nashville, Tennessee From the complete clinical and radiological files of the first 7500 patients having CT scans at this center, two series were separately obtained: The first series is characterized by abnormal CT findings of cerebellar atrophy. The second comprises those patients with cerebellar signs and symptoms as a chief complaint who had CT Scans. Four General classes of CT abnormalities were encountered: 1) Enlargement of cerebellar sulci. 2) Enlargement of cerebellopontine angle cisterns.
A C T scan routine suitable for use in screening psychiatric patients has been devised. Routine admission CT scans have been done on all admissions to a short-term psychiatric unit. Similar surveys of patients with epilepsy, long-term schizophrenia, and movement disorders are under way. The frequency and nature of the CT scan abnormalities will be discussed. Cost effectiveness of such studies is estimated. The use of an abbreviated CT scan routine in place of skull x-rays and nuclear scans in common clinical situations will be discussed.
CT Scan Appearance of the Brain in the Normal Elderly Population: A Correlative Study Carlos F. Gonzalez*, Robert L. Lantieri, and Robert J. Nathan Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania Advancing age is likely to be associated with an increase in degenerative changes in the brain tissue. Computerized tomography can provide an estimation of the pathologic changes of cerebral atrophy objectively. The correlation between the degree of atrophy and mental status using currently accepted testing techniques has not yet been established. A preliminary prospective evaluation with the CT scan of 100 patients over 65 years confirmed to be entirely normal by accepted functional and psychometric techniques will be presented. A quantitative system to evaluate the degree of atrophy has been utilized for the study, and conclusions will be drawn on individual psychometric parameters and the CT scan.
The CT Scan in the Diagnosis of Dementia: Relationship between Cortico-Cerebrai Atrophy and Cognitive Decline in Elderly Normal and Patient Groups Mohammad Sarwar*, Samuel D. Brinkman, and Harvey S. I',evin The University of Texas Medical Branch, Galveston, Texas
16th Annual Meeting of the American Society of Neuroradiology
To evaluate the relationship between cortico-cerebral atrophy and cognitive decline in the elderly, 30 normal volunteers between 62 and 92 years old, and 65 patients diagnosed as having dementia, hydrocephalus, or psychiatric disorder, received CT Scans and were administered a neuro-psychological test battery consisting of an intelligence test and memory tests. Measurements were taken from Polaroid images and 8 × 10 enlargements of the CT Scans. Reliability coefficients for the measures ranges from 0.86 to 0.97. The measurements included the planimetric ventricular/brain ratio, bifrontal and bicaudate ratios, and cortical sulci, as well as other measures not previously reported, e. g., the distance between the lateral wall of the third ventricle and the medial aspect of the Sylvian fissure (3V-SF). The results are consistent with the frequently reported decrease in brain bulk in normal aging, with the largest changes in the trigones (r = 0.45, p = 0.01). Decreases in the 3V-SF measurements were related to diminished cognitive functioning (r = 0.50, p = 0.004 respectively) for the normal controis. From the ongoing study, data will be presented on the realtionships between CT measures and cognitive functioning in the patient groups and the applicability of these relationships to the diagnosis of atrophic dementia.
strated various normal vessels, vertebral arteries, cerebral vessels in the neck and small vessels in the cranial cavity, including anterior and posterior lateral choroidal arteries. AVM's and small subdural hematomas were adequately shown. The modified basal view is better for demonstration of the tentorial opening and various herniations. Nonenhancement of the choroid plexus of the temporal horn in severe tentorial herniation may be due, we believe, to compression of the choroidal arteries. This may reduce the secretion of the CSF on the side of tumor. The pituitary infundibulum was seen in over 20% of cases. We had one case with marked enhancement in the pituitary, which could represent an incidental pituitary microadenoma. Conclusions 1) Newer scanners with better spatial resolution and faster scanning time, using a pressure injector which can be connected to the scanner control, would lead to better visualization of various cranial vessels. 2) The modified basal view is valuable in the diagnosis of lesions in relation to the tentorium and temporal lobes. 3) The enhancement in the pituitary infundibulum may be useful in the diagnosis of sella lesions.
The CT Scan in Patients with Suspected Cerebral Metastases
Cranial Computed Angio-Tomography Value in Diagnosing Intracranial Lesions
Michael S. Huckman*, Ruth G. Ramsey, and Gregory I. Shenk Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois
Norman E. Leeds*, Robert D. Zimmerman, and Eric J. Russell Montefiore Hospital and Medical Center, Bronx, New York
One hundred and two patients with known primary malignancies were referred for CT brain scans in search of cerebral metastases. The charts on these patients were reviewed and measurements of ventricular size index (vsi) were obtained using the method described by Banna whereby the minimum bicaudate distance is expressed as a percent of the internal diameter of the skull at the level where the measurement is made. A group of 199 normal individuals ranging in age from 10 to 91 years had ventricular size measurements and this became the control group. Only 25% of the patients examined showed a focal cerebral lesion on the C'T scan. Ventricular size measurements were made in the remaining 75%. This group was compared with the normal group and multiple regression analysis revealed that even when the two groups were adjusted for difference in age, the mean ventricular size was significantly higher in the cancer patients who had no focal lesion on CT scan. Within the experimental group differences in ventricular size could be accounted for by increasing age as could be done in the control group. Other variables such as chemotherapy, smoking, alcohol abuse, wide spread metastases, cachexia and multiple surgical procedures did not seem to demonstrate any correlation with ventricular size index.
