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Journal of the Anatomical Society of India

Morphometric Study Of The Ventricular System Of Brain By Computerised Tomography

Author(s): D'Souza e Dias Medora C. and Natekar Prashant E.

Vol. 56, No. 1 (2007-01 - 2007-06)

D’Souza e Dias Medora C. and Natekar Prashant E.

Goa Medical College, Goa.

Abstract:

Computerised Tomographic Scans (CT Scans) of 1000 patients were examined for the various morphometric measurements of the ventricles of the brain and it was observed that the width and the height of the fourth ventricle were 1.31 + 0.23 cms and 1.18 + 0.27 cms in males and 1.21 + 0.22 cms and 1.11 + 0.24 cms in females respectively; the width of the third ventricle was 0.45 + 0.29 cms and 0.39 + 0.17 cms in males and females respectively; the anteroposterior extent of the lateral ventricles (inclusive of their frontal horns) on the right side was 6.96 + 0.76 cms and 6.57 + 0.75 cms in males and females and on the left side was 7.09 + 0.78 cm and 6.73 + 0.77 cms in males and females; the anteroposterior extent of the frontal horns on the right side was 2.74 + 0.36 cms and 2.55 + 0.33 cms in males and females and 2.78 + 0.37 cms and on the left side was 2.58 + 0.35 cms in males and females.

This study was conducted to examine the size of the normal ventricular system of brain in a normal population of males and females and its clinical application.

Keywords: Brain, Lateral ventricles, Third ventricle, Fourth ventricle

Introduction:

Just as beauty lies in the eyes of the beholder, so is a good looking brain, or at least a brain that serves its user well. According to Corsellis (1976), Cobb (1965) once made a statement saying, “Only very small brains are inadequate and very large brains have no advantage over medium sized ones”. Studies by Bullock (1993) and Satz (1993) defined the ‘brain reserve hypothesis’ wherein size did relate to complexity and redundancy, and was a protective factor against ageing, injury and disease.

According to Schochet (1998) the brain undergoes many gross and histopathologic changes with advancing age, and also in various dementias,with regression of brain tissue leading to ballooning of the third ventricle and rounding of the angles of the lateral ventricles. Studies by LeMay (1984) attributed this ballooning of the third ventricle to a regression of the median nuclei of the thalami and a progressive diminution of the massa intermedia that joins them.

Various studies by Andreasen et al (1982), Kido et al (1989) and Huber et al (1990) clearly show an increase in the CSF spaces in dementia especially in Alzheimer’s disease and Parkinson’s disease. According to Corsellis (1976) and Creasy and Rapoport (1985) this was due to reduction in the size of nerve cells. Haaga (1994) reported ventricular enlargement to be a more sensitive indicator of cortical atrophy due to increasing age and dementias. Studies by McRae et al (1974) and Scott et al (1983) show larger lateral ventricles in epilepsy and depression respectively.

The aim of this morphometric study is to examine the range in size of the normal ventricular system of brain in humans and to find any relationship of this with gender and clinical correlations, in their diagnosis, treatment, and the need to intervene surgically (in particular by ventricular shunting procedures) and in judging the efficacy of treatment designed to deal with hydrocephalus.

Materials and methods:

This study was carried out on 1000 patients (500 males and 500 females) in the age group of 30 to 50 years, attending the department of Radiodiagnosis, at Goa Medical College, Bambolim, Goa. The cases were selected from the Goan population which comprises around 60% Hindus, 26% Christians and 14% Muslims. These patients were selected randomly and had no history of cerebral infarction, local mass lesions, probable communicating hydrocephalus, alcoholism, drug abuse, trauma or previous intra-cranial surgery and other hereditary diseases and were not on medication at the time of this study.

CT Scans of all patients were reported by individual radiologist scoring as normal. The CT Scanner used in this study was the Siemens Somatom A. R. C. having a fan beam scanner with a scan time of 1 to 10 seconds. The density of Cerebrospinal fluid was 10 Hounsfield units (HU); that of the white matter was 35 – 45 HU and that of the grey matter was 55 – 65 HU. The matrix was 256×256 with a slice thickness of 10 mm (Hounsfield 1973).

The patient was placed on the CT table and the head was centralized and supported for correct alignment and to reduce blurring of images. A lateral image was taken to confirm correct position of patient. Canthomeatal line was drawn and a line at an angle of 15 – 20 degrees to and 1 cm above it was drawn, representing the lowest tomographic section, which passed through the base of skull. A total of 8 to 10 sections were obtained without any overlap (Haaga et al 1994).

