Acta Neurochirurgica 32, 25--33 (1975) 9 by Springer-Verlag 1975
Neurosurgical Clinic of the University of Milan (Villani, Gaini) Neurosurgical Clinic of the University of Pavia (Brambilla, Paoletti) Neurosurgieal Division of the Fatebenefratelli Hospital of Milan (Caneschi, Frigeni)
Radioisotope Cisternography in Head-Injured Patients* By
R. Villani, S. M. Gaini, P. Paoletti, G. Brambilla, S. Caneschi, and G. Frigeni With 1 Figure
Summary Of 600 patients submitted to radioisotope eisternography carried out with radioiodinated h u m a n serum albumin (II~I-HSA) a group of 140 had head injuries. Our investigation was intended to study the modifications of CSF circulation and absorption which accompany cranio-eerebral trauma. Of 88 head injured patients who did not undergo operation 44 had transient loss of consciousness, and 44 were in prolonged coma. Fifty-two patients underwent operation. Of these 5 had skull fractures with dural lesions, 7 had extradural haematomas, 19 had subdural haematomas, and 21 had brain contusions. Cisternograms were performed at different time intervals after trauma, and in some instances the test was repeated in order to study the possible long term alterations of CSF circulation and absorption. Abnormalities of cisternographie pictures are classified into the following groups: 1~ asymmetric diffusion; 2~ operative cavity s~agnation; 3~ ventrieular reflux; 4 ~ associated abnormalities. Cisternographic features are analysed in relation to the corresponding clinical and pneumoencephalographic patterns in the patients examined. These investigations may enable us to recognise possible indications for shunt procedures in the management of CSF absorption defects, which are so frequently apparent after head injury.
Introduction The use of radioisotope eisteraography has been f o u n d helpful in studies of CSF flow a n d a b s o r p t i o n i, 2, 9, 10, 11, 21, 22, ea The most i m p o r t a n t investigations, were carried out on p a t i e n t s * This work was supported b y the "Consiglio Nazionale delle I~icerehe", Rome, I t a l y . - Grant No. 71.00905.043800.
R. Villani et al. :
with progressive dementia, motor retardation associated with urinary incontinence and ventricular enlargement with normal CSF pressure 1, 2, 3, 4, 5, 6~ 7, 13, 14~ 21, 22, 23~ 24, 25, 26, 27, 28, 29, 30 Other studies with radioisotope eisternography were carried out in different pathological conditions in order to evaluate abnormalities of CSF dynamics. Recently, cisternography has been applied to an evaluation of CSF flow and absorption in head injured patients s. I n surgically treated head injured patients we often observe clinical signs or symptoms of abnormal CSF dynamics. Encouraged by the results of cisternography in neurosurgical patients 14, 15, 16, 17, is, xg, we decided to evaluate abnormalities of CSF flow and absorption by this technique. At first we studied patients with clinically evident CSF abnormalities, and later we evaluated head injured patients with dementia without evidence of CSF abnormalities. Finally we studied patients who were apparently normal. All the groups included head injured patients, whether operated upon or not. Head injury involved sub-araehnoid bleeding with alteration in CSF reabsorption, which in some cases caused progressive ventricular enlargement and the clinical picture of normotensive hydrocephalus. We analysed two aspects of CSF abnormalities in the head injured patients. The first was the scope of radioisotope cisternography in evaluating abnormalities of CSF flow and absorption. The second (strictly clinical) was the incidence and significance for recovery of CSF abnormalities in these patients.
