Intracranial Hypotension : MRI

Case Report: 27 year old female without any previous co-morbidity and not on any medications was diagnosed with hydatidiform mole. Evacuation was done under spinal anesthesia. The next day following the procedure, she developed headache, which was only present on sitting on standing and was relieved on attaining supine position. After 2 days , she developed worsening of the headache which now became continuous and  she also developed right sided focal seizures in upper limb. Initial clinical diagnosis in the background of a hypercoagulable state (hydatiform mole), headache and seizures was cerebral venous thrombosis. However, since she developed a typical positional headache after the procedure under spinal, possibility of CVT secondary to Idiopathic Intracranial Hypotension was also considered and MRI with contrast advised. Case Submitted by Dr Rahul Rajeev, DM (Neurology Std)

MRI Finding: MRI reveals pachymeningeal enhancement on the CEMR sections. Outstanding finding in the images is  venous distension sign and apparent rounding of the cross-section of the dural venous sinuses.  Prominence of inferior intercavernous sinuses also noted. Pituitary appears bulky. Splenium of corpus callosum is drooping down. These findings are consistent with intracranial hypotension probably secondary to lumbar puncture. Also noted are small filling defect (thrombus) in superior sagittal sinus extending towards left possibly explaining the seizures on the right side.   MRI discussion : Dr Sumer Sethi, MD Radiology