Since the introduction of the newer cranial computed tomographic system in this department, we are able to identify with certainty most of the major vessels at the base and their branches. Vascular displacements of midline vessels and middle cerebral arteries may be identified to accurately localize the lesion. In addition, vascular occlusions may be suspected. Early draining veins and venous displacements are also identified. The importance of identification of vascular structures in the diagnosis of a variety of lesions will be demonstrated to show the advantage of the increased spatial and density resolution that is now possible with the advanced CT scanners currently available.
CT Angiography Taher E1 Gammal*, Marshall B. Allen, Jr., and Thomas Lott Medical College of Georgia, Augusta, Georgia We would like to present our experience with contrast enhancement in the demonstration of normal and abnormal cranial vessels, the tentorium, temporal lobes, and sella, using the modified basal view (5-20 ° above orbitomeatal line). In over 700 examinations using bolus technique (adult = 100-150 cc Renografin 60), the scan was done immediately following or during injection of the last 50 cc at preselected levels about the dorsum sellae. We demon-
Intraventricular Hemorrhage: Correlation of CT Scan Findings with Clinical, Angiogram, and Autopsy Findings L. O'Connor*, C. Hyshaw, J. Winter, J. Bentson, G. Wilson, and J. Campbell Martin Luther King, Jr., General Hospital, University of California Center for the Health Sciences, Los Angeles, California Intraventricular hemorrhage is a dramatic and life-threatening medical emergency. Before the advent of CT, the diagnosis of intraventricular hemorrhage was usually made only at autopsy. CT scanning is the diagnostic method of choice in making this diagnosis. The CT scans of 60 consecutive patients with intraventricular hemorrhage were reviewed. The etiologies for intraventricular hemorrhage fell into seven main categories in this order of frequency: 1) Aneurysms and vascular malformations 2) Hypertension 3) Trauma 4) Idiopathic
240 5) Pregnancy related - Five of six cases occurred during labor and delivery with no underlying predisposing lesion found at angiography or at autopsy. These five cases may be secondary to transient marked elevations in BP associated with straining during labor and delivery. At least one case was related to toxemia of pregnancy. 6) Iatrogenic 7) Tumor. Characteristic CT findings and patterns of intraventricular hemorrhage will be discussed. In a majority of cases, the etiology for the intraventricular hemorrhage can be suspected from the CT scan alone. The characteristic symptomatic presentation of these patients will be briefly discussed. The mortality rate is closely related to the distribution and amount of blood present in the ventricular system, as well as the age of the patient. Correlation with autopsy findings in 20 patients and with angiographic findings will also be presented.
Computerized Cranial Tomographic Findings in Cerebral Sino-Venous Occlusion F. S. Buonanno, D. M. Moody*, M. R. Ball, and D. W. Laster Bowman Gray School of Medicine, Winston-Salem, North Carolina Eleven patients with angiographically and/or pathologically verified cerebral sino-venous occlusions not directly caused by trauma were studied by computerized cranial tomography (CCT). Static radionuclide brain scans and dynamic radionuclide flow studies were also obtained in four patients; in two, findings diagnostic of lateral sinus thrombosis were noted. These comprised a "negative on dynamic, hot on static" image, as well as a "hot on static with non-filling on angiography." CCT findings included visualization of the thrombosed vein ("cord sign") or sinus ("A sign"); multiple focal bilateral parasagittal hemorrhages after contrast enhancement; intense tentorial enhancement; gyral enhancement indistinguishable from infarct; solitary intracerebral hematoma; small ventricles; normal scan. Excluding the patients with underlying meningioma, all three of whom survived, seven of the remaining eight patients expired during the acute phases of their illness, an 88% mortality. In this group is included one patient who had a normal CCT scan, albeit without contrast enhancement, who was diagnosed as pseudotumor cerebri. The need for full neuroradiologic evaluation, including angiography, is thus stressed if this highly fatal, yet treatable, condition is not to remain undiagnosed.
16th Annual Meeting of the American Society of Neuroradiology arising frequently off the cavernous carotid. On non-contrast CT (NCCT) the aneurysm may be isodense, particularly when thinwailed and without mural thrombosis or calicification. If the lesion is hyperdense, ring calcification of the aneurysmal wall or mural thrombus is frequently observed. With contrast administration, all aneurysms, with the exception of the completely thrombosed aneurysms, enhance. The non-thrombotic aneurysms enhance uniformity, while the partially thrombotic enhance in a "target" cell appearance, e.g., a central region of hyperdensity, a middle zone of less density, and an outer rim of hyperdensity. The completely thrombosed aneurysms lack the central region of enhancement but may have the peripheral ring enhancement. The isodense central region and lack of surrounding cerebral edema eliminates a malignant mass or abscess although "mass effect" is present. Neuropathologic examination of giant aneurysms were reviewed to elucidate the CT findings. The "target cell" appearance of partially thrombotic aneurysms is the result of iodinated vascular pool within the lumen of the aneurysm, relative non-enhancement of the mural thrombus, and the outer ring of enhancement due to contrast material within a plethora of small vessels in thickened arachnoid tissue. The completeIy thrombotic aneurysm falls to demonstrate luminal enhancement, with the ring enhancement again noted to be secondary to a greatly vascularized thickened arachnoid. Appropriate neuropathologic sections and CT scans of giant aneurysms will be presented.
