Abstract

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Objectives: The aim of the morphometric study was to examine the range in the normal size of the third ventricle in the North Indian population; males and in females living in Punjab and, assess the existence of its relationship with gender and age; and clinically correlate.

Materials and Methods: MRI of 300 subjects living in North India was examined for various morphometric measurements of the third ventricles of human brain. The study involved normal subjects from birth to 30 years. Measurements were plotted against age in years and gender; the variables were then analyzed statistically.

Results: It was observed that the antero-posterior length was 31.33±5.70mm in male, 28.25±2.44mm among female. Its height 23±2.46mm and 22.61±156mm, the width anterior to the interthalamic adhesion 5.38±1.33mm, 5.73±1.61mm, width posterior to the interthalamic adhesion 6.02±1.42mm, 6.08±1.49mm among  both male and female respectively.

Conclusion: Advances in surgical instrumentation and knowledge of the morbidities affecting the third ventricle of the brain have lead to this search to establish the normal size of the third ventricles and assess its gender and age variation.

Introduction

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The third ventricle, “ventricles tertius  cerebri,” is one of four connected, cerebrospinal  fluid-filled cavities of the human brain¹ .It is a median cleft between the two thalami, bordered inferiorly by the hypothalamus, communicates rostrally with lateral ventricle through interventricular foramina and caudally with fourth ventricle via cerebral aqueduct. The third ventricle develops from the central canal of the neural tube. The third ventricle originates from the portion of the tube, which in the future develops as the space of the diencephalon ².

Cotton et al studied third ventricle size in relation to cranial vault size and concluded that with advancing age there is gradual widening of the third ventricle ³. Investigated by Fannon

et al on patients in early episode psychosis found to have structural abnormalities in their third ventricle ⁴. Third ventricle enlargement in antipsychotic-naive patients with schizophrenia suggests abnormalities in the diencephalic region of the brain at the onset of the disease ⁵ .

 Various authors have measured width of the third ventricle, among diseased. Turner et al measured the width of the third ventricle among patients with multiple sclerosis and compared it against his control group using Magnetic Resonance Imaging (MRI), reported the width was much larger than the controls studied ⁶.  Pawar et al reported tumor in posterior third ventricular tumor causes obstructive hydrocephalus, shows dilated ventricles; corrected by ventriculo-peritoneal shunt ⁷. The third ventricle width among preterm’s were measured by Davies et al using cranial ultrasound, used in the diagnosis and assessment of ventricular enlargement in preterm infants and reported to have found no gender variation in his study ⁸. Schimmel et al showed significant enlargement in the length and width of the third ventricle among the infants with Trisomy 21 compared to the control group of unaffected newborns ⁹. Benedict et al compared the width of the third ventricle among patients of multiple sclerosis and normal subjects; the width among the control group was much smaller, as enlargement of the ventricles were observed in multiple sclerosis with associated neuropsychological impairments ¹⁰.

MRI is a medical imaging technique used to visualize details of internal structures. It uses the property of Nuclear magnetic resonance (NMR) to image nuclei of atoms inside the body providing good contrast between the different soft tissues of the body. MRI uses no ionizing radiation, thus safe to be used during the period of pregnancy. The Digital Imaging and Communication in Medicine (DICOME) is the most standardized method used to transfer image data and other medical information from one hospital to another between computers. Neuro-imagers and neuropsychologist use DICOME to compress the images, to transfer without the need to convert to an analytic form ¹¹.

Bargallo et al treated patients with Endoscopic Third Ventriculostomy (ETV), proved to have high success rate to treat hydrocephalus ¹². Singh et al investigated patients with obstructive hydrocephalus, divided into two study groups- above and below 2 years of age, who underwent endoscopic third ventriculostomy, clinical improvement post-surgical had shown a wide variation from the radiological improvement among most cases¹³.

Surgery in the region of the third ventricle poses a considerablechallenge, even for experienced neurosurgeons. Numerouspublications using various modalities, describing surgical approaches attests difficulties encountered when exploring this area ¹⁴. Based on these observations, this study was tailored for better understanding of the anatomy and examines the normal ranges of size of third ventricle and asses their difference with respect to age and gender. Thus use values for reference, to establish its normalcy among the living Indian population  and clinically  correlations for  diagnosis of hydrocephalus among pediatric age group, schizophrenia, psychosis, tumors among adults, dementia, Alzheimer’s among geriatric group and develop modalities of treatment as early as it  is diagnosed.

The aim of this morphometric study was to examine the range in the normal size of the third ventricle among both Indian male and in female population living in Punjab, and to assess its association with gender and age difference.

Methods

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Cross-sectional study, using cranial MRI obtained from Department of Radiology, Christian Medical College and Hospital, Ludhiana. The age and gender were matched among 150 males and females each; 300cases. The study involved normal subjects from birth to 30 years, categorized into groups of 0-2years, 3-5years, 6-9years and 10-14years, 15-19 years and above 20 years. Only normal MRI obtained from the Dept of Radiology were measured in the Anatomy Department. Approval was sought from the Ethics committee of Christian Medical College before the study started. A written standard consent was taken from all subjects willing to be part of the study.

The parameters in this study was measured by marking two points and join the two points; mentioned below by a straight line on the MRI using DICOME method to measure.  Points for antero-posterior length and height were best appreciated on the mid sagittal slice; Z, the anterior point marked on the lamina terminalis, Y, the posterior point on the posterior commissure points used in reference for antero-posterior length. X, the superior point is the highest curvature of the inferior surface of fornix and W is inferior point, marked on the superior surface of the mamillary body to measure the superior-inferior height. The axial slice was used to measure width anterior to interthalamic adhesion and width posterior to interthalamic adhesion. UR is a point on the right lateral wall of the third ventricle and UL is an identical point on the left lateral wall on thalamus points the width anterior. VR is point on the right lateral wall of the third ventricle and VL, the identical point on the left lateral wall on thalamus to measure width posterior to interthalamic adhesion.

Data collected were recorded on the performer, organized and entered on Excel spread sheet to be analyzed using SPSS 14 version. ANOVA was performed to define the correlation of parameters used in this study. p less than or equal to 0.05 was considered statistically significant.

Results

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Antero-posterior length of the third ventricle:

Table 1: Antero-posterior Length of Third Ventricle in Male and Female from 0->20 years

Age	Male					Female					p-value	t-value
	N	Mean	SD	SEM	CV	N	Mean	SD	SEM	CV
0.2.999	25	25.43	2.90	0.58	11.40	25	25.00	2.09	0.42	8.36	0.55	0.60
3-5.999	25	22.74	2.15	0.43	9.45	25	2.61	1.56	0.31	6.90	0.81	0.25
6-9.999	25	31.33	5.70	1.14	18.19	25	26.20	3.77	0.75	14.39	0.00	3.75
10-14.999	25	29.76	2.65	0.53	8.90	25	28.25	2.44	0.49	8.64	0.04	2.09
15-19.999	25	28.73	3.19	0.64	11.10	25	26.85	1.62	0.32	6.03	0.01	2.63
>20	25	26.92	2.22	0.44	8.25	25	25.34	1.94	0.39	7.66	0.01	2.67

The antero-posterior length of the third ventricle is greater in male was 31.33±5.70mm in male , 28.25± 2.44mm among female, maximum 20% seen in 6 to 9 years; with significant gender variation for 6 years through 20 years and above. A statistically significant of the variable was seen, where p is less than or equal to 0.05

 

Height of the third ventricle:

 

Table 2: Height of Third Ventricle in Male and Female from 0- >20 years

 

Age	Male					Female					p-value	t-value
	N	Mean	SD	SEM	CV	N	Mean	SD	SEM	CV
0.2.999	25	25.43	2.77	0.55	13.09	25	21.32	2.99	0.60	14.02	0.84	0.19
3-5.999	25	22.74	2.15	0.43	9.45	25	22.61	1.56	0.31	6.90	0.81	0.25
6-9.999	25	22.31	2.21	0.44	9.91	25	21.80	1.58	0.32	7.25	0.35	0.95
10-14.999	25	21.47	1.81	0.36	8.43	25	21.22	2.65	0.53	12.49	0.70	0.39
15-19.999	25	23.00	2.46	0.49	10.70	25	21.83	2.06	0.41	9.44	0.07	1.83
>20	25	21.57	1.95	0.39	9.04	25	20.48	1.55	0.31	7.57	0.03	2.18

 The height is seen to be maximum in male 25^±2.77 mm and 22.61^±156mm in female, 18% for 3-5 years and gender significant above 20 years. A significant of the variable was seen. Significant of the variable is seen, where p is less than or equal to 0.005.

 

 

 

Width, anterior to interthalamic adhesion of the third ventricle:

 Table 3: Width Anterior to Interthalamic Adhesion of Third Ventricle in Male and Female from 0- >20 years

 

Age	Male					Female					p-value	t-value
	N	Mean	SD	SEM	CV	N	Mean	SD	SEM	CV
0.2.999	25	4.00	0.57	1.11	14.25	25	3.77	0.54	0.11	14.32	0.15	1.45
3-5.999	25	3.90	0.74	0.15	18.97	25	3.82	0.49	0.10	12.83	0.67	0.43
6-9.999	25	4.37	0.80	0.16	18.31	25	4.07	0.81	0.16	19.90	0.20	1.31
10-14.999	25	5.30	1.67	0.33	31.51	25	5.73	1.61	0.32	28.10	0..36	0.93
15-19.999	25	4.83	0.88	0.18	18.22	25	4.72	1.05	0.21	22.25	0.68	0.42
>20	25	5.38	1.33	0.27	24.72	25	4.89	1.40	0.28	28.63	0.21	1.26

 

The width anterior 5.38±1.33mm in male, 5.73±1.61mm  in female, 20%for 10-14 years. No significant is appreciated.

