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Conray ventriculography in neurosurgical practice
Clin. RadioL (1974)25, 145-151
CONRAY
VENTRICULOGRAPHY
IN N E U R O S U R G I C A L
PRACTICE
D. K. PANDA, B. S. DAS, S. RATH* AND G. B. MOHANTY from the Departments of Neurosurgery and Radiology, S.C.B. Medical College, Cuttack, Orissa, India
1. 70 procedures of Conray ventriculography were performed in 68 patients ranging from 2½ months to 68 years of age, between 1970 and 1972. 2. An anterior frontal twist drill hole was found to be a safe route for cannulation of the ventricles for ventriculography. 3. A conclusive ventriculogram was obtained in 52 (76.5 %) patients. Ventriculography was •informative in 14 (20.5 %). Visualisation was poor in 2 (3%). 4. Reactions, such as headache, vomiting, fever and convulsions, were few but indicate continued caution. 5. There were 3 deaths which were considered due to the primary pathology itself. SICARD and Forestier introduced Lipiodol for myelography in 1922. Since then oily bases with iodinated compounds have been widely used in different neurological centres. Ethyliodo-phenylundecylate (Pantopaque or Myodil) was first used by Ramsey et aL for myelography in 1944 and by Bull in 1950 for ventriculography. Despite the excellent contrast it provides, there are many untoward reactions reported (Davis, 1956; Erickson et al., 1953; Hurteau et al., 1969; Marcovich et aL, 1941; and Tarlov, 1945). The globules of oily medium are capable of blocking the already narrowed aqueduct and rendering a partial obstruction complete. In patients with ventriculo-atrial shunts, the use of oily contrast media for ventriculography is contraindicated, for fear of shunt tube blockage and pulmonary embolisation. Radovici and Meller in 1932 used thorium dioxide 25 700,a water-miscible and possibly water-soluble medium, for complete visualisation of the ventricular system. The use of this medium produced untoward reactions (Alexander, Jung and Lymon, 1934; Stuck and Reeves, 1938). Stereotactic surgery has created a need for more accurate radiographic visualisation of the cerebral ventricles. Campbell et al. used 60 ~ methylglucamine iothalamate for ventriculography in 1964. Since then there has been much done in these fields. Heimburger et al. (1966) have reported the technique and the results of 102 procedures using methylglucamine iothalamate 60 700. Methylglucamine iothalamate 60700 was reported to produce less reaction in angiography than previously available contrast media, (Dotter et aL, 1962; Foster et al., 1962; and Hink and Dotter, 1962). It was
also found to be well tolerated when injected in small doses into the ventricles and cisterna magna of dogs and rabbits (Back, 1963; Kodama et al., 1962). Vinas et al. (1967) have performed ventriculograms by direct catheterisation of the third ventricle, using 2 c.c. of water soluble substance (Densopax). Handa and Handa (1969) have reported encouraging results with the use of Conray 280 for ventriculography in 25 cases of obstructive hydrocephalus. In the present study an attempt has been made to evaluate the suitability of Conray 280 for use in ventriculography for patients with tumour syndrome.
MATERIAL AND METHODS Conray 280 ventriculography was performed in 68 patients at the Neuro-Surgical service of S.C.B. Medical College and Hospital, Cuttack, India, during 1970-72. The patients subjected to ventriculography belonged to one of the following two groups: Group 1: Patients with signs and symptoms of intracranial tumour and suspected obstruction of C.S.F. pathways. Group 2: Patients with a clinical diagnosis of supratentorial space-occupying lesion with inconclusive angiographic findings. The right lateral ventricle was cannulated through a right frontal burrhole in a few cases initially. Subsequcntly a right or left frontal twist drill hole was made prior to cannulation. Coronal sutural separation was taken advantage of in a number of cases, whenever they were adequate on the plain fihn. In cases with hydrocephalus where the anterior fontanelle was open, the approach was made through the *Reprint requests to be sent to Dr. S. Rath, Prof. fontanelle. Neurosurgery Cuttack-7. The patients were placed in the supine position 145
146
CLINICAL RADIOLOGY
and a lumbar puncture needle was used to tap the ventricle. Once there was free flow of C.S.F., the needle was advanced to reach the maximum possible depth in the lateral ventricle and the needle was then rotated so that the bevelled side was facing medially. This was done to ensure proper filling of the third ventricle. This was followed by the injection of 3-5 c.c. of Conray 280 slowly, in about 10 seconds. At the completion of the injection, the needle was withdrawn. Anterior-posterior and lateral views of the skull were taken in rapid succession. Subsequent radiographs were taken if required after reviewing the wet films. In cases of supra-tentorial tumours postero-anterior and lateral views were obtained along with left side down and right side down positions.
poorly visualised. One case had a midline vermis tumour on posterior fossa exploration, and in the other case a ventriculo-peritoneal shunt was done. Decisions were taken in these two patients on clinical grounds. Table 5 outlines the reactions and complications of Conray Ventriculography In 68 cases, 70 procedures were performed. Twice Conray was injected accidentally into the subarachnoid space. One of these had severe focal cerebral seizures, which passed on to generalised convulsions. In the other case there was no seizure. Three patients (one each of brainstem tumour, communicating hydrocephalus and posterior fossa tumour) died 2-3 days after the procedure.
