F R O M THE D E P A R T M E N T O F N E U R O L O G Y , S O D E R S J U K H U S E T , S-100 64 S T O C K H O L M , S W E D E N .

QUANTITATIVE CISTERNOGRAPHY U.

In 1953 the use of

1 3 1

LYING-TUNELL

I - H S A o r R I S A w a s i n t r o d u c e d for s c i n t i m y e l o g r a p h y ( B A U E R

& Y U H L 1953). T h e C S F turnover of R I S A w a s e x p e r i m e n t a l l y a n a l y s e d by ISHIBASHI (1959). In m a n , a n e x p o n e n t i a l d i s a p p e a r a n c e of R I S A f r o m C S F has b e e n f o u n d f o l l o w i n g direct injection i n t o the cerebral ventricles, e m p l o y i n g either serial s a m p l i n g of C S F ( A T K I N S O N & F O L T Z 1962) o r external d e t e c t i o n ( M U N D I N G E R et coll. 1963). D i C H I R O (1964) i n t r o d u c e d R I S A c i s t e r n o g r a p h y for e v a l u a t i o n of the m o v e m e n t of C S F after l u m b a r injection of t h e tracer a n d external s c a n n i n g of t h e h e a d . T h i s m e t h o d w a s quantified ( L Y I N G - T U N E L L et coll. 1970), a n d later d e v e l o p e d u s i n g dif­ ferent external d e t e c t o r devices ( L Y I N G - T U N E L L & S O D E R B O R G 1 9 7 2 a, b ) .

Methods Primarily, a w h o l e - b o d y scanner w a s u s e d , w i t h a f o c u s s e d c o l l i m a t o r a n d a regional d o t c o u n t i n g t e c h n i q u e a p p l i e d t o the scintigrams ( L Y I N G - T U N E L L & S O D E R ­ BORG 1972 a). T h i s m e t h o d h a d certain d i s a d v a n t a g e s a n d a stationary

detector

system w i t h a l o n g straight b o r e lead c o l l i m a t o r w a s c o n s t r u c t e d . T h e d e s i g n a n d i s o response curves of t h e c o l l i m a t o r , as well as its p o s i t i o n i n g i n relation t o t h e basal cisterns have b e e n described p r e v i o u s l y

(LYING-TUNELL

& SODERBORG

1972 b ,

SODERBORG & L Y I N G - T U N E L L 1973). After l u m b a r injection of 3 7 0 0 k B q ( 1 0 0 /uCi) 1 3 1

I - H S A m e a s u r e m e n t s w e r e p e r f o r m e d f r o m t h e b a s a l cisterns a n d t h e parasagittal

region in anterior projections (Fig. 1) a n d f r o m the left u p p e r arm. T h e d i s a p p e a r a n c e of the tracer f r o m the basal cisterns w a s e x p o n e n t i a l a n d t h u s a b i o l o g i c half t i m e The author is now at Department of Neurology, Huddinge Sjukhus, S-141 86 Huddinge. Sub­ mitted for publication 23 December 1977. Acta Radiologica Diagnosis 19 (1978) Fasc. 6

Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 25, 2015

905

906

U. LYING-TUNELL CPM 2000-)

Fig. 1. Measurements from bas­ al cisterns ( O ) and parasagittal region ( • ) in one patient after subarachnoid injection of IHSA. 131

Hours

( B H T ) of the clearance c o u l d be calculated (Fig. 2 ) . Curves recorded f r o m the parasagittal region were often m o r e irregular. Tissue

background.

C a l c u l a t i o n s were b a s e d o n m e a s u r e m e n t s w i t h the stationary

d e t e c t o r f r o m t h e basal cisterns after i n t r a v e n o u s and s u b a r a c h n o i d

injections,

respectively ( L Y I N G - T U N E L L & S O D E R B O R G 1 9 7 2 b). After i n t r a v e n o u s injection, the q u o t i e n t of basal cistern t o arm activity w a s fairly c o n s t a n t , a n d t h u s it w a s possible t o calculate a p p r o x i m a t e l y the m a g n i t u d e of the c o n t r i b u t i o n of tissue b a c k g r o u n d at different times. A s s u m i n g that o n e w e e k after s u b a r a c h n o i d injection m o s t of the tracer h a s left t h e C S F , w h i c h is t h e n in equilibrium w i t h o t h e r tissues, the ratio of basal cistern t o a r m activity w a s calculated o n e w e e k after s u b a r a c h n o i d injection for cisternography. W i t h the c o r r e c t i o n factor t h u s o b t a i n e d , repeat m e a s u r e m e n t s of c o u n t rates o v e r the a r m were used t o calculate t h e tissue b a c k g r o u n d in the region of t h e basal cisterns at different times. T h e B H T w a s a l w a y s shorter after correction for tissue b a c k g r o u n d , t h e c o n t r i b u t i o n of w h i c h o b v i o u s l y increases with time. T h e level of tissue b a c k g r o u n d w a s f o u n d t o vary c o n s i d e r a b l y b e t w e e n different e x a m i n a ­ t i o n s , intraindividually as well as interindividually. T h e m e t h o d , i n c l u d i n g corrections for i s o t o p e d e c a y a n d for r o o m and tissue b a c k g r o u n d , w a s a p p l i e d p r o s p e c t i v e l y in a series of 7 0 patients e x a m i n e d with i s o t o p e c i s t e r n o g r a p h y ( L Y I N G - T U N E L L 1 9 7 7 ) . T h e n o m e n c l a t u r e for tracer kinetics suggested b y B R O W N E L L et coll. ( 1 9 6 8 ) w a s used. E a c h p o i n t o n the curves w a s w e i g h t e d with regard t o t h e total error, m a i n l y d e p e n d e n t o n c o u n t i n g statistics. H o w e v e r , the dif­ ferences b e t w e e n w e i g h t e d a n d n o n - w e i g h t e d v a l u e s were small and did n o t signif­ icantly influence t h e B H T c a l c u l a t i o n s . T h e error in d e t e r m i n i n g these

separate

p o i n t s , e s t i m a t e d b y r e p e a t i n g the m e a s u r e m e n t s in the s a m e patients within 3 0 min

Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 25, 2015

907

QUANTITATIVE CISTERNOGRAPHY CPM

hours

hours

Fig. 2. Representative semilog curves from 2 patients measured over the basal cisterns.

after r e p o s i t i o n i n g the d e t e c t o r , w a s f o u n d t o b e 3 . 8 per c e n t (n = 6 7 pairs). T h e straight lines o b t a i n e d in s e m i l o g a r i t h m i c p l o t s derived f r o m m e a s u r e m e n t s after p e a k activity h a d b e e n reached, viz. after 1 6 u p t o 4 8 h f o l l o w i n g injection. T h e y h a d h i g h correlation coefficients, with r - v a l u e s > 0 . 9 9 in 6 4 of t h e 7 0 cases. T h e error in deter­ m i n i n g the individual B H T , c a l c u l a t e d as t h e m e d i a n of t h e s t a n d a r d d e v i a t i o n s in the 7 0 curves, w a s f o u n d t o be 5 per c e n t of the m e a n B H T . C o r r e c t i o n for tissue b a c k g r o u n d in t h e s e 7 0 cases c a u s e d a n average decrease of B H T of 2 0 per c e n t (SE

2 % , range 0 - 6 9 % ) .

Reproducibility.

D u r i n g several years q u a n t i t a t i v e c i s t e r n o g r a p h y w a s p e r f o r m e d

twice in a n u m b e r of patients, usually b e c a u s e at t h e first a t t e m p t t h e a m o u n t of activity reaching the skull w a s insufficient for scintigraphy, t h o u g h it w a s e n o u g h for q u a n t i t a t i v e m e a s u r e m e n t s w i t h t h e s t a t i o n a r y d e t e c t o r . P a t i e n t s w i t h a m a j o r head injury or a n y o t h e r incident w h i c h c o u l d p o s s i b l y h a v e affected the C S F s y s t e m b e t w e e n the 2 e x a m i n a t i o n s were e x c l u d e d . F o u r t e e n p a t i e n t s w i t h repeat c i s t e r n o ­ g r a p h y r e m a i n e d for e v a l u a t i o n of the r e p r o d u c i b i l i t y of the m e t h o d ; 7 w i t h d e m e n t i a . T h e interval b e t w e e n t h e 2 c i s t e r n o g r a p h i e s r a n g e d f r o m o n e t o 9 m o n t h s . T h e individual B H T values are g i v e n in F i g . 3 . T h e relative error of this m e t h o d of deter­ m i n i n g cisternographic B H T w a s c a l c u l a t e d t o be 1 1 per cent.

Clinical aspects Biologic

half

time

of basal

cistern

clearance.

In the series of 7 0 p a t i e n t s i s o t o p e

cisternography and encephalography were performed ( L Y I N G - T U N E L L

1977).

The

d e g r e e of d e m e n t i a w a s b a s e d o n n e u r o l o g i c a n d p s y c h o m e t r i c e x p l o r a t i o n ( L Y I N G T U N E L L & M A R I O N S 1 9 7 5 b). T h e d i s a p p e a r a n c e rate of the tracer f r o m t h e basal cisterns w a s significantly s l o w e r in p a t i e n t s w i t h d e m e n t i a of different origins t h a n in the subjects w i t h o u t o b v i o u s brain injury, i.e. the B H T w a s significantly l o n g e r ( p < 0 . 0 0 1 ) in t h e patients w i t h d e m e n t i a ( F i g . 4 a), e v e n w h e n c o n s i d e r i n g s e p a r a t e l y

Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 25, 2015

908

U. LYING-TUNELL

Hours

4(h

Fig. 3. Biologic half time from 14 patients having undergone 2 cisternographies (I and II); r = 0.97, p < 0.001, (with the point in the upper right corner excluded, r = 0.83, p < 0.001).

'"



/ /

/ / V_

]

10

20

30 I

40 Hours

t h o s e w i t h o n l y slight m e n t a l r e d u c t i o n . T h e 1 7 p r e s u m a b l y n o r m a l subjects h a d a m e a n B H T of 9 . 8 h ( S D 4 . 1 ) . T h e v a l u e s in this g r o u p were fairly well separated f r o m t h o s e w i t h m a r k e d d e m e n t i a , 1 2 h c o n s t i t u t i n g a borderline v a l u e . A t e n c e p h a l o g r a p h y , t h e B H T v a l u e s correlated best w i t h t h e presence of biparietal convexity

air

block

(LYING-TUNELL &

MARIONS

1 9 7 5 a,

b,

MARIONS

&

LYING-

T U N E L L 1 9 7 7 ) , E v a n ' s i n d e x a n d t h e transversal w i d t h of t h e p o s t e r i o r part of t h e third ventricle. T h e c o m b i n e d results f r o m e n c e p h a l o g r a p h y a n d quantitative i s o t o p e c i s t e r n o g r a p h y h a d t h e best discriminative p o w e r in that all p a t i e n t s w i t h m e n t a l r e d u c t i o n of a n y degree h a d B H T > 1 2 h, o r parietal air b l o c k , o r b o t h . E n c e p h a l o g r a p h y is n o w t o s o m e e x t e n t replaced b y c o m p u t e r t o m o g r a p h y ( C T ) ; G A D O e t coll. ( 1 9 7 6 ) f o u n d a c l o s e c o r r e l a t i o n b e t w e e n C T findings a n d t h o s e at isotope cisternography in dementia. Normal

pressure

hydrocephalus

and effect

of CSF shunting.

