2026 Poster Presentations
P287: REGRESSION OF SYMPTOMATIC PITUITARY ENGORGEMENT FROM INTRACRANIAL HYPOTENSION AFTER EPIDURAL BLOOD PATCH
Akshay Save, MD; Carter Suryadevara, MD, PhD; Donato Pacione, MD; NYU Langone Health
Introduction: Intracranial hypotension is an increasingly diagnosed and recognized condition, most commonly resulting in postural headaches, neck stiffness, nausea, dizziness, and blurry vision. The causes are divided into two categories: spontaneous and iatrogenic. Spontaneous causes include cerebrospinal fluid-venous fistulas and post-traumatic, whereas iatrogenic causes are usually post lumbar puncture or after cerebrospinal fluid leak in spine surgery. Radiographic magnetic resonance imaging findings for intracranial hypotension include pachymeningeal enhancement, drooping of the splenium of the corpus callosum, pituitary engorgement, and in severe cases subdural hygromas/hematomas.
Case Presentation: We present the case of a 39-year-old female who presented with positional headaches, blurry vision, and left cranial nerve VI palsy one week post-partum. She had an uncomplicated vaginal delivery at an outside hospital with an epidural anesthesia catheter for pain control. There was no concern for cerebrospinal fluid leak during placement or removal of the epidural catheter. One week after the procedure she represented to the outside hospital with unremitting postural headaches and she was noted to have diplopia and blurry vision on left lateral gaze. A noncontrast MRI was obtained at the outside hospital and was interpreted as concerning for pituitary apoplexy with possible underlying pituitary macroadenoma. She was transferred to our institution for potential skull base intervention. At our hospital, a dedicated pituitary MRI study with and without contrast was obtained which showed diffuse pituitary engorgement and pachymeningeal enhancement concerning for intracranial hypotension (Figure 1). Her serologic endocrine studies were only notable for elevated prolactin in the post-partum setting. An MRI of the lumbar spine was obtained which revealed a fluid collection spanning L1-L4 as well as STIR changes in the interspinous space at L3-4 (Figure 2) consistent with post-procedure cerebrospinal fluid leak from epidural catheter placement.
She underwent an epidural blood patch in sitting position, which resulted in significant improvement of headaches and diplopia. She had persistent but slightly improved blurry vision after the procedure. The patient was discharged home on post procedure day 1. Three weeks after discharge, she had a repeat MRI of the brain and pituitary which showed significant regression of the pituitary gland and decrease in pachymeningeal enhancement (Figure 3). There was no evidence of a pituitary macroadenoma on repeat imaging. Clinically, she had full resolution of her postural headaches, double vision, and diplopia.
Conclusions: Intracranial hypotension can be mistaken for pituitary apoplexy. In patients who have undergone recent spinal procedures, there must be a high index of suspicion for post procedural cerebrospinal fluid leak
Figure 1
Coronal T1 post contrast and T2 sequences showing sellar engorgement and pachymeningeal enhancement
Figure 2
Sagittal MRI STIR sequence showing interspinous ligament hyperintensity and fluid collection consistent with iatrogenic cerebrospinal fluid leak
Figure 3
Coronal T1 post contrast and T2 sequences three-weeks after blood patch showing significant improvement in sellar engorgement and resolution of pachymeningeal enhancement.