• •

The Validity of Criteria for the Evaluation of Cerebral Neuroradiology

Atrophy by Computed Tomography 1

Michael S. Huckman, M.D., Jacob Fox, M.D., and Jordan Topel, M.D.

Computed tomography of the brain was used in evaluating demented and nondemented
elderly people. The incidence of convulutional atrophy and ventricular enlargement corre-
lated well with pathologic and pneumoencephalographic examination of a similar popula-
tion. Computed tomography also showed certain instances of dementia without atrophy
and evidence of atrophy without dementia. The absence of brain atrophy in a demented
patient should prompt a search for a potentially treatable cause of the dementia. The au-
thors discuss criteria for diagnosing atrophy by computed tomography and conclude that,
because of its noninvasive nature, it is a valuable aid in screening demented patients for
treatable disease.

INDEX TERMS: Brain, atrophy. Computed tomography

Radiology 118:85-92, July 1975

• •
years, the diagnosis of cerebral atrophy
F OR MANY
has been based on the demonstration of the "wal-
nut-like" (6) appearance of the brain at pneumoence-
phalography. With the advent of computed tomography
(4, 1, 7, 2), radiologists now have available a noninva-
sive, relatively safe method to attempt to make the
same determination which previously required pneu-
moencephalography with its attendant morbidity and ar-
tifacts (5, 8).
The purpose of this study is to determine the value of
computed tomography in the investigation of senile de-
mentia with the ultimate aim of being able to separate
treatable from nontreatable cases, and to try to predict
by computed tomography the degree of expected intel-
lectual impairment in cases with atrophy. The first part
of the study, presented here, deals with a correlation of
the results of computed tomography (CT) with the re-
sults of pathologic examination and air encephalogra-
phy in the examination of brains of demented and
nondemented people.
INVESTIGATION
Two groups of patients were used for this study
(TABLE I). The first group (Group 1) consisted of a care-
fully evaluated population of patients over the age of 60
with a clinical diagnosis of senile dementia (gradual
onset of intellectual deterioration without a history of
cerebrovascular accident or major focal neurologic defi-
cit on examination). Each of these 35 patients was ex-
amined by one of the neurologists participating in this
study (J.F. or J.T.).
The second group of patients consisted of all individu-
als over the age of 60 years in a series of 300 consecu-
tive computed tomograms. An attempt was made to ob-
tain a detailed history in each of these cases by chart
1 From the Departments of Diagnostic Radiology and Neurological Sciences, Rush-Presbyterian-St. Luke's Medical Center, Chicago, III. Pre-
sented at the Sixtieth Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago, III., Dec. 1-6, 1974. vb
review or by contacting the referring physician. An ade-
quate history was obtained in 48 such patients and
these constituted Group 2. The patients in this subhead-
ing were further subdivided as follows. Group 2A: pa-
tients with no major neurologic problem by history and
whose main complaint was either headache or dizzi-
ness (20 patients). Group 28: patients with confusion or
dementia by history (12 patients). Group 2C: patients
with other major neurologic problems by history (cere-
brovascular accidents, seizures, gait difficulty, acute
brain syndrome without residuum, etc.) (16 patients).
Group 2~ differed from Group 1 in that a thorough
neurologic examination other than the computed tomo-
gram was not carried out on the patients in Group 28.
Computed tomograms were obtained on all patients.
The position of the lowest tomographic cut was deter-
mined in the following manner (Fig. 1). From the outer
canthus of the eye, a line was drawn which made an
angle below the orbitomeatal line of 20°. This lower line
Table I: Clinical Material
Group 1. A carefully evaluated and examined group of 35 pa-
tients over the age of 60 years with a clinical diagnosis
of senile dementia as determined by neurologists
(J. F. and J. T.).
Group 2. Patients over the age of 60 in a group of 300 consecu-
tive patients undergoing computed tomography.
These patients were not personally examined by the
neurologists in this study. The clinical information
was obtained from chart review and the history from
the referring physician. The 48 patients in this group
were subdivided as follows:
A. Twenty patients with no major neurologic prob-
lem by history. The main complaint was usu-
ally headache or dizziness.
B. Twelve patients with confusion or dementia by
history.
C. Sixteen patients with a history of other major
neurological problems such as cerebrovascular
accident, seizure, gait difficulty, acute brain
syndrome without residuum, etc.

