Dural Enhancement Research Articles

Immunohistochemical profile of the dural tail in intracranial meningiomas.

The dural tail sign was first described as a thin, tapering rim of dural enhancement, in continuity with meningiomas on enhanced T1-weighted magnetic resonance (MR) images. However, the exact nature of the dural tail is still unclear. This study investigated the immunohistochemical (IHC) characteristics of the dural tail in intracranial meningiomas and the correlation between clinicopathological profiles and tumor invasion of the dural tail. The study group consisted of 36 patients of meningioma with the dural tail noted on MR imaging and in pathological findings, and 18 patients of meningioma without the dural tail as the control group. IHC staining of tumor masses and dural tails for vascular endothelial growth factor (VEGF), epithelial membrane antigen, CD34, Ki-67, and vimentin were performed. The data showed that 61.1 % (22/36) of cases in the study group revealed tumor invasion of dural tail, and 55.6 % (30/54) of all the cases demonstrated dura mater invasion in all the samples. The dura mater invasion was significantly positively related to invasion of the dural tail in the study group (p = 0.009). IHC staining detected higher expression of VEGF and CD34 in the dural tail than in the main tumor mass. Considering the high proportion of patients with tumor invasion into the dural tail, we tried to perform wide resection of the dural tail during intracranial meningioma surgery. Furthermore, VEGF was strongly expressed in tumor cells that invaded into the dural tail, and hence VEGF can be used as a marker to differentiate tumor cells from normal meningeal cells in the dural tail.

Localization of Cerebrospinal Fluid Leak in a Case of Spontaneous Intracranial Hypotension Using Dynamic Computed Tomography Myelography

EPIDURAL blood patch is the mainstay of treatment for persistent symptoms secondary to spontaneous intracranial hypotension.1 Determining the level of cerebrospinal fluid leak is thought to be an important consideration for optimal siting of the epidural blood patch injection.2 However, it is often difficult to determine the level of cerebrospinal fluid leak in spontaneous intracranial hypotension. “Dynamic” (as opposed to conventional) computed tomography myelography has recently emerged as a preferred diagnostic test for high-flow (“fast”) cerebrospinal fluid leaks, suspected by extra-arachnoid fluid on spinal magnetic resonance imaging.3 With dynamic computed tomography myelography, myelographic contrast is injected with the patient in the computed tomography scanner (tilted Trendelenburg using a wedge), followed by immediate and multiple computed tomography acquisitions.A 33-yr-old male patient presented to the emergency department with severe occipital headache. Computed tomography of the head demonstrated a chronic subdural hematoma. Head contrast magnetic resonance imaging showed diffuse dural gadolinium enhancement and a “sagging” brain. Spine magnetic resonance imaging revealed circumferential extradural fluid (“scattered” in cervical and “diffuse” in thoracic and lumbar regions). Surgical drainage of the subdural hematoma was performed. On postoperative day 1, headache symptoms were improved with no residual hematoma on repeated computed tomography of the head.However, persistent postural headaches prompted consultation of the acute pain service for evaluation and management of spontaneous intracranial hypotension. Despite lumbar epidural blood patch followed by 2 days of bed rest, headache symptoms returned on upright positioning. Dynamic computed tomography myelography performed on postoperative day 6 showed a high-flow cerebrospinal fluid leak between T4 and T5 (arrow in fig.), secondary to a midline spiculated osteophyte (arrow). Using fluoroscopic guidance, an epidural blood patch was performed between T3 and T4 (14 ml). Headache symptoms resolved and had not recurred at 12-month follow-up.The author declares no competing interests.

Spinal cerebrospinal fluid leaks detected by radionuclide cisternography and magnetic resonance imaging in patients suspected of intracranial hypotension

