Imaging in patient presenting with orthostatic headaches, nausea and vomiting.
Neuroradiology
Case TypeClinical Cases
AuthorsN. Sadeghi, J. Garbuzinski, C. Neugroschl, Ph. David, D. Balériaux
Patient46 years, female
The neurological examination was unremarkable apart from mild cervical stiffness. The patient also had a mild inflammatory syndrome with a white cell count of 11.3x10³/mm³(N:4-10.5x10³/mm³)and CRP of 1.3 mg/dl(N:<0.5mg/dl). Lumbar puncture revealed an initial low pressure of 3 cm H2O. The CSF analysis yielded evidence of blood contamination and a white cell count of 12/mm³(predominantly composed of lymphocytes), 150 mg/dl protein (N:30-60mg/dl), 65 mg/dl glucose(blood glucose of 101mg/dl), 123 mEq/L chlorine(N:118-132mEq/L) and 2.1 mEq/L lactate(N:0-2.4mEq/L). CSF cytology revealed no evidence of malignant cells; smears and cultures for bacteria, fungi or viruses were negative.
CT of the brain showed bilateral hemispheric subdural effusions with diffuse flattening of the cortical sulci over both cerebral hemispheres and a focal area of enhanced meningeal thickening in the right pontocerebellar angle. MR of the brain after contrast injection revealed, in addition, diffuse thickening and enhancement of the dura which was not visible on post-contrast CT.
Since 1991, the frequency of reported cases has increased because of the very sensitive and relatively specific changes found on brain and spinal MRI. The main MRI findings within the brain are diffuse pachymeningeal gadolinium enhancement, subdural fluid collections, descent of cerebellar tonsils, decrease in the size of prepontine and perichiasmatic cisterns, decrease in the size of the ventricles and sulcus, engorgement of the cerebral venous sinuses and enlargement of the pituitary gland. Spine MRI may show extra-arachnoid fluid, meningeal diverticula, meningeal enhancement and engorgement of the epidural venous plexus (1,2,3).
Radioisotope cisternography, CT myelography or MR myelography may be used in order to find the site of the CSF leak in those patient who do not improve spontaneously or after epidural blood patch. Surgical repair of the leak should be considered in these cases (4,5).
[1] 1. Pannullo SC, Reich JB, Krol G, Deck MDF, Posner JB. MRI changes in intracranial hypotension. Neurology 1993;43:919-26. (PMID: 8492946)
[2] 2. Rabin BM, Roychowdhury S, Meyer JR, Cohen BA, Lapat KD, Russell EJ. Spontaneous intracranial hypotension: spinal MR findings. Am J Neuroradiol 1998;19:1034-9. (PMID: 9672007)
[3] 3. Mokri B, Posner JB. Spontaneous intracranial hypotension: The broadening clinical and imaging spectrum of CSF leaks. Neurology 2000;55:1771-2. (PMID: 11134370)
[4] 4. Schievink WI, Meyer FB, Atkinson JLD, Mokri B. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Neurosurg 1996;84:598-605. (PMID: 8613851)
[5] 5. Matsumura A, Anno I, Kimura H, Ishikawa E, Nose T. Diagnosis of spontaneous intracranial hypotension by using magnetic resonance myelography. J Neurusurg 2000;92:873-6. (PMID: 10794305)
URL: | https://www.eurorad.org/case/1305 |
DOI: | 10.1594/EURORAD/CASE.1305 |
ISSN: | 1563-4086 |