85
86 MICHAEL S. HUCKMAN, JACOB Fox, AND JORDAN TOPEL
Fig. 1. This demonstrates how the
patient is marked for positioning in the
scanner. The upper line is the cantho-
meatal line, the lower line forms an angle
of 20° with the canthomeatal line. The
lower line lies flush with the outer rim of
the headcone. As a result, the lowest cut
is parallel to this line but 4.5 cm above it.
Fig. 2. Measurement (A) was made by
measuring the distance between the two hol-
low arrows and measurement (B) was made
by measuring the distance between the two
solid arrows. The sum of these two measure-
ments is then taken as the measurement of
relative ventricular size.
was placed flush with the outer margin of the headcone.
A line parallel to this line but 4.5 cm above it represent-
ed the lower border of the lowest tomographic section.
A total of six adjacent sections were obtained by three
excursions of the x-ray beam 180 0 around the head.
The tomograms were then photographed from the cath-
ode ray tube using a window width setting of 50 and a
window level setting between 5 and 10.
July 1975
The computed tomograms of the brains of the 55 pa-
tients (35 in Group 1; 20 in Group 2A) were then re-
viewed. As in the study undertaken by Gosling (3), they
were reviewed by a radiologist who was aware that ce-
rebral atrophy was the subject under investigation, but
knew nothing of the individual cases involved. Initially,
the tomograms were assembled in random order and
subjectively interpreted as to whether atrophy was or
was not present. If atrophy was present, it was divided
into categories of mild, moderate, and severe on the
basis of the presence of large ventricles and cortical
sulci. Those which demonstrated enlarged ventricles
with no evidence of enlarged cortical sulci were put into
a separate category.
Then, in order to be more objective, the tomograms
were reassembled in random order and reviewed by the
radiologist a second time with measurements of the
cortical sulci and ventricles obtained in each case in the
following manner (Fig. 2). Measurements were made on
the photographs using a translucent millimeter ruler. In
each scan, the following dimensions were measured:
(A) a line drawn between the most lateral portion of
each of the frontal horns; (B) the width of the lateral
ventricles in the region of the caudate nuclei, that being
the width of the two lateral ventricles just anterior to the
third ventricle; (C) the total width of the four largest cor-
tical sulci seen in the highest three tomographic cuts.
The A and B measurements were added together
and the sum was taken as the measurement of ventric-
ular size. These measurements were expressed in milli-
meters as measured on the photographs. Multiplying
these values by a factor of 3.63 would give the actual
dimension being measured. For the purpose of this
study, results were expressed as millimeters measured
on the Polaroid photographs.
RESULTS
In each case, the sum of the A and B measurement
(determined in mm on the photograph) was taken as
ventricular size. The sum of the four largest sulci (mea-
sured in mm in the three uppermost tomographic cuts)
was the numerical value of the degree of sulcus en-
largement. On the basis of these measurements, each
of the cases was put into one of the following five cate-
gories.
1. Normal by computed tomographic examination.
Ventricles measured 15 mm or less and the measure-
ment of the cortical sulci was 5 mm or less (Fig. 3).
2. Computed tomographic examination showed
questionable atrophy. The ventricles were between 16
and 20 mm and the cortical sulci were 5 mm or less; or
the ventricles were 15 mm or less, but the cortical sulci
were between 6 and 9 mm (Fig. 4).
3. Computed tomographic examination showed mild
atrophy. The ventricles measured between 16 and 20
mm and the sulci measured between 6 and 9 mm (Fig.
5).
4. Computed tomographic examination showed mod-
Vol. 116 Ev ALUATION OF CEREBRAL ATROPHY BY COMPUTED TOMOGRAPHY 87 Neuroradiology

Fig. 3. This is an example of a patient classified as Category I or normal by computed tomographic

examination.