The lateral ventricles on CT are seen in three or four contiguous slices; the highest tomogram to pass clearly through them contains the superior segments of the cellae mediae, with the corpus callosum in between; the superior segments of the trigones and occipital horns may also be seen; the next descending contiguous tomogram incorporates the frontal horns anteriorly and the occipital horns posteriorly whereas the temporal horns cannot be identified with certainty and their clear delineation implies that they are dilated; the third ventricle is seen between the thalami and the fourth ventricle is seen as an oval area at the center of the posterior fossa lower down, between the cerebellum and the pons (Gawler et al 1976). The measurements taken were as follows:

  1. Level of Fourth Ventricle
    1. Greatest height of fourth ventricle in cms (ab) (Fig 1).
    2. Greatest width of fourth ventricle in cms (cd) (Fig 1).
  2. Level of interventricular
    1. Length of frontal horns of Right lateral ventricle in Foramen. cms (measured from its tip to the interventricular foramen) (a-b) (Fig 2).
    2. Length of frontal horns of Left lateral ventricle in cms (measured from its tip to the interventricular foramen) (c-d) (Fig 2).
  3. Lateral ventricle above the
    1. Length of Right lateral ventricular body inclusive of level of interventricular foramen. frontal horn (taken from tip of frontal horn to the atrium) (a-b) (Fig 3).
    2. Length of Left lateral ventricular body inclusive of Frontal horn (taken from tip of frontal horn to the atrium) (c-d) (Fig 3).

The length of the third ventricle could not be measured as its posterior marker the pineal gland was not seen in CT Scan sections of all patients.

Statiscal analysis of the data was performed by using SPSS Software Package version 7.0 (SPSS Inc). The Mean and Standard Deviation (SD) of all measurements were estimated and 95% Confidence intervals (CI) both upper and lower were calculated for all. The data was also analysed by using Z test for significance of difference of the measurements between males and females.

The aim of this morphometric study was to examine the range in the size of the ventricular system in normal humans, both in males and in females, and to find out if there existed any relationship with gender and other clinical correlations.

Observations and results:

Fig. 1 shows the measurements taken of the fourth ventricle. When these were analysed it was observed that the height of the fourth ventricle was larger in males (1.18 + 0.27, 95% CI 0.65-1.71 cms) as compared to females (1.11 + 0.24, 95% CI 0.65-1.58 cms), which was statistically significant (z ≥ 1.96). The width of the fourth ventricle was also observed to be greater in males (1.31 + 0.23, 95% CI 0.85-1.77 cms) than in females (1.21 + 0.22, 95% CI 0.79-1.64 cms), which was also statistically significant (z ≥ 1.96) (Table no. I).

Fig. 2 shows the measurements taken of the third ventricle. After analysis of the width of the third ventricle it was observed to be greater in males (0.45 + 0.29, 95% CI 0-1.01 cms) than in females (0.39 + 0.17, 95% CI 0.05-0.72 cms) and this difference was statistically significant (z ≥ 1.96) (Table no. II).

Figs. 2 and 3 show various measurements taken of the lateral ventricles. On analyzing these it was observed that the anteroposterior extent of the left frontal horns (males = 2.78 + 0.37, 95% CI 2.06-3.50 cms and females = 2.58 + 0.35, 95% CI 1.89-3.26 cms) was greater than that of the right ones (males = 2.74 + 0.36, 95% CI 2.03- 3.46 cms and females = 2.55 + 0.33, 95% CI 1.91-3.19 cms). Also observed was that the anteroposterior extent of the left lateral ventricular body including its frontal horn (males = 7.09 + 0.78, 95% CI 5.55-8.63 cms and females = 6.73 + 0.77, 95% CI 5.23- 8.23 cms) was greater than the right one (males = 6.96 + 0.76, 95% CI 5.48-8.45 cms and females = 6.57 + 0.75, 95% CI 5.10-8.03 cms) (Table III).

Discussion:

The human nervous system is the most complex, widely investigated and yet poorly understood physical system known to mankind (Williams et al 1995). Studies by Ellis (1920), Pakkenberg and Volgt (1964), Baaron et al (1976) and De Kaban and Sadowsky (1978) revealed that brain regression involving both the cerebrum and the cerebellum usually began by the seventh decade and thereafter accelerated with advancing age.

According to Taveras and Wood (1976) the lateral ventricular contours are relatively constant, except for the occipital horns. Alterations in the brain with ageing have been the focus of many investigations. According to Fox et al (1975), Huckman et al (1975), Roberts and Caird (1976), LeMay (1984) and Lee and Krishna (1987), modern computerized x-ray tomography allows easy and safe noninvasive study of the ventricular system, without complications, so unlike the pneumoencephalogram and it can be used as a screening procedure for many illnesses. Roberts et al (1978) pointed out its value in evaluating dementia and its use in excluding brain diseases that mimic dementia of the Alzheimer type such as neoplasms, subdural hematomas, and cerebrovascular disease.

The range of changes in the ventricular size of the brain encountered in clinical practice can lead most people to believe that a decision taken without an exact measure of ventricular size, however, there is likely to be an increasing number of circumstances in which precise measurements will be of value.