Computed Tomography of the Paranasai Sinuses and Face: Pathological Anatomy John Hesselink*, Paul F. J. New, Kenneth R. Davis, Alfred Weber, Glenn H. Roberson, and Juan M. Taveras Massachusetts General Hospital Massachusetts Eye and Ear Hospital, Boston, Massachusetts Forty-seven abnormal computed tomography (CT) scans of the paranasal sinuses and face were reviewed and compared to surgical and pathological reports to evaluate the ability of CT scans to determine the extent of various pathological entities. Destruction of bony margins of the sinuses, invasion of the orbit, and displacement of the globe is clearly evident. The extent of invasion into the soft tissues of the face can also be determined. Protrusion into the oral cavity, nasal cavity, and pharynx helps to further localize the lesion.
The Neuropathologic Basis of CT Changes in Giant Cerebral Aneurysms, with Emphasis on the Partially and Completed Thrombosed Aneurysms
CT Coronal Sections of the Orbit Based on One Hundred Cases
Richard S. Pinto*, Irvin I. Kricheff, and Alan Butler New York University Medical Center, New York, New York The clinical manifestations of giant cerebral aneurysms are frequently nonspecific and without the acute symptomology of subarachnoid hemorrhage. Progressive dementia and evidence of increased intracranial pressure are the most frequent presenting symptoms. Cranial nerve palsies, particularly of the carotid cavernous syndrome complex, are most often found on examination. The CT scan is the initial diagnostic examination. Most giant aneurysms are observed involving or adjacent to the circle of Willis
Jaqueline Vignaud and M. L. Aubin Fondation Ophtalmologique A. de Rothschild, Paris, France The spatial resolution of coronal sections is better than computerized coronal reconstruction. In cases of tumors, it is useful to correctly delineate superior and inferior extraconical tumors and to locate the optic nerve with regards to intraconical tumors. In cases of endocrine proptosis, the volume of the muscles is easily evaluated. Coronal sections are the only sections avaluable to measure the density of the optic nerve. Coronal sections are also valuable for the localization of foreign bodies and in cases of orbital fractures.
16th Annual Meeting of the American Society of Neuroradiology
CAT Scans in Experimentally-lnduced Orbital Pseudotumors of the Rabbit Eye
Midline lntracranial Cystic Lesions: Is Computerized Cranial Tomography Alone Diagnostic?
Harvey ].Wilner*, Edward Cohn, Robert Jampel, and George Kling Harper Hospital, Detroit Medical Center, Wayne State University, Detroit, Michigan Retrobulbar injection of the rabbit orbit was made with an antigen solution. Only one eye of each rabbit was injected with a solution consisting of 5 mg protein in 0.1 ml normal saline. The other normal eye served as a control. Our method of sensitization and retrobulbar injection has been found to produce orbital inflammation that is histologically identical with pseudotumor of the orbit. CAT scans will be shown, as well as correlating photographs of the gross and micropathology.
C. V. G. Krishna Rao*, J. Powell Williams, Pulla R. S. Kishore, and Frederick S. Vines University of Maryland Medical School, Eastern Virginia Medical School, Medical College of Virginia, Baltimore, Maryland, and Norfolk and Richmond, Virginia
CT Evaluation of Intracerebral Leukemic Masses Lyle R. Wendling*, Laurence D. Cromwell, and Richard E. Latchaw Sacred Heart Medical Center, University of Washington Hospitals, University of Minnesota Hospitals, Spokane and Seattle, Washington, and Minneapolis, Minnesota Four patients with differing types of leukemia presented with clinical symptoms of a localized intracerebral mass. In each case, computed tomography (CT) demonstrated a mass of equal or slightly increased density relative to normal brain; a zone of surrounding cerebral edema was variable. In each case, the mass demonstrated uniform contrast enhancement. Two of these masses were located in the cerebellum, one was located in the left basal ganglia, and the fourth was located in the right occipital lobe. With improved results from more aggressive therapy protocols, we expect that more leukemic patients will survive longer and present a spectrum of clinical and radiological findings that may be different from those previously encountered. The CT appearance of these leukemic masses appears to be characteristic and quite different from the CT findings in other central nervous system complications of leukemia.
The Radiographic Appearances of lntracranial Leukemia and Lymphoma Julius Danziger*, Sidney Wallace, Stanley F. Handel, and Milam E. Leavens M. D. Anderson Hospital and Tumor Institute, Houston, Texas Abnormal radiographic findings demonstrated by computerized tomography, angiography, and pneumoencephalography in 31 patients with leukemia and lymphoma were reviewed. Although leukemia and lymphoma comprise a spectrum of disease, they invade the cranial vault and its contents in a similar fashion. The frequency of involvement is relatively common in leukemia, especially in childhood, while more unusual in lymphoma. Documentation of involvement of the meninges and brain is necessary for adequate therapeutic management. Neoplastic infiltration of the meninges and brain as well as hemorrhage, infarction or a combination of these were demonstrated radiographically in these patients.
