Cisternography and ventriculography gadopentate dimeglumine-enhanced MR imaging in pediatric patients: preliminary report

Abstract

Background and purpose: Complex CSF diseases may be underdiagnosed or poorly understood on conventional CT or MR imaging. Although intrathecal CT cisternography with water-soluble iodinated contrast medium has been used, very few studies have dealt with the intrathecal use of gadopentate dimeglumine (Gd-DTPA), though it appears superior to CT. We report our experience with the intrathecal use of Gd-DTPA for MR cisternography and ventriculography in pediatric patients referred for study and treatment of complex CSF-related diseases.

Materials and methods: Ten patients (range, 1 month-16 years of age) were selected after we obtained specific informed consent. Intrathecal gadolinium injection was performed via transfontanelle ventriculostomy, ventriculoperitoneal shunt reservoir, or lumbar puncture. Cases included spontaneous CSF leaks (n=1), complex traumatic frontoethmoidal fractures with suspected CSF leak (n=2), multiloculated congenital or acquired hydrocephalus (n=3), intraventricular tumor (n=1), suspected postoperative arachnoiditis (n=1), complex midline defect (n=1), and acquired orbital meningoencephalocele (n=1).

Results: No patient showed biologic, behavioral, or neurologic alterations. In complex hydrocephalus or intraventricular cysts, ventriculography Gd-DTPA MR imaging helped to differentiate isolation of a ventricle or noncommunicating cyst in all 4 patients. In suspected posttraumatic CSF leaks, the procedure established with precision the place of the leak in 1 patient and excluded it in the other. In 1 patient who underwent surgery for spinal cord neoplasm, the procedure excluded arachnoiditis. In the other 3 patients with complex CSF-related diseases, the procedure showed distinctive radiologic findings for the understanding and treatment of the disease. Altogether, in 8 patients, imaging findings influenced or changed clinical decisions and surgical planning.

Conclusions: Our preliminary results showed no side effects and potential useful clinical applications in the evaluation of CNS diseases involving the ventricular system or the subarachnoid space in selected pediatric patients.

Fig 1.

Complex hydrocephalus (patient 3). Axial T1-weighted spin-echo (SE) (A) and T2-weighted fast spin-echo (FSE) (B) images showing unilateral ventriculomegaly and midline cyst at the neonate stage and signs of corpus callosum agenesis. Axial (C) and sagittal (D) T1-weighted SE images at 1 month of life, after Gd-DTPA injection via transfontanelle ventriculostomy, show isolated right ventricular enlargement with lack of communication either with the left ventricle or with the midline cyst. Uniportal endoscopic approach was elected for the treatment of both the interhemispheric cyst and the isolated right ventricle.

Fig 2.

Dysraphic state with hypertelorism, intracranial suspected dermoid tumor, and bifid nose (patient 8). Coronal CT scan through the cribriform plate (A) and sagittal SE T1-weighted MR image through the anterior cranial fossa (B) do not exclude associated encephalocele. Intrathecal Gd-DTPA-enhanced T1-weighted SE fat-saturated images in sagittal (C) and coronal (D) planes show integrity of the anterior cranial fossa and absence of meningoencephalic herniation. Surgery was delayed without the fear of unnoticed sac rupture.

Fig 3.

Acquired orbital meningoencephalocele in a patient with osteopetrosis (patient 7). Coronal CT scan (A) through the orbits shows intraosseous spheric defect on the roof of the left orbit with intracranial canal connection. Notice additional intraosseous orbital defects in the roof of the right orbit. Coronal FSE T2-weighted image (B) shows an encephalocele contained within the roof of the left orbit and raises questions concerning the contents of the right osseous roof defects. Intrathecal Gd-DTPA-enhanced coronal T1-weighted SE fat-saturated image (C) shows free CSF communication between the brain and left orbital roof defect and an encephalocele contained within the cavity. No additional CSF leaks are seen within the bony defects on the right orbit roof, excluding a bilateral surgical subfrontal approach.

Fig 4.

Spontaneous otorrhea and dizziness (patient 10). A and B, Axial and coronal CT scans through the left middle ear and osseous labyrinth show absence of osseous cochlear dysplasia (A) and a bulbous appearance of the internal auditory canal (arrow in B), with no middle ear or mastoid cavity filling. C, Intrathecal Gd-DTPA-enhanced axial T1-weighted SE fat-saturated MR image through the upper medulla oblongata shows abnormal filling of the left cochlear structure (arrow). D–F, Coronal T1-weighted SE fat-saturated MR image through the cerebro-pontine angle cisterns. Spot view of the right side (D) shows CSF filling up to the lamina cribrosa. However, further membranous labyrinth structures (semicircular canals) are filled on the left side (arrow in E), as well as the cochlear duct (arrow in F). Additional CSF deposit is seen in the floor of the sphenoidal sinus (arrow in G) (the patient was positioned in a prone head-down position). This patient was eventually diagnosed with juvenile transient osteoporosis because of an upper limb pathologic fracture.