Method The tracer used in radioisotope cisternography was human serum albumin, labelled with 1131 (HSA-I13~-Sorin Saluggia). Each patient received 100 miero-Ci of high specific activity HSA-I 1~1 (0.2 miero-Ci/ml), in a volume of 2 ml, by the lumbar route. A half dose was administered by the occipital route. The highest dose of protein was 1 rag. All patients were pretreated with Lugol's solution (10 drops per day for 6 days), 15-50 mg of Dimethylaminopropylphenothiazine (Fargan-Farmitalia), and 2-Smg of Dexamethazone-21-Phosphate (Decadron-Merck) intramuscularly (both I hour before examination). Radioactivity was recorded with a Picker Magnascanner V. The technical data were: speed I00 cm/min, window 315-345, collimator at 31 holes. The scans were performed 6, 24, 48, and 72 hours after the tracer's administration in four views: anterior, posterior and both laterals. When possible, patients underwent air study and complete CSF chemical analysis. In all of the patients CSF pressure was lower than
I~adioisotope Cisternography in I-Iead-Injured Patients
Results and Discussion 140 cases of b r a i n t r a u m a selected from 600 p a t i e n t s s t u d i e d b y our group were analysed. T a b l e 1 shows our series of non surgical b r a i n injuries. T a b l e 2 shows our series of 52 b r a i n injuries t r e a t e d b y o p e r a t i o n a n d classified according to t h e t y p e of lesion. Table 1. Non Surgical Head-Injured Patients Seriousness of t r a u m a
No. of eases
Minor head-injury (without loss of consciousness) Fairly serious head-injury (transient loss of consciousness) Severe head-injury (neurological deficits with loss of consciousness) Very severe head-injury (prolonged coma)
32 37 7 88
Table 2. Head-Injured Patients Operated upon Type of lesion
No. of eases
Skull fractures with dural lesions Epidural hematomas Acute subdurM hematomas Chronic subdural hernatomas Intraeerebral hematomas Brain. contusions
5 7 13 6 2 19
Fig. 1 shows t h c classification of isotope cisternograms, where " N " indicates n o r m a l cases, " A D " indicates a s y m m e t r i c a l diffusion a n d a b s o r p t i o n of tracer, " O C S " indicates a c c u m u l a t i o n of t r a c e r in t h e o p e r a t i v e c a v i t y w i t h a clear defect in r e a b s o r p t i o n , a n d "VI~" indicates t h e case when t h e t r a c e r a p p e a r s diffused in t h e v e n t r i c u l a r s y s t e m with a m o r e or less d e l a y e d clearance. Two or m o r e of t h e a b o v e pictm-es m a y h a v e been presen~ in one a n d t h e s a m e p a t i e n t . ~Finaily t h e r e is a I 2 % unsuccessful injection group i n d i c a t e d b y " U I " .
R. Villani et al. : Radioisotope Cisternography
I n t h e g r o u p of n o n - o p e r a t e d p a t i e n t s (Table 3), t h e cisternographic p i c t u r e of 0CS is o b v i o u s l y missing. I n such p a t i e n t s t h e r e was a high p e r c e n t a g e of U I (16%), for which we can give no s a t i s f a c t o r y exp l a n a t i o n . N o r m a l c i s t e r n o g r a m s were p r e s e n t in p r a c t i c a l l y all t h e groups of subjects. H i g h e r incidences of A D a n d V R were r e c o r d e d in t h e w o r s t injured. I n 37 p a t i e n t s w i t h severe b r a i n i n j u r y t h e r e were 12 cases of VR. Table 3. I131-HSA Cgsternograms in Non-Surgical Head-Injured Patients lXIo. of cases
Minor head-injury F a i r l y serious head-injury Severe head-injury Very severe head-injury
12 32 37 7
2 7 3 2
9 15 14 1
1 6 7 3
-4 12 1
Table 4. I131-HSA Cisternograms in Head-Injured Patients Operated upon Type of lesion
No. of cases
Skull fractures with dural lesions Epidural hematomas Acute subdural hematomas Chronic subdural hematomas
5 7 13 6
1 4 3
3 3 4 1
2 3 3 1
Intraeerebral hematomas Brain contusions
A m o n g t h e o p e r a t e d p a t i e n t s (Table 4), t h e incidence of U I was w i t h i n n o r m a l limits. O t h e r cisternographie a b n o r m a l i t i e s were m o r e frequent. Only 9 p a t i e n t s h a d n o r m a l cisternographies. A D was f o u n d with all t y p e s of lesions w i t h no special incidence in one group. OCS was o b v i o u s l y o n l y f o u n d in some p a t i e n t s w i t h residual o p e r a t i v e cavities, while t y p e s of VI~ were p r e s e n t w i t h all t y p e s of lesion. I n t h e following t a b l e s we e x a m i n e d t h e possible relations b e t w e e n c i s t e r n o g r a m s showing v e n t r i c u l a r e n l a r g e m e n t a n d t h e clinical s t a t u s of t h e p a t i e n t s . W e considered only V R (associated w i t h v e n t r i c u l a r e n l a r g e m e n t a n d clinical d e t e r i o r a t i o n of t h e p a t i e n t ) as i n d i c a t i n g t h e d e s i r a b i l i t y of a C S F shunt. T a b l e 5 shows t h e d a t a r e g a r d i n g 51 n o n - o p e r a t e d cases w i t h n o r m a l CSF pressures.