ANALYSIS OF RESULTS 70 procedures o f Conray ventriculography were performed in 68 patients. The age of the patients ranged from 2½ months to 68 years. Table 1 shows the age incidence. The routes of entry into the ventricles are shown in Table 2. Table 3 outlines the parts of the ventricular system and C.S.F. pathways visualised in ventriculography. The present series is comparable with those of Heimburger et al. (1966) (33 cases with tumour and hydrocephalus), and Dinakar and Rao (1971). The anatomical site of the lesions as demonstrated ventriculographically is summarised in Table 4. In 52 cases the ventriculogram was conclusive. Seventeen of them had a normal ventriculogram. Out of 35 consecutive abnormal ventriculograms 27 cases were operated on and the anatomical sites of mass occupation were verified. In one case, diagnosed as a foramen of Munro block due to a third ventricular tumour, the lesion proved to be a subfrontal meningioma. Possibly the foramen of Munro was blocked secondarily as a result of ventricular distortion. Among the 14 cases considered to be informative, 7 were operated on without further investigations. Two of them had a negative exploration and the ventriculographic findings were considered misleading. Following Conray ventriculography, on a second occasion Myodil ventriculography was performed in 5 patients, out of which 3 were shown to have communicating hydrocephalus and 2 had definite posterior fossa tumours. The remaining 2 in the informative group were neither investigated further nor explored or to various reasons. On only 2 occasions were the ventriculograms
DISCUSSION The unparalleled radiographic visualisation and the minimal adverse reaction with Conray ventriculography is gratifying. Until recently Pantopaque ventriculography was thought to be the safest procedure. After the experimental work of Clark et al. (1971), it has been stated that injection of Pantopaque into the ventricular system may produce a variety of acute and chronic pathological changes. Multiple granulomatous lesions may develop in the ventricular wall and the surrounding brain parenehyma, choroid plexus, cranial nerves and arachnoid membrane. More serious changes were noted in animals with a greater degree of hydrocephalus. We have preferred to perform Conray ventriculography in cases of tumour syndrome and hydrocephalus instead of Myodil ventriculography for the following reasons: 1) The delineation of the ventricular system is not only comparable but superior to that of Myodil so far as the axial ventricles are concerned, ~Fig. 1). 2) The procedure as such was less complicated and needed less manipulation of the anaesthetised patient, and required only basic radiographic equipment. 3) Ill patients with a brain tumour seem to tolerate Conray in the ventricular system better than the oily medium. 4) It does not leave residual material. 5) It saves time and films. In the present series, an anterior frontal twist drill hole was used as the route of entry in most cases without any disadvantage. No morbidity or mortality can so far be attributed to ventriculography through a twist d~ill hole. Thus an operating session for a burrhole was avoided. Invariably the frontal drill hole could be done on the X-ray table with a
147
CONRAY V E N T R I C U L O G R A P H Y IN N E U R O S U R G I C A L P R A C T I C E TABLE 1
TABLE 2
Age h~ years
No. ofcases
Routes ofentry
0-10 11-20 21-30 31-40 41-50 51-60 61-70
21 13 14 13 5 Nil 2
Anterior frontal drill hole Anterior burr hole Wide coronal suture Anterior fontanelle
Total
68
No. ofcases
48 4 13 3
Total
T A B L E
Series Heimburger et aL (1966)
68
3
_ Ipsilat. lateral ventricle
Contralat. lateral ventricle
Third ventricle
Aqueduct
Fourth ventricle
CL~'terna magna
Cervical spinal
93 °Z
78 ~
72 ~
60 %
54 ~
--
--
--
97 ~
--
90 ~
63.3 %
73.3 ~
16.6 ~
--
--
90~
59~
81~
59~
57G
30~
34~
5~
/o
Cerebellar folia
& Rao
Dinakar
(1971) Present
TABLE 4 Conchtsive
Informative
Poor visualisation
Site No. of eases
No. verified
Cerebral Brain-stem Aqueduct Posterior fossa Communicating hydrocephalus Normal
9 3
9
18
16
Total
52
No. of cases
No. verified
m
No. of cases
No. verified
m
m _
1
3 17
10 3
7
1 1
1
2
1
m
m m
27
14
7
TABLE 5 Reactions
No. o f cases
% (approx.)
Headache Vomiting Fever Convulsions Death Uneventful
28 26 18 3 3 25
41 38 26 4 4 37
148
CLINICAL RADIOLOGY
FIG. 1 Normal Conray ventriculogram, clearly delineating all parts of lateral ventricle, third ventricle and fourth ventricle.
FIG. 2 Conray angiogram and Conray cystogram in a case of fronto-parietal glioma which had a cyst inside it.
FIG. 3A FIO. 3 ~ C o n r a y ventriculogram (A.P. Film) in an acoustic tumour showing visualisation of all parts of the ventricular system. Right to left shift of the fourth ventricle and escape of contrast into the'cisterna magna.
Fro. 3B Fro. 3B--Same patient as in Figure 3A (lateral film) showing all ventricles, contrast escaping into the cisterna magna, hydrocephalus and backward shift of the aqueduct indicating tumour anterior to brainstem.