Fig. 4. This represents a patient classified as Category II by Fig. 5. This represents a patient classified as Category III, or
computed tomography and shows questionable atrophy. mild atrophy by CT.

erate to severe atrophy. The ventricles were greater mm and the sulci were greater than 9 mm; or the sulci
than 20 mm and the sulci measured between 6 and 9 were greater than 9 mm and the ventricles were great-
mm; or the ventricles measured between 16 and 20 er than 20 mm (Figs. 6 and 7).
88 MICHAEL S. HUCKMAN, JACOB Fox, AND JORDAN TOPEL
Fig. 6. This represents a patient classified as Category IV
by CT and is an example of moderate atrophy.
5. Computed tomographic examination showed en-
larged ventricles without enlarged cortical sulci. In this
group, the ventricular measurement was greater than
20 mm, but there were no large cortical sulci. (Fig. 8).
By applying these criteria, we arrived at the results
seen in TABLE II. Of the group of 20 nondemented pa-
tients, those in Group 2A, 40 % were unequivocally
"normal" by measurement. An additional 45 % showed
questionable evidence of atrophy. Three (15 %) showed
moderate to severe dilatation of the ventricles and corti-
cal sulci. In the demented group, those in Group 1, one
individual (3 %) had unequivocally "normal" measure-
ments, 17 % showed questionable evidence of atrophy,
11 % showed mild atrophy, 60 % showed moderate to
severe atrophy and three patients (9 %) showed evi-
dence of large lateral ventricles without evidence of en-
larged cortical sulci. In the initial subjective classifica-
tion, the findings were quite similar and all but five cases
of demented patients were classified the same as they
were eventually classified by means of our measure-
ments.
Table II: Comparison of Clinical Classification of Patients with Degree of Atrophy as Determined by Computed Tomography
Group I
Clinical Classification Normal
1. Demented patients over the 1 (3%)
age of 60
2. A. No major neuologic 8 (40%)
problem by history
B. Patients with confusion 0(0%)
or dementia by chart
review
C. Patients with other 1 (6%)
neurological troubles
July 1975
DISCUSSION
Since the low numerical absorption value of cerebro-
spinal fluid makes cortical sulci and ventricles readily
visible on the computed tomogram (2, 7), it would seem
to be an ideal method by which to evaluate demented
patients. It visualizes the brain in an almost coronal pro-
jection, and it is therefore difficult to apply previously re-
ported radiographic methods in the current study. For
this reason, we initially chose to evaluate these studies
in a rather subjective manner and, finding this to be rea-
sonably valid, then proceeded to an arbitrary but more
objective method of evaluation. It is obvious that the
evaluation of the accuracy of CT in dementia seems to
be limited by the same factors that limit pneumoence-
phalography and perhaps even pathologic examination
of the brain, l.e., not all demented patients have "atro-
phy" and all patients with "atrophy" are not demented.
Even though it has been assumed for many years
that if cerebral atrophy could be demonstrated, it should
be presumed to account for the presence of dementia,
Gosling (3) states that sometimes no lesions are re-
vealed by air encephalography and dementia will remain
unexplained. He also said that generalized cerebral at-
rophy was occasionally found in patients without the
slightest impairment of mental function but on whom the
pneumoencephalogram was done for other reasons.
Mann (6) not only showed that a radiological opinion of
cortical atrophy at pneumoencephalography cannot
necessarily be equated with dementia but also that a
third of the patients with demonstrable radiological corti-
cal atrophy were free of any evidence of dementia at
five and ten year follow-up.
Tomlinson et. al. (9) examined the brains of 28 pa-
tients over the age of 65 (mean age 75) who were con-
sidered to be nondemented old people. Some of the pa-
tients had been admitted to the hospital in terminal
acute confusional states. Some were intellectually alert
but suffering from depression arising in old age, while
others had cerebrovascular disease and physical disa-
bility from strokes, but were intellectually unimpaired.
Cortical atrophy in these brains was determined by
measuring distance from the dura to the brain at autop-
sy and also by examining multiple coronal sections. A
gap of 1 cm or more between the brain and dura was
considered to represent marked atrophy. TABLE III sum-
marizes the observations made by Tomlinson (9) and
the results of the present study on cortical atrophy in a
Group II Group IV Group V
Questionable Group III Moderate to Enlarged
Atrophy Mild Atrophy Severe Atrophy Ventricles Only
6 (17%) 4 (11%) 21 (60%) 3 (9%)
9 (45%) 0 (0%) 3 (15%) 0 (0%)
4 (33%) 2 (17%) 4 (33%) 2 (17%)
4 (25%) 2 (13%) 9 (56%) 0(0%)
Vol. 116 EVALUATION OF CEREBRAL ATROPHY BY COMPUTED TOMOGRAPHY 89 Neuroradiology

Fig. 7. This patient was classified as Category IV also. This is an example of severe atrophy.

