Benign intracranial hypertension

Case contributed by Assoc Prof Frank Gaillard

Presentation

Months of daily headaches, worse with stooping and transient visual symptoms.

Patient Data

Age: 35 years
Gender: Female

CT brain

CT

No intra or extra axial bleed, collection or space occupying lesion. The ventricles and cisterns are normal. No midline shift or hydrocephalus. The pituitary fossa is enlarged and filled with CSF. 

MRI brain

MRI

Normal enhancement and flow within the dural venous sinuses, without evidence of thrombosis. Hypoplasia of the proximal left transverse sinus is noted, with 2 prominent arachnoid granulations within the mid portion.

A largely empty sella, increased tortuosity of the optic nerves, with prominence of their CSF envelopes, and flattening of the posterior globe contour at the level of the optic discs.

No intra or extra axial mass lesion or parenchymal signal abnormality. No areas of diffusion restriction. No abnormal contrast enhancement identified.

Annotated images

Annotated image

Empty enlarged sella is best seen on sagittal images (red arrow). On axial T2 images, the optic nerve sheaths are dilated and the region of the optic disc flattened and even slightly bulging into the globe (pink arrows), the MRI equivalent of fundoscopic features of papilledema. 

The right transverse sinus is stenotic / compressed distally (blue arrow) whereas the left is absent / hypoplastic (green arrows). The latter can be predicted based on the skull grooves, which is small on the left (yellow arrow) where as the right is sizable and normal (orange arrow).  

Case Discussion

This case demonstrates typical appearances of benign intracranial hypertension, one of the more common causes of an empty sella. 

This patient went on to have CSF pressures measured via a lumbar puncture which demonstrated elevated pressures (30cm H20). 

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