PMC4709961_01
Upper: T2-weighted axial MRI revealed enlarged ventricles. Lower: In T2-weighted coronal MRI also showed enlarged ventricles, however, the major feature of disproportionately enlarged subarachnoid-space was not obvious
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Fig1
However, the specific feature of narrowing of the sulci at the high convexity area was not obvious (Fig. 1).
Single-photon emission computed tomography revealed areas of relatively decreased blood perfusion around the Sylvian fissure, while increased blood perfusion in the external layer around the convexity side
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Fig2
Single-photon emission computed tomography revealed reduced cerebral blood flow (CBF) surrounding the Sylvian fissure, with relatively increased CBF in the convexity, which was consistent with the pattern for iNPH (Fig. 2).
MRI showed normal pituitary gland measuring 12 mm in maximum diameter with no deviation of stalk, and there is no tumor or inflammatory lesion around the hypothalamic-pituitary area. (Upper left: T1 coronal MRI, Upper right: T1 gadolinium coronal MRI, Upper right: T1 gadolinium sagittal MRI, lower left: T1 gadolinium sagittal MRI)
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Fig3
On MRI, pituitary gland was normal measuring 12 mm in maximum diameter with no enlargement or deviation of stalk, and there were no neoplastic lesions, inflammatory lesions in the pituitary area of the diencephalon, or changes suggesting that surgery had been performed in all sequences including contrast-enhanced dynamic images (Fig. 3).
Pituitary stimulation test using corticotropin-releasing hormone, thyrotropin-releasing hormone, luteinizing hormone-releasing hormone and growth hormone releasing hormone showed no response in plasma cortisol level and ACTH level, while other hormones showed adequate response
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Fig4
ACTH and cortisol responses only were found to have disappeared, and isolated ACTH deficiency was thus diagnosed (Fig. 4). After initiation of hydrocortisone supplements, her gait quickly improved.