CONRAY
VENTRICULOGRAPHY
mechanical sterile drill. Out of the 68 cases, 52 had clear and conclusive visualisation of the ventricular system and positive decisions were taken (Figs. 3, 5 and 6). Fourteen were informative, and only 2 were inconclusive due to poor visualisation. The reason for the latter sixteen cases being inconclusive diagnostically was the gross dilatation of the ventricular system, and insufficient contrast medium being injected during the procedure. For better visualisation GonzalezCornejo (1971) has used as much as 40 c.c. of Conray in a case of congenital hydrocephalus. Weiss and Raskind (1971) used up to a total of 15 c.c. in a dilated ventricular system for proper delineation. Nine cases of supra-tentorial tumours were inconclusive angiographically, and Conray ventricalography was diagnostic. It is usual in most neuro-surgical centres to follow on ventriculography with an operative procedure whenever a tumour is diagnosed. But for certain reasons it was not possible for us to adopt this practice. This provided us with an opportunity to study the reactions of Conray ventriculography alone. A number of minor reactions observed during and immediately after the procedure included headache, vomiting, and fever which were easily controlled by symptomatic treatment. There were 3 cases of convulsions during o r after the procedure; of which one had an accidental injection of Conray into the inter-hemispheric subarachnoid space. In the second case the contrast medium had escaped into the cisterna magna and the cervical subarachnoid space. The third patient was a case of supra-tentorial tumour, where the medium was injected into the cyst itself (Fig. 2). All our patients who developed convulsions had focal or generalised cerebral seizures with loss of consciousness. Dinakar and Rao (1971) made similar observations. Picaza et al. (1972), while reviewing 260 procedures of Conray ventriculography, reported five cases with convulsions. All of them had a tetany type of clonic seizure while fully conscious. When generalised, there was laryngeal spasm leading to apnoea. These patients did not respond to the usual anticonvulsant drugs and required curarisation for several hours. Such tetany type of seizure has not occurred in the present series of ventriculograms. The authors have experience of three cases who developed a spinal myoclonus-like state following Conray myelography. One patient developed a myoclonic state comparable to severe tetanic spasm with a normal level of consciousness. Heavy doses of phenobarbitone were of no avail. 50 mg. of Largactil and 50 rag. oI Phenergan injected
IN NEUROSURGICAL
PRACTICE
149
slowly intravenously terminated the spasms. The other two cases had minor spasms and were likewise controlled. Since then we have premedicated patients with Largactil and Phenergan prior to ventriculography also. There was one case with inadvertent subarachnoid injection of medium who had no convulsion. The radio-opaque substance was seen in the cisterna magna in 20 cases (30 ~), and the cervical spinal subarachnoid space in 23 cases (34 ~), of which one developed convulsions. The convulsions were easily controlled with phenobarbitone, diazepamPhenergan and Largactil. The absence of convulsions in the above mentioned cases, where radio-opaque substance was seen in the subarachnoid space, was probably due to dilution of the medium by the time it had escaped into the subarachnoid space through a patent fourth ventricle (Figs. 3, 5.). There were 3 deaths 2-3 days after the procedure, which we believe were due to the primary pathology. None of these had seizures. Two were critically ill at the time of the procedure and the third died 3 days after ventriculography, which could not be attributed to it. Water soluble contrast media, such as Conray 280, are cleared from the ventricles within a short time. Hence it provides an opportunity of repeating
FI~. 4 Conray ventriculogram (lateral film) showing characteristic picture in a .brainstem glioma.
150
CLINICAL RADIOLOGY
FIG. 5A Fra. 5A--Conray ventriculogram (A.P. Film) in an acoustic tumour showing shift of the fourth ventricle to opposite side.
Fro. 5~ FiG. 5B--Same patient as in Figure 5A showing escape of contrast into the cisterna magna.
FIa. 6A FIG. 6A--Conray ventriculogram in a case of supratentorial tumour (A.P. film).
FIG. 6B FIG. 6B--Conray ventriculogram in the same patient as in Figure 6A (lateral film).