PurposeAlthough many studies have described various features of neuroimaging tests associated with intracranial hypotension, few have examined their validity and reliability. We evaluated the association between CSF leaks detected by radionuclide cisternography and abnormal MRI findings in the accurate diagnosis of intracranial hypotension. Patients/methodsWe retrospectively assessed 250 patients who were suspected of intracranial hypotension and underwent subsequent radionuclide cisternography. We obtained 159 sagittal and 153 coronal T2-weighted MRI images and 101 gadolinium-enhanced T1-weighted MRI images. We assessed the CSF leaks in relation to a sagging brain, the maximum subdural space in sagittal and coronal images, and dural enhancement. ResultsOverall, 186 (74%) patients showed CSF leaks on radionuclide cisternography. A sagging brain was observed in 21 (13%) of the 159 patients with sagittal MRIs. A sagging brain was not associated with CSF leaks (14% vs. 10%; p=0.49). Compared to patients without CSF leaks, those with CSF leaks tended to have a larger maximum subdural space in both the sagittal (3.7 vs. 4.1mm) and coronal (2.5 vs. 2.8mm) images; however, the differences were not significant (p=0.18 and p=0.53, respectively). Dural enhancement was observed only in one patient, who presented with CSF leaks on radionuclide cisternography. ConclusionsOur study, which included a relatively large population, did not find any association between the findings of radionuclide cisternography and MRI. Future research should focus on identifying more valid neuroimaging findings to diagnose intracranial hypotension accurately.

Diagnostic value of MRI for spontaneous intracranial hypotension syndrome

Objective To analyze the magnetic resonance imaging （ MRI ） appearances of spontaneous intracranial hypotension syndrome （ SIHS） ,in order to improve the understanding of this disease .Methods The clini-cal data of 7 patients with SIHS confirmed by lumbar puncture were retrospectively analyzed .MRI was performed in all cases,in which there were 6 cases with contrast-enhanced MRI.Results All of them showed diffusely thickening of dural.6 cases with brain contrast-enhanced MRI demonstrated linear ,non-nodular and diffusely dural enhancement . The dilation of sinus and great vein were observed in 5 cases,subdural hydroma in 2 cases,brain sagging in 3 cases, pituitary gland plumpness in 2 cases,subdural hematoma in 1 case and 1 case with linear spinal dural enhancement . Conclusion The MRI manifestations of SIHS are characteristic ,and it will be helpful for the diagnosis by combining clinical data. Key words: Intracranial hypotension; Syndrome; Magnetic resonance imaging; Diagnosis

Alternative treatment of intracranial hypotension presenting as postdural puncture headaches using epidural fibrin glue patches: two case reports

Introduction: Intracranial hypotension is a neurologic syndrome characterized by orthostatic headaches and, radiographically, by dural thickening and enhancement as well as subdural collections. Several of etiologies exist, including surgical dural violations, lumbar puncture, or spontaneous cerebrospinal fluid leak. Current management includes conservative management consisting of bed rest, caffeine, and hydration. When conservative management fails, open surgical or percutaneous options are considered. Currently, the gold standard in percutaneous management of intracranial hypotension involves the epidural injection of autologous blood. Recently, some therapies for intracranial hypotension have employed the use of epidural fibrin glue. Case Presentation: Two cases of patients with persistent postdural puncture headaches are presented. Epidural fibrin glue injection alleviated the orthostatic headaches of two patients with intracranial hypotension. Conclusion: Although consideration must be afforded for the potential risks of viral transmission and aseptic meningitis, the utilization of epidural fibrin glue injection as an alternative or adjunct to the epidural blood patch in the treatment of intracranial hypotension should be further investigated.

Measuring CSF flow dynamics in spontaneous intracranial hypotension with phase-contrast magnetic resonance imaging: Potential implications for diagnosis and treatment

