Transcranial Doppler Ultrasonography Identifies Symptomatic Cavum Septum Pellucidum Cyst: Case Report

Abstract

Objective: Cavum Septum Pellucidum (CSP) cysts are considered normal anatomic variants, comprising as many as 15% of the adult
and 85% of pediatric populations. On rare occasions, the cavum can obstruct CSF outflow from the lateral ventricles causing elevated
intracranial pressure (ICP) and headaches. The purpose of this paper is to present a challenging case of new onset symptomatic CSP in a
previously healthy adult male without papilledema and elevated ICP detected
by transcranial Doppler (TCD) ultrasonography.
Clinical Presentation: A previously healthy 44 year-old man presented to the
neurology service with debilitating positional headaches that were mitigated
solely by recumbent positioning. A magnetic resonance imaging scan (MRI)
of the brain revealed a cavum septum pellucidum. A lumbar puncture
was performed and revealed normal ICP. No papilledema was evident on
fundoscopic examination. A CSF flow study revealed normal dye opacification
pattern without evidence of CSF leak.
Intervention: Without other clinical indicators of high ICP, but a history
suspicious for symptomatic CSP, TCD study was performed and revealed
abnormally low cerebral blood flow velocities (CBFV’s) and significantly
elevated pulsatility indices (PI’s) for patient’s age indicative of high ICP.
Endoscopic fenestration of the septum pellucidum was performed improving
the patient’s headaches and normalization of the PI’s and CBFV’s to normal
(p<0.01).
Conclusions: Symptomatic CSP is a difficult diagnosis to make based on existing
diagnostic paradigm. TCD in the absence of other objective confirmatory
studies, can aid in the diagnosis and provide information about the success of
fenestration of the cavum septum.