Studies by Gawler et al (1976) revealed that the greatest distance between the roof and the floor of the fourth ventricle was less than 1.2 cms with a mean of 1.08 cms; however in our study this distance is significantly larger in males (1.18 +0.27, 95% CI 0.65-1.71 cms) than in females (1.11 +0.24, 95% CI 0.65-1.58 cms). In our present study the width of the fourth ventricle, was found to be greater than the height in both genders and was more in males (1.31 +0.23, 95% CI 0.85-1.77 cms) than in females (1.21 +0.22, 95% CI 0.79-1.64 cms) (Table I).

Gawler et al (1976), Brinkman et al (1981) and Soininen et al (1982) found that the maximum width of the third ventricle had a mean of 0.46 cms, 0.59 cms and 0.92 +2.71 cms respectively, with higher values in males. In our present study we recorded this measure significantly higher in males (0.45 + 0.29, 95% CI 0.00-1.01 cms) as compared to females (0.39 + 0.17, 95% CI 0.05-0.72 cms) (Table II).

According to Glydensted (1977), Gomori et al (1984) Takeda and Matsuzawa (1985) and Goldstein et al (2001) the left lateral ventricle was larger than the right one and both were larger in males. In our study, the anteroposterior extent of the left frontal horns (males = 2.78 + 0.37, 95% CI 2.06-3.50 cms and females = 2.58 + 0.35, 95% CI 1.89-3.26 cms) was greater than that of the right ones (males = 2.74 + 0.36, 95% CI 2.03- 3.46 cms and females = 2.55 + 0.33, 95% CI 1.91-3.19 cms) (Table III).

The anteroposterior extent of the left lateral ventricular bodies including their frontal horns (males = 7.09 + 0.78, 95% CI 5.55-8.63 cms and females = 6.73 + 0.77, 95% CI 5.23- 8.23 cms) was greater than the right ones (males = 6.96 + 0.76, 95% CI 5.48-8.45 cms and females = 6.57 + 0.75, 95% CI 5.10-8.03 cms) (Table III).

In conclusion, the present study has defined the morphometric measurements of all the ventricles of the brain i.e. the fourth ventricle, third ventricle and lateral ventricles, which has clinical correlations in diagnosis, treatment and surgical intervention.

Fig. 1: Level of the fourth ventricle

Level of the fourth ventricle

Fig. 2: Level of the interventricular foramen

Level of the interventricular foramen

Fig. 3: Level above the interventricular foramen

Level above the interventricular foramen

Table No. I: Measurement of the fourth ventricle.

Parameter Gawler
Et al
Present Study
Males
n = 500
Females
n = 500
Fourth Ventricle Height
Mean (cms) 1.08 1.18* 1.11*
SD - 0.27 0.24
95% CI (L) - 0.65 0.65
95% CI (U) - 1.71 1.58
Fourth Ventricle Width
Mean (cms) - 1.31* 1.21*
SD - +0.23 +0.22
95% CI (L) - 0.85 0.79
95% CI (U) - 1.77 1.64

*z ≥ 1.96 = significant.

Table No. II: Measurement of the third ventricle.

Parameter Soininen
et al
1982
Brinkman
et al
1981
Gawler
et al
1976
Present Study
Males
n = 500
Females
n = 500
Third Ventricle
width (cms)
Mean*
0.92 0.59 0.46 0.45* 0.39
SD ± 2.71 - - ± 0.29 ± 0.17
95% CI (L) - - - 0.00 0.05
95% CI (U) - - - 1.01 0.72
*z ≥ 1.96 = significant.


Table III

Parameter Frontal horn Frontal horn + body
Males Females Males Females
R L R L R L R L
Length of lateral
Ventricle (cms)
Mean
2.74* 2.78* 2.55* 2.58* 6.96* 7.09* 6.57* 6.73*
SD ± 0.36 ± 0.37 ± 0.33 ± 0.35 ± 0.76 ± 0.78 ± 0.75 ± 0.77
95% CI (L) 2.03 2.06 1.91 1.89 5.48 5.55 5.10 5.23
95% CI (U) 3.46 3.50 3.19 3.26 8.45 8.63 8.03 8.23
*z ≥ 1.96 = significant.

Acknowledgement:

The authors wish to thank: Dr V. N. Jindal, Dean, Goa Medical College, Bambolim, Goa, for permitting us to carry out this present study in this prestigious institution. Dr. Mahesh Sardessai, Professor and HOD, Dept of Radiology, Goa Medical College, Bambolim, Goa, for allowing us the use of the CT Scan machine in the Radiodiagnosis department. Dr. Durgaprasad, Director of Planning and Statistics, Panjim, Goa, for his guidance in the statictical analysis. Dr. Sanjay Sardessai, Assoc. Professor, Dept of Radiology, Goa Medical College, Bambolim, Goa, for his invaluable guidance at the CT machine.

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