0:01

What are the other entities that are

0:03

associated with worse headache of life?

0:06

Well, pseudotumor cerebri, or what we now call

0:09

idiopathic intracranial hypertension, is another

0:14

entity that is associated with severe headaches.

0:17

The typical patient that is, uh, has been

0:21

described with a patient who has pseudotumor.

0:24

Cerebri is an, uh, overweight

0:27

individual who may show papilledema on clinical

0:31

evaluation. The papilledema is a manifestation of

0:34

that element of increased intracranial pressure,

0:38

which is associated with pseudotumor cerebri.

0:41

The imaging findings here are pretty dramatic.

0:43

Here,

0:44

we see that the patient has an enlarged

0:47

empty sella, has enlargement of the Meckel

0:52

cave region with the fifth cranial nerve.

0:56

Bilaterally, here you notice that the patient has

0:59

enlargement also of the optic nerve sheath complex.

1:04

These are very prominent here, and at least on

1:07

one of them, it looks as if there is papilledema

1:11

that is reverse cupping at the junction between

1:14

the optic nerve and the back of the globe.

1:17

Here we have flattening at the

1:20

back of the globe bilaterally.

1:23

It's no longer that normal rounded spherical shape

1:29

with dilatation of the optic nerve sheath complex,

1:33

and much more tortuosity of that optic nerve

1:38

sheath complex in and out of plane in this entity.

1:43

The ventricles are usually

1:45

normal to slightly small in size.

1:49

You know when you have the

1:50

high intracranial pressure?

1:52

There's a possibility

1:53

you might see actually small ventricles, so pap

1:56

edema, dilated optic nerve sheath complex, tortuous

2:00

optic nerve sheath complex, empty sella, dilated CSF

2:04

spaces in this case associated with Meckel's cave.

2:08

You can see it associated with some arachnoid

2:11

granulations, and then collapse of the venous

2:13

sinuses at the optic nerve sheath complex.

2:17

Injunction with the globe, you may occasionally see

2:20

high signal intensity on DWI imaging suggestive of

2:25

papillitis, idiopathic intracranial hypertension.

2:29

Pseudotumor cerebri has been associated with

2:34

narrowing of the venous sinuses, and it's

2:38

usually we're talking about the transverse sinus.

2:42

This raises the possibility of sort of

2:45

the quote-unquote chicken versus the egg.

2:48

Is the intracranial hypertension, that high

2:51

pressure collapsing the venous sinuses and

2:55

causing them to look like there's a stenosis?

2:58

Or does the stenosis itself lead to back

3:03

pressure venous congestion, which would cause

3:08

increased intracranial pressure?

3:10

It's not really clear.

3:11

What is clear is that a lot of patients do have

3:14

sinus stenosis who have idiopathic intracranial

3:17

hypertension, and if you stent that sinus and

3:22

improve the flow through that sinus, you do

3:25

see that the patient's symptoms get better.

3:28

The major symptoms here are gonna be headache.

3:31

However, the one that

3:33

concerns us the most is the visual loss

3:36

that can occur with pseudotumor cerebri, and

3:38

that visual loss can become permanent if you

3:41

have persistent high intracranial pressure.

3:46

So narrowing of the sinuses.

3:48

Now, please understand that asymmetry from

3:51

right to left in the transverse sinus is

3:55

the norm; we often see one dominant

3:59

venous sinus, transverse sinus.

4:01

So it's not until you see a focal area of narrowing

4:05

that you would be concerned about venous sinus

4:08

stenosis in idiopathic intracranial hypertension.

4:11

You may see it IIH, or you may see PSC,

4:16

pseudotumor or PTC for pseudotumor cerebri.

4:21

Here's another example.

4:22

In this case,

4:23

the narrowing of the venous sinus was

4:27

secondary to arachnoid granulations.

4:29

You always have to be cognizant of the

4:32

potential pitfall of calling a sinus narrowed

4:38

when all you're seeing is a focal indentation

4:41

of the sinus at an arachnoid granulation.

4:44

So these are the little bright things on T2, a scan

4:48

associated with the course of the transverse sinus.

4:51

Maybe an arachnoid granulation, which, as you

4:54

can see, may even invaginate into the sinus and

4:58

look like it's causing narrowing, or in this

5:01

case, maybe even a thrombus within the sinus.

5:03

Here's another arachnoid granulation, and as you can

5:06

see, these arachnoid granulations invaginate into the

5:09

sinus and cause narrowing, but this is a normal variant.

5:12

This is not due to the pseudotumor

5:15

cerebri, another sinus here.

5:17

Another arachnoid granulation infiltrating into

5:21

the sinus, in this case involving the bone as well.

5:24

Here's one that's involving the superior sagittal sinus

5:27

with what looks like a filling defect in the sinus,

5:30

but it's really these high signal intensity on T

5:33

2A scan, arachnoid granulation, invaginating

5:36

into the superior sagittal sinus or transverse sinus,

5:40

and causing an appearance of sinus stenosis.