PMC6308253_01
a-f Axial pre-contrast T2 FLAIR demonstrates appropriate sulcal CSF suppression (a). Same study shows bilateral papilledema (b). Axial pre-contrast T2 FLAIR after two lumbar punctures demonstrates Sulcal FLAIR hyperintensity (c) corresponding to vascular enhancement (d). One month later, there is resolution of Sulcal FLAIR hyperintensity (e) and decrease in leptomeningeal vascular prominence (f).
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She had an MRI of the orbits at an outside facility 1 week prior to presentation to our emergency department which demonstrated normal sulcal FLAIR suppression of fluid signal (Fig. 1a), papilledema (Fig. 1b) and a partially empty sella turcica. A repeat MRI of the brain was performed which showed sulcal FLAIR hyperintensity most pronounced close to the vertex (Fig. 1c) and posteriorly corresponding to smooth areas of linear or vascular enhancement (Fig. 1d). Repeat imaging performed one month later showed resolution of sulcal FLAIR hyperintensity (Fig. 1e) and enhancement (Fig. 1f).
PMC6308253_02
a-f Axial pre-contrast T2 FLAIR demonstrates appropriate sulcal CSF suppression (a). After lumbar puncture and subsequent lumbar drain placement, there is Sulcal FLAIR hyperintensity (b). Compared to pre lumbar puncture/drain T1 post contrast sequence (c), there is increased prominence of leptomeningeal vascularity (d) corresponding to sulcal FLAIR signal. Sagittal T1 sequence before (e) and after (f) lumbar puncture/drain shows interval sagging of the brainstem and enlargement of the pituitary gland.
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MRI of the brain was performed prior to lumbar puncture demonstrating a mild partially empty sella turcica but was otherwise unremarkable with normal sulcal FLAIR suppression of fluid signal (Fig. 2a). A few days later patient developed a low-pressure headache and repeat imaging of the brain showed sulcal FLAIR hyperintensity most pronounced close to the vertex (Fig. 2b) and posteriorly corresponding to smooth areas of linear or vascular enhancement (Fig. 2d) which was increased compared to the prior exam (Fig. 2C). Compared to prior MRI (Fig. 2e), there was also interval minimal sagging of the brainstem, with superior convexity of the pituitary gland (Fig. 2f).