Radionuclide Cisternography After Head Injury Barbara D. Barnes, MD, Julian T.
Hoff,
MD
patients with severe underwent radionuclide cisto detect early and late effects of trauma on cerebrospinal fluid (CSF) circulation. Thirty-one patients had subdural hematomas or hygromas and six had cerebral contusions without extracerebral masses. Cisternographic results were abnormal in 23 patients with subdural masses and normal in five who had only cerebral contusions. Of eight patients undergoing serial studies, one had persistent partial obstruction, five had partial resolution of abnormalities, and the two with progressive obstruction had their conditions improved by shunting. Angiography suggested transtentorial herniation in 11 patients with cisternal block, six of whom had clinical signs of herniation on the same side. \s=b\ Thirty-seven
injury ternography head
(Arch Neurol 33:21-25, 1976)
Radionuclide
cisternography has been used extensively to eval¬ uate the circulation of cerebrospinal fluid (CSF) in patients with demen¬ tia who had suspected communicat1
ing hydrocephalus. However, isotope
studies are uncommon in patients with head trauma.1" Alterations in CSF circulation might be expected from the tissue shifts that accompany brain injury and from the subarach¬ noid hemorrhage that commonly fol¬ lows head trauma.3·5"' This report describes cisternog¬ raphy in patients with severe head trauma. Follow-up studies were per¬ formed in eight of the patients to de¬ termine the evolution of CSF flow patterns after trauma and to identify patients whose recovery was im¬ paired by persistent obstruction of CSF circulation. SUBJECTS AND METHODS
Thirty-seven patients were studied by radionuclide cisternography. The results of the studies of these patients with head trauma were as follows: No. of No. of Patients Studies Subdural hematoma or hygroma 31 43 Contusion
(no operation,
Accepted
publication From the departments of neurology (Dr Barnes) and neurological surgery (Dr Hoff) and the Nuclear Medicine Laboratory, San Francisco General Hospital, University of California School of for
Feb 10, 1975.
Medicine.
San Francisco General Reprint requests Hospital, Ward 33, Room 3303,1001 Potrero Ave, San Francisco, CA 94110 (Dr Barnes). to
localized intracranial mass) Total
150 microcuries of iodinated I 131 serum albumin aggregated by intrathecal injec¬ tion into the lumbar subarachnoid space. Cisternographs were taken 4 and 24 hours after injection and in some patients 36 and 48 hours after injection. Multiple views of the head and the injection site were taken with a scintillation camera. The criteria used to evaluate the CSF flow patterns were as follows:
Normal There was free passage of CSF, indi¬ cated by unobstructed radioisotopic uptake from the injection site to the basal cisterns within four to six hours of injection. Radioactivity appeared in the Sylvian cisterns and the parasagittal region over the cerebral convexities in 24 to 48 hours without filling of the ventricles and was evident in the midline cisterns beneath the frontal lobes.
Mixed Pattern
Radioactivity appeared in the ventricles within three to four hours. Later views showed normal flow over the convexities with or without clearing of the ventricles. Ventricular reflux could coexist with a cisternal block.
Sylvian Cistern
no
6 37
7
50
Cisternography was repeated in eight pa¬ tients during their convalescence. The patients received 2 millicuries of technetium Tc 99m albumin aggregated or
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 06/20/2015
Block
Cisterns of the posterior fossa filled nor¬ mally, but one Sylvian cistern failed to fill and there was a persistent lack of flow over the convexity of the ipsilateral hemi¬ sphere. A partial block was identified by delayed filling of the Sylvian cistern and decreased flow over the hemisphere.
Thirty-four of the patients underwent transfemoral cerebral angiography, either before cisternography (26 patients), after cisternography (eight patients) or both (11
Convexity Pooling There was a focus of radioactivity over the convexity that persisted as long as ra¬
dioactivity
was
observed; cisternographic
patients).
results were otherwise normal. (Patients who had CSF collections caused by oper¬ ative removal of brain were excluded.)