Certain magnetic resonance (MR) techniques are flow sensitive, and phase-contrast magnetic resonance imaging (PC-MR) has been utilized both qualitatively and quantitatively to evaluate cerebrospinal fluid (CSF) flow in a variety of clinical conditions (1). Although spontaneous intracranial hypotension (SIH) is, by definition, a disorder of CSF homeostasis typically resulting from a spinal CSF leak, PC-MR has been studied very little in this setting. An initial case report in 2004 first documented decreased systolic and diastolic CSF flow volume at the level of the cerebral aqueduct using PC-MR in a patient with SIH (2). Although confined to a single patient, the findings were compelling because normalization was documented following resolution of SIH. A number of years elapsed before a more systematic study of PC-MR in SIH was completed when Hasiloglu et al. showed a change in CSF flow dynamics in 25 SIH patients compared with controls and further related the PC-MR findings to clinical findings and opening pressure (3). The manuscript entitled Usefulness of PhaseContrast Magnetic Resonance Imaging for Diagnosis and Treatment Evaluation in Patients with SIH by Tung et al. is a welcome addition to the existing body of literature (4). The discriminating power of some of the measured CSF flow parameters at the level of the cerebral aqueduct rivals that of the more widely accepted anatomic imaging features of SIH. Moreover, there may be potential for PC-MR to identify SIH patients who lack characteristic MR findings such as dural enhancement. The change in CSF flow witnessed with treatment suggests that PC-MR may also be beneficial for monitoring patient progress during treatment for SIH. The authors point out that results with PC-MR are known to vary in subjects in relation to age, sex, body mass index, cardiac function, and technical parameters (i.e. velocity encoding gradient, anatomic site, MR scanner, etc.). As a result, the impact of these variables will need to be more fully defined in SIH patients, as has been conducted for healthy subjects. Appropriately, the authors also recognize multiple potential technical limitations in their study. However, moving forward, a number of considerations unique to the use of PC-MR in SIH patients will need to be considered. Although correlation of CSF flow dynamics with patient symptoms and validated imaging findings in SIH is useful, a quantifiable relationship with opening pressure would be preferred. No lumbar punctures were performed in the current study to allow for correlation of opening pressure with CSF flow dynamics as measured by PC-MR (4). When patient presentation and imaging findings strongly suggest headache due to SIH, it is increasingly common in clinical practice to forego lumbar puncture for opening pressure measurement. Indeed, this approach is also endorsed in the International Classification of Headache Disorders, 3rd edition (beta version), which states that dural puncture to directly measure CSF pressure is not necessary in patients with positive MR findings (5). However, it would be ideal for future research studies using PC-MR in SIH to report opening pressures as much as possible. Applying PC-MR to SIH is a relatively new application of existing technology. Hasiloglu et al. demonstrated a significant positive correlation between opening pressure and multiple CSF flow parameters (CSF flow

Convexity meningiomas enhanced by sodium fluorescein

Background:The resection of the meningiomas surrounding the dura is an important goal during the removal of a convexity meningioma. The authors present the first application of sodium fluorescein (SF) as a tool for tumor and dural tail identification in convexity meningiomas.Methods:Five frontal convexity meningiomas operated on between December 2012 and April 2013 were included. After initial dissection a dose of 1 g of the SF, 20% was injected into a peripheral vein. Tumor and dural tail were removed using the correlation between magnetic resonance imaging (MRI) findings and transoperative SF enhancement.Results:Simpson Grade 1 removal was obtained in three cases, grade 2 in one atypical meningioma and grade zero in one case. SF dural tail enhancement was positive in all cases and histologic analysis evidenced involvement of the dura by tumors.Conclusion:SF enhancement was evident in meningiomas and dura surrounding the lesions. Histologic analysis confirmed dural involvement. SF could represent an universally available fluorescent tool for meningioma surgery.

Spontaneous Intracranial Hypotension with Magnetic Resonance Localisation of Spinal Cerebrospinal Fluid Leak

To increase the awareness of spontaneous intracranial hypotension (SIH), we report in this paper a middle-aged woman who presented with an intractable headache that worsened in sitting and standing positions (a postural headache). Magnetic resonance imaging (MRI) of the spine demonstrated a cerebrospinal fluid (CSF) leak at the level of the cervical spine, in addition to typical features in a brain MRI, including symmetrical subdural collections, circumferential dural enhancement and features of midbrain sagging. The patient underwent a surgical repair of the cervical CSF leak which resulted in a dramatic symptomatic improvement that was confirmed by follow-up imaging.

Detection of Cerebrospinal Fluid Leaks by Intrathecal Contrast-Enhanced Magnetic Resonance Myelography

A 70-year-old woman had double vision, nausea, neck pain, and acute bilateral hypacusis. The neurological examination showed nerve VI palsy on the right. There was no history of trauma. Brain magnetic resonance (MR) imaging was indicative of intracranial hypotension, with diffuse pachymeningeal thickening, strong dural enhancement, and frontoparietal subdural hygromas. A radioisotope cisternography, performed in the search for a potential spinal cerebrospinal fluid (CSF) leak, was inconclusive. Thus, intrathecal gadolinium-enhanced MR myelography was considered as a possible alternative. Before intrathecal gadolinium administration, an MR image of the spinal cord showed a small perineural cyst at the level of L2 on the right but no evidence of a CSF leakage. The intrathecal gadolinium-enhanced MR myelography provided clear-cut evidence of dural leaks along the right L2 and L3 nerve roots (Figure). According to these findings, targeted epidural blood patching was performed and the patient’s symptoms gradually improved during the following month. At 1-year follow-up, she was asymptomatic.

