J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.37.4.449 on 1 April 1974. Downloaded from Journal ofNeurology, Neurosurgery, and Psychiatry, 1974, 37, 449-454 Filling patterns in contrast ventriculography LAWRENCE FERGUSON' From the Division of Neurosurgery, Institute of Neurological Sciences, Southern General Hospital, Glasgow SYN OPSIS The filling patterns of a negative contrast material (air), a positive contrast water soluble material (Conray), and a positive contrast water insoluble material (Myodil) were examined in 60 normal ventriculograms. Using a scoring system developed for this study, Conray was found effective for outlining the ipsilateral (injected) lateral ventricle, the third ventricle, the aqueduct of Sylvius, and the fourth ventricle. Air was the most effective for the noninjected lateral ventricle, while Myodil was best for A-P demonstration of the aqueduct. The clinical implications of these findings are discussed. Now that angiography is the basic neuroradio- ate or meglucamine iothalamate 60% had been logical investigation in most clinics, ventriculo- injected through a frontal burr hole in every case Protected by copyright. graphy is more commonly reserved for accurate except one, where a parietal approach was used. A definition of specific regions either for localizing scoring system was devised for the lateral ventricle, third ventricle, aqueduct of Sylvius, and fourth lesions or identifying anatomical landmarks ventricle to minimize the influence of the imagina- during stereotactic studies. To be successful the tive eye (Table 1). examination must outline the desired area reliably while remaining safe for the patient. There is now available a variety of contrast 1 media: negative contrast, usually air, or positive TABLE contrast, which may be either in oily solution SCORING SYSTEM iophendylate (Myodil) or aqueous solution meglucamine iothalamate 60% (Conray). The Site Scores Total Lateral ventricle I point 1. Frontal horn increasing range of targets in stereotactic surgery 2. Trigone and the occasional need for localizing lesions in 3. Inferior horn http://jnnp.bmj.com/ 2 point 1. Clear demonstration of any part of the ventricular system make it un- amygdala 3-5 likely that any one contrast material would be 3rd ventricle 4 point 1. Filling superior in all circumstances. The following study 2. Anterior commissure contrast 3. Lamina terminalis of the filling characteristics of these 4. Optic recess agents, used in what proved to be normal ven- 5. Infundibular recess 6. Anterior floor triculograms, was made in an attempt to assess 7. Posterior floor the suitability of each agent for the particular 8. Posterior commissure 9. Pineal recess on September 28, 2021 by guest. situation. 10. Suprapineal recess 11. Posterior roof 12. Anterior roof 3 0 METHOD Aqueduct of I point 1. Superior segment of 2. Inferior aqueduct on Sixty normal ventriculograms which had been per- Sylvius lateral exposure formed as part of routine clinical practice in the 3. Complete AP outline 3 0 Institute of Neurological Sciences, Glasgow, be- 4th ventricle 1 point 1. Anterior medullary velum tween 1968 and 1971 were examined. Air, iophendyl- 2. Posterior medullary velum 3. Floor of 4th ventricle 'Present address: Department of Neurosurgery, Northwestern 4. Lateral recesses 4 0 University Medical School, Chicago, Illinois, U.S.A. 449 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.37.4.449 on 1 April 1974. Downloaded from 450 Lawrence Ferguson RESULTS POINTS Results using this scoring system are tabulated in Table 2. The maximum score is obtained by 0 multiplying the total for the particular situation in Table 1 by the number of cases using each 1 contrast agent (20). It will be noted that, while Conray gives a 2 generally good distribution, air scored only for the lateral and 3rd ventricles, while Myodil 3 ~~~~~~~~~~~~~~~~~~~I 5 10 15 CASES ZERO (a) ONE FACTORS TWO A. Superior I .-I THREE - i E Inferior NJE-R OF CASE FIG. 1. Lateral ventricle score. * Ipsilateral air. - Protected by copyright. M Contralateral air. Ipsilateral Conray. [ Contra- CGA-P lateral Conray. 5 10 iz15 2d NUMBER ff FACTORS scored in the 3rd ventricle, aqueduct, and 4th (b) ventricle. FIG. 3. (a) Aqueduct score. (b) Factor profile- aqueduct. Conray. E Myodil. LATERAL VENTRICLES Figure 1 portrays the individual case scores in points. The infer*ior horn did not fill in any case where one or m ore THIRD VENTRICLE The individual factor scores points were lost. The amygdala was seen 16 using the triad of contrast materials are shown in times with ipsilateral air, 13 times with if?sl- Fig. 2. The AC-PC line was clearly seen on a - lateral Conray, 12 times with contralateral air, single film in all 20 Conray studies and in 11 and and only five times with contralateral ConraY. seven of the air and Myodil studies respectively. http://jnnp.bmj.com/ The massa intermedia was noted in total in all FACTORS Conray studies, whereas with air