RESULTS All but one of the subdural masses in 31 patients were confirmed at oper¬ ation. Although one patient refused operation, his subdural hematoma was demonstrated by angiography. The majority of patients (23) had acute or subacute subdural masses and eight had chronic hematomas. In the acute
Ventricular Pattern
Radioactivity was present in the ventric¬ ular system and persisted there for 48
hours or more. There was no flow evident in or above either Sylvian cistern. In most cases, CSF samples were ob¬ tained before injection of the isotope. Table 1.—
Subdural Hematoma Interval Before evacuation After evacuation
patients also had epidural hematomas identified at operation and seven others required frontal or temporal lobectomy to remove dam¬ aged brain. Only three patients were studied before operation. In one patient, the correct
Hygroma
No. of Patients 3
Time After
Operation
No. of Studies 5
ementia; responded to shunt; self-care,
ternography pattern.
so
ieizures for 3 yr preoperatively; postoperatively, cortical sensory loss on left and hemiparesis; self-care
mentation; responded to shunt and completed education
without mass effect were evident in six patients, none of whom had angi¬ ographie signs of tentorial herniation or underwent operation. All 11 patients with obstructed CSF flow at the tentorial notch had a shift of the angiographie midline away from an extracerebral mass. Six of these patients had earlier radiographic signs of tentorial herniation that coincided with the tentorial ob¬ struction to CSF flow observed later. Each had severe head injury with an acute subdural hematoma. Of the re¬ maining five patients with cisternal CSF block without radiologically con¬ firmed herniation, three had subacute and two had chronic subdural collec¬ tions on the same side. Protein content of CSF taken dur¬ ing cisternography was correlated with the cisternographic patterns (Table 5). There was no relationship between the protein and the cis¬
Cisternographic Result Normal Tentorial block Mixed
on
Convexity Pool
Ventricular
left.
5.—Cerebrospinal Fluid Protein
No. of Studies
Protein Range, mg/100 ml
14
34-192 20-56 26-137
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 06/20/2015
No. of Studies
Hoff,
MD
patients with severe underwent radionuclide cisto detect early and late effects of trauma on cerebrospinal fluid (CSF) circulation. Thirty-one patients had subdural hematomas or hygromas and six had cerebral contusions without extracerebral masses. Cisternographic results were abnormal in 23 patients with subdural masses and normal in five who had only cerebral contusions. Of eight patients undergoing serial studies, one had persistent partial obstruction, five had partial resolution of abnormalities, and the two with progressive obstruction had their conditions improved by shunting. Angiography suggested transtentorial herniation in 11 patients with cisternal block, six of whom had clinical signs of herniation on the same side. \s=b\ Thirty-seven
injury ternography head
(Arch Neurol 33:21-25, 1976)
Radionuclide
cisternography has been used extensively to eval¬ uate the circulation of cerebrospinal fluid (CSF) in patients with demen¬ tia who had suspected communicat1
ing hydrocephalus. However, isotope
studies are uncommon in patients with head trauma.1" Alterations in CSF circulation might be expected from the tissue shifts that accompany brain injury and from the subarach¬ noid hemorrhage that commonly fol¬ lows head trauma.3·5"' This report describes cisternog¬ raphy in patients with severe head trauma. Follow-up studies were per¬ formed in eight of the patients to de¬ termine the evolution of CSF flow patterns after trauma and to identify patients whose recovery was im¬ paired by persistent obstruction of CSF circulation. SUBJECTS AND METHODS
Thirty-seven patients were studied by radionuclide cisternography. The results of the studies of these patients with head trauma were as follows: No. of No. of Patients Studies Subdural hematoma or hygroma 31 43 Contusion
(no operation,
Accepted
publication From the departments of neurology (Dr Barnes) and neurological surgery (Dr Hoff) and the Nuclear Medicine Laboratory, San Francisco General Hospital, University of California School of for
Feb 10, 1975.
Medicine.