A Case of Bellʼs Palsy Heralding Leptomeningeal Carcinomatosis from Metastatic Gastric Adenocarcinoma

Purpose: Leptomeningeal carcinomatosis is a rare complication of solid tumors. We present an unusual case of a patient who presented with Bell's palsy and ocular symptoms as a result of meningeal carcinomatosis from metastatic gastric adenocarcinoma. A 27-year-old Hispanic woman presented to her primary care physician with headaches, left facial paresis, and was diagnosed with Bell's palsy. She was started on oral steroids and subsequently presented to our hospital 1 week later with intensifying headaches and blurry vision. She had no other significant comorbidities. Upon further review, she had an upper endoscopy 1 year ago in her home country for dyspepsia revealing a 1cm gastric ulcer on lesser curve, biopsy showing atypical cells and no follow-up. She had a strong family history of gastric cancer. Her physical exam findings were remarkable for left facial droop, decreased visual acuity, decreased left sided facial sensation and a palpable, 3-cm pelvic mass. Laboratory information revealed mild anemia and cholestatic liver function tests. An MRI of the brain revealed optic nerve enhancement and a few areas of dural enhancement. She underwent a lumbar puncture, CT of the chest and SPECT gallium scan revealing mediastinal, abdominal lymphadenopathy and a large pelvic mass. She was suspected to have sarcoidosis with neurologic involvement and bilateral uveitis. One week after discharge, she became icteric and had increasing abdominal pain; laboratory data showed AST 178, ALT 287, alkaline phosphatase 265, total bilirubin 1.5, and lipase of 3778. Magnetic retrograde cholangiopancreatography revealed obliteration of the pancreatic duct in the head and neck of the pancreas, extrinsic obstruction of the common bile duct from periportal lymph nodes, dilated intrahepatic bile ducts, multiple liver lesions, diffuse abdominal mediastinal lymphadenopathy and a large pelvic mass. Endoscopic retrograde cholangiopancreatography revealed a large friable mass extending from the gastro-esophageal junction to mid-body, along the lesser curvature of the stomach. The antrum and duodenum were free of tumor. A biliary plastic stent was placed and gastric biopsies revealed infiltrating high-grade adenocarcinoma, negative for Helicobacter pylori. The patient subsequently underwent pelvic mass biopsy and staging scans, which showed involvement of lungs, liver, pancreas, bone and meninges consistent with metastatic gastric adenocarcinoma. This case highlights leptomeningeal carcinomatosis presenting as Bell's palsy from a rapidly progressing gastric adenocarcinoma. Systemic symptoms in such cases should raise concern among clinicians for either direct organ involvement or paraneoplastic syndromes.

Tolosa-Hunt syndrome—a rare cause of headache and ophthalmoplegia

A 54-year-old African American woman came to our hospital with a 1-week history of severe right-sided retro-orbital pain and blurry vision. 2 days after onset of unilateral throbbing eye pain she developed intermittent blurry vision, which was worse with rightward gaze. She had no facial droop or language impairment, and no previous episodes of headache or visual changes. She had no history of orbital trauma. Her only previous medical diagnoses were schizophrenia and depression. She was taking aripiprazole and escitalopram daily.

