MRI changes in intracranial hypotension

Abstract

We report seven patients with the syndrome of intracranial hypotension who were referred to Memorial Sloan-Kettering, primarily because of suspicion of meningeal tumor or infection raised by the finding of meningeal enhancement on MRI. In three patients, symptoms occurred after lumbar puncture; in four, there was no clear precipitating event. Lumbar puncture after MRI in six patients revealed low CSF pressure (six patients) and pleocytosis or high protein, or both (four patients). Three patients had subdural effusions. Six patients had measurable descent of the brain on midsagittal images. Postural headache resolved in all seven patients, six of whom had follow-up MRIs. Meningeal enhancement resolved or diminished in all six. Subdural effusions resolved spontaneously in two and were evacuated (but were not under pressure) in one. Downward brain displacement improved or resolved in all patients. The clinical syndrome and MRI abnormalities generally resolve on their own. An extensive workup is not helpful and may be misleading. Patients should be treated symptomatically.

Dissociation between the severity of cerebrospinal fluid hypovolemia and MRI findings

“…These symptoms worsen within fifteen minutes after sitting or standing. Meningeal enhancement is frequently observed [2]. We present a case of CSF hypovolemia with dissociation between its severity and the MRI findings.…”

Bilateral sixth cranial nerve palsy after unintentional dural puncture

“…2,3 CNP after dural puncture is attributed to continuous CSF leakage through the dural hole. 4 Magnetic resonance imaging has demonstrated that this results in intracranial hypotension with descent of the brain, even in the supine position, causing traction of the sixth nerve and pain-sensitive structures. 4 The stretching of the nerve is thought to cause local ischemia and nerve dysfunction.…”

“…4 Magnetic resonance imaging has demonstrated that this results in intracranial hypotension with descent of the brain, even in the supine position, causing traction of the sixth nerve and pain-sensitive structures. 4 The stretching of the nerve is thought to cause local ischemia and nerve dysfunction. 5 This can be seen in association with other signs of intracranial hypotension such as vertigo, nausea, and vomiting.…”

Headache in intracranial hypotension

“…Magnetic resonance imaging (MRI) reveals diffuse meningeal thickening, gadolinium enhancement, and subdural fluid collections (hygromas and rarely haematomas), at times associated with diminished size of the subarachnoidal cisterns, with the descent of the cerebellar tonsils or with flattening of the optic chiasm [4][5][6][7][8][9]. In such cases, differential diagnosis with systemic diseases like rheumatoid arthritis, mucopolysaccaridosis, sarcoidosis and meningeal carcinomatosis must be performed [10][11][12].…”