F o u r patients with

n o r m a l pressure h y d r o c e p h a l u s a c c o r d i n g t o classic criteria ( O J E M A N N et coll. 1 9 6 9 ) w e r e e x a m i n e d b y q u a n t i t a t i v e c i s t e r n o g r a p h y b e f o r e a n d after clinically successful ventriculo-atrial s h u n t i n g a d m o d u m P u d e n z u s i n g a l o w pressure valve. O n e of t h e s e p a t i e n t s h a d a h i s t o r y of s u b a r a c h n o i d h e m o r r h a g e a n d a d u r a t i o n of s y m p t o m s of 3 m o n t h s , o n e a h i s t o r y of s t e r e o t a c t i c cerebral surgery f o r p a r k i n s o n i s m a n d a duration of s y m p t o m s for 2 1 months; in the remaining 2 patients n o etiology w a s k n o w n a n d t h e d u r a t i o n of s y m p t o m s w a s 6 years. O b s e r v a t i o n t i m e after s h u n t i n g r a n g e d b e t w e e n 2 . 5 a n d 4 y e a r s . A l l i m p r o v e d c o n s i d e r a b l y . O n e of t h e p a t i e n t s w i t h i d i o p a t h i c h y d r o c e p h a l u s , a 6 6 - y e a r - o l d w o m a n , h a d a clinical history of p r o g r e s s i v e d e t e r i o r a t i o n f o r 6 years. S h e w a s disoriented w i t h a K o r s a k o f f defect

Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 25, 2015

QUANTITATIVE CISTERNOGRAPHY

909

of m e m o r y , u n a b l e t o walk, s t a n d o r e v e n sit b y herself, a n d w a s i n c o n t i n e n t . A n excellent, a l t h o u g h s o m e w h a t u n e x p e c t e d , clinical i m p r o v e m e n t e n s u e d a s h u n t i n g p r o c e d u r e ; she b e c a m e c o n t i n e n t , able t o w a l k w i t h o u t a n y difficulty a n d w a s dis­ c h a r g e d f r o m the h o s p i t a l in a n i m p r o v e d m e n t a l state, a slight m e m o r y d i s o r d e r being the o n l y residue. T h e o b s e r v a t i o n t i m e w a s 4 years. T h e patient w i t h s u b a r a c h n o i d h e m o r r h a g e h a d a similar c o u r s e of

excellent

i m p r o v e m e n t . T h e r e m a i n i n g 2 patients a l s o i m p r o v e d c o n s i d e r a b l y after s h u n t i n g . E n c e p h a l o g r a p h y and i s o t o p e c i s t e r n o g r a p h y w e r e p e r f o r m e d in all p a t i e n t s ; b e ­ fore s h u n t i n g all h a d a m a r k e d c o m m u n i c a t i n g h y d r o c e p h a l u s , persistent ventricular i s o t o p e activity and a c o n v e x i t y b l o c k for b o t h air a n d i s o t o p e s . T h e w a s h o u t of R I S A f r o m the b a s a l cisterns w a s c a l c u l a t e d u s i n g t h e c o r r e c t i o n for tissue b a c k ­ g r o u n d ; the B H T v a l u e s a p p e a r in F i g . 4 b. Before s h u n t i n g , the w a s h o u t w a s s l o w ; after shunting t h e B H T v a l u e s were all shorter a n d fell well w i t h i n t h e p o s t u l a t e d n o r m a l range. P o s t o p e r a t i v e i s o t o p e c i s t e r n o g r a p h y indicated f l o w of activity t o t h e ventricles after 2 4 h, m o r e or less persistent a l s o after 4 8 h. N o a p p a r e n t activity w a s r e c o r d e d in t h e Sylvian or interhemispheric fissures, n o r o v e r t h e c o n v e x i t y , e x c e p t p o s s i b l y in o n e case. In 2 p a t i e n t s , c i s t e r n o g r a p h y u s i n g different i s o t o p e s w a s p e r f o r m e d several years after s h u n t i n g (Figs 5, 6). T h e p a t i e n t s were t h e n still in t h e s a m e g o o d clinical c o n d i t i o n s , w i t h f u n c t i o n i n g s h u n t s a n d w i t h scintigraphic i n d i c a ­ tion of a reversed f l o w . It is of interest t o c o m p a r e these results w i t h t h o s e p r e v i o u s l y o b t a i n e d b y t h e

Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 25, 2015

910

U. LYING-TUNELL

a

b

c

Fig. 5. Cisternography using T c - H S A 3.5 years after shunting. Anterior views after a) 5, b) 24 and c) 48 hours. Activity in the ventricles and Sylvian fissures even after 48 h in spite of the short physical half time of the isotope used. 9t

m

s c i n t i g r a p h i c m e t h o d f o r q u a n t i t a t i v e c i s t e r n o g r a p h y ( L Y I N G - T U N E L L & SODERBORG 1972 a ) a n d a r e g i o n a l d o t c o u n t i n g t e c h n i q u e ( L Y I N G - T U N E L L & SODERBORG 1972 c), t h o u g h this m e t h o d was a d m i t t e d l y s o m e w h a t crude. At that time, ventriculo-atrial s h u n t s w e r e i n s e r t e d in 6 p a t i e n t s w i t h p r e s e n i l e d e m e n t i a b u t n o gait d i s t u r b a n c e o r urinary

incontinence.

These

patients

had

cisternographic

and

encephalographic

f i n d i n g s c o n s i s t e n t w i t h c e r e b r a l a t r o p h y a c c o r d i n g t o t h e c r i t e r i a given by PATTEN & B E N S O N ( 1 9 6 8 ) . T h e c l e a r a n c e of i s o t o p e f r o m t h e b a s a l c i s t e r n s w a s s l o w . T h e o p e r a ­ t i o n d i d n o t result in a s i g n i f i c a n t clinical i m p r o v e m e n t . Q u a n t i t a t i v e c i s t e r n o g r a p h y w a s c a r r i e d o u t p r e - a n d p o s t o p e r a t i v e l y in 4 of t h e s e p a t i e n t s , r e v e a l i n g n o significant c h a n g e of B H T : p r e o p e r a t i v e l y , t h e m e a n B H T f r o m t h e b a s a l c i s t e r n s w a s 2 2 h ( r a n g e 1 8 - 2 8 h), p o s t o p e r a t i v e l y 23 h ( r a n g e 1 8 - 2 8 h ) .