Idiopathic Pachymeningitis Presenting with Progressive Sensorineural Hearing Loss, Tinnitus and Confusion

The patient was a 74-year-old female who presented with progressive left hearing loss, nonpulsatile tinnitus, and confusion. She denied headache, visual symptoms, and vertigo. She had a normal neurotologic examination. Pure tone audiometry showed left low frequency sensorineural hearing loss (SNHL) and a bilateral symmetric high frequency SNHL, with word recognition of 100% right, 46% left (Fig. 1). Serologic studies revealed a nonspecific monoclonal gammopathy. Other serologic tests were negative, including CBC, ANA, Lyme titer, syphilis, angiotensin converting enzyme, anti-double stranded DNA and ANCA antibodies. Cerebrospinal fluid testing revealed normal cytology with a mild increase in protein. Computed tomography of the abdomen and chest was normal, as was bone marrow biopsy. Magnetic resonance imaging (MRI) demonstrated diffuse smooth dural thickening and enhancement consistent with idiopathic hypertrophic pachymeningitis (IHP) (Fig. 2). Figure 1 Pure tone audiograms from 2009 through 2012, demonstrating progressive hearing loss in the left (A) and right (B) ears. At baseline (solid black line), the patient had a left 30 dB SRT and 100% WR, and a right SRT of 20 dB and WR 100%. After onset of ... Figure 2 Axial T1-weighted contrast-enhanced MRI of brain from prior to treatment (A) demonstrating initial enhancement of dura of the internal auditory canals left > right (arrowheads) prior to treatment. Following pulse steroid treatment (B), a significant ... The patient was initially treated with oral prednisone with minimal improvement. She then received IV methylprednisolone infusions every two weeks for two months with improvement in left hearing, tinnitus, mental status, and dural enhancement on MRI. Six months following initial presentation, she showed no further progression of her symptoms while off steroid therapy.

Nasal Obstruction and Anosmia

A56-year-oldwomanpresentedwitha several-yearhistoryofnasal obstructive symptoms and anosmia. Despite previous courses of fluticasonepropionate,sheexperiencedno improvement.Shehad noassociatedpain, rhinorrhea,headaches, changes invision,or epistaxis, and her medical history was negative for either allergic rhinitis or chronic rhinosinusitis. Findings from the physical examinationwerenotable forbilateral, obstructingnasalmassesarising from the superior nasal cavity (Figure, A). She was placed on a 14-day course of oral prednisone, 60 mg perday,witha5-day taper, inaddition to fluticasonenasal spray.The patient reported some initial improvement of her symptomswhile taking prednisone, albeit without complete resolution, with return of her symptoms after cessation of systemic steroids. A computed tomographic (CT) scan was obtained and demonstrated polypoid masses within the olfactory clefts bilaterally with marked demineralization of the cribriform plates (Figure, B). Magnetic resonance imaging (MRI) demonstrated soft-tissue changes at the crista galli extending to the margin of the cribriform plate without dural enhancement or intracranial involvement. The patient was subsequently taken to the operating room for abiopsyandbilateral subtotal resectionof themasses.Hematoxylineosin stain of the specimen at low (Figure, C) and high (Figure, D) magnifications revealedproliferationofglandular structureswithciliatedepitheliumandabundant goblet cells. Glandswere in continuity with the surface epithelium, invaginating into the submucosa without evidence of epithelial dysplasia or atypia. Without further treatment, the patient reported complete resolution of her symptoms 1 year postoperatively. What is your diagnosis? A B

Thirty-Two-Year-Old Man With Osteolytic Skull Lesion

Figure 1: A 32-year-old man presented with a right frontal throbbing headache for 8 weeks and swelling of the right side of his scalp. The patient is sexually active with multiple male partners. His scalp examination revealed a tender area of swelling, 2 to 3 cm over the right side of the head. Serum RPR was reactive 1:64. Lumber puncture revealed pleocytosis with white blood cells of 33. The patient was started on penicillin IV for neurosyphilis.Within 24 hours, patient developed a Jarisch-Herxheimer reaction, and his scalp swelling increased in size. A and B, Skull x-ray and CT scan revealed osteolytic lesion of the calvarium (arrows). C, Magnetic resonance imaging with gadolinium revealed dural enhancement overlying the right convexity with focal areas of abnormal enhancement involving the calvariumextending into soft tissues (arrow). After 2 weeks of therapy, his scalp swelling significantly decreased and his headache completely resolved.