Fig. l. Classification of eistcrnographic pictures; N (normal), AD (asymmetric diffusion), OCS (operative cavity stagnation), VR (vcntricular reflux)
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Satisfactory correspondence between isotope cisternograms a n d air studies m u s t be stressed. E i g h t p a t i e n t s showed 3 of the typical alterations listed, a n d 7 of these h a d satisfactory results from CSF shunts. Table 5. Results oJ 51 Non-Surgical Head-Injuries with Normal C S F Pressure Submitted to I i s i - H S A Cisternography and Pneumoencephalography Air study P~I-HSA No. of cisternograms cases normal
- - Dementia - - motor abnormalities - - ineontinentia
-2 ( 1 impr.)
7 (all impr.)
Table 6. Results o] 29 Head-Injuries with Normal CS_F Pressure, Operated upon, Submitted to Iiai-HSA Cisternography and Pneumoencephalography Air study Ii31-HSA No. of eisternography cases normal
- - Dementia - - m o t o r abnormalities - - incontinentia
(not impr.) OCS VR
-6 (all impr.)
Two p a t i e n t s i n the AD group with v e n t r i c u l a r e n l a r g e m e n t a n d psychic deterioration h a d CSF shunts. One of these did n o t i m p r o v e clinically. The highest n u m b e r of p a t i e n t s who h a d CSF s h u n t s was in the group p r e s e n t i n g with loss of consciousness a n d neurological deficits (5 cases); one was in the group with prolonged coma a n d a n o t h e r h a d received m i n o r t r a u m a two m o n t h s earlier. I n T a b l e 6 operated p a t i e n t s are listed using the same classifications,
Radioisotope Cisternography in Head4njured Patients
Of the 7 patients with VR, ventricular enlargement, and psychic and motor deterioration, 6 were submitted to CSF shunts with clear iraprovement. The one shunted patient in the AD group showed no clinical improvement. Five of the 6 patients treated with a CSF shunt had brain contusions and one had a chronic subdurM hematoma. There were subjects in both groups having Vl% and ventricular enlargement who were not submitted to a CSF shunt because they had demonstrated progressive and spontaneous improvement in their clinical status (6 eases). Isotope cisternography was repeated after a certMn period in 2 eases with normal results. We would like to point out the possibility of the coexistence of VR with a normal sized ventricular system, which is, however, associated with rapid clearance of the tracer. Concerning the first problem analysed in our study, isotope eisternography has demonstrated that 73 of the 140 patients studied had alterations of CSF diffusion. The most important cisternographie abnonnality, defined as VR, was present in 32 cases. Our first conclusion is t h a t alterations of CSF circulation are evident in 50% of the brain injured patients studied and t h a t isotope eisternography is the preferred test for their identification. The second aspect of our research concerned an attempt to compare cisternography and the clinical status of the patients with the possible evidence of ventrieular enlargement. Surgical treatment was carried out only in those cases whose VR pictures corresponded to ventricular enlargement and persistent clinical deterioration. The purpose of our research was to limit the number of patients treated with CSF shunts. We can conclude t h a t all the patients treated in accordance with these criteria obtained satisfactory improvement, while no good results were achieved in the two patients without VR. The cisternographie picture defined as V1% seems to be of particular importance for the identification of CSF alterations responsible for ventrieular enlargement and psychomotor deterioration. We can conclude by summarizing our results as follows : 1. Isotope cisternography is the preferred test for identifying alterations in CSF circulation. 2. Such alterations are present in a high percentage of head injured patients. 3. VR is the cisternographie abnormality which most clearly gives evidence to alteration in CSF dynamics. 4. VR is insufficient on its own as an indication for CSF shunt procedures. It, must be associated with ventrieular enlargement, and persistent psychic deterioration.