A variety of cystic lesions have been seen on the CT Scan. In most cases a reasonable diagnosis as to the possible etiology can be arrived at based on the density measurements, the location, and the patient's symptomatology as well as the plain skull film findings. This, however, is difficult in cystic lesions occurring in the midline since they are either in the subarachnoid space adjacent to the cistern or close by or within the ventricular space such as the third or lateral ventricles. This is especially a problem when the cyst wall is very thin and the fluid within the cyst has a similar range of density as the adjacent CSF. Further neurodiagnostic studies, particularly air studies, are necessary for demarcating the cyst from the adjacent cistern or ventricles. Air studies were not only useful in demarcating the cyst but also in planning the surgical approach. This paper deals with the neurodiagnostic studies relating to a variety of cystic lesions in the midline region situated supratentorially and in the tentorial hiatus. The following examples will be demonstrated: 2)Suprasellar arachnoid cyst, 2)Rathke's cleft cyst, 3)Cyst of the septum pellucidum acting as a mass lesion, 4) Cyst of the cavum vergae, 5) Agenesis of the corpus callosum with associated loculated cyst, and 6) Cyst in the quadrigeminal cistern adjacent to a large suprapineal recess.
The Radiological Diagnosis of lntraventricular Cysts Paul F. J. New* and Kenneth R. Davis Massachusetts General Hospital, Boston, Massachusetts Neuroepithelial cysts are relatively uncommon benign cysts of developmental origin that usually originate in the roof of the third ventricle and grow to expand into the ventricular system. They present a spectrum of computed tomographic (CT) attenuation characteristics, from low to high values. Those with attenuation values similar to cerebrospinal fluid may present diagnostic difficulties on CT. Intraventricular ependymal and glial cysts are extremely rare entities that may be difficult to diagnose and to differentiate from other thin walled inlraventricular cysts, such as occur in cysticercosis and echinococcal infestation. Intraventricular epidermoid cysts may also be difficult to differentiate. The contributions of CT, angiography, and cerebral pneumography to the diagnosis of the above entities will be described and illustrated with examples of each.
Distinctive CT Appearance of the Low Grade Supratentorial Glioma Alan T. Butler* New York University Medical Center, New York, New York Since the publication of the first clinical results of computed tomography in 1973, the value of CT in the anatomic delineation of cerebral masses has been universally accepted. The widespread use
242 of contrast enhancement has led to inferences regarding the histopathological nature of cerebral mass lesions, particularly in the differentiation of malignant brain tumors from meningiomas. Recent evidence suggests that low grade supratentorial gliomas can be differentiated from high-grade gliomas with the use of contrast enhancement CT. To date, there has been no published indepth analysis of the low-grade supratentorial glioma. During the past three years, 40 surgically verified low-grade supratentorial gliomas have been collected. Preoperative pre- and postcontrast enhancement CT scans were performed in all cases. The distinctive pre- and postcontrast enhancement appearance of the low-grade glioma will be discussed. Histographic analysis of the lucent low-grade and high-grade glioma has been performed, and the results will be discussed.
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Head Trauma - Radiologic/Pathologic Correlation Kenneth G. Rieth*, LeRoy Riddich, David O. Davis, and Amar Gulati George Washington University Medical Center, Washington, D.C. While t h e computed tomographic findings in brain trauma have been extensively described, there has been little pathologic correlation. We have been reviewing the gross and microscopic findings in brains from patients dying from head trauma with subsequent postmortem examination by the medical examiner's pathologist. Some discrepancy in terminology between pathology and CT has been discovered. Therefore, in this presentation, we will define the pathologic terminology and illustrate CT gross pathologic correlations from these patients. Examples of extra- and intra-axial hematomas and hemorrhage, contusions, necrosis, and lacerations will be compared and discussed.
The Prediction of Brain Tumor Histology Using the Change of Effective Atomic Number with Contrast Enhancement Richard E. Latchaw*, J. Thomas Payne, and Lawrence H. A. Gold University of Minnesota Hospitals, Minneapolis, Minnesota The methodology and calculations for determining the effective atomic number of intracranial tissues by CT scanning has been presented previously. Preliminary studies have indicated the value of the change of the effective atomic number of a tumor following contrast enhancement in predicting its histology. A large series of intracranial neoplasms has been studied with this method. The change of effective atomic number with enhancement effectively separates the three groups: gliomas, meningiomas and metastases. There is no correlation, however, between the change of effective atomic number and the degree of malignancy of gliomas. Other numerical parameters are less helpful in predicting brain tumor histology.
Value of CT as an Index of Malignancy of Brain Tumors Sadek K. Hilal* and C. H. Chang The Neurological Institute of New York, New York, New York Two hundred intracranial tumors were studied by the EMI Mark I Scanner. There were 110 gliomas, 40 meningiomas and 50 metastases. The photographic hard copy and the numerical print-outs were analyzed. The initial density of a given tumor and the amount of enhancement after contrast injection were measured. Also, the size of the tumor nodule and the peritumoral lucency were measured and corrected for magnification. Several indices of malignancy were developed from this data and were correlated with the histological grade and patient survival. The relative size of the edema was of some help. More important, however, was the relationship between the initial density of the tumor and the degree of enhancement. This index shows significant correlation with the histological grade. The analysis of this data indicates further that there are two mechanisms contributing to the radiolucency of a tumor. Assumptions as to their natures will be discussed. Patient survival in our material appears to depend on the tumor size to a greater extent than on the histological grade. A discussion of this relationship will be made.
