228 lines
23 KiB
Markdown
228 lines
23 KiB
Markdown
---
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title: "Small Ventricles"
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docid: "2f99bc62-163e-41aa-b190-0da8a4de6d11"
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authors:
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- key: "d19354f3-7ff2-495a-ad3f-064122e45602"
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value: "Bernadette L. Koch, MD"
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- key: "f184750a-90b4-47a7-907b-23b05d70357a"
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value: "Chang Yueh Ho, MD"
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breadcrumbs:
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-
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name: "Brain"
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slug: "brain"
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treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
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-
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name: "Differential Diagnosis"
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slug: "differential-diagnosis"
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treeNodeId: "a7fdd139-664e-4bb8-8d18-400e4733ff60"
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-
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name: "Ventricles, Periventricular Regions"
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slug: "ventricles-periventricular-regions"
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treeNodeId: "353c434a-a6fc-4ef1-8786-d30a1988a4dc"
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-
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name: "Generic Imaging Patterns"
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slug: "generic-imaging-patterns"
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treeNodeId: "969c31a2-ef56-4fc3-9125-05857cf9aac3"
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-
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name: "Small Ventricles"
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slug: "small-ventricles"
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treeNodeId: null
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category: "Brain"
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documentVersionId: "5b4a0ab0-ffd6-4209-a606-7d38fb6ec442"
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imageCount: 27
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lastUpdated: "01/26/23"
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pageDescription: "Small Ventricles"
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pageKeywords: "Brain, Differential Diagnosis, Ventricles, Periventricular Regions, Generic Imaging Patterns, Small Ventricles"
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pageTitle: "Small Ventricles | STATdx"
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enhancedTitle: "Small Ventricles"
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type: "DDX"
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references: true
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breadcrumbs:
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- "Brain"
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- "Differential Diagnosis"
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- "Ventricles, Periventricular Regions"
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- "Generic Imaging Patterns"
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- "Small Ventricles"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Clinical features usually help define cause
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- ## Helpful Clues for Common Diagnoses
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- **Normal Variant (Young Brain)**
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- Small ventricles in children & young adults may be normal
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- Look for visualization of sulci at vertex & sylvian fissures to exclude diffuse cerebral edema
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- **CSF Shunts & Complications**
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- **Slit ventricle syndrome**: Symptoms of ↑ ICP with collapsed shunted ventricles
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- Noncompliant ventricles, stiff brain, or overshunting
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- Anti-siphon devices (gravitational shunt valves) to prevent overshunting
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- **Posttraumatic Brain Swelling**
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- Diffuse edema with sulcal & ventricular effacement
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- Frequently with associated diffuse axonal injury
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- Focal edema from contusions may cause ventricular effacement & herniation
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- **Herniation Syndromes, Intracranial**
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- Ventricular effacement from herniation due to hematoma & tumors
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- Increasing subfalcine herniation → ipsilateral ventricular effacement & contralateral ventricular dilatation
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- **Adult Hypoxic-Ischemic Injury**
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- Hypoxic-ischemic injury (HII) = global HII, global anoxic injury, & cerebral hypoperfusion injury or cerebral hypoperfusion → diffuse cytotoxic edema
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- CT: Diffuse cerebral edema + small ventricles & sulci
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- ↓ gray-white differentiation, hypodense basal ganglia, bright cerebellar reversal sign
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- MR: Diffuse cortical ↑ T2 signal & ↓ diffusion
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- ± pattern of central gray ↓ diffusion
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- **Neonatal Hypoxic-Ischemic Injury**
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- Hypoxic-ischemic encephalopathy from perinatal hypoxia or hypoperfusion
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- Deep or central pattern: Deep gray ± brainstem injury & loss of cortical ribbon on T2WI
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- Most likely to cause small ventricles
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- Peripheral pattern = injury to watershed zones, less likely to cause diffuse cerebral swelling
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- ## Helpful Clues for Less Common Diagnoses
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- **Hyperglycemia**