and Myodil in- I FILING complete delineation was more often the rule. ANTRIEORCOIMIMIIIiSSUR -E- ciII lMTIWUS =A---- AQUEDUCT OF SYLVIUS Figures 3a and b outline IOPTICRECESS = the case scores and the factor profile using EaIII Myodil and Conray. Single points were given if, on September 28, 2021 by guest. LIL INOTEROR FLOE - !LPCoTEIE FLOEII EL on lateral exposures, the superior (factor A) or a6F --I-----I-z=~m the inferior part (factor B) of the aqueduct was seen. The third point was given only if both I ESS _ _ superior and inferior segments could be clearly L ROO identified on the anteroposterior (AP) view. L ANTERO RIO When Conray is used, the of 21' 1(D. 20 excellent filling the anterior recesses may make identification of the FIG. 2. Factor profile-3rd ventricle. aqueduct on AP views difficult, for in the 11 * Air. Conray. X Myodil. cases where the aqueduct was not identified J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.37.4.449 on 1 April 1974. Downloaded from Filling patterns in contrast ventriculography 451 FACTORS DISCUSSION A. LATERAL FILL -~~~~~~~~~~~~-------- different media is dis- 8. ANTERIOR FILL ----m--lillilll When the usefulness of C. ANt MEDULLARY VELUM ------------- cussed in particular situations, the following 0. POST.MEDNLLARY VELUM I matters need to be considered: the reliability of E. SUPERIOR FLOOR ----------5 - - -- visualizing those structures which may be diffi- F. INFERIOR FLOOR -- cult to see due to overlap of adjacent structures, I---- I G. LATERAL RECESSES --------- or their inherently small size with associated low I AC-PC IAUEDUCT FASTIGIUM or being rela- 1. 3r VENTRILE AUEDUCT levels of contrast material, their I ik ., UTERAL RECESSES in ' I'}'fI' .m09 tively inaccessible to a particular contrast FACTOR SCOE material. The technical ease of injection and the FIG. 4. Factor profile-4th ventricle. subsequent manipulation of the patients are also Conray E Myodil. a consideration. Complications, both immediate and delayed, are likewise decisive factors. Comparative studies of contrast media for TABLE 2 ventriculography tend not to lay sufficient emphasis on the particular requirements of this RESULTS investigation in different circumstances. When held Site Maximunm Air Conray Myodil pneumoventriculography undisputed popu- score larity the emphasis was on total visualization of Protected by copyright. Injected lateral ventricle 70 66 63-5 the ventricular system, which often led to exces- Contralateral lateral sive amounts of air being used and to unduly ventricle 70 63 415 - 3rd ventricle 60 36-75 57-8 36 prolonged examinations. An early criticism of Aqueduct of Sylvius 60 - 47 37 small volume positive contrast ventriculography 4th ventricle 80 - 78 70 (Myodil) was that only part of the system was shown, but in many instances only part of the system is of interest-for example, stereotaxy. That is why our study has been directed at clearly, excellent filling of the anterior recesses indicating the reliability of these different agents occurred 10 times, whereas in the nine cases in showing different parts of the system, because where the aqueduct was identified clearly the no one medium would be expected to be ideal in anterior recesses were seen well in only three all circumstances. when the conventional Towne's view was used. The analysis of the relative merits of water The Myodil studies achieved more perfect scores soluble contrast materials as compared with air than the Conray, but there were also five cases in and insoluble positive agents is not new. Walter http://jnnp.bmj.com/ which a zero score was achieved. This emphasizes Dandy recognized the advantages of water the difficulty in maintaining the oily contrast soluble media, but because of complications materials in the proper position until radio- used air in his pioneer ventriculograms (Dandy, graphs are taken. 1918). He was later of the opinion that there was absolutely no justification for using opaque FOURTH VENTRICLE The individual factor filling material as a means of diagnosis or localization profiles for Myodil and Conray are presented in of any tumour of the brain (Dandy, 1936). How- on September 28, 2021 by guest. Fig. 4. Factors H and I were scored as positive ever, because of inconstant filling of the axial only when the three elements were seen on a ventricular system when air or other gases were single film. The angle of the apex of the fourth used, Sicard and Forrestier (1922) performed the ventricle is more often acute-that is, less than first positive contrast ventriculogram using the 50 -when Conray is used due to more frequent oil-soluble Lipiodol. The irritative properties of filling of the posterior superior recesses, while Lipiodol soon became apparent (Lysholm, 1935) this angle is usually greater than 70° when and then Bull (1950) reported the first use of Myodil is employed due to filling of the dorsal Myodil in ventriculography. The proponents of median recess (the fastigium).