Further Experience with Contrast Enhanced Computed Tomography in Head Trauma Fong Y. Tsai*, James E. Huprich, Hervey D. Segall, James S. Teal, Antonia Pena, and Michael A. Stecker LAC-USC Medical Center, Los Angeles, California The value of CT in the evaluation of head trauma is well established. Contrast enhanced CT scans have been neglected as a valuable adjunctive procedure in the evaluation of head trauma. In our series of 300 patients with head trauma, contrast enhancement was seen in 45% of cases. When present, contrast enhancement frequently altered the appearance of obvious lesions and aided in the detection of occult lesions. Contrast enhancement proved to be of most value in the detection of isodense subdural hematomas and contusions. Differences in the appearance between traumatic and non-traumatic intracerebral hemorrhage frequently allowed their differentiation on non-contrast scans. The presence of intraventricular hemorrhage was common in patients with head trauma and did not necessarily indicate a grave prognosis as was previously thought. The presence of contrast enhancement within the intraventricular hemorrhage was, however, associated with a poor prognosis.
Serial CT as an Indicator of Prognosis in the Mnagement of the Acute Head Injured Patient A. K. Girevendulis, P.R.S. Kishore, M.H. Lipper, J.D. Miller, F. S. Vines, D. P. Becker, and R. Sweet Medical College of Virginia, Richmond, Virginia Ninety-five patients presenting with severe head injury were serially scanned on days 1, 3, 5, 14, 90 and one year. Only patients who were unable to follow even simple commands due to disordered level of consciousness were included in this study. Clinical outcome ranged from excellent recovery to total disability, with moderate disability being defined as presence of neurological deficit preventing normal function, but allowing self care. Patients whose CT's were normal initially and remained normal through day 90 made an excellent recovery. Subsequent ventricular enlargement on serial CT, most marked by 90 days, was associated with some degree of diasbility. All patients presenting with focal low density zones on day one did well, in contrast to the patients presenting with diffuse low
16th Annual Meeting of the American Society of Neuroradiology density zones of whom 50 per cent were left with varying degrees of disability. Delayed ventricular enlargement on serial CT in this group also was associated with an outcome ranging from mild to total disability. Twenty-three pure intracerebral hematomas and contusions were studied. Although eight showed complete CT resolution by day 14, only three of these patients did well and the remaining five were left with disability ranging from severe to total. Of the remaining 15, five deaths occurred, five did well and five were left with disability ranging from severe to total. Poor outcome was directly associated with the size of the hematoma and the degree of midline shift. Fourteen intracerebral hematomas were associated with extraaxial lesions. This group had the highest death rate, 8 out of 14.
The Correlation of Late Post-Traumatic Computed Tomographic Findings with Psychological Testing and Neurological Deficit Robert A. Zimmerman*, Barbara Uzzell, Larissa T. Bilaniuk, Howard Hurtig, and Carol Dolinskas Hsopital of the University of Pennsylvania, Philadelphia, Pennsylvania The followup data on head injury patients ,has revealed a significant degree of correlation between the post-traumatic sequelae shown on computed tomography (CT) and psychological aberrations. Sequential CT examinations on these patients.show traumatic changes with vary depending on the initial type of lesion. Comparison has been made between post-traumatic computed tomographic patterns, psychological testing, and the presence of neurological deficit. The presentation will attempt to answer the question of how accurate is CT in predicting the neurological and pyschological deficits in the post-traumatic patient. Three hundred and forty acute cerebral head injury patients have been studied under an NIH protocol by computed tomography during a 21/2 year period. Eighty percent of the severe head injuries (51% of the population) and 48% of the less severe head injuries (49% of the population) have been examined sequentially by computed tomography. Twenty percent of the severe head injury survivors have been evaluated by sequential psychological testing.
The Complementary Roles of Real-Time Imaging of the Carotid and other Noninvasive Tests for Diagnosis of Carotid Disease Robert H. Ackerman*, Don S. Pryor, Juan M. Taveras, Kenneth R. Davis, and Glenn H. Roberson Massachusetts General Hospital, Boston, Massachusetts Results of preliminary evaluation of a real-time ultrasound imaging system for the carotid arteries indicate a complementary but meaningful role for this modality in the workup of patients with suspected carotid disease. An instrument developed by the Stanford Research Institute has been employed in the Carotid Evaluation Laboratory of the Massachusetts General Hospital where its potential has been compared to other noninvasive tests for diagnosis of carotid disease and to carotid arteriography. The other tests include thermography, periorbital directional Doppler ultrasonography, oculoplethysmography, and bruit analysis. Xerography of the neck was done for three months on the initial 150 patients
243 evaluated with the carotid scanner to determine how carotid calcification may effect the images of the vessels. This report discusses preliminary observations on the contribution of such an imaging system to the evaluation of patients with suspected carotid disease, where the technique fits into the noninvasive aramentarium, and electronic and/or mechanical limitations to its usefulness. Some examples of the application of the technique to the imaging of infant cerebral tissue will also be presented.