Discussion I t is e s s e n t i a l t o e v a l u a t e t h e different c o m p a r t m e n t s of t h e C S F s p a c e s e p a r a t e l y in o r d e r t o a v o i d c o m p o s i t e c u r v e s of different m o d e s of flow. T h e c u r v e s f r o m t h e b a s a l c i s t e r n s closely fitted a m o n o - e x p o n e n t i a l f u n c t i o n . T h i s s u p p o r t s t h e a s s u m p ­ t i o n s t h a t o n e c o m p a r t m e n t w a s o b s e r v e d ( S H I P L E Y & C L A R K 1972) w i t h

uniform

d i s t r i b u t i o n of a c t i v i t y a n d n o f u r t h e r inflow of a c t i v i t y i n t o t h e c o m p a r t m e n t u n d e r o b s e r v a t i o n . T h e s e 2 f a c t o r s c o n s t i t u t e p r e r e q u i s i t e s f o r t h e c a l c u l a t i o n of ( S O L O M O N 1949,

L Y I N G - T U N E L L & S O D E R B O R G 1972

BHT

a, S O D E R B O R G & L Y I N G - T U N E L L ) .

In t h e b a s a l c i s t e r n s m a r k e d p u l s a t i v e m o v e m e n t s h a v e b e e n o b s e r v e d ( D u B O U L A Y e t c o l l . 1972), p r o m o t i n g a t h o r o u g h m i x i n g of t h e injected i s o t o p e w i t h C S F in t h i s r e g i o n . P a r t of t h e i n t e r h e m i s p h e r i c fissure p r o j e c t s o v e r t h e b a s a l c i s t e r n s in t h e view u s e d for m e a s u r e m e n t s b u t t h e s e r e g i o n s c o n s t i t u t e a d i r e c t l y c o n t i n u o u s c o m ­ partment. T h e g r e a t v a r i a t i o n in t i s s u e b a c k g r o u n d b e t w e e n different e x a m i n a t i o n s i n d i c a t e s

Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 25, 2015

91 1

QUANTITATIVE CISTERNOGRAPHY

Fig. 6. Cisternography using I n - D T P A 4 years after shunt­ ing. Anterior and lateral views after a, b) 6, c, d) 24, e, f) 48 and 72 hours, respectively. Activity only in the ventricles as a sign of reversed flow. The shunt valve is demonstrated at 6 and 24 hours. l u

e

f

t h a t it is i m p o r t a n t t o a c c o u n t for t h i s f a c t o r . T h e i n d i c a t o r s u b s t a n c e m a y leave t h e C S F s p a c e a l o n g n e r v e s (STEER & H O R N E Y 1 9 6 8 ) , o r l e a k t o s u r r o u n d i n g

tissues

a t t h e site of injection, c a u s i n g t h e ' h o t s p o t ' w h i c h is often e n c o u n t e r e d . T h u s , t h e m e t h o d of m e a s u r i n g t h e t r a n s p o r t of i s o t o p e s f r o m C S F t o b l o o d , w h i c h h a s b e e n s u g g e s t e d for a s s e s s i n g h y d r o c e p h a l u s ( A B B O T T & A L K S N E 1 9 6 8 ) , is s u b j e c t t o v a r i o u s t e c h n i c a l e r r o r s ( W I L L I A M S e t coll. 1 9 7 0 ) . M A H A L E Y e t coll. ( 1 9 7 4 ) c o m p a r e d n u c l i d e levels in b l o o d a t i s o t o p e c i s t e r n o g r a p h y in 1 5 p a t i e n t s w i t h p r o b a b l e n o r m a l p r e s ­ sure hydrocephalus and 2 2 considered to have Alzheimer's disease. T h e

clinical

c o u r s e of e a c h p a t i e n t w a s f o l l o w e d b y r e v i e w of t h e r e c o r d s . T h e y f o u n d a h i g h e r m e a n b l o o d a c t i v i t y in t h e l a t t e r g r o u p , b u t t h e r e w a s a c o n s i d e r a b l e o v e r l a p in l o w

Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 25, 2015

912

U. LYING-TUNELL

v a l u e s b e t w e e n the 2 g r o u p s . T h e a u t h o r s c o n c l u d e d that 7 of t h e 37 patients probably did n o t h a v e n o r m a l pressure h y d r o c e p h a l u s , w h i c h suggests that t h e m e t h o d has a l i m i t e d clinical value. O n l y part of the activity reaches the intracranial C S F space ( D i C H I R O 1966, S O D E R B O R G & L Y I N G - T U N E L L ) b u t the a m o u n t of activity reaching the basal cisterns d o e s n o t influence its clearance ( S O D E R B O R G & L Y I N G - T U N E L L ) . A negligible fraction of t h e i s o t o p e labelled a l b u m i n enters t h e n e r v o u s tissue directly f r o m the C S F (LEE

& O L S Z E W S K I 1960,

H O C H W A L D & W A L L E N S T E I N 1967). M I L H O R A T & H A M M O C K

(1971) c o n s i d e r e d t h e a p p a r e n t d o u b l e o u t l i n e of t h e ventricular system at i s o t o p e v e n t r i c u l o g r a p h y f r o m p a t i e n t s w i t h h y d r o c e p h a l u s as a s u b s t a n t i a t i o n of a rapid a n d extensive m i g r a t i o n of t h e i s o t o p e labelled a l b u m i n i n t o the brain tissue. H o w ­ ever, G R I F F I T H & S T A D D O N ( 1 9 7 3 ) expressed dissentient o p i n i o n s o n the basis of their e x p e r i e n c e u s i n g a glass ventricular m o d e l . In t h e p r e s e n t series, t h e curves f r o m t h e parasagittal region were often m o r e ir­ regular, p r o b a b l y in part d u e t o t h e relatively late a p p e a r a n c e of m a x i m u m activity, w h e n tissue b a c k g r o u n d h a d r e a c h e d significant levels. M e a s u r e m e n t

