Case - 50 yo male,

[jmj11]

Life long history of chonic holocephalic headache.  He has been diagnosed as "tension headache" (whatever that really is) and chronic migraine. He has tried almost everything you can imagine with absolutely no benefit. he has had normal CT scans.  He has had a marginal normal MRI. What do you see here? What image is this? What is the mechanism of what you see that possibly (not certain yet) could be causing his constant headache?  Any guesses?

[badwolf]

Just a student here, but I'll take a guess. Filling defect caused by arachnoid granulation of the superior sagittal sinus.

[jmj11]

Just a student here, but I'll take a guess. Filling defect caused by arachnoid granulation of the superior sagittal sinus.

Excellent response! Actually it is a cystic formation but you got the geography correct. So how could this little cyst cause daily headaches?

[badwolf]

I am thinking that the lesion creates a venous sinus pressure gradiant resulting in headache.

[jmj11]

I am thinking that the lesion creates a venous sinus pressure gradiant resulting in headache.

This must have been too easy. You should be proud of yourself because I would not have know this as a student. There is probably an intermittent increased spinal fluid pressure elevation too (opening pressures were normal).

[badwolf]

Thank you, but it wasn't easy. I did take my time thinking about it and studying the image. I appreciate these patient cases, because they are challenging and a great learning experience. Thank you for posting.