Inflammation of the Neck -- Special Emphasis on the Prevertebral Space -- A Radiographic-Sonic Diagnostic Combined Approach P. B. Wollschlaeger*, G. Wollschlaeger, K.L. Krabbenhoft, Wm. R. Darmody, R. M. Ho, T. Coleman, and J. Tolliver Wayne State University School of Medicine, Detroit, Michigan During the past 12 months, we encountered approximately 100 scans with inflammation of the cervical region. The different stages of inflammation range between cellulitis and abscess formation, granulation to necrosis and fibrosis. Some of these cases presented with neurological signs and others were prone to develop symptoms because of the anatomical site of the inflammatory process. Our workup consists of: 1) X-ray of vertebral column, possible tomography 2) Sonography of the neck. 3) Angiography and/or myelography as indicated. Special attention will be paid to the diagnostic importance of sonography of the neck Mth emphasis on the prevertebral space concerning the presence of fibrosis, granulation tissue, necrosis, and abscess formation. The post-operative value of sonography will be demonstrated.
Detection of Hydrocephalus in Infants Comparison between Cross Sectional Ultrasound and CT Images M. Leon Skolnick*, Arthur E. Rosenbaum, Terrance Matzuk, A. Norman Guthkelch, and E. Ralph Heinz University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Twenty infants under one year of age were examined by crosssectional ultrasound and CT in similar planes. The accuracy of the two imaging modalities was compared for determining the degree of lateral and third ventricular dilatation. The ultrasound images were primarily recorded with a mechanical servo-controlled real-time scanner of our own design that produced either sector or trapezoid images. The transducer assembly is a compact, vibration free, hand held unit that produces a 60 ° arc image. Transducer frequency was 2.25 MHz. To image the ventricles, the transducer assembly was applied to the side of the patient's head along a plane roughly parallel to the axial CT plane and rocked slightly until the ventricular walls were optimally displayed. A few of the patients were also studied with a contact scanner, the Unirad EP, using 3.5 or 5 MHz transducers. The CT scans were obtained with either the AS&E or EMI Mark I (head) scanner. The configuration and magnitude of the cerebral ventricles displayed on the ultrasound scans were diagnostically similar to those seen on CT. In over half of the infants, the difference in biventricu-
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lar width of the frontal horns on ultrasound and CT was less than 0.5 cm. Ultrasound fully detected the spectrum of normal to markedly dilated ventricles. These results strongly suggest that ultrasound imaging could be substituted for CT scans especially in the serial evaluation of infants whose ventricles have been shunted for control of ventricular dilatation. Radiation exposure is obviated and the examination can be performed even in the moving child.
The management of patients with cervical spinal cord injury remains controversial. Advocates of surgical therapy instituted solely in order to achieve stabilization of the axial skeleton find challenge from proponents of nonoperative management. Nonetheless, it is generally agreed that compromise to the spinal cord by extradural impingement such as disc herniation or hematoma is an indication for surgical decompression. The absence of spinal cord compression obviates the need for surgery if that criterion provides the sole operative indication. Radiographic evaluation of patients with acute injury of the cervical spine is difficult and often frustrating. Non of the traditional radiologic procedures has been totally satisfactory in so far as meeting the criteria of simplicity, safety, and reliability. Metrizamide myelography offers a new alternative in the radiologic study of acute cervical spine injury. We have examined eight patients who had sustained acute injury of the spinal cord with this agent via lateral C1-2 puncture. The procedure is very simple and safe. The diagnostic information obtained has surpassed that given by any of the other more traditional methods or agents. This paper will review the results in these eight patients.
Long-Term Effects of Intrathecal Depo-Medrol P. M. Duchesneau*, M. A. Weinstein, and D. P. Wesolowski Cleveland Clinic Foundation, Cleveland, Ohio Instillation of steroids into the subarachnoid space in the form of Depo-medrol has been used for symptomatic relief in various conditions. Good relief of radicular pain has been obtained in many patients with nerve root irritation. Intrathecal Depo-medrol (ITDM) has also been used prophylactically to prevent "Pantopaque arachnoiditis" following myelography, especially if any bleeding encountered during the procedure might be expected to produce more severe changes. Subjectively, there does appear to be a significant reduction in postmyelogram complaints within the first few weeks following the study. However, several months after the myelogram, some of these patients are seen with residual, recurrent, or even new complaints. Repeat myelograms in many showed arachnoidal changes, with mild to moderate blunting of root sleeves. A more consistent finding was apparent adherence of the nerves to each other within the subarachnoid sac. In more severe cases, this mimicked the appearance of a low conus, or "tethered" cord. There was a high correlation between symptoms and arachnoid changes. Then changes were present in 90% of those given Depo-medrol with the prior myelogram. Arachnoid changes were conspicuously absent in those who did not receive Depo-medrol, suggesting that long term effects were opposite to those desired.
Effect of Dehydration on the Side Effects from Metrizamide Myelography O. P. Eldevik*, K. O. Nakken, and V. M. Haughton Ulleval Hospital, Oslo, Norway and Milwaukee County General Hospital, Milwaukee, Wisconsin The effect of dehydration on the incidence of side effects from metrizamide myelography was studied. One-hundred consecutive patients scheduled for myelography were fasted overnight before myelography and then randomly divided into two groups. Group I received 2 1. of fluids intravenously just prior to myelography, Group II did not receive any fluids. Both groups had standardized myelography with metrizamide (170 mg I/ml). Side effects were recorded 24 and 48 hours after myelography. Headache, vomiting and some other side effects were less common and less severe in the hydrated group. Clear liquids orally or intravenous fluids are recommended prior to myelography to minimize side effects.