CONRAY VENTRICULOGRAPHY IN NEUROSURGICAL PRACTICE the procedure after some days if deemed necessary. Oily contrast m e d i u m , such as Myodil, when scattered in the ventricles a n d s u b a r a c h n o i d space produces a bizarre picture o n subsequent ventriculography. The necessity of screening can also be dispensed with while performing C o n r a y ventriculography. It is concluded that C o n r a y ventriculography is a relatively safe procedure a n d the quality of the results is comparable and to some extent superior to oily m e d i u m studies. However, the rare occurrence of cerebral seizures o f tetany type of convulsions should be kept in mind. G r e a t care m u s t be taken to avoid extra-ventricular deposition of the contrast medium. Acknowledgement.--We wish to record our appreciation to May & Baker (India) Private Limited, Calcutta, who have helped us in various ways in performing the above work. REFERENCES ALEXANr)~R,L., JUNG,T. S. & LYMON,R. S. (1934). Colloidal thorium dioxide - its use in intracranial diagnosis and its fate on direct injection into the brain and ventricles. Archives of Neurology and Psychiatry (Chicago), 32, 1143-1158. Quoted by Hughes, R. (1953). BULL, J. W. D. (1950). Positive contrast ventriculography. Acta. Radiologica, 34, 253-268. BACK, N. (1966). Effect of subacute intraventricular administration of meglumine iothalamate (Couray) in adult pure-bred Beagle dogs. Roswell Park Memorial Institute. Quoted by Heimburger, et al., 1966. CAMPBELL, R. L., CAMPBELL, J. A., HEIMBURGER, R. F., KALSBECK, J. E. t~; MEALEY, J., JR. (1964). Ventriculography and myelography with absorbable radiopaque medium. Radiology, 82, 286-289. CLARK,R. G., MILHORAT,T. H., STANLEY,W. C. & CHIRO, G. D. (1971). Experimental pantopaque ventriculography. Journal of Nearosurgery, 34, 387-395. DAVIES, F. L. (1956). Effect of unabsorbed radiographic contrast media on the central nervous system. Lancet, 2, 747-748. DINAKAR, I. & RAO, S. B. (1971). Couray ventriculography. Neurology India, 19, 27-30. DOTTER, C. T., STRANBE,K. R., BILBAO,M. K. and Hinck, V. C. (1962). A new contrast medium for intravascular use. Northwest Medicine (Seattle), 61, 41-46. ER~CKSON,T. C. & VANBAAREN,H. J. (1953). Late meningeal reaction to ethyliodophenylundecylate used in myelography. Journal of the American Medical Association, 153, 636. FOSTER, J. H., WrNEREY,E. W., KILLEN,D. A. & SESSIONS~ R. T. (1962). A new angiographic contrast medium, sodium iothalamate 80 %. Journal of the American Medical Association, 182, 1009-1013.
151
GONZALEZCORNEJO, S. (1971). Conray ventriculography in the diagnosis of intraventricular and posterior fossa lesions. Journal of Neurosurgery, 34, 405-407. HANDA, J. t~; HANDA, H. (1969). Methyl-glucamine iothalamate 60% for cerebral ventriculography. American Journal of Roentgenology, 107, 631-636. HEIMBURGER, R. F., CAMPBELL, R. L., KALSBECK, J. E., MEALEY,J., JR. & GOODELL,C. L. (1966). Positive contrast ventriculography using water soluble media. Journal of Neurology, Neuro-surgery and Psychiatry, 29, 281-290. HINCK, V. C. & DOTTER,C. T. (1962). Cerebral angiography with 60 % Conray, preliminary report. Journal of Neurosurgery, 19, 312-313. HUGHES, R. (1953). Chronic changes in the central nervous system following thorotrast ventriculography. Proceedings of the Royal Society of Medicine, 46, 191-195. ]:tURTEAU, E. F., BAIRD, W. C. ~. SINCLAIR, E. (1954). Arachnoiditis following the use of iodized oil. Journal of Bone and Joint Surgery, 393-400. KODAMA,J. K., BUTLER,W. M., TUSING,T. W. & HALLETT, F. P. (1962). Iothalamate: A new intravascular radiopaque medium with unusual pharmacotoxic inertness. Expositions of Moleculon Pathology Supplement, 2, 65-80. LANG, E. K., RUSSELL,J. R. (1970). Pantopaque ventriculography: Demonstration and assessment of lesions of 3rd ventricle and posterior fossa. Journal of Neurosurgery, 32, 5-15. MARCOVICFI,A. W., WALKER,A. E. & JESSICO,C. M. (1941). The immediate and late effects of the intracranial injection of iodized oil. Journal of the American Medical Association, 116, 2247. PICAZA, J. A., HUNTER, S. E. • LEE, L. (1972). Seizures associated with the use of meglumine iothalamate 60 in ventriculography. Journal of Neurosurgery, 36, 474-480. RAMSEY, G. H., FRENCH, J. D. & STRAIN, W. H. (1944). Iodinated organic compounds as contrast media for radiographic diagnoses. Pantopaque myelography. Radiology, 43, 236. RADOVICI,A. & MELLER,O. (1932). Essai de liquidographic cephalorachidienne encephalo-myelographic par le thorotrast sousarachnoidien. Bulletin Acadamie de Medicin (Paris), 107, 314-317. SICARD, J. A., FORESTIER, J. (1926). Roentgenographic exploration of central nervous system with iodized oil (Lipiodol). Archive de Neurologie, 16, 420-434. STUCK, R. M. & REEVES,J~). L. (1938). Dangerous effects of thorotrast used intracranially with special reference to experimental production of hydrocephalus. Archives of Neurology and Psychiatry (Chicago), 40, 86-115. TARLOV, I. M. (1945). Pantopaque meningitis disclosed at operation. Journal of the American Medical Association, 129, 1014-1016. VINAS, F. J., MARRIONUEVO,P. J. & DUJOVRY, M. (1967). Ventriculography by direct catheterization of third ventricle using a water soluble substance. American Journal of Roentgenology, 101, t41. WEISS, S. R. & RAS~ZING,R. (1971). Conray ventriculography in the diagnosis of brain tumours and congenital malformations in children. Journal of Neurosurgery, 34, 408-411.
