Presentation
Three months history of severe headache and persistent watery nasal discharge. The referring doctor has a concern for possible CSF rhinorrhea. On specific questioning, she says the discharge is only from the left nostril. There is no history of trauma or surgery.
Patient Data
There are several features which suggest an underlying benign intracranial hypertension.
- sella is expanded and partially empty.
- prominence of bilateral Meckel's caves with prominence of CSF space surrounding bilateral oculomotor nerves.
- prominent distention of bilateral perioptic CSF space.
- left transverse sinus appears narrower in caliber in comparison to the right side. suggestion of small focal stenotic areas in the lateral part of bilateral transverse sinuses.
- small right encephalocele along the anterior wall of the right middle cranial fossa. A small part of the inferior temporal gyrus is seen projecting into a CSF outpouching in this region. The appearance is suggestive of small encephalocele.
In addition, there is a small medial sphenoid meningocele on the left side, immediately anterior to the Meckel's cave. A tiny fluid cleft between this and adjoining fluid opacified left sphenoid and posterior ethmoid sinuses.
Prominent perioptic CSF space (Red arrow)
Right encephalocele (blue arrows)
Prominent CSF space around left oculomotor nerve (black circle)
Linear CSF signal (yellow arrow) between the left medial sphenoid meningocele laterally and the left sphenoid sinus medially.
Case Discussion
Idiopathic intracranial hypertension is increasingly identified as a predisposing cause for spontaneous CSF leaks. It is suggested that chronically elevated intracranial pressures result in skull bone thinning and formation of meningo-encephaloceles with subsequent CSF leaks, if the pressure continues to be elevated.
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