Ventricular Anatomy Across CT and MRI in Hydrocephalus: A Retrospective Study

<b>Background/Objectives</b>: Hydrocephalus is a complex neurological disorder marked by abnormal cerebrospinal fluid dynamics and ventricular enlargement. Despite breakthroughs in neuroimaging, diagnosis and longitudinal the application of imaging markers for the diagnosis and longitudinal monitoring of hydrocephalus remains challenging in routine clinical practice. The present study examines the behavior and cross-modality agreement of commonly used linear ventricular measurements under routine imaging conditions, at a single Romanian tertiary-care center characterized by heterogeneous acquisition protocols and limited availability of advanced volumetric techniques. <b>Methods</b>: We conducted a single-center retrospective observational study of 68 adults with hydrocephalus. Linear ventricular metrics, including Evans index and third-ventricle width, were measured on all available CT and MRI scans. CT–MRI agreement was assessed using paired examinations within a 90-day window. Longitudinal changes were analyzed using first–last and pre–post VP shunt comparisons. Associations between baseline imaging features and VP shunt placement were evaluated using rule-based and odds ratio analyses. <b>Results</b>: CT and MRI measurements demonstrated strong agreement for both Evans index (r = 0.93) and third-ventricle width (r = 0.90), with minimal systematic bias. Longitudinal analyses demonstrated small-magnitude changes in ventricular size following intervention, with substantial inter-individual variability. VP utilization increased across Evans index strata, reaching 100% in patients with values ≥0.50. Transependymal cerebrospinal fluid exudation showed the strongest association with subsequent VP shunting. Imaging-based rules exhibited expected trade-offs between sensitivity and specificity. <b>Conclusions:</b> Standard linear ventricular parameters exhibited adequate cross-modality agreement and clinically important longitudinal behavior in this cohort. While insufficient as standalone predictors, these readily available imaging markers remain important tools when combined with a comprehensive clinical assessment.