CEREBROSPINAL FLUID IMAGING :CEREBROSPINAL FLUID IMAGING


CSF IMAGING :CSF IMAGING OUTLINE CSF ANATOMY AND PHYSIOLOGY CISTERNOGRAPHY CLINICAL APPLICATION NORMAL PRESSURE HYDROCEPHALUS CSF SHUNTS EVALUATION CSF LEAKAGE EVALUATION OF PATINTS RECEIVING INTRATHECAL CHEMOTHERAPY CONCLUSION


CSF IMAGING- CSF ANATOMY AND PHYSIOLOGY :CSF IMAGING- CSF ANATOMY AND PHYSIOLOGY CSF axis can be divided into three distinct regions Ventricles The brain subarachnoid space Spinal subarachnoid space The production and resorption of CSF - Choroid plexuses (60%), interstitial fluid - Arachnoid villae


CSF IMAGING- CSF ANATOMY AND PHYSIOLOGY :CSF IMAGING- CSF ANATOMY AND PHYSIOLOGY The direction of CSF flow


CSF IMAGING- CISTERNOGRAPHY :CSF IMAGING- CISTERNOGRAPHY DiChiro firstly described for hydrocephalus in 1964 Radiopharmaceuticals: Previous drugs: Yb-169 DTPA or Tc-99m HSA Current drugs: In-111 DTPA: - FDA proved, better imaging characteristics, longer half-life, lower dosimetry with single dose vial (250μCi) Tc-99m DTPA


CSF IMAGING- CISTERNOGRAPHY :CSF IMAGING- CISTERNOGRAPHY Imaging procedure Inject radiopharmaceutical into subarachnoid space Taking image Imaging times: Early leakage: evaluate CSF leakage 1 hr: thoracic-lumbar spine 2 - 3 hr: base of te skull to visualize basilar cisterns Delay image: depend on clinical demand Obtain anterior, posterior, and both lateral views of the head at 3, 24, and 48hr.


CSF IMAGING- CISTERNOGRAPHY :CSF IMAGING- CISTERNOGRAPHY Tracer movement through the CSF axis


CSF IMAGING- CISTERNOGRAPHY :CSF IMAGING- CISTERNOGRAPHY Cisternogram images related to anatomy


CSF IMAGING- CLINICAL APPLICATION (NPH) :CSF IMAGING- CLINICAL APPLICATION (NPH) NORMAL PRESSURE HYDROCEPHALUS Previously: obstructive communicating hydrocephalus with no definable zone of physical obstruction Curently: synonymous with obstructive communicating hydrocephalus →NPH: 2nd etioloy of hydrocephalus(Chahlavi A, El-Babaa SK, Luciano MG. Adult-onset hydrocephalus. Neurosurg Clin N Am 2001;12:753—760)


CSF IMAGING- CLINICAL APPLICATION (NPH) :CSF IMAGING- CLINICAL APPLICATION (NPH) The role of radionuclide cisternography Firstly, the combination with other image modalities and clinical findings is important(to differentiate NPH from other disorders) In NPH, the patient who will benefit from surgical shunt therapy may be guided by radionuclide cisternography. However, some reports recently published cisternography does not contribute additional informationabove that of the combination of CT and clinical assessment (Vanneste J, Augustijn P, Davies GA, et al. Normal-pressure hydrocephalus. Is cisternography still useful in selecting patients for a shunt? Arch Neurol 1992;49:366-370).


CSF IMAGING- CLINICAL APPLICATION (NPH) :CSF IMAGING- CLINICAL APPLICATION (NPH) Imaging procedure Inject radiopharmaceutical into subarachnoid space Taking image All images should be obtained for 50k counts Imaging times: 1 hr: thoracic-lumbar spine 2 - 3 hr: base of te skull to visualize basilar cisterns 24 and 48 hr: evaluation of ventricular reflux and arachnoid villi resorption Obtain anterior, posterior, and both lateral views of the head at 3, 24, and 48hr.


CSF IMAGING- CLINICAL APPLICATION (NPH) :CSF IMAGING- CLINICAL APPLICATION (NPH) Clinical patterns of cerebrospinal fluid flow Type IV: persistent ventricular activity, in adequate clearance Type IIIB: transient ventricular activity, clearance without usual migration Type IIIA: clearance by usual Type II: delayed migration Type I: normal


CSF IMAGING- CLINICAL APPLICATION (NPH) :CSF IMAGING- CLINICAL APPLICATION (NPH) Surgical intervention Dramatic effect on patient symptoms can only be found in 50% of patients(Vanneste JA: Diagnosis and management of normal-prssure hydrocephalus. J Neurol 2000;247:5-14) The symptom improve in NPH after surgical intervention may depend on following condition The cause of NPH Clinical presentation: the longer the worse prognoeis The time of symptom onset The association between other cerebrovascular insufficiency or other disorders