CONRAY
VENTRICULOGRAPHY
IN N E U R O S U R G I C A L
PRACTICE
D. K. PANDA, B. S. DAS, S. RATH* AND G. B. MOHANTY from the Departments of Neurosurgery and Radiology, S.C.B. Medical College, Cuttack, Orissa, India
1. 70 procedures of Conray ventriculography were performed in 68 patients ranging from 2½ months to 68 years of age, between 1970 and 1972. 2. An anterior frontal twist drill hole was found to be a safe route for cannulation of the ventricles for ventriculography. 3. A conclusive ventriculogram was obtained in 52 (76.5 %) patients. Ventriculography was •informative in 14 (20.5 %). Visualisation was poor in 2 (3%). 4. Reactions, such as headache, vomiting, fever and convulsions, were few but indicate continued caution. 5. There were 3 deaths which were considered due to the primary pathology itself. SICARD and Forestier introduced Lipiodol for myelography in 1922. Since then oily bases with iodinated compounds have been widely used in different neurological centres. Ethyliodo-phenylundecylate (Pantopaque or Myodil) was first used by Ramsey et aL for myelography in 1944 and by Bull in 1950 for ventriculography. Despite the excellent contrast it provides, there are many untoward reactions reported (Davis, 1956; Erickson et al., 1953; Hurteau et al., 1969; Marcovich et aL, 1941; and Tarlov, 1945). The globules of oily medium are capable of blocking the already narrowed aqueduct and rendering a partial obstruction complete. In patients with ventriculo-atrial shunts, the use of oily contrast media for ventriculography is contraindicated, for fear of shunt tube blockage and pulmonary embolisation. Radovici and Meller in 1932 used thorium dioxide 25 700,a water-miscible and possibly water-soluble medium, for complete visualisation of the ventricular system. The use of this medium produced untoward reactions (Alexander, Jung and Lymon, 1934; Stuck and Reeves, 1938). Stereotactic surgery has created a need for more accurate radiographic visualisation of the cerebral ventricles. Campbell et al. used 60 ~ methylglucamine iothalamate for ventriculography in 1964. Since then there has been much done in these fields. Heimburger et al. (1966) have reported the technique and the results of 102 procedures using methylglucamine iothalamate 60 700. Methylglucamine iothalamate 60700 was reported to produce less reaction in angiography than previously available contrast media, (Dotter et aL, 1962; Foster et al., 1962; and Hink and Dotter, 1962). It was
also found to be well tolerated when injected in small doses into the ventricles and cisterna magna of dogs and rabbits (Back, 1963; Kodama et al., 1962). Vinas et al. (1967) have performed ventriculograms by direct catheterisation of the third ventricle, using 2 c.c. of water soluble substance (Densopax). Handa and Handa (1969) have reported encouraging results with the use of Conray 280 for ventriculography in 25 cases of obstructive hydrocephalus. In the present study an attempt has been made to evaluate the suitability of Conray 280 for use in ventriculography for patients with tumour syndrome.
MATERIAL AND METHODS Conray 280 ventriculography was performed in 68 patients at the Neuro-Surgical service of S.C.B. Medical College and Hospital, Cuttack, India, during 1970-72. The patients subjected to ventriculography belonged to one of the following two groups: Group 1: Patients with signs and symptoms of intracranial tumour and suspected obstruction of C.S.F. pathways. Group 2: Patients with a clinical diagnosis of supratentorial space-occupying lesion with inconclusive angiographic findings. The right lateral ventricle was cannulated through a right frontal burrhole in a few cases initially. Subsequcntly a right or left frontal twist drill hole was made prior to cannulation. Coronal sutural separation was taken advantage of in a number of cases, whenever they were adequate on the plain fihn. In cases with hydrocephalus where the anterior fontanelle was open, the approach was made through the *Reprint requests to be sent to Dr. S. Rath, Prof. fontanelle. Neurosurgery Cuttack-7. The patients were placed in the supine position 145
146
CLINICAL RADIOLOGY
and a lumbar puncture needle was used to tap the ventricle. Once there was free flow of C.S.F., the needle was advanced to reach the maximum possible depth in the lateral ventricle and the needle was then rotated so that the bevelled side was facing medially. This was done to ensure proper filling of the third ventricle. This was followed by the injection of 3-5 c.c. of Conray 280 slowly, in about 10 seconds. At the completion of the injection, the needle was withdrawn. Anterior-posterior and lateral views of the skull were taken in rapid succession. Subsequent radiographs were taken if required after reviewing the wet films. In cases of supra-tentorial tumours postero-anterior and lateral views were obtained along with left side down and right side down positions.
poorly visualised. One case had a midline vermis tumour on posterior fossa exploration, and in the other case a ventriculo-peritoneal shunt was done. Decisions were taken in these two patients on clinical grounds. Table 5 outlines the reactions and complications of Conray Ventriculography In 68 cases, 70 procedures were performed. Twice Conray was injected accidentally into the subarachnoid space. One of these had severe focal cerebral seizures, which passed on to generalised convulsions. In the other case there was no seizure. Three patients (one each of brainstem tumour, communicating hydrocephalus and posterior fossa tumour) died 2-3 days after the procedure.
