A 45-year-old man with new-onset postural headache.

A 72-year-old man, history withheld.

A 39-year-old woman with breast cancer.

A 63-year-old man with a history of kidney transplantation. FLAIR, fluid attenuated inversion recovery.

A 55–year-old woman, history withheld. FLAIR, fluid attenuated inversion recovery.


  • MRI scans from five patients demonstrate diffuse pachymeningeal enhancement.

  • Case A involves diffuse smooth pachymeningeal enhancement, small subdural effusions, caudal displacement of supratentorial structures, low-lying cerebellar tonsils, prominence of the pituitary gland with the pituitary protruding beyond the margins of the sella, and a prominent transverse sinus with a convex inferior border (known as venous distention sign [VDS]). Note the absence of leptomeningeal enhancement or pachymeningeal nodularity.

  • Case B involves marked diffuse thickening and enhancement of the pachymeninges, a positive VDS sign, small subdural effusions, and mild prominence of the pituitary gland, along with a ventricular shunt with its tip in the frontal horn of the right lateral ventricle and slitlike ventricles (also note the artifact from the shunt apparatus outside the calvarium). The brain does not have a sunken appearance despite the marked pachymeningeal thickening.

  • Case C involves pachymeningeal enhancement with areas of nodularity, unlike the other cases shown in which the pachymeningeal enhancement is smooth. Closer inspection of the images reveals multiple skull lesions. Also, note the concave inferior border of the transverse sinus (a negative VDS sign), unlike in cases A and B.

  • Case D involves diffuse smooth pachymeningeal enhancement in addition to a heterogeneously enhancing mass centered in the right basal ganglia. A negative VDS sign is noted.

  • Case E involves mild diffuse pachymeningeal enhancement in addition to extensive nodular leptomeningeal enhancement. Nonspecific areas of FLAIR hyperintensity also are noted, along with a negative VDS sign.


Case A

Spontaneous (primary) intracranial hypotension (IH) (imaging and clinical criteria); improved after treatment with an epidural blood patch

Case B

Chronic shunting for aqueductal stenosis with pachymeningeal thickening that has been stable over many years

Case C

Disseminated breast cancer with biopsy-proven osseous metastases

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