0:00

Dr. Schupack,

0:01

this is a 46-year-old man who was referred in for,

0:05

quote unquote,

0:06

migraine headaches by somebody with general

0:09

medical knowledge. But not a neurologist.

0:11

Not a neurosurgeon.

0:12

Somebody who doesn't really practice avidly

0:15

or consistently in the neural space.

0:19

And we've got an axial T1 non-contrast,

0:23

which I'm going to scroll for.

0:24

You got kind of a weird look of the brainstem right here.

0:27

That's disturbing. And as we keep going,

0:30

maybe there's some extra-axial collections on both sides.

0:34

No maybe about it. They're present.

0:36

The ventricles aren't big.

0:38

And then we have a sagittal here that shows the pituitary

0:43

gland. Since we're in the suprasellar section,

0:45

it's a little juicy for an adult male.

0:49

Adult male. We'd like to see it under seven or 8 mm,

0:53

maybe 6 mm. This one's substantially more than that.

0:56

Maybe the dural venous sinuses and the

0:58

torcular are a little prominent.

1:00

And certainly the clival veins are a little prominent.

1:03

So what's going to be the diagnosis here?

1:05

And how do you explain the fact that you can hardly see

1:08

the pituitary? It looks kind of squishy in there,

1:10

and the pituitary gland looks a little big.

1:12

In fact. Now,

1:13

I'll mag it up a little bit while you're chatting.

1:16

Right. So the patient's there,

1:19

and I think the first question when you see this

1:21

scan is you go and ask the patient, well,

1:23

I heard you had headaches.

1:25

What makes them better? And the answer, I can tell you.

1:29

What it's going to be?

1:30

Oh, they're better when I lie down.

1:31

Boy, when I sit up, horrible.

1:33

Okay. Now, why is that?

1:36

Because mine get better when my spouse is happy with me.

1:39

But go ahead. Yeah, I guess that's occurred occasionally.

1:42

Okay. But anyway, Dr.

1:44

Pomeranz pointed out a number of things.

1:47

One is,

1:50

so we're wondering about hypotension

1:52

with postural headaches.

1:53

So if we can establish that they're postural and the reason

1:56

that we're really highly suspicious is because of this.

2:00

Okay. Remember the Monroe Kelly hypothesis, Dr.T?

2:03

I do remember that from medical school.

2:06

Okay,

2:06

so the volume and pressure in the head is due to three

2:10

components: the soft tissue, the CSF, and the blood.

2:13

Okay? So if one gets smaller, the other gets bigger.

2:16

Okay, so you have something here.

2:19

So this is not going to be hypertension, right?

2:21

Because something sucked the brain down enough to create

2:25

potential space that is going to fill with fluid.

2:27

The extra-axial collections rule out hypertension.

2:30

Right. So we're really working on hypotension,

2:33

I would say.

2:33

The other thing is the suprasellar cisternal effacement,

2:36

right? And the sellar is not empty.

2:39

If anything, it's a little chubby.

2:41

Okay. The pituitary is a little chubby.

2:43

And then the same phenomenon, right?

2:45

Clival veins. Right. So if the pressure is down,

2:47

veins get bigger.

2:49

So you get these prominent and clival veins.

2:51

Now, I think, on the post-contrast,

2:53

just to kind of seal the deal.

2:56

Yeah. So we got a little bit of enhancement, right?

3:00

Your collections. Enhancements of the pachymeninges.

3:02

Of the pachymeninx. Okay,

3:04

so we're kind of on the track here with hypotension.

3:08

Now, then,

3:09

the next question that the clinician is going to ask is,

3:12

well, why? I mean, is there a CSF leak at the skull base?

3:17

Or maybe there was a little trauma or something?

3:20

Sure. Well, the answer is going to be, look at the spine.

3:24

Okay. These are going to be from a spinal source almost.

3:28

You'd think, well, okay, it should be in the head,

3:31

a CSF leak, but it's almost always from the spine.

3:33

And spontaneous ones are going to be due to sort

3:36

of a root chief cyst that is ruptured.

3:39

And sometimes you'll do a scan of the spine and see that

3:41

these people have a bunch of root chief cysts.

3:43

You can't tell exactly which one it is,

3:45

but the source is going to be spinal.

3:48

And the spontaneous ones,

3:49

and I've seen it actually happen from a sneeze.

3:51

But that's such a good point,

3:53

because the findings are in the brain.

3:55

You think, well, let's find the leak in the brain.

3:58

Well, that would be appropriate if it was a post-surgical case.

4:00

Surgical case.

4:01

But you're right, most of these you're right, as usual.

4:05

Most of these happen in the spine

4:07

and often in the lumbar spine.

4:08

But you may have to completely go up and down the spine

4:11

with very high resolution, overlapping 3D sections,

4:16

and then you can reformat them.

4:17

I like to have 50% overlap.

4:19

I like to have 1 mm.

4:21

Yeah, it takes a little bit of time,

4:22

but it's certainly better than trying to do dilogram in

4:25

a patient, and it usually will give you the answer.

4:28

We've got Pachymeningeal enhancement,

4:30

and you can see these extra-axial collections a little

4:33

more clearly. You can see that for a middle-aged man,

4:36

the sella is a little bit juicy.

4:38

And all you have to do to think about the findings here is

4:40

everything is trying to get bigger to fill

4:43

up this space of negative pressure.

4:46

And it can happen all the way up and down the neural axis.

4:48

So when you go in the spine mean,

4:50

sometimes the veins are so massive,

4:52

I have seen them be confused with extra-axial masses.

4:56

And that would be a big surprise for a surgeon to get in.

5:00

And attack some tumor,

5:01

and it turns out to be dilated veins from SIH,

5:04

spontaneous intracranial hypotension.

5:08

Not to be confused with idiopathic intracranial

5:11

hypertension IIH, also known as pseudotumor cerebra.