Isolated plasma cell granuloma of the meninges

A 77-year-old female with hypertension, presented with right partial motoric seizures. Neurological examination showed right hemiparesis. Brain MRI revealed extensive post-contrast interhemispheral dural, pachymeningeal and leptomeningeal enhancement of the left cerebral hemisphere (Fig. 1), which were initially interpreted as meningeal carcinomatosis. However, CSF analysis performed on two occasions, with normal cell count, glucose and protein levels, did not show malignant cells. Chest and abdominal CT scan and mammography were normal. Brain and meningeal biopsies were performed and histological findings (Fig. 2) were consistent with plasma cell granuloma. Following this bone marrow biopsy, skeletal X-rays survey, peripheral blood cell count, renal function, calcium and protein electrophoresis were normal. The patient was treated with corticosteroids without any neurological sequel and significant improvement of MRI findings. This case emphasizes how the diagnosis of leptomeningeal carcinomatosis remains challenging, as neither CSF cytology nor MRI is adequately sensitive for the diagnosis. Plasma cell granulomas are uncommon, benign inflammatory masses of unknown etiology [1]. They are histologically characterized by polyclonal plasma cells, large histiocytes with lymphophagocytosis and fibrosis [1]. There are only few reports of isolated CNS plasma cell granuloma in the literature [1]. Based on similar histological features, plasma cell granulomas, Rosai–Dorfman disease, and idiopathic hypertrophic pachymeningitis are now believed to form a spectrum of inflammatory or reactive conditions with, probably, the same unknown etiology [2, 3]. Rosai–Dorfman disease, or sinus histiocytosis, with massive lymphadenopathy, is a benign idiopathic histiocytic proliferative disease with pathognomonic histological and immunohistochemical characteristics. Extranodal involvement occurs in 43 % of cases [4], and by December 2008 111 cases of Rosai–Dorfman disease involving the central nervous system had been reported in the literature [5]. The main histopathological differentiation between plasma cell granuloma and Rosai–Dorfman disease is a careful appraisal of the morphological features together with the absence of emperipolesis in the S100-positive D. Kolenc S. Dotlic Department of Pathology, University Hospital Center Zagreb, Zagreb, Croatia

Granulomatosis with polyangiitis masquerading as giant cell arteritis

A 65-year-old man presented with headache, weight loss, occasional scalp tenderness, and visual loss in his left eye, which worsened over a number of weeks to bare light perception. There was a left relative afferent papillary defect with a swollen disc and a small amount of associated hemorrhage. Erythrocyte sedimentation rate (ESR) was 16 mm/1st h, C-reactive protein (CRP) was 3.3 mg/l (normal \7). Temporal artery biopsy demonstrated no evidence of arteritis. On initiation of corticosteroids, his vision improved dramatically and the corticosteroids were subsequently weaned to zero over a period of 6–8 weeks. Three months later, he re-presented with left-sided ptosis and worsening headache. There had been weight loss (7 kg within the prior 6 months). Examination revealed a complete left-sided ptosis, with normal eye movements. Visual acuity was measured at 6/5 on the right and 6/9 on the left. Slit-lamp examination was unremarkable. Laboratory investigations revealed mild eosinophilia (0.78, range 0.04–0.4 9 10/l), an ESR of 9 mm/1st h, and a CRP of 13 mg/l. Serum complement levels were reduced: C3 \0.04 g/l (range 0.75–1.88), C4 \0.01 g/l (range 0.14–0.61). Dipstick urine testing was negative for blood and protein. Urinalysis was negative for casts and red cells. Serum anti-nuclear antibody, extractable nuclear antigen, anti-neutrophil cytoplasmic antibody (ANCA), PR3 and MPO antibodies were negative. Chest radiograph was normal. Dedicated gadolinium-enhanced magnetic resonance imaging (MRI) of the orbits and brain revealed dural enhancement and thickening over the left and right temporal lobes (Fig. 1), with normal orbits. Cerebrospinal fluid (CSF) examination demonstrated an absence of cells with normal glucose and protein concentrations. CSF bacterial and TB cultures and CSF ANCA were negative. The patient was commenced on high-dose corticosteroids (1 mg/kg/day), with resolution of his headache over the following days. The CRP level and eosinophilia normalized quickly. The ptosis improved significantly but not completely. Biopsy of the fronto-temporal dura mater demonstrated thickened dura (Fig. 2a), with multifocal infiltration by cellular aggregates comprised of an admixture of mature lymphocytes, plasma cells, and multinucleate giant cells (Fig. 2c). Foci of necrosis were present (Fig. 2b), and characterized by accumulation of polymorphonuclear A. McCarthy T. Lynch K. O’Rourke (&) Dublin Neurological Institute at the Mater Misericordiae University Hospital, 57 Eccles St, Dublin 7, Ireland e-mail: killian.orourke@gmail.com