Metrizamide Myelography through Supine Lateral C1-2 Puncture in early Management of Acute Cervical Spine Cord Injuries Jin S. Leo*, R. Thomas Bergeron, Irvin L Kricheff, and M. Vallo Benjamin New York University Medical Center, New York, New York
CTT of the Spine George Krol*, Rheza Khomeini, and Michael Deck Memorial Sloan Kettering Cancer Center, New York, New York One hundred cases of CT of lumbar, thoracic, and cervical spine were reviewed. Different methods of localization of level of section were used, including placement of opaque catheters on the skin and fluoroscopy. A method of localization of CT section is proposed which involves "transposition" of the cut of interest on the routine AP view of spine correcting for magnification values. Based on pathology scans were divided into groups. Owing to the nature of the institution, most of the abnormal cases were metastatic or primary tumors. Radiographs of all cases were reviewed, and the accuracy of both modes was compared. CT scans proved to be very useful in the evaluation of small lesions in vertebral bodies and particularly in the evaluation of the paravertebral soft tissues.
CT Level Identification: Catheter Markers Versus a New Device S. H. Lee*, T. Villafana, M. S. Lapayowker, and B. Borra Temple University Hospital, Philadelphia, Pennsylvania Continuing problems in CT examinations of the spine or other body parts are: a) identifying initial scan level in order to minimize "search" time, b) the ability to identify any particular level with respect to the initial level and c) correlating CT scan with anatomy on a scout film. Common CT features including automatic incrementation of the patient table and recording of slice number and amount of incrementation are not adequate. Accordingly, radiopaque catheter markers attached to the patient have been recommended. These may give objectional reconstruction artifacts which can be confused with motion and beam hardening artifacts and serve to deteriorate the image. A new air groove/acrylic device was designed and constructed which provides for a patient oriented reference system free of reconstruction artifacts. A comparison between this new device and the catheter marker is presented for both water bath phantom and actual patient scans.
16th Annual Meeting of the American Society of Neuroradiology The device may also be used for anatomical orientation on scout films since air spaces will be visualized adequately. However, to enhance this visualization, another overlay identical in dimension but air grooves replaced with copper wires can be used to facilitate correct identification of each level of interest. This system can be applied to accurate localization of lesions of the spine or other body organs, precise localization of intracranial lesions prior to surgery, and perhaps in radiation therapy planning.
presence or degree of compromise of the spinal canal caused by displaced bony fracture fragments. Computed tomography has proven useful not only in detecting the presence of bony fragments projecting into the spinal canal but also in assessing the degree of narrowing of the spinal canal caused by the displaced fragments. Using a program readily available to the computer operator at the time of the examination, the actual degree of compromise of the spinal canal can be calculated. Examples of impingement on the spinal canal by vertebral body and posterior element fractures will be shown employing cross-sectional area measurements and sagittal/coronal reconstruction.
Quantitative Measurement of the Lumbar Spinal Canal by Computed Tomography
Christopher G. Ullrich*, Eugene F. Binet, and Michael G. Sanecki State University of New York, Upstate Medical Center, Syracuse, New York
Computed Tomography in the Evaluation of the Postoperative Spine
A precise and practical method of calculating the cross-sectional area of the bony lumbar spinal canal has been developed utilizing a program readily available to the operator of the Ohio-Nuclear DeltaScan unit. The method incorporates the irregular region of interest and histogram functions within the computer. An accurately calibrated grid exactly identifies the spinal segment being measured. Quantitative analysis, rather than subjective evaluation, of the dimensions of the bony spinal canal is possible with this method. Based on an analysis of 40 individuals, normal cross-sectional areas and diameters of the lumbar spinal canal in the adult have been calculated.
Stephen L. G. Rothman*, Robert B. Geehr, E. Leon Kier, and Harry B. Hoffman Yale University School of Medicine, New Haven, Connecticut The radiologic assessment of the previously operated spine is one of the most difficult diagnostic problems facing the neuroradiologist. A series of patients were evaluated by computed tomography after undergoing spine surgery. CT provides high contrast axial tomograms which have aided in diagnosing a variety of postoperative problems. It is possible to evaluate facet hypertrophy, postoperative bony spurs, and other spine fusion problems. CT is also helpful in the evaluation of postoperative infections. 83
Manifestations of Fractures of the Spine as seen on Computed Tomography S. M. Wolpert, R. M. Scott, B. L. Carter, S. C. Belkin, and E.N. Faerber* Tufts-New England Medical Center, Boston, Massachusetts Nine patients with fractures of the spine (5 lumbar, 3 cervical, and 1 dorsal) were investigated by spinal computed tomography (CT). An evaluation was made of the appearances as seen on CT and also of the ability by CT to separate fractures of the vertebral body from those of the posterior elements and arches. This study will present our results in this small series of patients and also compared the CT results to those obtained by plain films. Standard polytomography was obtained in two patients. We found that CT is excellent for the demonstration of the site of instability, allowing operations to be specifically tailored to fit the fracture type. Where neurologic deficit is not the primary problem and spinal canal stabilization is the major therapeutic goal, CT may be the only necessary study.