ANALYSIS OF RESULTS 70 procedures o f Conray ventriculography were performed in 68 patients. The age of the patients ranged from 2½ months to 68 years. Table 1 shows the age incidence. The routes of entry into the ventricles are shown in Table 2. Table 3 outlines the parts of the ventricular system and C.S.F. pathways visualised in ventriculography. The present series is comparable with those of Heimburger et al. (1966) (33 cases with tumour and hydrocephalus), and Dinakar and Rao (1971). The anatomical site of the lesions as demonstrated ventriculographically is summarised in Table 4. In 52 cases the ventriculogram was conclusive. Seventeen of them had a normal ventriculogram. Out of 35 consecutive abnormal ventriculograms 27 cases were operated on and the anatomical sites of mass occupation were verified. In one case, diagnosed as a foramen of Munro block due to a third ventricular tumour, the lesion proved to be a subfrontal meningioma. Possibly the foramen of Munro was blocked secondarily as a result of ventricular distortion. Among the 14 cases considered to be informative, 7 were operated on without further investigations. Two of them had a negative exploration and the ventriculographic findings were considered misleading. Following Conray ventriculography, on a second occasion Myodil ventriculography was performed in 5 patients, out of which 3 were shown to have communicating hydrocephalus and 2 had definite posterior fossa tumours. The remaining 2 in the informative group were neither investigated further nor explored or to various reasons. On only 2 occasions were the ventriculograms
DISCUSSION The unparalleled radiographic visualisation and the minimal adverse reaction with Conray ventriculography is gratifying. Until recently Pantopaque ventriculography was thought to be the safest procedure. After the experimental work of Clark et al. (1971), it has been stated that injection of Pantopaque into the ventricular system may produce a variety of acute and chronic pathological changes. Multiple granulomatous lesions may develop in the ventricular wall and the surrounding brain parenehyma, choroid plexus, cranial nerves and arachnoid membrane. More serious changes were noted in animals with a greater degree of hydrocephalus. We have preferred to perform Conray ventriculography in cases of tumour syndrome and hydrocephalus instead of Myodil ventriculography for the following reasons: 1) The delineation of the ventricular system is not only comparable but superior to that of Myodil so far as the axial ventricles are concerned, ~Fig. 1). 2) The procedure as such was less complicated and needed less manipulation of the anaesthetised patient, and required only basic radiographic equipment. 3) Ill patients with a brain tumour seem to tolerate Conray in the ventricular system better than the oily medium. 4) It does not leave residual material. 5) It saves time and films. In the present series, an anterior frontal twist drill hole was used as the route of entry in most cases without any disadvantage. No morbidity or mortality can so far be attributed to ventriculography through a twist d~ill hole. Thus an operating session for a burrhole was avoided. Invariably the frontal drill hole could be done on the X-ray table with a
147
CONRAY V E N T R I C U L O G R A P H Y IN N E U R O S U R G I C A L P R A C T I C E TABLE 1
TABLE 2
Age h~ years
No. ofcases
Routes ofentry
0-10 11-20 21-30 31-40 41-50 51-60 61-70
21 13 14 13 5 Nil 2
Anterior frontal drill hole Anterior burr hole Wide coronal suture Anterior fontanelle
Total
68
No. ofcases
48 4 13 3
Total
T A B L E
Series Heimburger et aL (1966)
68
3
_ Ipsilat. lateral ventricle
Contralat. lateral ventricle
Third ventricle
Aqueduct
Fourth ventricle
CL~'terna magna
Cervical spinal
93 °Z
78 ~
72 ~
60 %
54 ~
--
--
--
97 ~
--
90 ~
63.3 %
73.3 ~
16.6 ~
--
--
90~
59~
81~
59~
57G
30~
34~
5~
/o
Cerebellar folia
& Rao
Dinakar
(1971) Present
TABLE 4 Conchtsive
Informative
Poor visualisation
Site No. of eases
No. verified
Cerebral Brain-stem Aqueduct Posterior fossa Communicating hydrocephalus Normal
9 3
9
18
16
Total
52
No. of cases
No. verified
m
No. of cases
No. verified
m
m _
1
3 17
10 3
7
1 1
1
2
1
m
m m
27
14
7
TABLE 5 Reactions
No. o f cases
% (approx.)
Headache Vomiting Fever Convulsions Death Uneventful
28 26 18 3 3 25
41 38 26 4 4 37
148
CLINICAL RADIOLOGY
FIG. 1 Normal Conray ventriculogram, clearly delineating all parts of lateral ventricle, third ventricle and fourth ventricle.
FIG. 2 Conray angiogram and Conray cystogram in a case of fronto-parietal glioma which had a cyst inside it.
FIG. 3A FIO. 3 ~ C o n r a y ventriculogram (A.P. Film) in an acoustic tumour showing visualisation of all parts of the ventricular system. Right to left shift of the fourth ventricle and escape of contrast into the'cisterna magna.
Fro. 3B Fro. 3B--Same patient as in Figure 3A (lateral film) showing all ventricles, contrast escaping into the cisterna magna, hydrocephalus and backward shift of the aqueduct indicating tumour anterior to brainstem.