1%. Villain eL al. :
1. Adams, R . D . , G.M. Fischer, S. Hakim, R . G . Ojem~nn, and W. H. Sweet, Symptomatic occult hydrocephalus with "normal" ccrebrospinalfluid pressure: treatable syndrome. New Eng. J. Med. 273 (1965), 117--126. 2. - - F u r t h e r observations on normal pressure hydrocephalus. 1)roe. Roy. Soc. Med. 59 (1966), 1135--1139. 3. Akerman, M., 1). Derome, et G. Guiot, Le transit radio-isotopique dans les hydrocephalies. Neurochirurgie 16 (1970), 117--126. 4. Alker, G. J., E. V. Leslie, and F. Glasauer, Five years experience with isotope cisternography and ventriculography. I X Symposium Neuroradiologicum, Goeteborg, 24/29; 8, 1973. Book of Abstracts, n. 97. 5. Ashburn, W . L . , and G. Di Chiro, Radioisotope cisternography and ventriculography. I n : Radionuclide Application in Neurology and Neurosurgery. Wang, Y., and P. Paoletti, eds., p. 165. Springfield, Ill. : Ch. C Thomas. 1970. 6. Bannister, R., E. Gilford, and 1%. Kocen, Isotope encephalography in the diagnosis of dementia due to communicating hydrocephalus. Lancet 2 (1967), 1014--1017. 7. Benson, D . F . , M. Le May, and D. I~. 1)atten, Diagnosis of normal pressure hydrocephalus. New Eng. J. Med. 283 (1970), 609--615. 8. Creissard, 1), A. Redondo, L. I-Iarispe, et B. Jacquinot, Le transit gamma-enedphalographique dans [e L.C.1%. chez les traumatis4s du crane (et en p6riode post-operatoire). Minerva Neurochirurgica 16 (1972), 175--179. 9. Di Chiro, G., Movement of the cerebrospinal fluid in h u m a n beings. Nature (London} 204 (1964), 290--291. 10. - - W. L. Ashburn, and W . H . Briner, Technetium Tc 99m serum alburnin for cisternography. The use of high specific activity of Tc 99m serum albumin as a tracer for subarachnoidal and ventricular scintiphotography. Arch. Neurol. 19 (1968), 218--227. 11. - - A. K. Ommaya, W. L. Ashburn, and W. I-I. Briner, Isotope cisternography in the diagnosis and follow~up of eerebrospinal fluid rhinorrea. J. Neurosurg. 28 (1968), 522--529. 12. - - W . L . Ashburn, and A.S. Grove, Which radioisotopes for brainscanning. Neurology 18 (1968), 225--236. t3.----L. S. Zeiger, and G . L . Shall, t~adioisotope encephalo-eisternography and encephMo-ventriculography. J. Neurosurg. 36 (1972), 127--132. i4. Forslo, M., B. Forssman, S. Jarpe, and C. l~adberg, I~IHSA eisternography in the study of suspected hydrocephMus diagnostic and therapeutic experiences. I I Symposium Neuroradiologicum, Goeteborg 24/29; 8, 1970. Book of Abstracts, n. 99. 15. Frigeni, G., S. )~i. Gaini, 1). Paoletti et 1%. Villani, 1)rime esperienze di cisternografia e ventriculografia isotopica in pazienti di interesse neurochirurgieo. Min. Neuroehir. 14 (1970), 215--224. 16. Isotope cisternography. Consideration on abnormal pictures. Acta Neurochir. (Wien) 25 (1972), 145--163. 17. La cisternographie isotopique dans l'6tude des alt6rations de la dynamique du L.C.R. apr~s traitemeng neurochirurgical. Min. Neurockir. 16 (1972), 186--191.