 

 

Width, posterior to the interthalamic adhesion of the third ventricle:

Table 4: Width Posterior to Interthalamic Adhesion of Third   Ventricle in Male and Female from 0- >20 years

 

Age	Male					Female					p-value	t-value
	N	Mean	SD	SEM	CV	N	Mean	SD	SEM	CV
0.2.999	25	4.52	0.58	0.12	12.83	25	4.17	0.56	0.11	13.43	0.04	2.16
3-5.999	25	4.27	0.75	0.15	17.56	25	4.15	0.52	0.10	12.53	0.50	0.68
6-9.999	25	4.95	0.66	0.13	13.33	25	4.50	0.71	0.14	15.78	0.03	2.31
10-14.999	25	5.86	1.62	0.32	27.65	25	6.08	1.49	0.30	24.51	0.63	0.49
15-19.999	25	5.35	0.90	0.18	16.82	25	5.09	1.09	0.22	21.41	0.36	0.92
>20	25	6.02	1.42	0.28	23.59	25	5.55	1.27	0.25	22.88	0.22	1.25

 

 

The width posterior 6.02±1.42mm in male  , in female 6.08±1.49mm , 19% for both 10-14 years and above 20. Statistically significant of the variable is seen.

Discussion

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Schimmels et al studied the length of the third ventricle in among infants with Trisomy and healthy control using ultrasound ⁹. They measured the length of the control as 0.63±0.3cms and width as 0.19±0.06cms; in the present study only infants with normal MRI had their readings recorded, the length accounts to 15%; 2.5±2.90cms among males and 2.5 ±2.09cms among female infants; and the width both anterior 14%, 0.4±0.57cms and 0.37 ±0.54cms in male and female respectively; and posterior 15%, 0.45±0.58cms in male and 0.41± 0.56cms. Butox et al worked with MRI to find the height of third ventricle as 68% in patients with hydrocephalus ¹⁵. In the present MRI study all normal cases has their height recorded, the maximum was 18% among 3-6 years of age and 16% among infants.

Benedict et al compared the width of the third ventricle using MRI among patients with multiple sclerosis and normal subjects, the width among the control group was 2.25±0.82mm ¹⁰;the value, 5.38±1.33mm, 5.73±1.16mm for anterior width and 6.02±1.42mm, 6.08±1.49mm  for posterior width were recorded among the North Indian males and females respectively. Schmike et al measure the diameter of the third ventricle with a mean value of 4mm in patients with Multiple Sclerosis ¹⁶. Present study considered only normal MRI findings, mean width can be correlated to be closer to Schmike et al study. Turner et al estimated healthy control for the width of the third ventricle, concluded 5.14±1.98mm using MRI ⁶. This compared to the present study falls well in the range of width anterior to interthalamic adhesion 5.38±1.33mm in adult male and 5.73±1.61mm in adult females. 

Limited study is done on gender variation. The age changes in the present study showed wide variation with no systematic increase. More cases should be similarly analyzed in the future.

Annelies et al measure the width of third ventricle among 321 patients of post aneurysmal subarachnoid hemorrhage as 8mm by MRI ¹⁷. The present study only considered normal MRI for the study and the values are much smaller in the normal living population of Punjab. Medora et al concluded in their CT based study that width of the third ventricle among female is 0.39± 0.17cms; smaller than the one recorded among male 0.45±0.29cms ¹⁸. This study was conducted on MRI, but the value is significantly smaller for the population studied.

Limited literature is given for the third ventricle regards its measure; hence true comparison was very difficult. Many studies were conducted for surgical instrumentation as Endoscopic Third ventriculostomy (ETV); but information is scares about the measures before or after the procedure. Thus the present study has concluded the morphometeric measurements for the living population of Punjab, recorded in this study from birth to 30 years of age of the third ventricle has its true clinical implication.

Conclusion

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The morphometric parameters of the third ventricle studied by MRI in living 150 male and female each of Punjab, North India showed,  antero-posterior length is statistically significant  from 6-30 years; height, significant for 20 years and above this  measures are greater in male. Width anterior to the interthalamic adhesion has no statistical significant; and posterior is significant among 0-2 years and 6-9 years showing minor variation in female. To conclude the measurements from birth to 30 years of age the third ventricle has clinical implication.

Reference

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Source(s) of Funding

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None

Competing Interests

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None

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