geometry

w o u l d a l s o s e e m less suitable: a small shift of the d e t e c t o r u p w a r d s w o u l d result in t h e r e c o r d i n g of v a u l t activity, while a small shift d o w n w a r d s w o u l d result in m e a s u r e m e n t of activity, if any, in the lateral ventricles w i t h a n e x p e c t e d flow dif­ ferent f r o m t h a t in t h e parasagittal region. M e a s u r e m e n t s o v e r t h e ventricles were a v o i d e d o n a c c o u n t of s u p e r i m p o s i t i o n of the large fissures, i.e. t h e interhemispheric fissure in t h e anterior v i e w , and t h e Sylvian fissures in the lateral view. T h e effect of this is c o n s i d e r a b l e , d u e t o a b s o r p t i o n a n d the inverse square l a w of radiation physics. F o r o b v i o u s r e a s o n s , m e a s u r e m e n t s o v e r t h e entire skull were a v o i d e d . A K E R M A N et coll. ( 1 9 7 2 ) e s t i m a t e d the ventricular v o l u m e f r o m scans and calculated t h e d i s a p p e a r a n c e rate of the tracer f r o m t h e ventricles. H o w e v e r , the m e t h o d has several d i s a d v a n t a g e s , as p o i n t e d o u t b y H A R B E R T e t coll. (1974). Intraventricular i s o t o p e injection is required a n d r e s o l u t i o n is t o o p o o r t o a l l o w a satisfactory defini­ t i o n of t h e projected ventricular area ( G R I F F I T H & S T A D D O N ) . Certainly a n a n a l o g o u s v o l u m e e s t i m a t e of t h e b a s a l cisterns w o u l d n o t be less crude. T h e m o v e m e n t of i s o t o p e labelled a l b u m i n has b e e n c o n s i d e r e d t o represent 'bulk f l o w ' f r o m the ventricles t o the s u b a r a c h n o i d s p a c e ; the m o d e of m o v e m e n t is clearly d e m o n s t r a t e d at c i s t e r n o g r a p h y ( P E N N I N G & F R O N T 1975). A transient intraventri­ cular activity d o e s n o t necessarily m e a n that C S F f l o w s b a c k w a r d s . B E L L O N I (1951) d e m o n s t r a t e d by use of a glass m o d e l of t h e C S F s p a c e that pressure variations gave rise t o counter-currents; a s l o w C S F f l o w m a y t h u s b e c o u n t e r a c t e d b y transmitted arterial p u l s a t i o n s . H o w e v e r , t h e patients w i t h n o r m a l pressure h y d r o c e p h a l u s in the present report h a d a m a r k e d , or persistent, ventricular activity. T h i s w a s the case a l s o after insertion of t h e s h u n t t u b e , a l t h o u g h there w a s a c o n c o m i t a n t n o r m a l i z a ­ t i o n of the clearance of i s o t o p e f r o m t h e basal cisterns. T h e s e findings indicate a n increased d r a i n a g e of C S F , m a i n l y t h r o u g h t h e s h u n t t u b e via the ventricles. S u c h scintigraphic i n d i c a t i o n of a reversed f l o w after s h u n t i n g of adult patients agrees

Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 25, 2015

QUANTITATIVE CISTERNOGRAPHY

913

with other reports ( A L K E R & LESLIE 1 9 6 9 , M A T I N et coll. 1 9 7 0 , M C C U L L O U G H et coll. 1 9 7 2 , C U R L et coll. 1 9 7 2 ) . M C C U L L O U G H e t coll. a n d C U R L e t coll. a l s o f o u n d t h a t total h e a d c o u n t curves h a d a n earlier p e a k a n d a m o r e rapid clearance after s h u n t i n g . F o r m a t i o n a n d a b s o r p t i o n of C S F t a k e s place t h r o u g h o u t t h e s u b a r a c h n o i d s p a c e , w i t h varying rate of e x c h a n g e f o r different c o n s t i t u e n t s ( S W E E T e t coll. 1 9 5 4 ) . T h u s , the turnover of C S F m a y b e increased a l s o b y drainage ' b a c k w a r d s ' . T h e disappear­ a n c e rate of t h e injected activity is of c o u r s e v o l u m e - d e p e n d e n t ( L Y I N G - T U N E L L & S O D E R B O R G 1 9 7 2 a, S I E G E L & J O H N S O N 1 9 7 4 ) . A p o s t o p e r a t i v e d e c r e a s e i n size of t h e

basal cisterns, if any, w o u l d t h u s c o n t r i b u t e t o a s h o r t e n i n g of t h e B H T f r o m this region. A n increased w a s h o u t of m e t a b o l i t e s f r o m t h e C S F , or, i n t h e case of c h a n g e d surface t o v o l u m e ratio, a n i m p r o v e d e x c h a n g e rate of different s u b s t a n c e s b e t w e e n the brain a n d the C S F , m i g h t i m p r o v e brain m e t a b o l i s m a n d t h u s h a v e bearing u p o n the clinical i m p r o v e m e n t after s h u n t i n g ( L Y I N G - T U N E L L 1 9 7 7 ) . C o n s i s t e n t w i t h this h y p o t h e s i s , a decreased cerebral m e t a b o l i s m w a s f o u n d i n a g r o u p of 7 p a t i e n t s w i t h n o r m a l pressure h y d r o c e p h a l u s , a s c o m p a r e d w i t h 1 0 h e a l t h y subjects, a p p r o a c h i n g n o r m a l levels after clinically successful s h u n t i n g ( L Y I N G - T U N E L L e t coll. 1 9 7 7 ) . A s l o w C S F turnover is c l o s e l y correlated w i t h m e n t a l r e d u c t i o n b u t n o t w i t h a g e p e r se ( L Y I N G - T U N E L L 1 9 7 7 ) . H E N R I K S S O N & V O I G T ( 1 9 7 6 ) r e c e n t l y c l a i m e d t h a t t h e