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- Diabetic ketoacidosis (DKA): Diffuse cerebral edema
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- ± osmotic demyelination
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- **Cerebral Infection**
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- Gray & white matter T2 hyperintensity & edema
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- Mild restriction on DWI common in viral encephalitis
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- **Intracranial Hypotension**
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- "Slumping" midbrain, acquired tonsillar herniation, diffusely enhancing dura, veins/dural sinuses distended
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- Interpeduncular cistern lower than dorsum sella
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- Best evaluated on sagittal images
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- **Idiopathic Intracranial Hypertension**
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- Dilated optic nerve sheaths, posterior globe flattening, empty sella, slit-like ventricles rare
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- ## Helpful Clues for Rare Diagnoses
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- **Inborn Errors of Metabolism (Acute Presentation)**
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- Acute exacerbation + diffuse edema & brain injury → mass effect on ventricles
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## References
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# Selected References
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1. [Panagopoulos D et al: Shunt over-drainage, slit ventricle syndrome, programmable valves and anti-siphon devices. a narrative review of a multifactorial and intractable problem. J Integr Neurosci. 21(3):84, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35633165%5Bpmid%5D)
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1. [Bond KM et al: Spontaneous intracranial hypotension: atypical radiologic ppearances, imaging mimickers, and clinical look-alikes. AJNR Am J Neuroradiol. 41(8):1339-47, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32646948%5Bpmid%5D)
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1. [Kranz PG et al: Spontaneous intracranial hypotension: pathogenesis, diagnosis, and treatment. Neuroimaging Clin N Am. 29(4):581-94, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31677732%5Bpmid%5D)
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1. [Rekate HL: Shunt-related headaches: the slit ventricle syndromes. Childs Nerv Syst. 24(4):423-30, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18259760%5Bpmid%5D)
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## Images
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### Selected Images
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**CSF Shunts & Complications**
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*Axial NECT shows completely collapsed lateral ventricles with a shunt catheter <img src='img/arrows/WS.png'/>. Slit ventricle syndrome must have clinical symptoms of ↑ intracranial pressure with slit appearance of the lateral ventricles due to shunt.*
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**Posttraumatic Brain Swelling**
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*Axial CT in a 9-year-old injured by a horse shows bilateral scalp hematomas, effacement of sulci, loss of gray-white matter differentiation, and small lateral ventricles. Also note small foci of hemorrhagic shear-type injury <img src='img/arrows/WS.png'/> at the gray-white junction in the frontal lobes.*
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**Herniation Syndromes, Intracranial**
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*Axial NECT shows complete loss of the left middle cerebral artery gray-white distinction with cytotoxic edema and left-to-right subfalcine herniation <img src='img/arrows/WS.png'/>. Note the compression of the ipsilateral left lateral ventricle and enlargement of the right lateral ventricle <img src='img/arrows/WO.png'/> from entrapment.*
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**Adult Hypoxic-Ischemic Injury**
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*Axial NECT shows diffuse effacement of ventricles and sulci from diffuse cerebral edema. There is focal symmetric hypodensity of the globi pallidi <img src='img/arrows/WS.png'/> in this patient with a history of cardiogenic shock.*
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**Neonatal Hypoxic-Ischemic Injury**
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*Axial PD MR in a 2-day-old with severe deep/central pattern of hypoxic-ischemic injury demonstrates small lateral ventricles and cerebral sulci, as well as symmetric, hyperintense signal in the bilateral globus pallidus, putamen, and thalamus <img src='img/arrows/WS.png'/>.*
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**Hyperglycemia**
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*Axial NECT in a 12-year-old with altered mental status and diabetic ketoacidosis shows near-complete effacement of the lateral ventricles, perimesencephalic cisterns, and cerebral sulci related to diffuse cerebral edema.*
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**Cerebral Infection**
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*Axial FLAIR MR shows diffuse gray matter swelling and hyperintensity with resulting effacement of the cerebral sulci and right lateral ventricle. This patient eventually succumbed to rabies encephalitis.*
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**Intracranial Hypotension**
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*Sagittal T1 MR shows downward displacement of the cerebellar tonsils <img src='img/arrows/WS.png'/> and brainstem. There is effacement of the suprasellar cistern <img src='img/arrows/WO.png'/>. Note effacement of the interpeduncular cistern <img src='img/arrows/WC.png'/>, which has moved below the level of the dorsum sella, related to "brainstem sagging."*
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### Additional Images
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**CSF Shunts & Complications**
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*Axial NECT shows small ventricles <img src='img/arrows/WS.png'/> and indeterminate shunt position <img src='img/arrows/WO.png'/>. Symptomatic ventricular collapse is known as slit-like ventricle syndrome and suggests overshunting.*
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**Posttraumatic Brain Swelling**
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*Axial GRE MR in an 4-year-old pedestrian struck by a motor vehicle shows scalp swelling, small ventricles and sulci, and multifocal areas of hemorrhagic shear type injury <img src='img/arrows/WS.png'/>.*
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**Posttraumatic Brain Swelling**
