1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Steven J Goldstein Affiliation: University of Kentucky

2. MedPix No: 13516 - History Pt Demographics: Age = 50 y.o. Gender = woman 50 year old woman with headaches and blurred vision for 1 month. Downloaded by (-1)

3. MedPix No: 13516 - EXAM & LABS Obese womanPapilledema with elevated optic discs.

4. Empty Sella from pseudotumor cerebri (bilateral Transverse sinus stenoses) Empty Sella - Dilated optic nerve sheaths due to increase CSF volume/pressure. Bilateral transverse sinus stenoses on MRV - - Downloaded by (-1)

5. Cerebral Pseudotumor with bilateral Transverse sinus stenoses Empty Sella (subarachnoid space * herniating into pituitary fossa) - Dilated optic nerve sheaths due to increase CSF volume/pressure. Bilateral transverse sinus stenoses on MRV - SS - Sphenoid Sinus - - Downloaded by (-1)

6. Pseudotumor cerebri, transverse sinus stenosis Empty Sella - Dilated optic nerve sheaths due to increase CSF volume/pressure. Bilateral transverse sinus stenoses on MRV - - Downloaded by (-1)

7. Pseudotumor cerebri, transverse sinus stenosis Dilated optic nerve sheaths (arrows) due to increased CSF volume/pressure. Bilateral transverse sinus stenoses on MRV. Cerebral peduncle (CP) Quadrigeminal plate (arrowheads). - - Downloaded by (-1)

8. Pseudotumor cerebri, transverse sinus stenosis Empty Sella - Dilated optic nerve sheaths due to increase CSF volume/pressure. Bilateral transverse sinus stenoses on MRV - - Downloaded by (-1)

9. Pseudotumor cerebri, transverse sinus stenosis Dilated optic nerve sheaths (arrows) due to increased CSF volume/pressure. Bilateral transverse sinus stenoses on MRV. - - Downloaded by (-1)

10. Pseudotumor cerebri, transverse sinus stenosis Empty Sella - Dilated optic nerve sheaths due to increase CSF volume/pressure. Bilateral transverse sinus stenoses on MRV - - Downloaded by (-1)

11. Pseudotumor cerebri, transverse sinus stenosis Empty Sella, pituitary stalk (arrowhead). Also labeled: - arrows - normal enhancement of lacrimal glands - crbll - cerebellum - lat - lateral rectus muscle - med - medial rectus muscle - pons - brainstem - temporal - lobe - - Downloaded by (-1)

12. Transverse sinus stenosis (bilateral), Pseudo tumor Empty Sella - Dilated optic nerve sheaths due to increase CSF volume/pressure. Bilateral transverse sinus stenoses on MRV - - Downloaded by (-1)

13. Transverse sinus stenosis (bilateral), Pseudo tumor Empty Sella - Dilated optic nerve sheaths due to increase CSF volume/pressure. Bilateral transverse sinus stenoses on MRV - - Downloaded by (-1)

14. Transverse sinus stenosis (bilateral) Slightly oblique 3D MRV showing bilateral transverse sinus stenoses (arrows) on MRV. IJV = Internal Jugular Vein. Also labeled, the ascending superficial vein of Trollard (vertical, connecting to superior sagittal sinus. - - Downloaded by (-1)

15. Transverse sinus stenosis (bilateral), Pseudo tumor Empty Sella - Dilated optic nerve sheaths due to increase CSF volume/pressure. Bilateral transverse sinus stenoses on MRV - Downloaded by (-1)

16. Transverse sinus stenosis (bilateral), Pseudo tumor Bilateral transverse sinus stenoses on MRV (arrows) - Downloaded by (-1)

17. Transverse sinus stenosis (bilateral), Pseudo tumor Empty Sella - Dilated optic nerve sheaths due to increase CSF volume/pressure. Bilateral transverse sinus stenoses on MRV - - Downloaded by (-1)

18. *Idiopathic* Intracranial Hypertension Bilateral transverse sinus stenoses (arrows) on MRV. - - Downloaded by (-1)

19. FINDINGS Empty Sella Dilated optic nerve sheaths due to increase CSF volume Bilateral transverse sinus stenoses on MRV

20. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Optic neuritis - Hydrocephalus - Intracranial hypertension - Sinus Thrombophlebitis

21. Diagnosis: Pseudotumor cerebri (idiopathic intracranial hypertension) Dx Confirmed by: MRI, MRV, and clinical examination

22. DISCUSSION Pseudotumor cerebri is increased intracranial pressure NOT caused by a mass lesion. It may result from increased CSF presure with or without increased venous pressure. Some cases, like this one, are associated with stenosis of the large dural sinuses. - - PMID: 17008839 - PMID: 18458863 - - - http://www.medscape.com/viewarticle/714384 - - http://www.ihrfoundation.org/intracranial/hypertension/more_info/homepage_feature/intr acranial/hypertension/info/C140 - - http://www.ajnr.org/cgi/content/abstract/22/1/196