PARACLINICAL EXAMINATIONS IN NEUROSURGERY

Conf.Dr.Dumitru Mohan

1.X-RAY (ROENTGEN RADIATION)

The simple X-ray examination can be used to track down some
development anomalies of the cranium or of the spinal column, and to track
down pathological traumatic, degenerative or osseous-tumours
modifications, or modifications secondary to the development of some
intracranial expansive processes of various origins.
Incidences may vary by case:
- antero-posterior for tracking down midline shift of the pineal gland-
from spaceoccupying lesion;
- lateral for tracking down potential fractures;
- tangetial for tracking down recesses of the calvaria;
- Hirtz view for examining the base of the cranium;
- antero-posterior, lateral and ¾ oblique central incidence for various
segments of the vertebral column;
- transoral incidence for odontoid process fractures.
With the simple X-ray examination of the cranium one can see the 2
surfaces of the skullcap (calvaria). The width of the external surface is
around 1mm and the internal surface’s width can vary from 1-2mm. The
diploe is 2/3 of the width of the calvaria, and is more developed in the
occipital region at the level of the external occipital protuberance. The
cranial suture can be anfractuous, linear or squamous. The digital
impressions that can be seen on the internal surface of the calvaria are the
imprint of the cerebral convolutions, of the Pacchioni granulations and those
of the arteries and veins.
The X-ray image may reveal some specific modifications in case of
some craniocerebral affections:
- in case of traumatisms one can see fractures, splinters and
intracranial foreign bodies as well as old traumatisms osseous
sequelae (aftereffects);
- skullcap asymmetries can be observed in the chronic subdural
hematoma, temporal tumors, meningiomas, cerebral hemiatrophy;
- the intracranial hypertension syndrome causes modifications in the
suture, the diffuse or circumcised thinning of the skullcap, widening
of the diploic venous channels;

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 - multiple myeloma appears in the form of hypertransparent zones
with leveled edges and with a neat rounded aspect similar to trepan
holes;
- osteolytic bone metastases appear as multiple zones of osseous
rarefaction with leveled edges which rapidly develop.
The simple X-ray of the vertebral column reveals the normal or
pathological character of the elements the vertebral column (rachis) consists
of: vertebral bodies, articular processes, intervertebral discs, vertebral
pedicles, vertebral laminae, spinous processes, transverse processes,
vertebral foramen.
The following can be seen for the vertebral column:
- rachidian malformations: the absence of the vertebral body, spina
bifida, reduced number of vertebrae, deviations of the vertebral
column;
- vertebromedullary traumatisms: fractures of the vertebral bodies, of
the vertebral arch and spinous processes, contorsions;
- rachidian tumors that cause atrophy of the pedicles, widening of the
vertebral foramen, bone damage in case of vertebral metastasis;
- degenerative lesions of the rachis: lumbar disc herniation causes
intervertebral space narrowing, spondilolistezis, scoliosis and the
reduction of the physiological lordosis.

2.MYELOGRAPHY
The examination of nervous tissues located within the spinal canal
requires radiographic contrast in the subarachnoid space. Negative (air) and
positive (iodized substances) contrast agents have been used in turns. Today
the following are used: hydrosoluble, hyperbaric, hypoallergenic solutions
which spread rapidly in the CSF and in the blood.
The contrast agent may be inserted via lumbar puncture or
suboccipital (cisternal) puncture.
The purpose of the myelography is to indicate the anatomical position
of the pathological processes in the vertebral canal and identify their relation
to the dura (extra or intradural) or that to the spinal cord (extra or
intramedullary). When the area of focus is the lumbar column, it is called
radiculography.
The transit of the contrast agent towards the cranium or cauda offers
information regarding the liquid passage, the existence of myelic or radicular
compression which in the x-ray examination can display as:
- complete stop of the contrast agent (marked compression);
- partial stop, forming a gap-like shape (partial compression);
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 - pushing of the dural sac, radicular amputation (an aspect of disc
herniation).
As it is a invasive method lately it’s being replaced by MRI (magnetic
resonance imaging).

3.PNEUMOENCEPHALOGRAPHY AND
VENTRICULOGRAPHY
The neuroradiological examinations using air as a contrast agent were
first introduced in the field by Dandy in 1918 and for over 3 decades it were
the main methods of neuroradiological diagnostic.
These methods use inert and noninvasive air for contrasting.
In the pneumoencephalography air is pumped using the lumbar or
suboccipital puncture in the subarachnoid space.
In ventriculography air is pumped directly into the ventricles using the
puncture method, thus making it possible to observe indirectly intracranial
expansive processes, whilst in case of intracranial tumors the image is direct.

