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Age: 61

Sex: Female

Indication: Headache

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Case #18


Findings

  • Marked diffuse smooth dural thickening and enhancement with corresponding FLAIR signal hyperintensity, extending into the bilateral internal auditory canals
  • Upward convex appearance of the pituitary gland
  • Drooping of the optic chiasm, which is draped across the superior margin of the pituitary gland
  • Dilated appearance of both transverse sinuses with suggestion of convex inferior borders
  • Mamillopontine distance measures 4 mm
  • Pontomesencephalic angle measures 32 degrees
  • Interpeduncular angle measures 35 degrees
  • Inferior descent of both cerebellar tonsils into the foramen magnum


Diagnosis

  • Intracranial hypotension

Sample Report

Constellation of findings, including diffuse dural thickening and enhancement, upward convex appearance of the pituitary gland, “midbrain sag”, and low-lying cerebellar tonsils, is highly suggestive of intracranial hypotension. Recommend correlation with CSF pressure measurement and consideration of further imaging to assess for possible CSF leak.

Otherwise, no evidence of acute intracranial abnormality.


Discussion

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Images

Classic findings of intracranial hypotension including upward convex appearance of the pituitary gland (red arrow), low-lying optic chiasm (yellow arrow), and inferior descent of the cerebellar tonsils (blue arrow). Normal comparison on the right. Decreased mamillopontine distance in this patient with intracranial hypotension on the left; normal control on the right. Decreased pontomesencephalic angle in this patient with intracranial hypotension on the left; normal control on the right. Decreased interpeduncular angle in this patient with intracranial hypotension on the left; normal control on the right.



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