San Francisco General Reprint requests Hospital, Ward 33, Room 3303,1001 Potrero Ave, San Francisco, CA 94110 (Dr Barnes). to
localized intracranial mass) Total
150 microcuries of iodinated I 131 serum albumin aggregated by intrathecal injec¬ tion into the lumbar subarachnoid space. Cisternographs were taken 4 and 24 hours after injection and in some patients 36 and 48 hours after injection. Multiple views of the head and the injection site were taken with a scintillation camera. The criteria used to evaluate the CSF flow patterns were as follows:
Normal There was free passage of CSF, indi¬ cated by unobstructed radioisotopic uptake from the injection site to the basal cisterns within four to six hours of injection. Radioactivity appeared in the Sylvian cisterns and the parasagittal region over the cerebral convexities in 24 to 48 hours without filling of the ventricles and was evident in the midline cisterns beneath the frontal lobes.
Mixed Pattern
Radioactivity appeared in the ventricles within three to four hours. Later views showed normal flow over the convexities with or without clearing of the ventricles. Ventricular reflux could coexist with a cisternal block.
Sylvian Cistern
no
6 37
7
50
Cisternography was repeated in eight pa¬ tients during their convalescence. The patients received 2 millicuries of technetium Tc 99m albumin aggregated or
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 06/20/2015
Block
Cisterns of the posterior fossa filled nor¬ mally, but one Sylvian cistern failed to fill and there was a persistent lack of flow over the convexity of the ipsilateral hemi¬ sphere. A partial block was identified by delayed filling of the Sylvian cistern and decreased flow over the hemisphere.
Thirty-four of the patients underwent transfemoral cerebral angiography, either before cisternography (26 patients), after cisternography (eight patients) or both (11
Convexity Pooling There was a focus of radioactivity over the convexity that persisted as long as ra¬
dioactivity
was
observed; cisternographic
patients).
results were otherwise normal. (Patients who had CSF collections caused by oper¬ ative removal of brain were excluded.)
RESULTS All but one of the subdural masses in 31 patients were confirmed at oper¬ ation. Although one patient refused operation, his subdural hematoma was demonstrated by angiography. The majority of patients (23) had acute or subacute subdural masses and eight had chronic hematomas. In the acute
Ventricular Pattern
Radioactivity was present in the ventric¬ ular system and persisted there for 48
hours or more. There was no flow evident in or above either Sylvian cistern. In most cases, CSF samples were ob¬ tained before injection of the isotope. Table 1.—
Subdural Hematoma Interval Before evacuation After evacuation
patients also had epidural hematomas identified at operation and seven others required frontal or temporal lobectomy to remove dam¬ aged brain. Only three patients were studied before operation. In one patient, the correct
Hygroma
No. of Patients 3
Time After
Operation
No. of Studies 5
ementia; responded to shunt; self-care,
ternography pattern.
so
ieizures for 3 yr preoperatively; postoperatively, cortical sensory loss on left and hemiparesis; self-care
mentation; responded to shunt and completed education
without mass effect were evident in six patients, none of whom had angi¬ ographie signs of tentorial herniation or underwent operation. All 11 patients with obstructed CSF flow at the tentorial notch had a shift of the angiographie midline away from an extracerebral mass. Six of these patients had earlier radiographic signs of tentorial herniation that coincided with the tentorial ob¬ struction to CSF flow observed later. Each had severe head injury with an acute subdural hematoma. Of the re¬ maining five patients with cisternal CSF block without radiologically con¬ firmed herniation, three had subacute and two had chronic subdural collec¬ tions on the same side. Protein content of CSF taken dur¬ ing cisternography was correlated with the cisternographic patterns (Table 5). There was no relationship between the protein and the cis¬
Cisternographic Result Normal Tentorial block Mixed
on
Convexity Pool
Ventricular
left.
5.—Cerebrospinal Fluid Protein
No. of Studies
Protein Range, mg/100 ml
14
34-192 20-56 26-137
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 06/20/2015
No. of Studies
