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: