Radiology Teaching Files > Case 44970953

Contributed by: Robert DeWitt, Resident, Wilford Hall Medical Center, Texas, USA.
Patient: 62 year old female
History: 62 yo female with history of breast cancer and chronic headache

Fig. 1: Axial T1 Post Gad

Fig. 2: Coronal T1 Post Gad

Fig. 3: Sagittal T2

Fig. 4: Sagittal CT of the spine

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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Additional Details:

Case Number: 44970953Last Updated: 07-29-2010
Anatomy: Cranium and Contents   Pathology: Other
Modality: CT, MRAccess Level: Readable by all users
Keywords: pachymeningeal thickening, dural enhancement

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