C S F f l o w n o t o n l y decreases w i t h increasing age, b u t a l s o that this decrease is directly d e p e n d e n t o n age. T h e y e x a m i n e d a series of c i s t e r n o g r a m s w h i c h t h e y regarded a s n o r m a l , b u t the criteria for n o r m a l i t y were d u b i o u s . T h e y d i d n o t report t h e clinical d i a g n o s e s o r mental states of t h e patients. It is well k n o w n that p a t i e n t s w i t h brain a t r o p h y have a t o p o g r a p h i c a l l y n o r m a l distribution of activity o v e r t h e c o n v e x i t i e s at cisternography, a l t h o u g h d e l a y e d ( D E L A N D et coll. 1 9 7 1 ) . It is a l s o well k n o w n t h a t in older a g e g r o u p s d e m e n t i a is p r o b a b l y t h e m o s t i m p o r t a n t i n d i c a t i o n f o r cisternography, with t h e a i m of selecting p a t i e n t s w i t h n o r m a l pressure h y d r o c e ­ p h a l u s w h o m i g h t benefit f r o m shunting. T h u s , a clinically u n s e l e c t e d g r o u p of patients will h a v e cisternographic c h a n g e s c o n c o m i t a n t w i t h a g e , i n t h e s a m e w a y as signs of m y o c a r d i a l infarcts at E C G are m o r e frequent in o l d e r a g e g r o u p s ( L Y I N G T U N E L L 1 9 7 8 ) . T h e signs of a s l o w C S F f l o w , w h i c h H E N R I K S S O N & V O I G T f o u n d i n older a g e g r o u p s , m a y well be a s s o c i a t e d w i t h m e n t a l r e d u c t i o n . A t a n y rate, their results o b v i o u s l y c a n n o t p r o v e the existence of a c a u s a l relationship b e t w e e n c i s t e r n o ­ graphic c h a n g e s a n d a g e p e r se. T h e described m e t h o d of q u a n t i t a t i v e c i s t e r n o g r a p h y h a s theoretical a s w e l l a s clinical implications since it c o n s t i t u t e s a nearly a t r a u m a t i c w a y of d e t e r m i n i n g o n e i m p o r t a n t c o m p a r t m e n t of C S F flow u n d e r a l m o s t p h y s i o l o g i c c o n d i t i o n s . T h e re­ producibility w a s g o o d at repeat e x a m i n a t i o n s of t h e s a m e p a t i e n t s i n a clinical s t e a d y state. T h e s l o w i s o t o p e w a s h o u t in patients w i t h d e m e n t i a h a s theoretical interest a n d t h e m e t h o d h a s practical d i a g n o s t i c i m p o r t a n c e in differentiating these patients f r o m , f o r instance, t h o s e w i t h m e n t a l d e p r e s s i o n . It c o n t r i b u t e s t o t h e d i a g n o s i s of disturbances of C S F f l o w and offers possibilities of e s t i m a t i n g the effect of different therapeutic m e a s u r e s o n C S F turnover. 58 - 7 8 5 8 4 1

Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 25, 2015

U.

914

LYING-TUNELL

T h e t e c h n i q u e f o r r e g i o n a l a n d q u a n t i t a t i v e c i s t e r n o g r a p h y is n o w a d o p t e d t o the u s e of

1 1 1

I n - D T P A a n d a c o m p u t e r assisted g a m m a c a m e r a , w h i c h h a s certain practi­

cal a d v a n t a g e s . In a p r e l i m i n a r y series of e x a m i n a t i o n s b y this m e t h o d , straight lines w e r e o b t a i n e d f r o m t h e b a s a l cisterns in s e m i l o g a r i t h m i c p l o t s ( L Y I N G - T U N E L L et coll. 1 9 7 8 ) . T i s s u e b a c k g r o u n d w a s n e g l i g i b l e . C h e l a t e h a s a greater t r a n s e p e n d y m a l diffu­ s i o n t h a n a l b u m i n w h i c h h a s a m o l e c u l a r w e i g h t a b o u t 1 0 0 t i m e s that of chelate ( H A R B E R T et coll. 1 9 7 3 ) . P A R T A I N et coll. ( 1 9 7 6 ) c o n c l u d e d f r o m their w o r k w i t h m a t h e m a t i c a l m o d e l s t h a t t r a n s m e n i n g e a l t r a n s p o r t w a s t h e m a j o r r o u t e of e l i m i n a ­ m

t i o n of I n - D T P A f r o m C S F , a l t h o u g h t h e r e b y i n v a l i d a t i n g o n e of t h e a s s u m p t i o n s f o r their m o d e l s . T h e fact t h a t the late i m a g e s at i n d i u m c i s t e r n o g r a p h y were s o m e ­ w h a t blurred s u p p o r t s this v i e w . T h e a p p a r e n t diffuse dispersal of

m

I n - D T P A was

c o n s i d e r e d b y SCHOSSBERGER & T O U Y A ( 1 9 7 6 ) a s p r o v i d i n g e v i d e n c e that cisterno­ g r a p h y d o e s n o t d e m o n s t r a t e C S F f l o w . H o w e v e r , this s t a t e m e n t d o e s n o t s e e m t o b e true for c i s t e r n o g r a p h y u s i n g

1 3 1

I - H S A . First, linear s c a n s d e m o n s t r a t e d a n effective

m o v e m e n t of the activity t o w a r d s t h e c r a n i u m ( L Y I N G - T U N E L L & S O D E R B O R G 1 9 7 2 a). S e c o n d , significant c o r r e l a t i o n s w e r e f o u n d b e t w e e n clearance rate of t h e activity a n d clinical c o n d i t i o n s ; in particular, clearance rates n o r m a l i z e d after

shunting

( F i g . 4 ) . P r o b a b l y c o m p o u n d s of h i g h e r m o l e c u l a r w e i g h t t h a n chelate, s u c h as a l b u m i n or i n u l i n , are m o r e suitable for e v a l u a t i o n of C S F d y n a m i c s , u n d e r the c o n d i t i o n t h a t s u b t r a c t i o n is m a d e for tissue b a c k g r o u n d .

S U M M A R Y

By quantitative cisternography using a stationary detector system with correction for tissue background, an exponential elimination of I - H S A from the basal cisterns was demonstrated, allowing calculation of a biologic half time (BHT) of the clearance curve at a satisfactory level of reproducibility. 'Normal' range of B H T was calculated. Demented patients had significantly longer B H T . In 4 patients with normal pressure hydrocephalus prolonged B H T turned normal after shunting, paralleled by marked clinical improvement, in contrast to previous findings in 4 patients with presenile dementia. The method is now being modified employing ^ I n - D T P A and a computer assisted gamma camera for regional dynamic analysis. 131