CONRAY
VENTRICULOGRAPHY
mechanical sterile drill. Out of the 68 cases, 52 had clear and conclusive visualisation of the ventricular system and positive decisions were taken (Figs. 3, 5 and 6). Fourteen were informative, and only 2 were inconclusive due to poor visualisation. The reason for the latter sixteen cases being inconclusive diagnostically was the gross dilatation of the ventricular system, and insufficient contrast medium being injected during the procedure. For better visualisation GonzalezCornejo (1971) has used as much as 40 c.c. of Conray in a case of congenital hydrocephalus. Weiss and Raskind (1971) used up to a total of 15 c.c. in a dilated ventricular system for proper delineation. Nine cases of supra-tentorial tumours were inconclusive angiographically, and Conray ventricalography was diagnostic. It is usual in most neuro-surgical centres to follow on ventriculography with an operative procedure whenever a tumour is diagnosed. But for certain reasons it was not possible for us to adopt this practice. This provided us with an opportunity to study the reactions of Conray ventriculography alone. A number of minor reactions observed during and immediately after the procedure included headache, vomiting, and fever which were easily controlled by symptomatic treatment. There were 3 cases of convulsions during o r after the procedure; of which one had an accidental injection of Conray into the inter-hemispheric subarachnoid space. In the second case the contrast medium had escaped into the cisterna magna and the cervical subarachnoid space. The third patient was a case of supra-tentorial tumour, where the medium was injected into the cyst itself (Fig. 2). All our patients who developed convulsions had focal or generalised cerebral seizures with loss of consciousness. Dinakar and Rao (1971) made similar observations. Picaza et al. (1972), while reviewing 260 procedures of Conray ventriculography, reported five cases with convulsions. All of them had a tetany type of clonic seizure while fully conscious. When generalised, there was laryngeal spasm leading to apnoea. These patients did not respond to the usual anticonvulsant drugs and required curarisation for several hours. Such tetany type of seizure has not occurred in the present series of ventriculograms. The authors have experience of three cases who developed a spinal myoclonus-like state following Conray myelography. One patient developed a myoclonic state comparable to severe tetanic spasm with a normal level of consciousness. Heavy doses of phenobarbitone were of no avail. 50 mg. of Largactil and 50 rag. oI Phenergan injected
IN NEUROSURGICAL
PRACTICE
149
slowly intravenously terminated the spasms. The other two cases had minor spasms and were likewise controlled. Since then we have premedicated patients with Largactil and Phenergan prior to ventriculography also. There was one case with inadvertent subarachnoid injection of medium who had no convulsion. The radio-opaque substance was seen in the cisterna magna in 20 cases (30 ~), and the cervical spinal subarachnoid space in 23 cases (34 ~), of which one developed convulsions. The convulsions were easily controlled with phenobarbitone, diazepamPhenergan and Largactil. The absence of convulsions in the above mentioned cases, where radio-opaque substance was seen in the subarachnoid space, was probably due to dilution of the medium by the time it had escaped into the subarachnoid space through a patent fourth ventricle (Figs. 3, 5.). There were 3 deaths 2-3 days after the procedure, which we believe were due to the primary pathology. None of these had seizures. Two were critically ill at the time of the procedure and the third died 3 days after ventriculography, which could not be attributed to it. Water soluble contrast media, such as Conray 280, are cleared from the ventricles within a short time. Hence it provides an opportunity of repeating
FI~. 4 Conray ventriculogram (lateral film) showing characteristic picture in a .brainstem glioma.
150
CLINICAL RADIOLOGY
FIG. 5A Fra. 5A--Conray ventriculogram (A.P. Film) in an acoustic tumour showing shift of the fourth ventricle to opposite side.
Fro. 5~ FiG. 5B--Same patient as in Figure 5A showing escape of contrast into the cisterna magna.
FIa. 6A FIG. 6A--Conray ventriculogram in a case of supratentorial tumour (A.P. film).
FIG. 6B FIG. 6B--Conray ventriculogram in the same patient as in Figure 6A (lateral film).