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*Axial NECT shows hyperdense foci of diffuse axonal injury <img src='img/arrows/WS.png'/>, which is commonly associated with traumatic cerebral edema. Note sulcal and ventricular effacement <img src='img/arrows/WO.png'/>. Loss of gray-white differentiation is common.*
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**Posttraumatic Brain Swelling**
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*Axial GRE MR shows multiple punctate areas of susceptibility in the subcortical frontal white matter but also in the splenium of the corpus callosum <img src='img/arrows/WS.png'/> from diffuse axonal injury. Less well appreciated on this sequence are small lateral ventricles and cerebral edema.*
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**Herniation Syndromes, Intracranial**
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*Axial NECT shows low-density subacute infarcts in the cerebellar hemispheres. Basal cisterns are effaced <img src='img/arrows/WS.png'/>, as is the 4th ventricle <img src='img/arrows/WO.png'/> in this patient with transtentorial herniation. Herniation syndromes typically result from trauma, ischemia, or mass.*
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**Herniation Syndromes, Intracranial**
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*Axial NECT shows small ventricles and right occipital and vermian <img src='img/arrows/WS.png'/> low density due to infarct. Basal cisterns are effaced. Vermis is herniated upward through the tentorial incisura <img src='img/arrows/WO.png'/>, displacing midbrain anteriorly and superiorly.*
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**Adult Hypoxic-Ischemic Injury**
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*Axial NECT shows a typical case of impending brain death with diffuse cerebral edema. Note diffuse sulcal effacement, small ventricles <img src='img/arrows/WS.png'/>, and decreased gray-white matter differentiation within the cerebral hemispheres.*
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**Adult Hypoxic-Ischemic Injury**
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*Axial PD FSE MR shows enlarged, bilateral, hyperintense deep nuclei <img src='img/arrows/WS.png'/> and small ventricles <img src='img/arrows/WC.png'/> from mass effect in hypoxic-ischemic encephalopathy. Cortical hyperintensity is less prominent than on DWI (not shown) except for more advanced bilateral occipital involvement <img src='img/arrows/BO.png'/>.*
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**Cerebral Infection**
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*Axial FLAIR MR shows near-confluent T2 hyperintensity in the deep white matter <img src='img/arrows/WS.png'/> and small ventricles <img src='img/arrows/WO.png'/> related to mild mass effect from encephalitis.*
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**Cerebral Infection**
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*Axial CECT shows thick, enhancing frontal leptomeninges <img src='img/arrows/WS.png'/> with adjacent frontal lobe hypodensity from edema and mass effect on the frontal horns. This was pyogenic meningitis with adjacent cerebritis.*
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**Cerebral Infection**
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*Axial T1 C+ FS MR shows subtle enhancement of the pial surface of the brain <img src='img/arrows/WS.png'/>. Note associated ependymitis <img src='img/arrows/WC.png'/> and choroid plexitis <img src='img/arrows/WO.png'/>, which may complicate meningitis. Ventricles are small <img src='img/arrows/BS.png'/> due to diffuse brain edema, although when pial exudates obstruct CSF flow, hydrocephalus is more common.*
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**Cerebral Infection**
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*Coronal T1 C+ MR shows meningitis complicated by local cerebritis, as evidenced in this patient with focal mass effect, small ventricles, and ill-defined enhancement <img src='img/arrows/WS.png'/>.*
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**Idiopathic Intracranial Hypertension**
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*Sagittal T1 MR shows an empty sella <img src='img/arrows/WS.png'/> and small ventricles <img src='img/arrows/WC.png'/> in a patient with idiopathic intracranial hypertension or "pseudotumor cerebri."*
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**Idiopathic Intracranial Hypertension**
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*Coronal T1 MR in a young woman with headaches and papilledema shows very small lateral ventricles <img src='img/arrows/WS.png'/>. Superficial sulci <img src='img/arrows/WO.png'/> also look somewhat less prominent than normal. Pituitary gland <img src='img/arrows/WC.png'/> is normal for a young, menstruating female.*
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**Idiopathic Intracranial Hypertension**
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*Axial T2 MR shows increased fluid in the optic nerve sheaths <img src='img/arrows/WO.png'/> and mild flattening of the globes at the optic nerve heads <img src='img/arrows/BO.png'/>. Note the partly empty sella <img src='img/arrows/WS.png'/>. Findings suggest idiopathic intracranial hypertension that can be confirmed with CSF opening pressures.*
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**Intracranial Hypotension**
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*Sagittal T1 MR shows a "slumping midbrain," where the midbrain is displaced below the dorsum sellae <img src='img/arrows/WS.png'/>. Ventricles are commonly small <img src='img/arrows/WC.png'/>. The cerebellar tonsils are typically low-lying or herniated. Diffuse dural enhancement is characteristic. Subdural collections are uncommon (15%).*
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**Intracranial Hypotension**
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*Axial T1 C+ MR shows symmetric, small ventricles <img src='img/arrows/WS.png'/> and smooth, diffuse, linear pachymeningeal thickening and enhancement <img src='img/arrows/WO.png'/>.*
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**Inborn Errors of Metabolism (Acute Presentation)**
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*Axial T2 MR shows diffuse, acute brain swelling in maple syrup urine disease and small ventricles due to subacute edema of deep white matter <img src='img/arrows/WO.png'/>, thalami <img src='img/arrows/WC.png'/>, and internal capsules.*
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**Intracranial Hypotension**
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*Axial T1 C+ MR shows diffuse dural enhancement <img src='img/arrows/WS.png'/> and leptomeningeal enhancement <img src='img/arrows/WO.png'/> from venous distention. There are small lateral ventricles. Intracranial hypotension is commonly from CSF leak through a dural defect or from LP.*
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