Article abstract
Using pneumoencephalography and computerized axial tomography (EM1
scanning) Polaroid@pictures, the relationship between ventricular size and
cerebral size was investigated in 35 patients. Evans index was used for
pneumoencephalograms, and planimetric measurement of the ventricular
and cerebral cross-sectional areas was used for EM1 scanning. The
percentage ratio for the latter technique is termed VBR. The correlation
coefficient between the two methods was 0.9510 (p < 0.001).
Comparing Evans index and
computerized axial tomography
in assessing relationship of
ventricular size to brain size
V. SYNEK, M.D., J. R. REUBEN, M.B., Ch.B., and G. H. DU BOULAY, M.B., F.R.C.P., F.F.R.
I t has become apparent since the advent of com-
puterized axial tomography (EM1 scanning) that
ventricular pathology is easily and reliably assessed by
this method. This innocuous and repeatable method
weighs heavily against pneumoencephalography,with its
accepted morbidity and possible mortality.
For a proper assessment of ventricular dze in
relationship to the brain and particularly in follow-up
studies in patients with abnormal ventricular systems, a
quantitativemethod is required. This was accomplished in
our preliminary study,2 in which EM1 scans were studied
and the ventricular-brain cross-sectional area percentage
ratio (VBR) related. The findings suggested that the VBR
is approximately 5 in normals, 7 in equivocal cases, and
above 10 in abnormal conditions. However, in order to
confirm the findings, a comparison was undertaken
between Evans index3 and VBR in the same patients.
Material and method. Thirty-five patients who had had
successful pneumoencephalograms and EM1 scans (80
X80 matrix) at this hospital were selected. This series
comprised 21 males and 14 females, with a mean age of
From the Lyshoh RadiologicalDepartment,The National Hospital, Queen
Square, London, WCIN 3BG.
Received for publication May 30, 1975.
Requests for reprints should be addressed to Dr. Synek, Department of
Clinical Neurophysiology,Sahlgren Hospital, GGteborg, Sweden.
39.8 years (age range 1 to 73 years). No patient with
supratentorialtumor or vascular pathology was included.
Patients in this series were divided into normals (15),
those with cerebral atrophy (9), and those with
hydrocephalus (11) according to the results and final
clinical diagnosis. Two cases of hydrocephalus were
caused by aqueduct stenosis and three by posterior
fossa tumor. EM1 scanning always preceded
pneumoencephalography.
Evans index. Pneumoencephalography was carried
out under general anesthesia with the patient initially in
the sitting position in a somersaulting chair. Between 35
and 60 ml of air was fractionally introduced into the
lumbar subarachnoid space. Anteroposterior x-rays of
the head were made in the usual brow-up position. Figure
1 shows the measurements taken from one film. The
Evans index is:
Transverse diameter of anterior horns
Greatest internal transverse diameter of the skull
VBR. The Polaroid pictures of EM1 scans (80 X 80
matrix) were measured using a planimeter (OTT 9541-32,
West Germany). The perimeter of the ventricular system
and brain as seen in cuts 2A and 2B or 3A (figure 2) was
circumscribed, and the cross-sectional surface area was
read off the planimetric counter. Each measurement was
done 10 times, and the mean reading was taken. This
figure was checked by tracing the outline of brain and
visible ventricular system onto millimeter-squared paper
NEUROLOGY 26: 231-233, March 1976 231
Assessing relationship of ventricular size to brain size
Figure 1. Diagram showing measurements taken to
express Evans index. a - a = span of anterior horns of
lateral ventricles. A - A = greatest internal diameter of the
skull.
and calculating the cross-sectional area. Only the areas in
+
the ventricular system with a density of -2 to 10 (EM1
density reference scale) were considered. In a few patients
in whom the ventricular outline was indistinct, reference
was made to the EM1 printout. Figures 3, 4, and 5 are
Polaroid pictures of examples from each of the subgroups
(normal, cerebral atrophy, and hydrocephalus).
The exact localization of the ventricular perimeter
according to the density scale on the Polaroid pictures is
difficult and depends on various technical factors as
discussed by Gawler and associate^.^ In difficult cases,
reference was made to the EM1 printout.
Figure 3. Polaroid picture of cut 2A (figure 2) in a patient
showing a normal cerebral ventricular system. Part of the
lateral ventricles and the third ventricle are clearly seen.
232 NEUROLOGY March 1976
/-------
5-5
Figure 2. Diagram illustratingthe levels of the tomographic
cuts taken with the EM1scanner. Reproducedfrom Gawler
J, du Boulay GH, Bull JWD, et aL4
The VBR is expressed by
ventricular cross-sectional area x 100
brain cross-sectional area
The brain cross-sectional area is uncorrected for the
ventricular cross-sectional area.
Results. Comparing Evans index and VBR, a correlation
coefficient of 0.9510 (p < 0.001) was found. The table
shows the results in detail.
Discussion. Evans stated that for normals, the ratio
between the transverse diameter of the anterior horns of
Figure 4. Cut 3A (figure 2) showing lateral ventricular
dilation in a patient with cerebral atrophy (Polaroid picture).

Figure 5. Hydrocephalus shown in cut 2B (figure 2)
Polaroid picture. The lateral ventricles, third ventricle, and
temporal horns are dilated.
the lateral ventricles and the greatest internal diameter of
the skull ranges between 0.16 and 0.29 (mean value 0.23
SD t 0.04). Early or questionable enlargement is
suggested by values between 0.25 and 0.30, while values
above the latter figure indicate definite ventricular
enlargement.
Table. Results and correlation of Evans index and VBR in 35 patients
In this series, Evans index was 0.26 in normal patients
and 0.45 in those with cerebral atrophy or hydrocephalus,
while the VBR for those subgroups worked out to 4.29,
16.6, and 36.3, respectively. The correlation coefficient
betweenEvans index and VBR was0.9510(p< 0.001).
A VBR value of 10 or greater is significantly different
from normal at the 0.1 percent level. This close
correlation shows that (1) VBR is comparable to Evans
index in assessing ventricular size relative to brain size,
and (2) VBR may be helpful in evaluating changes in size
of the ventricular system in follow-up studies. This has
depended in the past on a subjective interpretation of
successive EM1 pictures in the same patient.
Acknowledgment
We wish to thank Dr. J. Gawler for kindly allowing us to use his material and
for his advice.
REFERENCES
1. HounsfieldGN: Computerizedtransverse axial scanning (tomography):
Part 1. Description of system. Br J Radio1 46:1016-1022, 1973
2. Synek V, Reuben JR: The ventricular-brain ratio using planimetric
measurement of EM1 scans. (In press)
3. Evans WA: An encephalographc ratio for estimating ventricular
enlargement and cerebral atrophy. Arch Neurol 47931-937, 1942
4, Gawler J, du Boulay GH, Bull JWD, et al: Computerized tomography
(the EM1 scanner). A comparison with pneumoencephalography and
ventriculography. (In press)
NEUROLOGY March 1976 233
Comparing Evans' index and computerized axial tomography in assessing relationship of
ventricular size to brain size
V. SYNEK, J. R. REUBEN and G. H. DU BOULAY
Neurology 1976;26;231
DOI 10.1212/WNL.26.3.231

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