Abstract Details

Title Venous Engorgement as a Pitfall: Postpartum Intracranial Hypotension Mimicking Pituitary Mass

Topic Headache

Presentation(s) P6 - Poster Session 6 (5:00 PM-6:00 PM)

Poster/Presentation
Number 15-011

Objective To describe a postpartum case of intracranial hypotension presenting with pituitary enlargement mimicking a sellar mass, emphasizing venous engorgement as an underrecognized imaging feature and highlighting diagnostic and therapeutic challenges.

Background Intracranial hypotension classically presents with orthostatic headache and MRI findings such as pachymeningeal enhancement and brain sag. Pituitary enlargement from venous engorgement is less widely emphasized and may be misinterpreted as macroadenoma or physiologic postpartum hyperplasia, delaying correct diagnosis and treatment.

Design/Methods A 25-year-old woman developed severe, near-constant headaches within five days postpartum after a technically challenging epidural. Associated symptoms included photophobia, nausea, and fluctuating blurred vision (left greater than right), with improvement when supine. Concern for abnormal fundus appearance on bedside exam prompted hospital evaluation. She underwent multimodal imaging and subspecialty consultations.

Results Brain MRI demonstrated diffuse pachymeningeal enhancement, midbrain sagging, and pituitary enlargement displacing the optic apparatus. MR venography was normal. Ophthalmology exam showed 20/20 OD and 20/25 OS vision, sharp discs, and no papilledema or hemorrhages, suggesting venous congestion rather than raised intracranial pressure. Spine MRI revealed long-segment dorsal dural displacement and extensive thoracolumbar extradural T2/STIR hyperintensity, interpreted as epidural venous engorgement in the setting of CSF hypotension. An epidural blood patch produced immediate headache relief, but symptoms recurred after several days at reduced intensity, now responsive to acetaminophen. At neurosurgical follow-up, she continued to report low-pressure headaches, and repeat pituitary MRI was recommended for ongoing evaluation.

Conclusions

Pituitary enlargement in intracranial hypotension reflects venous engorgement and can mimic mass lesions or be misattributed to postpartum physiology. This case underscores the importance of considering intracranial hypotension in postpartum headache, recognizing pituitary hyperemia as part of the imaging spectrum, and appreciating that treatment often requires repeat or targeted interventions.

Authors/Disclosures
Shawn J. Marcell, MD (LSU Department of Neurology) PRESENTER	Dr. Marcell has nothing to disclose.
Anthony Pham, MD (LSUHSC)	Dr. Pham has nothing to disclose.
Nina Patel	Ms. Patel has nothing to disclose.
Brian J. Copeland, MD (LSU Health Sciences Center-New Orleans)	Dr. Copeland has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Teva Neurosciences. The institution of Dr. Copeland has received research support from Ipsen Biopharmaceuticals.
Rima N. El-Abassi, MD (LOUISIANA STATE UNIVERSITY)	Dr. El-Abassi has nothing to disclose.

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