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The Pneumoencephalographic Findings in Various Forms of Cerebellar Degeneration

The Pneumoencephalographic Findings in Various Forms of Cerebellar Degeneration The Pneumoencephalographic Findings in Various Forms of Cerebellar Degeneration 1 Marjorie LeMay , M.D. and Artur Abramowicz , M.D. ↵ 1 From the Departments of Radiology, the Peter Bent Brigham Hospital, the Boston Veterans Administration Hospital and Harvard Medical School, and the Departments of Neurology at Boston Veterans Administration Hospital and Tufts University School of Medicine, Boston, Mass. Presented at the Fiftieth Annual Meeting of the Radiological Society of North America, Chicago, 111., Nov. 29-Dec. 4, 1964. Excerpt Cerebellar disorders caused by hereditary, toxic, and nutritional factors are encountered with considerable frequency in clinical neurological practice, but the roentgen diagnosis of cerebellar atrophy has been uncommon. In the past two years we have observed 16 cases with radiological evidence of gross cortical cerebellar atrophy, and all but 1 had clinical evidence of a cerebellar deficit. In 3 of the patients the possibility of a posterior fossa mass had been raised clinically. Because we have found the pneumoencephalogram to be so helpful in establishing the diagnosis of cerebellar atrophy and because we have noted a close relationship between the clinical findings and the radiological diagnosis of gross cerebellar atrophy, it seems worthwhile to present a review of our experience and technics. In the past, the pneumoencephalographic diagnosis of cerebellar degeneration has most often depended upon indirect evidence; notably, the demonstration of an enlarged fourth ventricle and/or cisterna magna. The diagnosis of cerebellar atrophy on only the basis of a large cisterna magna, however, is untenable since the cistern is occasionally very large without cerebellar disease. Enlargement of the fourth ventricle probably denotes a local degenerative process, or aplasia, but gross cortical cerebellar atrophy may be present without ventricular enlargement. In fact, only 1 of our 16 cases with pneumoencephalographic signs of gross cortical cerebellar atrophy evidenced enlargement of the fourth ventricle. The direct demonstration of the sulci, therefore, is of great importance in defining the presence or absence of atrophy. The cerebellar sulci will be shown only occasionally on routine pneumoencephalography, but Lindgren in 1949 (7), while describing various technics for its performance, pointed out that when a patient's head is in extreme flexion, air injected slowly will pass over the posterior surface of the cerebellum. It usually is necessary to take films immediately to show air over the cerebellum because it frequently leaves this area when the position of the head is changed. Robertson (9) also described filling of the superior cerebellar space and cerebellar sulci with the patient's head in extreme flexion and stressed the need of demonstrating the cerebellar sulci for the radiological diagnosis of atrophy. The most striking studies demonstrating cerebellar sulci are those by Thiébaut et al . (11), and it is essentially their technic we have usually followed. After the injection of 5 to 10 cc of air into the lumbar subarachnoid space with the patient's head in slight flexion, postero-anterior and lateral films are obtained to verify that the gas is in the subarachnoid space and that there is no ventricular distortion due to a mass. The following procedure is then carried out: With the patient's head flexed so the occiput is the highest point of the vault, 10 cc of air is injected as rapidly as possible. The head is maintained in this position for ten seconds. The chin is then elevated so that Reid's base line forms a 20-to 30-degree angle with the horizontal, and this position is maintained for ten seconds. The head is again placed in extreme flexion, 5 cc of additional gas is injected as rapidly as possible, and an autotomo-gram is obtained. If the cerebellar sulci have not filled at this time, the procedure can be repeated. We have found that even if the cerebellar sulci are not demonstrated after repeating the procedure, they may still fill without the injection of more air if the patient is placed prone on the radiographic table and postero- anterior and brow-down films are made before the antero-posterior and brow-up films. Once the patient is supine, much of the air leaves the superior cerebellar space and the sulci are no longer well delineated. Figure 1, A is an autotomo-gram obtained during a routine fractional pneumoencephalographic procedure. Figure 1, B shows the same patient after 15 cc more air has been injected rapidly, following the procedure described above. In a patient in whom a posterior fossa tumor is a very likely clinical diagnosis, we usually do not use the Wackenheim technic. Instead, after a fractional study with 5 to 10 cc of air has ruled out a mass, 5 cc more air is injected slowly with the head in extreme flexion. Copyrighted 1965 by The Radiological Society of North America, Inc. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Radiology Radiological Society of North America, Inc.

