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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 59, Num. 3, 2011, pp. 493-494

Neurology India, Vol. 59, No. 3, May-June, 2011, pp. 493-494


Authors' reply

A Sen, C Kesavdas

Imaging Sciences and Interventional Radiology, SCTIMST, Thiruvananthapuram, Kerala, India

Correspondence Address: C Kesavdas Imaging Sciences and Interventional Radiology, SCTIMST, Thiruvananthapuram, Kerala India

Date of Submission: 01-May-2011
Date of Decision: 16-May-2011
Date of Acceptance: 16-May-2011

Code Number: ni11154


We agree with Dr. Saifudheen comments, [1] that fluctuation in intracranial pressure may have a role in the etiopathogenesis of intermittent cerebral herniation and CSF rhinorrhea; in fact, we have concluded our letter [2] saying that its role should be studied. However, our patient had no definite features of idiopathic intracranial hypertension (IIH). There was no clinical suspicion of intracranial hypertension or evidence of papilledema. Other than an empty sella and a mildly prominent perioptic nerve sheath fluid, none of the other classical radiological signs [3],[4],[5] of intracranial hypertension (such as vertical buckling of optic nerve and flattening of the posterior sclera) were present.

Noting the finding of an empty sella we had raised the possibility of intracranial hypertension and had suggested CSF pressure recording to our referring clinicians for completion of workup. Since the patient had become asymptomatic after the lumbar puncture done to rule out meningitis, the clinicians were reluctant to repeat the procedure for a pressure recording. The possibility that CSF pressure could be low during the asymptomatic period was also considered. The patient has been discharged. The referring clinicians have agreed to do a CSF pressure recording if the patient presents again with headache or CSF rhinorrhea.


1.Saifudheen K. Intermittent herniation of brain causing intermittent cerebrospinal fluid rhinorrhea. Neurol India 2011;59:493.  Back to cited text no. 1  [PUBMED]  
2.Sen A, Kesavadas C. Intermittent herniation of brain: A rare cause of intermittent cerebrospinal fluid rhinorrhea. Neurol India 2011;59:131-2.  Back to cited text no. 2    
3.Brodsky MC, Vaphiades M. Magnetic resonance imaging in pseudotumor cerebri. Ophthalmology 1998;105:1686-93.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Jinkins JR, Athale S, Xiong L, Yuh WT, Rothman MI, Nguyen PT. MR of optic papilla protrusion in patients with high intracranial pressure. AJNR Am J Neuroradiol 1996;17:665-8.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Gass A, Barker GJ, Riordan-Eva P, MacManus D, Sanders M, Tofts PS, et al. MRI of the optic nerve in benign intracranial hypertension. Neuroradiology 1996;38:769-73.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]

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