Fig. 8. This is an example of a patient in Category V by CT. The patient has large lateral ventricles
without evidence of large cortical sulci. This patient was subsequently shown to have communicating
hydrocephalus by isotope cisternography.

group of "normal" elderly patients. Forty-six per cent of and none showed evidence of moderate or severe corti-
the group examined pathologically had normal cortical cal atrophy. In the group examined by computed tomog-
sulci, 54% showed evidence of slight cortical atrophy, raphy, 75 % showed normal (5 mm or less) measure-
90 MICHAEL S. HUCKMAN, JACOB Fox, AND JORDAN TOPEL July 1975

Table III: Comparison of Degree of Convolutional Atrophy in a acute dementia and cerebrovascular accidents. Such
Pathologically Examined Group of Brains of Normal Old People
and a Similar Group Examined by Computed Tomography patients were not included in our group of controls. The
average age of the normal patients in the pathologically
Slight Moderate
Normal to Severe examined group was also slightly higher than in our
Sulci Convoltional Convolutional group of nondemented patients.
Atrophy Atrophy
In 1970, Tomlinson et a/. (10) examined the brains of
Present Study 15 (75%) 3 (15%) 2 (10%) 50 demented old people (mean age 74 years). TABLE IV
Study of Tomlinson, 13 (46%) 5 (54%) 0(0%)
et al. (9) summarizes a comparison of these findings to those in
a group of elderly demented patients examined by
computed tomography for cortical atrophy. Forty per
cent of the pathologically examined brains showed no
Table IV: Comparison of Degree of Convolutional Atrophy in a
Pathologically Examined Group of Demented Old People and a cortical atrophy, 44 % showed slight atrophy, and 16 %
Similar Group Examined by Computed Tomography showed moderate to severe convolutional atrophy.
Moderate Thus, by their examination, moderate to severe atrophy
Slight
to Severe was limited to demented individuals. By CT, our group of
Normal Convo-
Convo-
Sulci lutional demented individuals showed that 29 % had normal cor-
lutional
Atrophy
Atrophy tical sulci, 37 % showed slight sulcal enlargment and
Present Study 10 (29%) 13 (37%) 12 (34%) 34 % showed evidence of moderate to severe sulcal
Study of Tomlinson, 20 (40%) 22 (44%) 8 (16%) enlargement.
et. al. (10)
The similarity between the Tomlinson series and our
series is apparent when we compare the percentage of
demented patients with normal sulci to those with slight,
Table V: Comparison of Ventricular Size in a Pathologically moderate, or severe sulcal enlargement. It then be-
Examined Group of Brains of Normal Old People and a comes evident that in our series there is a 71 % indi-
Similar Group Examined by Computed Tomography
cence of slight, moderate, or severe sulcal enlargement
Slightly Moderate and in the Tomlinson series there is a 60% incidence.
to Severe
Normal Increased Increase in Pathologic examination of normal elderly brains for
Ventricles Ventricular Ventricular
Size Size ventricular size (TABLE V) showed that 25 % of the sup-
posedly normal brains had normal-sized ventricles,
Present Study 10 (50%) 8 (40%) 2 (10%) 35 % showed slightly enlarged ventricles, and 40 % had
Study of Tomlinson, 7 (25%) 10 (35%) 11 (40%)
et al. (9) evidence of moderate to severe enlargement (9). Our
series (TABLE V) showed that 50 % of the normal pa-
tients had normal ventricles, 40 % had slight enlarge-
ment, and 10% had moderate to severe enlargement.
Table VI: Comparison of Ventricular Size in a Pathologically
Examined Group of Brains of Demented Old People and a The more liberal inclusion of acute dementia and cere-
Similar Group Examined by Computed Tomography brovascular accidents in the series of Tomlinson et. a/.
Slightly Moderate might explain the higher incidence of moderate to se-
to Severe vere ventricular enlargement and the lower incidence of
Normal Increased Increase in
Ventricles Ventricular Ventricular normal ventricular size in their series of normal patients
Size Size
compared to those examined by CT.
Present Study 1 (3%) 13 (37%) 21 (60%) A very close correlation occurred in comparison of
Study of Tomlinson, 3 (6%) 12 (24%) 35 (70%) ventricular size in the two groups of demented individu-
et. al. (10)
als. The series of Tomlinson (10) showed (TABLE VI) nor-
mal ventricles in 6 %, slight increase in ventricular size
in 24 %, and moderate to severe increase in size in
ment of sulcal size, 15 % showed slight increase of cor- 70 %. Our series (TABLE VI) correlated reasonably well,
tical size 6-9 mm), and 2 (10%) showed moderate to showing a 3% incidence of normal ventricular size, a
severe sulcal enlargement (greater than 9 mm). Ninety 37% incidence of slight increase in size, and a 60%
per cent of our cases were either normal or had slight occurrence of moderate to severe increase in ventricu-
cortical atrophy demonstrated by computed tomogra- lar size as determined by CT.
phy. One hundred per cent of the group of patients in The expected incidence of atrophy in demented pa-
the Tomlinson study showed either normal sulci or a tients as determined by sulcal and ventricular size at
slight increase in sulcal size which seems to show a pneumoencephalography was shown to be 85 % in the
reasonably close correlation between the two methods report of Gosling (3) who examined 68 patients with se-
of determining cortical atrophy. The fact that a higher nile dementia. If we were to summate the demented pa-
percentage of the pathologically examined brains tients in our study (TABLE II) who were in Groups 1\1 and
showed slight cortical atrophy may be because that IV by computed tomography and if we were to add half
group of "normal" patients included individuals with of the patients in Group II (questionable atrophy) this
Vol. 116 EVALUATION OF CEREBRAL ATROPHY BY COMPUTED TOMOGRAPHY 91 Neuroradiology

