Presentation
Few weeks of worsening headaches, provoked by moving, and diplopia. Ventricular enlargement on initial CT head at local hospital.
Patient Data
The lateral ventricles are both enlarged, with thin margin of transependymal high signal suggesting CSF shift.
The third ventricle is also enlarged. The anterior supraoptic and infundibular recesses are rounded, with depression of the third ventricle floor. The tip of the basilar artery is immediately inferior to the floor, with very little space between this and the clivus (limiting access for ETV).
The cerebral aqueduct has a funneled appearance, with a distal web before the normal sized fourth ventricle.
Flow studies demonstrate maintained CSF flux through the foramen magnum and in the prepontine cistern, but no appreciable flow through the aqueduct stenosis.
Case Discussion
Aqueduct stenosis is a rare congenital finding, or can occur as an acquired lesion following infection, hemorrhage or in idiopathic late onset settings.
The use of high resolution T2 weighted sequences are essential to identify and characterize any ventricular lesions (this case shows the improvement over standard FLAIR and T1w volumes). The distal aqueduct web is best seen on the DRIVE. CSF flow studies can also be used to assess any patency, or response to intervention.
In this case, no specific cause was identified from the history. Due to the lack of space beyond the flattened floor of the third ventricle, endoscopic third ventriculostomy was not considered, with CSF diversion instead performed via lateral ventriculoperitoneal shunting.
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