Z U S A M M E N F A S S U N G

Durch quantitative Cisternographie unter Anwendung eines stationaren Detector-systems mit Korrektion fur den Gewebehintergrund, wurde eine exponentionelle Elimination von I - H S A von den basalen Cisternen nachgewiesen, die eine Berechnung der biologischen Halbwert Zeit ( B H T ) der Ausscheidungskurve bei einem zufriedenstellenden Niveau von Reproduzierbarkeit erlaubt. Der 'normale' Bereich der B H T wurde berechnet. Demente Patienten hatten eine signifikant langere B H T . Bei 4 Patienten mit Hydrozephalus mit normalem Druck normalisierte sich die verlangerte B H T nach einer Shuntoperation in Parallelitat zu einer bedeutenden klinischen Verbesserung im Gegensatz zu friiheren Befunden bei 4 Patienten mit praseniler D e m e n s . D i e Methode ist nun verandert unter A n ­ wendung v o n I n - D T P A und einer Computer-unterstiitzten Gammakamera fiir eine regionale dynamische Analyse. 1 3 1

l n

Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 25, 2015

QUANTITATIVE CISTERNOGRAPHY

915

R E S U M E

La cisternographie quantitative utilisant un systeme de detecteur stationnaire avec correc­ tion pour le bruit de fond des tissus, a permis de mettre en evidence une elimination exponentielle de I - H S A a partir des citernes basales, permettant de calculer une demi-vie biologique (BHT) de la courbe de clearance avec un niveau satisfaisant de reproductibilite. Les auteurs ont calcule un intervalle 'normal' de B H T . Les patients dements ont une B H T significativement plus longue. Chez 4 malades atteints d'hydrocephalie a pression normale, la B H T prolongee est revenue a la normale apres derivation, accompagnee par une ameliora­ tion clinique importante et contrastant avec les resultats obtenus precedemment chez 4 malades atteints de demencj pre-senile. Cette methode est maintenant modifiee en utilisant I n - D T P A et une gamma-camera assistee par ordinateur pour une analyse dynamique regionale. 131

l u

R E F E R E N C E S

ABBOTT M. and ALKSNE J . F . : Transport of intrathecal I Neurology (Minneap.) 18 (1968), 870.

1 2 6

R I S A t o circulating plasma.

AKERMAN M., DE TOVAR G . and G U I O T G . : Radioisotope cisternography and ventriculo­

graphy in noncommunicating hydrocephalus. In: Cisternography and hydrocephalus, p. 483. Edited by J . C. Harbert, D . C. McCullough, A . J . Luessenhop and G . D i Chiro. Charles C. Thomas, Springfield, 111. 1972. ALKER G . J . and LESLIE E. V.: Isotope cisternography and ventriculography. Acta radiol. Diagnosis 9 (1969), 589. ATKINSON J . R. and FOLTZ E. L.: Intraventricular 'RISA' as a diagnostic aid in pre- and postoperative hydrocephalus. J . Neurosurg. 19 (1962), 159. BAUER F. K . and Y U H L E. T.: Myelography by means of I . The myeloscintigram. N e u r o ­ logy (Minneap.) 3 (1953), 341. BELLONI G . B.: The diffusion of substances in the subarachnoid spaces. J . Neurol. N e u r o ­ surg. Psychiat. 14 (1951), 314. 1 3 1

BROWNELL G . L., BERMAN

M. and ROBERTSON J . S.: Nomenclature for tracer kinetics.

Int. J . appl. Radiat. 19 (1968), 249. C U R L F. D . , HARBERT J . C. and M C C U L L O U G H D . C : Quantitative cisternography. A n aid

to diagnosis. In: Cisternography and hydrocephalus, p. 4 4 1 . Edited by J . C . Harbert, D . C. McCullough, A . J . Luessenhop and G . D i Chiro. Charles C. Thomas, Springfield, 111. 1972. D E L A N D F. H., JAMES JR A . E., W A G N E R J R H . N . and H O S A I N F . : Cisternography with

i 6 9 b - D T P A . J . nucl. Med. 12 (1971), 683. D i CHIRO G . : Movement of the cerebrospinal fluid in human beings. Nature 204 (1964), 290. — Observations o n the circulation of the cerebrospinal fluid. Acta radiol. Diagnosis 5 (1966), 988. Y

D u BOULAY G . , O ' C O N N E L L J . , CURRIE J . , BOSTICK T. and VERITY P.: Further investigations

o n pulsative movements in the cerebrospinal fluid pathways. Acta radiol. Diagnosis 13 (1972), 496. G A D O M. H., COLEMAN R. E., LEE K . S., M I K H A E L M. A . , ALDERSON P. O. and A R C H E R

C. R.: Correlation between computerized transaxial tomography and radionuclide cisternography in dementia. Neurology (Minneap.) 26 (1976), 555. GRIFFITH H . B. and STADDON G . : Transventricular absorption and isotope ventriculography. Arch. Neurol. 28 (1973), 272.

Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 25, 2015

916

U. LYING-TUNELL

HARBERT J. C , H A D D A D D . and M C C U L L O U G H D . C : Quantitation of cerebrospinal fluid

shunt flow. Radiology 112 (1974), 379. — REED V. and M C C U L L O U G H D . C : Comparison between I - H S A and Y b - D T P A for cisternography. J. nucl. M e d . 14 (1973), 765. HENRIKSSON L . and VOIGT K.: Age-dependent differences of distribution and clearance patterns in normal R I H S A cisternograms. Neuroradiology 12 (1976), 103. H O C H W A L D G . M . and WALLENSTEIN M . : Exchange of albumin between blood, cerebro­ spinal fluid, and brain in the cat. Amer. J. Physiol. 212 (1967), 1199. ISHIBASHI T . : Studies o n the dynamics of the cerebrospinal fluid using radioactive isotopes. Part I. The formation and the absorption of cerebrospinal fluid. Tohoku J. exp. Med. 70 (1959), 49. LEE J. C. and OLSZEWSKI J.: Penetration of radioactive bovine albumin from cerebrospinal fluid into brain tissue. Neurology (Minneap.) 10 (1960), 814. LYING-TUNELL U . : Cerebrospinal fluid turnover and convexity block in mental impairment. A controlled prospective study. Neurology (Minneap.) 27 (1977), 460. — Letter t o the Editor. Neuroradiology 14 (1978), 275. — and MARIONS O . (a): Air filling of the subarachnoid space over the cerebral convexities at repeat encephalography. Neuroradiology 9 (1975), 187. (b): A triad of airencephalographic findings in patients with mental impairment. A controlled prospective study. Neuroradiology 9 (1975), 251. — and SODERBORG B. (a): Quantitative scintigraphic method of estimating the circulation of cerebrospinal fluid. Acta radiol. Diagnosis 13 (1972), 554. (b): Quantitative methods of estimating C S F flow. In: Cisternography and hydro­ cephalus, p. 503. Edited by J. C. Harbert, D . C. McCullough, A . J. Luessenhop and G . D i Chiro. Charles C. Thomas, Springfield, 111. 1972. (c): The dot counting method in scintigraphy. Acta radiol. (1972), Suppl. N o . 313, p. 229. — BERGVIK A . and SODERBORG B.: Quantitative cisternography. In: Radioaktive Isotope in Klinik und Forschung. Band XIII, Teil I, p. 357. Herausgegeben v o n R. Hofer. Verlag H . Egermann, Wien 1978. — LINDBLAD B. S., M A L M L U N D H . O . and PERSSON B.: Cerebral blood flow and metabolic rate of oxygen, glucose, lactate, pyruvate, ketone bodies and amino acids in patients with normal pressure hydrocephalus before and after shunting and in normal subjects. Acta neurol. scand. 56 (1977) Suppl. N o . 64, p. 338. 131