Intracranial Hypotension: Improved MRI Detection With Diagnostic Intracranial Angles

Intracranial hypotension is an uncommon cause of headaches that is often misdiagnosed. The classic MRI features of intracranial hypotension can be variable and subjective. The purpose of this study was to provide objective criteria in the MRI evaluation of intracranial hypotension by quantifying normal values for the pontomesencephalic angle, mamillopontine distance, and lateral ventricular angle. A retrospective review of patients with the clinical diagnosis of intracranial hypotension and a control group was performed with measurements of the pontomesencephalic angle, mamillopontine distance, and lateral ventricular angle. Qualitative evaluation of other MRI findings included dural enhancement, venous engorgement, subdural collections, brainstem slumping, and tonsillar herniation. In 29 patients with intracranial hypotension, the mean pontomesencephalic angle, mamillopontine distance, and lateral ventricular angle were 41.2° (SD, ± 17.4°), 4.4 mm (SD, ± 1.8), and 130.1° (SD, ± 9.8°), respectively. In the control group, the mean pontomesencephalic angle, mamillopontine distance, and lateral ventricular angle were 65° (SD, ± 9.9°), 7.0 mm (SD, ± 1.3), and 132.2° (SD, ± 5.7°), respectively. The differences in the pontomesencephalic angle and mamillopontine distance values for the intracranial hypotension group versus the control group were statistically significant (p < 0.01). The difference in the lateral ventricular angle measurements was not statistically significant (p = 0.37). Cutoff points of a 5.5-mm mamillopontine distance and 50° pontomesencephalic angle were estimated using receiver operating characteristic curves. In patients with the clinical suspicion of intracranial hypotension, we found that cutoff values of 5.5 mm or less for the mamillopontine distance and 50° or less for the pontomesencephalic angle were sensitive and specific in strengthening the qualitative MRI findings. Therefore, quantitative assessments may provide a more accurate diagnosis.

Teaching Neuro Images : CSF leaks and spontaneous intracranial hypotension

A 30-year-old man developed a severe postural headache over a period of a month. MRI revealed diffuse dural enhancement ([figure 1][1]), and radionuclide cisternography showed widespread CSF leaks ([figure 2][2]). It has been suggested that spontaneous intracranial hypotension is caused by CSF

GETTING THAT SINKING FEELING…. AN UNUSUAL CAUSE OF DEMENTIA

A 58 year old woman with no medical or family history became increasingly apathetic and jovial over several weeks, with a headache lacking postural features. Impaired episodic memory and unsteady...

Cervical Extradural “En-Plaque” Meningioma

Spinal meningiomas with concurrent extradural localization and "en-plaque" growth are exceptional, with only five reported cases in the literature. We report another case and discuss the peculiar diagnostic and surgical features of this very unusual pattern of growth. A 74-year-old woman was observed because of a rapidly progressive tetraparesis, more marked in the left arm. Magnetic resonance imaging depicted an inhomogeneously enhancing tumor of the cervical spine, extending from C4 to T1, with diffuse dural enhancement and extension into the left brachial plexus roots. At operation by laminotomy from C4 to C7 a firm posterior extradural tumor arising from the dura was resected; however, the diffusely infiltrated dura could not be removed. Histology was in favor of a transitional meningioma (WHO I). Postoperatively, irradiation to the operative field with 50 Gy was performed. At follow-up, 18 months after surgery, clinical improvement to moderate tetraparesis was evidenced. Spinal extradural "en-plaque" meningiomas have been mainly reported in women and at the cervical region, and show extension to many spinal levels as well as diffuse dural infiltration. Preoperatively, they may be differentiated from spinal metastases and lymphomas because of the presence of a "dural tail" sign and calcifications. The surgical resection is mainly limited to the posterior and lateral extradural tumor component, whereas the whole invaded dura is very difficult to resect, mainly in cases with circumferential infiltration. This results in a high rate of tumor recurrence.