CSF IMAGING- CLINICAL APPLICATION (CSF shunts evaluation) :CSF IMAGING- CLINICAL APPLICATION (CSF shunts evaluation) Types of CSF shunts: Ventriculoperitoneal, ventriculoatrial, lumboperitoneal shunts Current ventricular systems: proximal tubing, reservoir/valve, distal tubing


CSF IMAGING- CLINICAL APPLICATION (CSF shunts evaluation) :CSF IMAGING- CLINICAL APPLICATION (CSF shunts evaluation) The function of nuclear medicine techniques This technique has been used successfully for many years to evaluate these shunts for obstruction Radiophamaceutical: TC-99m DTPA 0.5-1 mCi, Indium-111 DTPA 250 μCi Tc-99m DTPA is preferred due to short T1/2, low radiation dose, easy availability, the characteristic of renal extraction and excretion


CSF IMAGING- CLINICAL APPLICATION (CSF shunts evaluation) :CSF IMAGING- CLINICAL APPLICATION (CSF shunts evaluation) Methods for evaluating shunt obstruction: Initial: CSF reservoir Radiology for evaluating structural components Radionuclide studies Protocol of image technique Sites of injection depend on the types The tracer is injected to the shunt reservoir or lumbar subarachnoid space Radioactive markers may be placed on the sternal notch, xiphoid, umbilicus 10 second/frame images for 3 min, 1min/frame or 27 min


CSF IMAGING- CLINICAL APPLICATION (CSF shunts evaluation) :CSF IMAGING- CLINICAL APPLICATION (CSF shunts evaluation) Interpretation Tracer may move proximal or distal If tracer does not move efficiently →reservoir pumped Final images( if poor progation of the tracer is still found) Examination should be complete in 1 hour or more


CSF IMAGING- CLINICAL APPLICATION (CSF shunts evaluation) :CSF IMAGING- CLINICAL APPLICATION (CSF shunts evaluation)


CSF IMAGING- CLINICAL APPLICATION (CSF leakage) :CSF IMAGING- CLINICAL APPLICATION (CSF leakage) Etiology: trauma, surgical procedure, tumor, spontaneously Sites of leakage: any where along spinal and brain subarachnoid spaces The majority of leakage site: nasopharyngeal region CSF rhinorrhea: skull base from frontal sinuses to temporal bone


CSF IMAGING- CLINICAL APPLICATION (CSF leakage) :CSF IMAGING- CLINICAL APPLICATION (CSF leakage) CSF leakage in the head region


CSF IMAGING- CLINICAL APPLICATION (CSF leakage) :CSF IMAGING- CLINICAL APPLICATION (CSF leakage) Clinical presentation: Serous drainage from the nose, ear, skin. frontal headache that improves in the lying position Types of survey CT with intrathecal contrast injection Radionuclides: especially when small, intermittent leaks


CSF IMAGING- CLINICAL APPLICATION (CSF leakage) :CSF IMAGING- CLINICAL APPLICATION (CSF leakage) Cisternogram protocol Radiopharmaceutical: In-111 DTPA & Tc-99m DTPA In nasopharyngeal leak, In-111 DTPA is preferred For nasopharyngeal leak Pledgets placed Via lumbar puncture Initial images: 30 min to 1 hrs Latter images: 6 hrs (with pledgets removed) Delayed images: 24 hrs later


CSF IMAGING- CLINICAL APPLICATION (CSF leakage) :CSF IMAGING- CLINICAL APPLICATION (CSF leakage) Pledgets placement


CSF IMAGING- CLINICAL APPLICATION (CSF leakage) :CSF IMAGING- CLINICAL APPLICATION (CSF leakage) Interpretation CSF leaks are seen as an increasing accumulation of activity Pledgets evaluation: Tracer from small leakage and nasal secretion may be contaminated via blood stream Determine the origin of leakage (anterior versus posterior) Criteria: intranasal pledget /plasma ratio Normal: less thant 1.5 Postive: >2-3/1


CSF IMAGING- CLINICAL APPLICATION (patients receiving intrathecal chemotherapy) :CSF IMAGING- CLINICAL APPLICATION (patients receiving intrathecal chemotherapy) Evaluation of patients Receiving Intrathecal Chemotherapy Evaluation of Brain Fluid-Filled Structures Cisternogram in Benign Increased Intracranial Pressure Evaluation of CSF pumps for Continous Delivery of Medication


CSF IMAGING- CONCLUSION :CSF IMAGING- CONCLUSION Radionuclide cisternography has been used for may years in NPH and evaluate who will benefit from a CSF shunt. However, better results is found by means of clinical and radiological findings. CSF leakage: nuclear medicine was important, especially in patients with slow intermittent processes CSF shunt studies also provide important information for further management. The results of unclear studies are still major determinations for the clinician to follow.


CSF imaging :CSF imaging Reference Nuclear medicine Annual 2004 nuclear medicine in clinical diagnosis and treatment The requisites nuclear medicine Thanks for your attention