Table Of ContentRadiological Exploration
of the Ventricles
and Subarachnoid Space
By G. Ruggiero
J. Bories . A. Calabro· G. Cristi . G. Scialfa
F. Smaltino . A. Thibaut
With the Cooperation of
G. Gianasi . G. Maranghi . Ch. Philipp art
E. Signorini
With 90 Partly Coloured Figures
(279 Separate Illustrations)
Springer -Verlag
Berlin· Heidelberg . New York 1974
ISBN-13: 978-3-642-88033-9 e-ISBN-13: 978-3-642-88031-5
DOl: 10.1007/978-3-642-88031-5
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© by Springer-Verlag Berlin Heidelberg 1974.
Softcover reprint of the hardcover 1s t edition 1974
The use of general descriptive names, trade marks, etc. in this publication, even if the
former are not especially identified, is not be taken as a sign that such names as understood
by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone.
To the "Ecole de Saint' Anne"
Preface
A few evenings ago in the Hall of the Neurological Clinic of Bologna University
Dr. HENRI HEcAEN gave a lecture on the physiopathology of writing. As I was
listening to his learned exposition, memories returned to me of times when my
reaction to his work was not always the enjoyment of a quiet listener; namely, of the
times when, ten years before, during the" seances du samedi" at the Neurosurgical
Center of Saint' Anne Hospital in Paris, our meetings often consisted of disputes, in
a sparkling tangle of alliances and hostilities, which would often result in clashes
between TALAIRACH,AJURIAGUERRA, BREGEAT, M., and Mme DELL,KLoTz (each one
passionately pleading for his own speciality), with a brillant chorus of collaborators:
CONSTANS, ABouLKER, DELIGNE, SADOUN, BANCAUD ... enlivening the scene. I re
member the discussions on clinical cases, the "lettres au directeur et aux medicins
soignants" in which GUILLY was a master of diplomacy, the biting hints at the
administrators, the smiles between allies or lovers. And in that casbah-like uproar of
students, doctors, patients, attendants, technicians, and spectators, the voice of the
"Grand Chef," preceded by a slam on the table, ringing out loudly: "Nom de Dieu!
Voulez-vous vous taire et nous foutre la paix?" Monsieur David was always able to
humanize any abstract problem. Saint' Anne! An arena where we dealt with the
latest findings of neurology, psychiatry, stereotaxis, neurosurgery, neurophthalmo
logy, electroencephalography and neuroradiology.
lowe my career to having met Erik Lindgren and Marcel David. To the former
I shall always be indebted for the rigor he employed in teaching me the basic elements
of neuroradiology and the techniques of scientific research; the example of the latter
still guides me in the difficult task of directing a large department of medicine with
the goals of increasing humanity, indulgence, and humility.
It is unlikely that I will again find the ideal condition of cooperation with so many
masters of the neurological sciences. If it were not for some of my works which are
included in the vast bibliography of the" Ecole de Saint' Anne," I would perhaps
wonder today if I merely imagined I was fortunate enough to have been one of its
members. However, more than the works published and the honors achieved, it is
my having in turn been able to establish a school of neuroradiology that perhaps
makes me worthy of belonging to that circle of scientists.
This volume is dedicated to the" Ecole de Saint' Anne" and this preface is the
only part signed by me alone. As a matter of fact, this work does not follow the
traditional pattern requiring that each chapter be signed by its author; on the con
trary, here the responsibility for every line belongs to all the authors. In this way,
I wish to thank my pupils of that time, who are today my friends and colleagues, for
accepting my advice and believing in my principles. My thanks also to those who,
for reasons independent of our will, do not appear among the authors of this book.
Bologna, 1967
VIII Preface
1971. The last four years have been hard for my country: continual strikes in hospitals,
together with an organizational standstill, and often bitterness and discontent on the
part of the Italian physicians. These are the essential reasons why this work has been
delayed. I apologize to my foreign collaborators, hoping nonetheless that the revision
of this book will appease their disappointment for the long wait.
End of 1972 GIOVANNI RUGGIERO
Acknowledgments
We wish to thank
Mrs. GIULIA RUGGIERO and Miss FULVIA BONOMO for the first draft of the English
text.
Professor GIANCARLO PIAZZA for reviewing the English text.
Miss GABRIELLA GALLETTI for her secretarial work, with the cooperation of Mrs.
ADRIANA LAFFI and Mrs. TAMARA FRASNEDI.