Fig. 9. The history and computed tomograms are compatible with previous cerebrovascular acci-
dents. Large areas of diminished density in the left hemisphere are seen on the 1A, 1B, 2A, and 28
cuts.

would give an incidence of 80% with atrophy as deter-

mined by CT taking into account both sulcal enlarge-
ment and ventricular enlargment. This again would
suggest a fairly close relationship between the evalua-
tion of dementia by pneumoencephalography and by
CT. The somewhat higher incidence of atrophy as de-
termined by pneumoencephalography might actually be
due to the occasional false-positive ventricular enlarge-
ment due to gaseous distention of the ventricles at
pneumography (5, 8).
It is interesting to note that in our group of demented
patients, three had evidence of enlarged lateral ventri-
cles without evidence of enlarged cortical sulci. One of
these patients (Fig. 8) was later proved by isotope cist-
ernography to have low pressure hydrocephalus. The
other two both had histories and computed tomographic
pictures compatible with previous cerebrovascular acci-
dents (Fig. 9).
Three patients in this series were discovered to have
potentially treatable illnesses. Two of them, one with hy-
pothyroidism (Fig. 10) and one with pernicious anemia
(Fig. 11), had almost complete resolution of the demen-
tia after appropriate therapy was instituted. Both of
these patients were in Group 2 by computed tomogra-
phic examination (questionable atrophy). Another pa-
tient (Fig. 12) with hypothyroidism was in Group 4 by CT
(moderate atrophy) and responded only partially to ther-
Fig. 10. This was a demented patient with hypothyroidism who
apy. This suggests that the absence of major atrophy by was classified as having questionable atrophy. His dementia re-
CT in a demented patient should make the physician sponded well to thyroid replacement therapy.
92 MICHAEL S. HUCKMAN, JACOB Fox, AND JORDAN TOPEL July 1975

Fig. 11. This patient had dementia and pernicious anemia. Appropriate therapy for his anemia re-
sulted in marked improvement in his mental status.

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Fig. 12. This patient had hypothyroidism but by CT was in

Group 4 (moderate atrophy). His dementia responded only par-
tially to thyroid replacement therapy.

particularly suspicious of a potentially treatable illness.

Department of Diagnostic Radiology
Whether patients with moderate or severe atrophy may Presbyterian-St. Luke's Hospital
have reversib'le illnesses is yet to be answered. Chicago, III. 60612