Obstructive hydrocephalus - aqueductal stenosis

Case contributed by Dr Mostafa Mahmoud El-Feky

Presentation

Symptoms of increased intracranial pressure as vomiting, headache, and seizures. History of previous attacks of meningitis.

Patient Data

Age: 35 years
Gender: Female

MRI demonstrates marked dilatation of the supratentorial ventricular system noted with associated enlarged 4th ventricle, associated with webs at the distal portion of the aqueduct, causing marked tight distal stenosis and with proximal funnelling. This is associated with decreased mamillopontine distance (3 mm) and periventricular T2/FLAIR hyperintensity reflecting associated transependymal permeation. Webs are also noted at the 4th ventricular outlet foramina, notably the median foramen of Magendie, with consequent supratentorial ventricular dilatation and prominent 4th ventricle

Dynamic CSF flow study and ultra-thin 3D T2 Sagittal sequences revealed: multiple webs at the distal portion of the aqueduct with consequent tight aqueductal stenosis and at 4th ventricle outlet foramen. Very poor/absent CSF flow signal across the aqueduct at cine phase sequences matching the markedly tight focal aqueductal stenosis.

Case Discussion

Multiple webs noted at the distal portion of the aqueduct and 4th ventricle outlet foramina, with a consequent marked tight aqueductal stenosis are suggestive of post-meningitic sequelae. Subsequent active obstructive tetraventricular hydrocephalic changes are noted with transependymal permeation. The absence of a flow-void signal intensity on sagittal T2 images at the aqueductal level is a suggestive sign of aqueductal stenosis. MRI CSF flow study is helpful to determine the level of obstructive hydrocephalus.

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Case information

rID: 43104
Published: 27th Feb 2016
Last edited: 8th Dec 2018
Inclusion in quiz mode: Included
Institution: Dar El Ashaa Center

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