3b (Brain) - Answer: 55-year-old man presents with headache, neck pain and dizziness

HISTORY: 

This 55-year-old male presents with headache, neck pain and dizziness.


(QUIZ ANSWER) PRIMARY FINDING: 

Intracranial hypotension.


Using the diagnostic web viewer, we have provided images that assist in telling our clinical story. Areas of significance are indicated below.


FINDINGS:

Calvarium is intact. No Chiari malformation. 

No suprasellar cisternal effacement or tonsillar descent. Prominent torcula and clival veins. 

Thin CSF intensity extraaxial collections without atrophy. Ventricles are small. Cerebral hemispheres and deep nuclei are without hemorrhage, mass or edema. Bilateral extraaxial collections measure 4mm right, 3mm left in thickness. 

Diffusion-weighted images are without a diffusion-restrictive defect. 

Carotid and basilar artery flow voids are intact. 

No internal auditory canal or cerebellopontine angle masses. 

Venous sinuses are patent. 

No confluent otomastoid airspace disease. 

Multiple foci of parenchymal hyperintensity may represent gliosis of microangiopathic origin. 

Brainstem and cerebellum are without hemorrhage, mass, or edema. Subtle hyperintensities within the right pons may represent gliosis or microangiopathic origin. 


CONCLUSION: 

1. Bilateral extraaxial proteinaceous fluid intensity collections measuring 4mm right, 3mm on the left. The torcula and clival veins are prominent and ventricles are small. Findings could represent chronic subdural hematomas; however, in the setting of venous distention and small ventricles, additional differential may include CSF hypotension if headaches are postural and this diagnosis is clinically relevant. Further evaluation may include cervical and thoracic spinal MRI cisternography of heavily water-weighted sequences to identify a potential spinal source of CSF fistula. 

2. Multiple supratentorial and right-sided pontine hyperintensity may represent gliosis of microangiopathic origin without evidence of acute ischemia on diffusion-weighted images. 

3. No acute parenchymal hemorrhage.


Discussion
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  MSK MRI
  Neuro MRI
  Body MRI