Mr. ANDREA COLINA R. T., Mr. CARLO DE GRASSI R. T., and Mr. QUINTO GASPERINI
R. T. for their cooperation in preparing the radiographic and photographic material.
We are also indebted to the Administration of the Ospedale Maggiore of Bologna
who helped to make this work possible by allowing us to call upon the assistance of
some of the hospital personnel.
Introduction
RUGGIERO'S monograph on fractional encephalography, published in 1957 (374), was
based on the analysis of about 700 examinations collected over five years. One of the
purposes of the present work is to record the progress achieved in this fundamental
technique.
In the 1957 work the comparison between encephalography and ventriculography
was the subject of an exhaustive discussion. Such a discussion is not included here,
because this is a different kind of book, and especially because of the low incidence
of ventriculography in our present material, where this examination is performed
only in the rare cases of unsuccessful encephalography. However, as ventriculography
still enjoys considerable prestige in other departments, its technique is still covered
in this book.
A long chapter has been devoted to techniques with opaque contrast media, which
have been used with considerable success in recent years, especially in neurological
and neurosurgical centers not associated with departments of neuroradiology.
The neuroradiologist is a specialist in irradiation, not only by X-rays. Therefore,
the exploration of fluid pathways by means of radioactive isotopes finds a suitable
place in this book. The present monograph is limited to the technique, but, since
the development of diagnostic methods is mirrored by technical progress, we do not
hesitate to refer to clinical discussions, when we deem it useful to illustrate and justify
an aspect of the technique itself.
Unless otherwise indicated, the material on which this work is founded-case
reports and iconography-comes from the archives of the Divison of Neuroradiology
of the Ospedale Maggiore of Bologna. This department performs neuroradiological
procedures on the patients of two neurosurgical divisions, but it also has its own
wards, reserved for patients applying directly to the department or coming from
other areas for a diagnostic clarification. Thus, the neuroradiologist does not merely
perform the examinations required by other specialists, he is also directly involved
in the diagnostic problem (377, 382, 384), taking on himself the responsibility of the
patient for the time he is under his care. In particular, this has contributed to an
increased objectivity and validity of the chapters devoted to the clinical aspects of the
examinations. In the preface we have stated that every part of the book reflects the
opinion of all its authors. However, in cases where one of the authors has published
some particular contribution his name is mentioned directly.
For the readability of the text, sometimes it was not possible to avoid such general
expressions, such as "according to us", "we think", "it seems to us", etc. Obviously
these terms refer to all authors; if one of them has a different opinion, his name is
mentioned and the editorial "we" must be ascribed to GIOVANNI RUGGIERO. The
term" our department" refers to the Division of Neuroradiology of the Ospedale
Maggiore of Bologna, or, in the case of examinations performed by RUGGIERO with
the Princeps 60, to the Clinic Villalba, also in Bologna.
Contents
Chapter I. Fractional Encephalography
I. Introduction . . . . . . . . . .
2. Technical Equipment and Set-Up of Rooms 3
Motorized Rotating Chairs. 4
The Neurocentrix 5
Camera 70-mm ... 5
3. Staff . . . . . . . . . 5
4. Preparation of the Patient 7
5. Encephalography Today. Schematic Outline of an Examination 7
Subtentorial Structures. 9
Occipital Horns. 11
Frontal Horns . . . . 11
6. Lumbar Puncture . . . . . 11
7. Image Amplifier with Television Control. 14
Shortening of the Examination . . . 14
Evaluation of the Amount of Contrast 14
8. Examination of the Occipital Horns in Sitting Position. 14
9. Examination of the Temporal Horns . . . . . . . . 15
Maneuvers for the Filling of a Single Temporal Horn 16
