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Dr. Schupack,

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this is a 31-year-old woman who presents with visual symptoms,

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in fact, visual disturbance,

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optic neuropathy and morbid obesity.

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She's already had one lap band procedure.

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You've got before you a sagittal T1 spin echo.

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Do a little bit of scrolling there, a little funny-looking

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cella. You can have a J-shaped cella normally.

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So the question is,

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is it J-shaped or is it actually a little bit empty?

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And then the axial projection, a T2.

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Let's scroll up and down a little bit and

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look at the optic apparatus and the base of the brain.

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And here is an axial T1-weighted image with contrast.

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There's no real enhancement here,

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although it's interesting that the venous channels are not very

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prominent. So go ahead and comment on this case, if you would.

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Okay, well,

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the first thing is we got a demographic to deal with,

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that is young female with headaches and visual disturbance.

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So we're already put.

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US on the trail to a couple of diagnoses that we're

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going to be very interested in, one in particular.

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And so let's look at a few findings.

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So we're talking about visual disturbance, a little sclero,

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flattening optic nerve sheath, dilation.

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Now, the cella is empty, or partially empty,

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which is a pretty common finding in elderly patients.

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But in a 31-year-old, I believe it's less common.

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It's unusual. And if you could just stop for 1 second.

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If I could just interject.

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The stalk is midline and it's got this funny oblong shape to it.

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And then one other thing is, in a J-shaped cella,

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you're going to have some pretty good cellar tissue in the back,

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and then it kind of fades away as it kind of loops forward.

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Whereas here, when I take away my drawing,

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you can see there's very little cellar tissue posteriorly.

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So it's not going to be a J-shaped cella,

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it is going to be a partial empty cella.

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Right. And we got a little bit of tonsillar sagging.

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Okay, now, the Meckel's caves are not particularly large.

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And do they get large with both spontaneous intracranial

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hypotension and pseudotumor cerebri,

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or more frequently with pseudotumor cerebri?

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More frequently with pseudotumor cerebri.

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Now,

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the veins you were talking about in that earlier discussion when

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we were talking about a hypotension state vein are big, right?

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So Monroe Kelly hypothesis something gets big,

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something else has to get small.

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So if the brain is kind of fat,

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which is maybe part of the physiology of intracranial

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hypertension, the veins are small.

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Okay, so that's a difference.

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The cella is partially empty instead of extra.

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A little extra chubby. Yeah, the opposite, right?

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Big cellar in SIH and small or partially empty

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cellar in IIH or pseudotumor cerebri.

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Right.

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And then there's no extra-axial collections or enhancement.

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Right, because the brain is.

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Taking up a little more space, right?

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There's no space around it being created and pseudotumor

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cerebral entity. So we got a bunch of findings here,

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and we got a really suggestive demographic.

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And it's important that there are a lot of people out there

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with headaches, okay? But headaches, visual disturbance,

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because this is an important diagnosis because these

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people can lose vision permanently, okay?

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So making that diagnosis critical,

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and treatment can be very critical.

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You really should recommend visual field examination

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and CSF pressure. CSF pressure?

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Visual analysis by an ophthalmologist to see if there's

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papilledema or pseudopapilledema. So these are important things,

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actually,

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to respectfully put into your dictation when you are suspicious

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of this diagnosis, especially with visual symptoms.

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What about the character of the headache in SIH spontaneous

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intracranial hypotension versus IIH idiopathic intracranial

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hypertension? Well, what's the difference?

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Hypotension and those of.

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Who have done some myelography are going to be very familiar

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with this. The postural headache is better when I lie down.

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Boy, when I sit up, my head feels like it's going to explode.

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So that's a hypotension headache.

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Just like if you drain CSF and a myelogram.

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It's still leaking a little bit.

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Okay, this is different.

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It's sort of a morning kind of headache.

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But the key is if it's headaches only, no visual disturbance,

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no findings on eye examination.

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They probably would try to treat it medically,

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but when they start losing vision,

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that's when you have things like shunts, lumbar.

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Shunts are going to be part of the considerations for these kind

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of things because you do not want them to go in advance

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and lose vision. Here's another finding.

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You talked about flattening of the sclera, but corkscrew.

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Yeah, corkscrew. Appearance of the optic nerve,

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kind of a tortuous optic nerve.

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Another sign. So, in summarizing, you know,

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patients with pseudotumorous cerebral,

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which is now called idiopathic intracranial hypertension,

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usually middle-aged women,

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more common in individuals that are overweight.

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Not true for spontaneous intracranial hypotension.

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The vasculature,

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particularly the venous vasculature, dilated

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NSIH narrow or small in IIH,

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the extra-axial collections present in SIH not present in IIH,

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the ventricles are often slit-like in spontaneous

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intracranial hypotension.

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Let's look at our ventricles here and see if they're slit-like

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they are. In this case, the ventricles variable in size in IIH,

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they can be really small or they can be normal.

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These are real small, so in either one,

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the ventricles can be pretty small.

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Sagging of the chiasm and the optic apparatus and structures

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above the cella. You can see that in either one, SIH or IIH,

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sagging of the cerebellar tonsils,

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either one SIH or IIH pituitary big in hypotension.

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Intracranial hypotension, empty cellar or.

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Small pituitary in idiopathic,

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intracranial hypertension or pseudotumorous cerebri.

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So those are some summary ways you can differentiate two

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conditions that are somewhat and then similar in your mind.

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The Pachymeningeal enhancement, when you start seeing that,

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that's also taking along the hypotension.

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Yeah, that goes down the hypotension road,

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not the pseudotumorous cerebral road.

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And that is wrap Pomeranz out and Schupack out.