169

BERGQUIST D . , BOHMER G . , M A L M L U N D H . O . , M A R I O N S O . and SODERBORG B.: Studies

in presenile dementia. Acta neurol. scand. 46 (1970) Suppl. N o . 43, p. 90. M C C U L L O U G H D . C , F o x J. L., C U R L F. D . and G R E E N R. C : Effects of C S F shunts on

intracranial pressure and C S F dynamics. In: Cisternography and hydrocephalus, p. 335. Edited by J. C. Harbert, D . C. McCullough, A . J. Luessenhop and G . D i Chiro. Charles C. Thomas, Springfield, 111. 1972. M A H A L E Y J R M . S., W I L K I N S O N J R R. H., SIVALINGHAM S., FRIEDMAN H . , TYSON W. and

GOODRICH J. K.: Radionuclide blood levels during cisternography of patients with normal-pressure hydrocephalus or Alzheimer's disease. J. Neurosurg. 41 (1974), 471. MARIONS O . and LYING-TUNELL U . : Constancy of convexity air block on pneumoencephalo­ graphy. Neuroradiology 13 (1977), 191. M A T I N P., G O O D W I N D . A . and D E N A R D O G . L.: Cerebrospinal fluid scanning and ventri­ cular shunts. Radiology 94 (1970), 435. MILHORAT T. H. and HAMMOCK M. K.: Isotope ventriculography. Interpretation of ventri­ cular size and configuration in hydrocephalus. Arch. Neurol. 25 (1971), 1.

Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 25, 2015

QUANTITATIVE CISTERNOGRAPHY

917

M U N D I N G E R F . , A N L A U F M . und B O U C H A R D G . : D i e cardiale Impulsfrequenzmessung des 131

Jod -Hippuran, eine neue Methode zur Passagepriifung ventriculo-atrialer Shunts und die ventrikulare Resorptionsprufung zur Differentialdiagnose der Hydrocephali. Acta neurochir. (Wien) 11 (1963), 272. OJEMANN R. G . , FISHER C. M., A D A M S R. D . , SWEET W . H . and N E W P. F. J.: Further

experience with the syndrome of 'normal' pressure hydrocephalus. J. Neurosurg. 31 (1969), 279. PARTAIN C. L „ A L D E R S O N P . O . , D O N O V A N R. L . , SIEGEL B. A . , R U J A N A V E C H N . , JOHNSTON

R. E. and STAAB E. V.: Regional kinetics of Indium 111-DTPA in CSF imaging of normal volunteers. In: Radiopharmaceutical dosimetry symposium, p. 404. H E W Publication ( F D A ) 76-8044, Washington D . C . 1976. PATTEN D . H. and BENSON D . F.: Diagnosis of normal-pressure hydrocephalus by R I S A cisternography. J. nucl. Med. 9 (1968), 457. PENNING L . and F R O N T D . : Brain scintigraphy. Excerpta Medica, Amsterdam 1975. SCHOSSBERGER P. F. and TOUYA J. J.: Dynamic cisternography in normal dogs and in human beings. Neurology (Minneap.) 26 (1976), 254. SHIPLEY R. A. and CLARK R. E.: Tracer methods for in vivo kinetics. Chap. 1, Academic Press, N e w York 1972. SIEGEL B. A . and JOHNSON E. W.: Measurement of intrathecal I -albumin transport t o plasma. Neurology (Minneap.) 24 (1974), 501. SODERBORG B. and LYING-TUNELL U . : H o w much radioactivity reaches the basal cisterns at cisternography? In: Radioaktive Isotope in Klinik und Forschung. Band X , p. 203. Herausgegeben von K. Fellinger und R. Hofer. Urban und Schwarzenberg, Miinchen, Berlin, Wien 1973. SOLOMON A. K.: Equations for tracer experiments. J. clin. Invest. 28 (1949), 1297. STEER J. C. and HORNEY F. D . : Evidence for passage of cerebrospinal fluid along spinal nerves. Canad. med. Ass. J. 98 (1968), 71. 131

SWEET W. H., BROWNELL G . L . , SCHOLL J. A., BOWSHER D . R., B E N D A P. and STRICKLEY E . :

The formation, flow and absorption of cerebrospinal fluid; newer concepts based o n studies with isotopes. Res. Publ. Ass. nerv. ment. Dis. 34 (1954), 101. WILLIAMS J. P., PRIBRAM H. F. W., L Y N D E R. H . and SHARPE A . R.: I s o t o p e cisternography

in the evaluation of patients with subarachnoid hemorrhage. J. nucl. Med. 11 (1970), 592.

Downloaded from acr.sagepub.com at University of Manitoba Libraries on June 25, 2015

Quantitative cisternography.

F R O M THE D E P A R T M E N T O F N E U R O L O G Y , S O D E R S J U K H U S E T , S-100 64 S T O C K H O L M , S W E D E N . QUANTITATIVE CISTERN...
2MB Sizes 0 Downloads 0 Views