4.CEREBRAL ANGIOGRAPHY
Cerebral angiography is a technique used to view the topographical
anatomy of the cerebral circulation. The first successful cerebral
angiography was done by Egas Moniz in 1927.
Viewing the intracranial circulation can be done by injecting the
iodized solution either directly using the carotid puncture method or by
selective catheterization. Selective catheterization uses the Seldinger
method, the most safe and frequently used area being the femoral artery.
The complications of arteriography refer to potential reaction when
administering the contrast agent, the risk of embolization at the level of the
arterial puncture and local hemorrhagic complications.
Angiography is used to indirectly expose some intracranial expansive
processes by showing the contralateral shift of the vascular structures or by
showing avascular spaces (in subdural hematoma a avascular biconvex lens
can be seen on the surface of the brain). Also it is the method of choice in
cerebral vascular affections for discovering arterial occlusions or stenoses
and cerebral aneurysms.
Another area in which angiography is used is that of detecting the
vascular pedicles of the arterovenous malformations and some
hypervascularized tumors, in order to embolize them.
This method offers high quality images of the magistral blood vessels
of the neck and in some places it has become the method of choice in
detecting carotid atheromatous disease.
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 5. COMPUTED TOMOGRAPHY (CT-SCAN)
CT scanning was first introduced in the medical field in the mid ’70
revolutionizing the diagnosis of intracranial and spinal neurosurgical
pathology.
Computer tomography was discovered by the engineer G. Hounsfield
in 1972 and applied in medicine by Dr.J.Ambrose in 1973.
The ‘native’ image (without the help of iodized substances) is able to
show the blood content of potential lesions or that of ventricular structures.
It is necessary to repeat the examination after administering an iodized
substance i.v. for showing neoplastic lesions.
The most frequently used terms in CT-scan are:
- isodensity – the normal tomographic density of the brain, which
shows up as gray on the CT-scan image;
- hypodensity – the normal aspect of the CSF which shows up as
black;
- hyperdensity – the normal aspect of the bone and blood which shows
up white;
- mass effect – refers to the compressive effect of a pathological
process of the cerebral structures.
Computer tomography aspects in the pathological processes:
- in cerebral hemorrhages one can see the intraparenchymal blood
reflow as a well defined hyperdense image, having a mass effect over
the neighboring tissues that can be seen starting with the first hours
from the onset; after two days a hypodense image appears around the
hyperdensity – perilesional edema;
- cerebral abscesses appear as a well defined formation, the capsule is
hyperdense whiles the necrotic tissues from inside is hypodense;
- tumours processes have variable densities but it has contrast medium
uptake and does not stay within the arterial distribution area;
- extradural hematoma appears as a hyperdense image in the shape of
a lens placed between the skullcap and the cerebral parenchyma;
- in craniocerebral traumatisms one can observe cerebral contusion
which appears in the hyperdense areas at the superficial level in the
cerebral parenchyma.
CT-scanning is the first choice in case of emergencies for its low cost,
accessibility and high sensibility in detecting cerebral hemorrhages,
intracerebral calcifications and bone lesions.
This method is also used when evaluating the vertebral column
although the amount of information is rather low, as this method is best for
viewing bone tissues. It is used in vertebral column traumatisms and
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discopathies, although the MRI can show more of the relations between the
soft tissues and the spinal cord.

6. ULTRASONOGRAPHY
The ultrasound-based examination of the cervico-cephalic circulation
is noninvasive and wide spreading. Echo-tomography and the spectral
analysis Doppler exam are the most frequently used methods.
Physiologically blood flows laminar through the unaffected cervical
vessels. In case of arterial stenosis the velocimetric curves change their
aspect, and the sound of the speaker changes its tonality due to the increase
of the blood flow through the stenosised segment and due to the turbulent
flow in the post-affected segment..
Transcranial Doppler allows an evaluation of the intracranial
hemodynamics, cervical lesions, intracranial stenoses or the subarachnoid
hemorrhage spasm.
The transcranial Doppler examination can be done by focusing on 3
transcranial ”windows”:
- transorbital: ophthalmic arteries, carotid siphos, anterior cerebral
arteries;
- transtemporal: anterior cerebral arteries, posterior cerebral arteries,
middle cerebral arteries, anterior and posterior communicating
artery;
- foramen magnum: the terminal segment of the vertebral artery,
basilar trunk and its ramifications.
In carotid stenosis surgery, the Doppler method has be proved 90-95
% of the time efficient. The flat, atheromatous plaques are hypoechogenic.
The ulcerated plaques form heterogeneously, while the calcified plaques
appear hyperechogenic.