Simultaneous Filling of the Two Temporal Horns 18
10. Tomography 19
Literature . . . . 19
Technique . . . . 22
Autotomography 22
Conventional Tomography 22
Equipment 23
Type of Cancellation 25
Layer Thickness 25
Choice of the Cutting Plane 27
Uses of Tomography 29
Conclusions . . . . . . . . . 35
11. Subtraction . . . . . . . . . 50
12. Long Focus-to-Film Distance Radiography and Magnification 54
13. Technique for Examination of the Cerebello-Pontine Angle 54
14. Encephalographic Technique for the Examination of the Sellar Region 55
15. Encephalographic Technique in Cases of Atrophy. 59
Cerebellar Atrophy . . 59
Cerebral Atrophy . . . 61
16. Encephalography with Urea 64
Introduction and Literature 64
XII Contents
Mechanism of Action of Urea and Mannitol 65
Technique . . 67
Complications 68
Results 68
17. Encephalography with Pulmonary Hyperventilation 71
18. Late Radiographic Follow-up 71
19. Gaseous Contrast Media 77
Introduction . . . . . . . . 77
Gases Used in Total and Subtotal Encephalography 78
Atmospheric Air . . . 78
Experimental Works. . 78
Manner of Injection. . 80
Reaction of the Patient 80
Air Reabsorption . . . 80
Cytochemistry of CSF . 80
CSF Pressure. 8 I
Ozone. . . . . . . 81
Oxygen . . . . . . 81
Experimental Work 8 I
Clinical Work 8 I
Carbon Dioxide 8 I
Nitrogen. 8 I
Helium . 81
Xenon 82
Acetylene 82
Ethylene . 82
Nitrous Oxide 83
Summary 83
Gases Used in Fractional Encephalography 83
Air and Oxygen 83
Summary 84
Helium 85
Carbon Dioxide 85
Nitrous Oxide . 85
Indication of the Method 86
Conclusions . . . . . . . . 86
20. Anesthesia in Fractional Encephalography 86
Introduction . . . . . . . . . . . . . 86
Preparation of the Patient before Encephalography without Anesthesia. 87
"Classical" General Anesthesia. . . 87
Premedication . . . . . . . . . 87
Induction of General Anesthesia . 87
Maintenance of General Anesthesia 87
Post-Examination Care . . . . . 88
Anesthesia with y-Hydroxybutyric Acid (g.h.b.a.) 88
Pharmacology . . . . . . . . . . . . . 88
y-Hydroxybutyric Acid in Encephalography 88
Neuroleptonalgesia (NLA) 89
Pharmacology . . . . . . . . . . . . . 89
Contents XIII
Technique. . . . . . . . . . . . . . . . . 89
Gas Exchange . . . . . . . . . . . . . . . . . 90
The Contrast Gas is Air and the Anesthetic Gas is Nitrous Oxide 90
The Contrast Gas is Nitrous Oxide and the Anesthetic Gas is Nitrous
Oxide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Inhalation of Oxygen after Encephalography Performed with Air or
Oxygen ......... . 91
General Anesthesia with Ketamine 91
Conclusions . 91
21. Complications 92
Introduction. 92
Results . . . 92
Chapter II. Gas Ventriculography
I. Historical Background. 95
2. Technique . . . . . . . . . 95
Introduction . . . . . . . . 95
"Ventriculography without Air Injection" GARDNER and FRAZIER [162] (1929) 96
DEERY'S Technique [108] (1931). . . . . . . . . . . . . . . . . . . . 96
LYSHOLM'S Maneuver [268-270] (1935) for the Visualization of the Aqueduct
and the Fourth Ventricle. . . . . . . . . . . . . . . . . . . " 96
TWINING'S Maneuver [461, 462] (1939) for Filling the Third Ventricle, the
Aqueduct, and the Fourth Ventricle. . . . . . . . . . . . . . . . . . 96
VERBIEST'S Technique [468,469] (1947). . . . . . . . . . . . . . . . . 97
ZIEDSES DES PLANTES' Maneuvers [487,488] (1953) for the Study of the Third
Ventricle, Aqueduct, and Fourth Ventricle, and for the Study of the Temporal
Horns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Central Ventriculography of AZAMBUJA, ARANA-INIGUEZ, SANDE, and GARCIA-
GUELFI[19](1956) ......................... 98
Fractional Ventriculography by LAINE, RIFF, DE LANDTSHEER, and GAUBERT
[245,246] (1957) . . . . . . . . . . 99
ROSTOTSKAYA'S Technique [372] (1958) . 101
CALABRO'S Technique [70] (1967) 101
3. Complications 101
Introduction . . . . . . . . 101
Analysis of the Literature 102
Mortality . . . . . 103
Material and Methods 104
Comment 105
Conclusions 106
Chapter III. Positive-Contrast Ventriculography
1. Introduction . . . . . . . 107
2. Iodinated Oils . . . . . . 107
Analysis of the Literature 107
Chemistry and Physics. . . 108
Lipiodol and its Derivatives 108
Lipiodol ... 108
Fluid Lipiodol . . . . . 108