CONRAY VENTRICULOGRAPHY IN NEUROSURGICAL PRACTICE the procedure after some days if deemed necessary. Oily contrast m e d i u m , such as Myodil, when scattered in the ventricles a n d s u b a r a c h n o i d space produces a bizarre picture o n subsequent ventriculography. The necessity of screening can also be dispensed with while performing C o n r a y ventriculography. It is concluded that C o n r a y ventriculography is a relatively safe procedure a n d the quality of the results is comparable and to some extent superior to oily m e d i u m studies. However, the rare occurrence of cerebral seizures o f tetany type of convulsions should be kept in mind. G r e a t care m u s t be taken to avoid extra-ventricular deposition of the contrast medium. Acknowledgement.--We wish to record our appreciation to May & Baker (India) Private Limited, Calcutta, who have helped us in various ways in performing the above work. REFERENCES ALEXANr)~R,L., JUNG,T. S. & LYMON,R. S. (1934). Colloidal thorium dioxide - its use in intracranial diagnosis and its fate on direct injection into the brain and ventricles. Archives of Neurology and Psychiatry (Chicago), 32, 1143-1158. Quoted by Hughes, R. (1953). BULL, J. W. D. (1950). Positive contrast ventriculography. Acta. Radiologica, 34, 253-268. BACK, N. (1966). Effect of subacute intraventricular administration of meglumine iothalamate (Couray) in adult pure-bred Beagle dogs. Roswell Park Memorial Institute. Quoted by Heimburger, et al., 1966. CAMPBELL, R. L., CAMPBELL, J. A., HEIMBURGER, R. F., KALSBECK, J. E. t~; MEALEY, J., JR. (1964). Ventriculography and myelography with absorbable radiopaque medium. Radiology, 82, 286-289. CLARK,R. G., MILHORAT,T. H., STANLEY,W. C. & CHIRO, G. D. (1971). Experimental pantopaque ventriculography. Journal of Nearosurgery, 34, 387-395. DAVIES, F. L. (1956). Effect of unabsorbed radiographic contrast media on the central nervous system. Lancet, 2, 747-748. DINAKAR, I. & RAO, S. B. (1971). Couray ventriculography. Neurology India, 19, 27-30. DOTTER, C. T., STRANBE,K. R., BILBAO,M. K. and Hinck, V. C. (1962). A new contrast medium for intravascular use. Northwest Medicine (Seattle), 61, 41-46. ER~CKSON,T. C. & VANBAAREN,H. J. (1953). Late meningeal reaction to ethyliodophenylundecylate used in myelography. Journal of the American Medical Association, 153, 636. FOSTER, J. H., WrNEREY,E. W., KILLEN,D. A. & SESSIONS~ R. T. (1962). A new angiographic contrast medium, sodium iothalamate 80 %. Journal of the American Medical Association, 182, 1009-1013.
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GONZALEZCORNEJO, S. (1971). Conray ventriculography in the diagnosis of intraventricular and posterior fossa lesions. Journal of Neurosurgery, 34, 405-407. HANDA, J. t~; HANDA, H. (1969). Methyl-glucamine iothalamate 60% for cerebral ventriculography. American Journal of Roentgenology, 107, 631-636. HEIMBURGER, R. F., CAMPBELL, R. L., KALSBECK, J. E., MEALEY,J., JR. & GOODELL,C. L. (1966). Positive contrast ventriculography using water soluble media. Journal of Neurology, Neuro-surgery and Psychiatry, 29, 281-290. HINCK, V. C. & DOTTER,C. T. (1962). Cerebral angiography with 60 % Conray, preliminary report. Journal of Neurosurgery, 19, 312-313. HUGHES, R. (1953). Chronic changes in the central nervous system following thorotrast ventriculography. Proceedings of the Royal Society of Medicine, 46, 191-195. ]:tURTEAU, E. F., BAIRD, W. C. ~. SINCLAIR, E. (1954). Arachnoiditis following the use of iodized oil. Journal of Bone and Joint Surgery, 393-400. KODAMA,J. K., BUTLER,W. M., TUSING,T. W. & HALLETT, F. P. (1962). Iothalamate: A new intravascular radiopaque medium with unusual pharmacotoxic inertness. Expositions of Moleculon Pathology Supplement, 2, 65-80. LANG, E. K., RUSSELL,J. R. (1970). Pantopaque ventriculography: Demonstration and assessment of lesions of 3rd ventricle and posterior fossa. Journal of Neurosurgery, 32, 5-15. MARCOVICFI,A. W., WALKER,A. E. & JESSICO,C. M. (1941). The immediate and late effects of the intracranial injection of iodized oil. Journal of the American Medical Association, 116, 2247. PICAZA, J. A., HUNTER, S. E. • LEE, L. (1972). Seizures associated with the use of meglumine iothalamate 60 in ventriculography. Journal of Neurosurgery, 36, 474-480. RAMSEY, G. H., FRENCH, J. D. & STRAIN, W. H. (1944). Iodinated organic compounds as contrast media for radiographic diagnoses. Pantopaque myelography. Radiology, 43, 236. RADOVICI,A. & MELLER,O. (1932). Essai de liquidographic cephalorachidienne encephalo-myelographic par le thorotrast sousarachnoidien. Bulletin Acadamie de Medicin (Paris), 107, 314-317. SICARD, J. A., FORESTIER, J. (1926). Roentgenographic exploration of central nervous system with iodized oil (Lipiodol). Archive de Neurologie, 16, 420-434. STUCK, R. M. & REEVES,J~). L. (1938). Dangerous effects of thorotrast used intracranially with special reference to experimental production of hydrocephalus. Archives of Neurology and Psychiatry (Chicago), 40, 86-115. TARLOV, I. M. (1945). Pantopaque meningitis disclosed at operation. Journal of the American Medical Association, 129, 1014-1016. VINAS, F. J., MARRIONUEVO,P. J. & DUJOVRY, M. (1967). Ventriculography by direct catheterization of third ventricle using a water soluble substance. American Journal of Roentgenology, 101, t41. WEISS, S. R. & RAS~ZING,R. (1971). Conray ventriculography in the diagnosis of brain tumours and congenital malformations in children. Journal of Neurosurgery, 34, 408-411.