Postoperative Lumbar Spinal Canal Stenosis: Evaluation of 164 Patients with Axial Radiography R. M. Quencer*, F.R. Murtagh, M . J . D . Post, H.L. Rosomoff, and N. A. Stokes University of Miami School of Medicine, Miami, Florida Evaluation of the postoperative spine is frequently difficult because standard radiography often fails to demonstrate abnormalities within the lumbar spine at or adjacent to the surgical level. Use of axial radiography whether computed tomography (CT) or transverse axial tomography (TAT) allows visualization of the spinal canal in an axial section thus allowing a more accurate determination of the presence of spinal canal stenosis. Both CT and TAT were utilized to study 164 postoperative patients who had persistent or recurrent low back symptoms. Twenty-eight percent (28%) with previous laminectomy/disectomy and 43% of patients with previous midline posterior spinal fusion demonstrated canal stenosis. The high incidence of stenosis following fusion is explained by overgrowth of the fusion mass into the canal. Although a laminectomy may also stimulate exuberant bone growth, it is probable that many patients operated upon for an HNP had an underlying stenotic canal. A large percentage (91%) of patients improved after removal of the abnormal bone which had been shown with axial radiography.
Computed Tomography in the Evaluation of Post-Traumatic Impingement on the Spinal Canal
Eugene F. Binet, Christopher G. Ullrich*, and Michael G. Sanecki State University of New York, Upstate Medical Center, Syracuse, New York
Computed Tomographic Metrizamide Myelography of Congenital Abnormalities of the Spinal Canal and its Contents in Infants and Children
Evaluation of the spinal canal in patients with bony and/or ligamentous injury of the spine is often quite difficult. Plain radiographs and even tomographs often do not accurately identify the
Derek C. Harwood-Nash*, Charles R. Fitz, Margareta Resj6, and Sylvester Chuang The Hospital for Sick Children, Toronto, Ontario
16th Annual Meeting of the American Society of Neuroradiology
Subsequent to our initial report of this procedure to the Society in 1977, we have performed over 70 computed tomographic metrizamide myelograms (CTMM). An increasing number of these myelograms were performed on children with simple or complex congenital anomalies of the spine, cord, and coverings. The clinical, surgical, and therapeutic impact of this procedure in our institution has been dramatic. Besides clear understanding of the radiographic pathology, surgical treatment is better judged and performed and the pathological anatomy is precisely outlined. So much so, that we now recommend in selected cases, plain films of the spine and a primary CTMM without a standard myelogram. This procedure now totally obviates necessity for air myelography, even in suspect hydromyelia, and also Pantopaque myelography. The dosage of metrizamide is a third of that used for standard metrizamide myelography, the complications are far less, anaesthesia or heavy sedation is obviated, and the procedure is quick. We will demonstrate the technique of this procedure and its clinical significance in a gamut of congenital anomalis varying from neurenteric cysts to lipomeningoceles.
Metrizamide Ventriculography and Myelography with CT in Children Receiving Intrathecal Chemotherapy Michel D. F. Deck*, George Krol, David A. Rottenberg, and Jeffrey Allen Memorial Sloan Kettering Cancer Center, New York, New York Seven patients under 12 years of age have been evaluated using metrizamide in the subarachnoid space to establish patency of the cerebrospinal fluid pathways before institution of intrathecal chemotherapy or intravenous chemotherapy. The technique has been useful not only in outlining the CSF pathways but also in delineating normal and pathological anatomy. Methods of estimating accurate ventricular volume have been developed using computer analysis of CT sections. Serial CT scans after introduction of metrizamide into the cerebral ventricles has permitted an estimation of CSF turnover that may be useful in predicting potential brain toxicity from certain chemotherapeutic agents and also in demonstrating changes in CSF dynamics following therapy.
Announcements Eigth Congressof the EuropeanSociety of Neuroradiology Strasbourg, 7-8 September 1979
Friday, 7 September." Morning-Session: Characteristic, specific and pathognomonic neuroradiological findings in clinical neurology and neurosurgery. How far should the radiologist go? When should one gild the lily? i Introduction: A. Wackenheim - L. Penning. Invited papers: G. Ruggiero - S. Hilal - J. Bories - G. Salamon. Papers devoted to the theme (for members of the Society and of the Congress).
Friday, 7 September: Afternoon-Session: Computer Tomography in normal and pathological physiology. Introduction: G. du Boulay. Invited papers: H. Hacker - D. Balerianx, J. Flament, L. Jeanmart - J. M. Callle. Papers devoted to the theme (for members of the Society and of the Congress).
Saturday, 8 September: Morning-Session: Free five minutes papers (for members of the Society and of the Congress).
Saturday, 8 September: 14h30: General assembly of the European Society of Neuroradiology.
President: Professeur A. Wackenheim, Service de Neuroradiologie, C. H. U. de Strasbourg - B. P. 426, 67091 Strasbourg Cedex.
Responsiblefor the Text: The Editorsin Chief(see the firstpagesof this issue) Responsiblefor advertisements:L. Siegel,G. Martin,Kurfiirstendamm237, D-1000Berlin15, Springer-Verlag,Berlin-Heidelberg-NewYork Printedin Germanyby aprinta.Wemding/Schwaben Copyright© by Springer-VerlagBerlin . Heidelberg1978