7. MAGNETIC RESONANCE IMAGING (MRI)

Magnetic resonance imaging (MRI) is a method that has been used
since the beginning of the ’80 and it has made a major progress in
neuroimaging as it is noninvasive and riskless.
This method is based on electronic spin under the action of an
electromagnetic field, having higher resolution images than those of the
tomography. The MRI images have the advantage of being on 3 planes
(axial, coronal, sagittal) and can be seen in 2 ways (T1 and T2).
MRI offers the most sensitive method for discovering cerebral tumors
and it is very efficient/effacing in investigating the posterior fossa. The MRI

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detects over 95% of the cerebral tumors. Using paramagnetic agents
increases delimitations of the tumors.
The acoustic neuromas are clearly shown and the postcontrast images
done in T1 allow viewing of intracanalicular tumors up to 1-2mm in
diameter. The T2 image sensitivity to changes in the tissue with high content
of water makes this method very sensitive infectious and inflammatory
modifications of the cerebral tissue allowing it to identify encephalitis
manifestation.
In order to make cerebral vascularization visible through the use of
Angio-MRI, the artero-venous malformations or aneurysm vascular
malformation must be exposed.
The spinal MRI allows viewing between the vertebral columns as well
as getting section images in multiple planes. Intramedullary lesions can be
viewed directly.
Intradural extramedullary lesions and their clear relation to the spinal
cord and the roots of the rachidian nerves can we seen clearly on T1 and T2
images. Bone destruction following extradural neoplastic lesions and bone
metastases can be accurately observed.
The MRI is also the method of choice in myelo-radicular investigation
due to its ability to expose degenerative intervertebral disc disease, prolapse,
protusion, or sequestered disc fragments, compression of the roots of the
rachidian nerves.
A total contraindication refers to cardiac pacemakers that are sensitive
to paramagnetic fields and surgical staples that can shift place due to the
electromagnetic field of the MRI.

8. CEREBRAL SCINTIGRAPHY
It is a paraclinical method of investigation which records the
radiations emitted by a radioactive substance administered orally or
intravenous. This kind of substances can cross the hematoencephalic barrier
only in pathological cases, focusing on the affected areas. The most
frequently used radiopharmaceuticals are Iodine 131 fixed on albumin,
Indium 113m, and Technetium 99m.
This method is mostly used for cerebral tumor diagnosis. The tumors
appear as highly radioactive areas the more vascularized they are. The areas
of radioactive indicator build-up are called ‘hot spots’, but in order for them
to be accessed and viewed through this method they need to be bigger than
2-2,5 mm. The examination is done in AP (anteroposterior) projection and
lateral projection. Among all the cerebral tumors the meningiomas are best
exposed.
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 In case of nontumor lesions the accuracy of the method is dropping
however the lesions still appear as hot spots. The difference between the
tumor lesions and nontumor lesions can be seen in scintigraphic
reexaminations in time: nontumor lesions tend to disappear whilst the tumor
lesions persist or even progress.
Today, a full body bone scintigraphy with 99 m-Tc diphosphate is the
method of choice for exposing skullcap bone lesions, especially if multiple
metastasis of the skeleton and of the vertebral column is suspected. This
method of investigation is as effective in case of other affections of the
column: osteodiscitis, osteoporosis, systematic affection at the level of the
column.

9.EXAMINATION OF THE CEREBROSPINAL FLUID (CSF)

The main purpose of the CSF is that of mechanical protection of the
brain and the spinal cord, also maintaining a constant intracranial pressure.
The CSF exam is done in case of diagnosis of the CNS (central
nervous system) infections (meningitis, encephalitis), subarachnoid
hemorrhage, medullary compressions. Therapeutically it’s use is limited, for
example in intrathecal therapy of meningeal neoplasms or fungal meningitis.
The major contraindications is intracranial hypertension syndrome.
Therefore it is absolutely necessary that lumbar puncture be performed after
the depth of the eye exam. If intracranial hypertension is present, the lumbar
puncture can cause cerebral herniation leading to worsening the condition of
the patient and/or quickly leading to his/her death.
The CSF is extracted by lumbar puncture in the lateral decubitus or in
a siting position, the patient’s body being in total flexion in order to increase
the interspinous spaces. The area must be disinfected with iodized alcohol
prior to doing the puncture, which is done with a 8-10 cm needle with stylet,
at the level of the line that connects the iliac crests (lumbar space L4-L5, in
particular case one space up or down). By removing the stylet the CSF drops
can be collected in sterile test tubes (in total 5-10 ml). After the puncture the
patient must remain several hours in the ventral decubitus, and for the next
24 hours in dorsal decubitus.
The suboccipital puncture is performed in the same conditions, the
head being flexed, at the level of the intersection of the bimastoid line with
the medial line to allow penetration through the atlanto-occipital space into
the cistern magna.
The CSF is colourless and clear. Its transparency and color can be
modified by a large number of cells, by proteinorraquia or the presence of
the erythrocytes becoming opalescent, turbid and reddish.
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