20 yo female with a history of hypopituitarism (central adrenal insufficiency, central hypothyroidism) as well as Chiari malformation, POTS on florinef/midodrine (since 2012), pseudotumor s/p LPS revision most recently 12/16/2014, and MTHFR mutation who presented with acute on chronic refractory headaches, nausea, and vomiting. Urinary incontinence, evaluate for tethering or compression. Brain: Again seen are postsurgical changes of suboccipital craniectomy for Chiari decompression. Low-lying cerebellar tonsils with pointed morphology are unchanged. There are mildly diminished CSF spaces ventrally and dorsally at the foramen magnum but not significantly changed. Biphasic flow is slightly diminished but otherwise preserved ventrally and dorsally. Finding is unchanged. There is a small focus of tenting involving the left dorsal cerebellar surface seen on the high-resolution fiesta sequence which is unchanged since 8/1/2013 and may represent scarring.Compared to MRI dated 5/27/2014, there is slight increase in sagging appearance of the brain with mildly diminished suprasellar cistern compared to prior. There is no restricted diffusion to suggest acute ischemia. No intracranial hemorrhage. No intracranial mass or mass-effect. The ventricles are unchanged in size and configuration without evidence of hydrocephalus. No abnormal parenchymal or meningeal enhancement. Major flow-voids are preserved.There is stable prominence of the pituitary gland measuring up to 11 mm in the craniocaudal dimension and is appropriate for patient's age. Subcentimeter nonenhancing pituitary lesion measuring 3 mm at the junction of the pituitary gland and infundibulum (sagittal postgad series 1801 image 8/15 and axial 3D T1 PG series 1901 image 123/350) remains unchanged since at least 12/31/2013. Mild apparent thickening of the pituitary infundibulum is also unchanged. There is contact of the pituitary gland with the optic chiasm. Paranasal sinuses and mastoid cells are clear. Bone marrow signal and extracranial soft tissues are within normal limits. Complete Spine:No evidence of cervical syrinx or other cord signal abnormality. The spine alignment is anatomic. The vertebral body heights are preserved. Bone marrow signal is within normal limits. No evidence of significant disk disease, spinal canal or neural foramina stenosis. The paraspinal soft tissues and musculature are unremarkable.The conus medullaris normally at mid L1. Filum terminale appear normal in signal intensity, length and caliber. No signal abnormality or masses including lipoma involving the filum terminale. The spinal canal is intact with no evidence of dysraphism. Prone images demonstrate appropriate ventral displacement of the conus.There are several Schmorl nodes of the thoracic spine. There is small disc protrusion at T11-T12 which is stable to minimally minimally more prominent compared to 4/18/2012 and associated with mild indentation of the right ventral cord. No cord signal abnormality.
1. Postsurgical changes of Chiari decompression with no significant change in appearance of the low-lying cerebellar tonsils. There is mildly diminished CSF space ventrally and dorsally which is not significantly changed. Biphasic flow is slightly diminished but otherwise preserved ventrally and dorsally at the foramina magnum. No significant change. There is a small focus of tenting involving the left dorsal cerebellar surface seen on the high-resolution FIESTA sequence which is unchanged since 8/1/2013 and may represent scarring. Compared to 5/27/2014 there is suggestion of brain sagging and slight interval decrease in size of the suprasellar cistern; finding may be related to some intracranial hypotension possibly related to recent lumbar puncture; correlate with any postural component of headaches or low CSF pressures. 2. Unchanged ventricles without evidence of hydrocephalus. No intracranial mass or mass-effect is seen.3. Unchanged prominence of the pituitary gland which measures up to 11 mm in the craniocaudal dimension is appropriate for the patient's age. Tiny 3-mm focus of non-enhancement in the superior aspect of the pituitary gland is unchanged and may represent a tiny microadenoma.4. No evidence of syrinx or other cord signal abnormality. Conus is in normal position. No findings to suggest tethered cord. Appropriate ventral conus motion on the prone sequence.5. Small disk protrusion at the T12-L1 level is stable to minimally more prominent compared to 4/18/2012 and is associated with mild indentation of the right ventral cord at this level.