MRI of a Brain Under Pressure
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Images From Headache MRI of a Brain Under Pressure Case submitted by William O’Connor; Stephen D. Silberstein Department of Neurology, Jefferson Headache Center, Thomas Jefferson University Hospital, Philadelphia, PA A 19-year-old female complained of right-sided headache for 1 month and over the 2 weeks preceding initial evaluation experienced diplopia and progres- sive “blurring” of vision in the right eye. Her examina- tion was notable for reduced visual acuity bilaterally, an inferomedial visual field deficit OD, bilateral pa- pilledema, and a left abducens palsy. Lumbar puncture demonstrated an opening pressure >550 mm H 2 O. Brain MRI showed reversal of the optic nerve heads, flattening of the posterior sclerae and a partially empty sella (Figures 1 and 2). Brain MRV was normal. One month following placement of a lum- boperitoneal shunt and initiation of treatment with Fig 1.—Bilateral papilledema. Reversal of the optic nerve heads and flattening of the posterior sclerae are demonstrated on T 1 - weighted, post-gadolinium axial MRI of the orbits. topiramate, her headaches and papilledema had resolved. In one study evaluating the utility of brain MRI in idiopathic intracranial hypertension, characteris- tic findings (in descending order of frequency) in- cluded flattening of the posterior sclerae, empty sella, enhancement of the prelaminar optic nerve, dis- tention of the perioptic subarachnoid space, verti- cal tortuosity of the orbital nerve, and reversal of the optic nerve head. 1 With exception of the en- hancement of the prelaminar optic nerve, all of these abnormalities were observed in only 5% of controls. 68
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Transcript of MRI of a Brain Under Pressure
Images From Headache
MRI of a Brain Under Pressure
Case submitted by William O’Connor; Stephen D. SilbersteinDepartment of Neurology, Jefferson Headache Center, Thomas Jefferson University Hospital,
Philadelphia, PA
A 19-year-old female complained of right-sidedheadache for 1 month and over the 2 weeks precedinginitial evaluation experienced diplopia and progres-sive “blurring” of vision in the right eye. Her examina-tion was notable for reduced visual acuity bilaterally,an inferomedial visual field deficit OD, bilateral pa-pilledema, and a left abducens palsy. Lumbar puncturedemonstrated an opening pressure >550 mm H2O.Brain MRI showed reversal of the optic nerve heads,flattening of the posterior sclerae and a partially emptysella (Figures 1 and 2). Brain MRV was normal.
One month following placement of a lum-boperitoneal shunt and initiation of treatment with
Fig 1.—Bilateral papilledema. Reversal of the optic nerve heads and flattening of the posterior sclerae are demonstrated on T1-weighted, post-gadolinium axial MRI of the orbits.
topiramate, her headaches and papilledema hadresolved.
In one study evaluating the utility of brain MRIin idiopathic intracranial hypertension, characteris-tic findings (in descending order of frequency) in-cluded flattening of the posterior sclerae, empty sella,enhancement of the prelaminar optic nerve, dis-tention of the perioptic subarachnoid space, verti-cal tortuosity of the orbital nerve, and reversal ofthe optic nerve head.1 With exception of the en-hancement of the prelaminar optic nerve, all ofthese abnormalities were observed in only 5% ofcontrols.
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Fig 2.—Empty sella. Partially empty sella is seen on T1-weighted sagittal MRI of the brain.
Especially in patients with intracranial hyperten-sion who lack papilledema, brain imaging may helpin establishing the correct diagnosis. In addition, serialbrain imaging theoretically could assist in assessing re-sponse to therapeutic intervention.
REFERENCE
1. Brodsky MC, Bathiades M. Magnetic resonanceimaging in pseudotumor cerebri. Ophthalmology.1998;105:1686-1693.