The Pneumoencephalographic Findings in Various Forms of Cerebellar Degeneration

Radiology , Volume 85 (2): 284 – Aug 1, 1965

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Publisher
Radiological Society of North America, Inc.
Copyright
Copyright © 1965 by Radiological Society of North America
ISSN
1527-1315
eISSN
0033-8419
DOI
10.1148/85.2.284
pmid
14323904
Publisher site
See Article on Publisher Site

Abstract

The Pneumoencephalographic Findings in Various Forms of Cerebellar Degeneration 1 Marjorie LeMay , M.D. and Artur Abramowicz , M.D. ↵ 1 From the Departments of Radiology, the Peter Bent Brigham Hospital, the Boston Veterans Administration Hospital and Harvard Medical School, and the Departments of Neurology at Boston Veterans Administration Hospital and Tufts University School of Medicine, Boston, Mass. Presented at the Fiftieth Annual Meeting of the Radiological Society of North America, Chicago, 111., Nov. 29-Dec. 4, 1964. Excerpt Cerebellar disorders caused by hereditary, toxic, and nutritional factors are encountered with considerable frequency in clinical neurological practice, but the roentgen diagnosis of cerebellar atrophy has been uncommon. In the past two years we have observed 16 cases with radiological evidence of gross cortical cerebellar atrophy, and all but 1 had clinical evidence of a cerebellar deficit. In 3 of the patients the possibility of a posterior fossa mass had been raised clinically. Because we have found the pneumoencephalogram to be so helpful in establishing the diagnosis of cerebellar atrophy and because we have noted a close relationship between the clinical findings and the radiological diagnosis of gross cerebellar atrophy, it seems worthwhile to present a review of our experience and technics. In the past, the pneumoencephalographic diagnosis of cerebellar degeneration has most often depended upon indirect evidence; notably, the demonstration of an enlarged fourth ventricle and/or cisterna magna. The diagnosis of cerebellar atrophy on only the basis of a large cisterna magna, however, is untenable since the cistern is occasionally very large without cerebellar disease. Enlargement of the fourth ventricle probably denotes a local degenerative process, or aplasia, but gross cortical cerebellar atrophy may be present without ventricular enlargement. In fact, only 1 of our 16 cases with pneumoencephalographic signs of gross cortical cerebellar atrophy evidenced enlargement of the fourth ventricle. The direct demonstration of the sulci, therefore, is of great importance in defining the presence or absence of atrophy. The cerebellar sulci will be shown only occasionally on routine pneumoencephalography, but Lindgren in 1949 (7), while describing various technics for its performance, pointed out that when a patient's head is in extreme flexion, air injected slowly will pass over the posterior surface of the cerebellum. It usually is necessary to take films immediately to show air over the cerebellum because it frequently leaves this area when the position of the head is changed. Robertson (9) also described filling of the superior cerebellar space and cerebellar sulci with the patient's head in extreme flexion and stressed the need of demonstrating the cerebellar sulci for the radiological diagnosis of atrophy. The most striking studies demonstrating cerebellar sulci are those by Thiébaut et al . (11), and it is essentially their technic we have usually followed. After the injection of 5 to 10 cc of air into the lumbar subarachnoid space with the patient's head in slight flexion, postero-anterior and lateral films are obtained to verify that the gas is in the subarachnoid space and that there is no ventricular distortion due to a mass. The following procedure is then carried out: With the patient's head flexed so the occiput is the highest point of the vault, 10 cc of air is injected as rapidly as possible. The head is maintained in this position for ten seconds. The chin is then elevated so that Reid's base line forms a 20-to 30-degree angle with the horizontal, and this position is maintained for ten seconds. The head is again placed in extreme flexion, 5 cc of additional gas is injected as rapidly as possible, and an autotomo-gram is obtained. If the cerebellar sulci have not filled at this time, the procedure can be repeated. We have found that even if the cerebellar sulci are not demonstrated after repeating the procedure, they may still fill without the injection of more air if the patient is placed prone on the radiographic table and postero- anterior and brow-down films are made before the antero-posterior and brow-up films. Once the patient is supine, much of the air leaves the superior cerebellar space and the sulci are no longer well delineated. Figure 1, A is an autotomo-gram obtained during a routine fractional pneumoencephalographic procedure. Figure 1, B shows the same patient after 15 cc more air has been injected rapidly, following the procedure described above. In a patient in whom a posterior fossa tumor is a very likely clinical diagnosis, we usually do not use the Wackenheim technic. Instead, after a fractional study with 5 to 10 cc of air has ruled out a mass, 5 cc more air is injected slowly with the head in extreme flexion. Copyrighted 1965 by The Radiological Society of North America, Inc.

Journal

RadiologyRadiological Society of North America, Inc.

Published: Aug 1, 1965

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