Radioisotope Cisternography in Head-Injured Patients
18. Frigeni, O., S. I~I. Gaini, P. Pao!etti e~ R. Villani, Study of possible postsurgical complications in neurosurgery using radioisotope eisternography. I n : Cisternography and Hydrocephalus. A Symposium, ed. J. C. Harbert, cap. 23. Springfield, I11.: Ch. C Thomas. 1972. 19. Post.surgical normal pressure hydrocephalus. I n press on Excerpta Med. Int. Congr. Series 1972. 20. Oaini, S. IV[., P. Paoletti, R. Villani, and G. Frigeni, High specific activity I T M and Tc 99m albumin for studying the cerebrospinal fluid circulation in infantile and childhood hydrocephalus. Acta Neurochir. (Wien) 23 (1970), 31 46. 21. Hakim, S., Algunas observaciones sobre la pression del L.C.R. Sindrome Hidrocefaliea en el adulto con "presion normal" det L.C.R. Univcrsidad Javeriana, Tesis de Grade: 957, BegetS., Columbia, S.A. majo 1964. 22. - - and I~. D. Adams, The special clinic problem of symptomatic hydroeephalus with normal cerebrospinal fluid pressure. J. Neurol. Sci. 2 (1965), 307--327. 23.-and C.M. Fischer, Occult I-Iydroeephalus. Eng. J. Med. 274 (1966), 466--471. 2 4 . - Biomechanies of hydrocephalus. I n : Cistcrnography and Hydrocephalus. A Symposium, ed. J . C . Harbert, cap. 3. Springfield, Ill.: Ch. C Thomas. 1972. 25. Heinz, E . R . , D. O. Davis, and H. Karp, Abnormal isotope cisternography in symptomatic occult hydrocephalus. Radiology 95 (1970), 109--120. 2 6 . - - - - - - C l i n i c a l , radiological, isotopic and pathologic correlation m normotcnsive hydrocephalus, i n : Cisternography and Hydrocephalus. A Symposium, ed. J. C. Harbert, cap. 17. Springfield, Ill.. : Ch. C Thomas. 1972. 27. James, A . E . , F . H . De Land, and F . J . Hedges, Normal pressure hydrocephalus. Role of eisternography in diagnosis. J. A. M. A. 213 (1970), 1015--1020. 28. 3~eCullough, D.C., J . C . Harbert, G. Di Chiro, and A. K. Ommaya, Prognostie criteria for eerebrospinal fluid shunting from isotope cisternography in communicating hydrocephalus. Neurology 20 (1970), 594--598. 29. Patten, D . H . , and D . F . Bcnson, Diagnosis of low pressure hydrocephalus by C.S.F. I T M scanning. J. Nuc. Med. 8 (1967), 267---272. 30. Tater, C. H., J. F. Fleming, R. H. Sheppard, and V. M. Turner, A radioisotopic test for communicating hydrocephalus. J. Neurosurg. 28 (1968), 327--340. Authors' address: Prof. Dr. g. Villani, Neurosurgical Clinic of the University of Milan, Vie, F. Sforza 35, 1-20122 Mila~, Italy.
Acta Neurochirurgica,Vol.32, Fasc. 1--2