|Patient: 62 year old female|
|History: 62 yo female with history of breast cancer and chronic headache|
Selected axial and coronal T1 weighted gadolinium enhanced images of the brain demonstrate diffuse smooth pachymeningeal (dura-arachnoid) thickening and enhancement. Notice gyri/sulci are not involved in the enhancement pattern indicating that this is NOT a leptomeningeal process (pia-arachnoid not involved).
Sagital T2 weighted image through the midline brain demonstrates normal developmental anatomy.
Sagital CT reformation through the spine demonstrates diffuse sclerosis consitentent with diffuse axial skeletal metastasis.
|Diagnosis: breast cancer metastatic disease to the skull|
The differential for pachymeningeal enhancement is broad and includes metastatic disease (especially involving the skull), intracranial hypotension, sarcoidosis, CSF leak (s/p lumbar puncture or VP shunt), subarachnoid hemorrhage, and idiopathic hypertrophic cranial pachymeningitis as well as infection.
Upon obtaining additional history from the refering provider, patient had orthostatic qualities to her headache. Additional imaging demonstrates diffuse axial skeleton sclerotic metastic disease involving her thoracic and lumbar spine. Lumbar puncture revealed an opening pressure of 12cm H2O with 6cm H20 necessary for the diagnosis of intracranial hypotension.
Supporting MR findings for intracranial hypotension would have been downward sagging of the midline structures (cerebellar tonsils and floor of the third ventricle), widening of the subarachnoid convexity spaces, small ventricles and prominent dural venous sinuses. None of these findings were present on this particular exam.
The Core Curriculum: Neuroradiology. Mauricio Castillo. p124
Neuroradiology: The Requisites. Second Edition. Robert Grossman. p281
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Case Number: 44970953Last Updated: 07-29-2010 The reader is fully responsible for confirming the accuracy of this content.
The reader is fully responsible for confirming the accuracy of this content.