case_images: PMC7265414_01
case_images: Previous MRI (a) High-resolution T2 MRI showing cerebral aqueduct stenosis/web. (b) Axial FLAIR MRI showing abnormal signal in the optic chiasm extending to bilateral optic tracts and in the midbrain from the interpeduncular fossa extending between the red nuclei to the area of the oculomotor nuclei.
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case_images: PMC7265414_01_SNI-11-98-g004.jpg
case_images: F4
case_images: On MRI later in 2018, she was found to have new fluid-attenuated inversion recovery (FLAIR) signal changes in bilateral optic nerves and the midbrain [Figure 4], SWI and DWI were normal.
case_images: Preshunt adjustment axial T1 MRI demonstrating slit ventricles suggestive of shunt overdrainage.
case_images: SNI-11-98-g005.jpg
case_images: PMC7265414_01_SNI-11-98-g005.jpg
case_images: F5
case_images: There were no FLAIR changes or evidence of mechanical distortion from brain 'sag' [Figures 5 and 6].
case_images: Preshunt adjustment sagittal T2 MRI showing normal 4th ventricle and cistern spaces, no distortion of brainstem or splenium and no tonsillar herniation.
case_images: SNI-11-98-g006.jpg
case_images: PMC7265414_01_SNI-11-98-g006.jpg
case_images: F6
case_images: There were no FLAIR changes or evidence of mechanical distortion from brain 'sag' [Figures 5 and 6].
case_images: Five months postshunt adjustment looking straight ahead with no downward gaze preference, strabismus or ptosis. Subtle horizontal divergence.
case_images: SNI-11-98-g007.jpg
case_images: PMC7265414_01_SNI-11-98-g007.jpg
case_images: F7
case_images: During her admission, the VP Codman Certas shunt settings were changed from 4 to 5 which gave her marked improvement with nystagmus, postural symptoms, and the ability to move her eyes above midline when looking up, however, not full resolution of the upgaze palsy [Figures 7-9].
case_images: Five months postshunt adjustment looking down. Left eye deviation laterally.
case_images: SNI-11-98-g008.jpg
case_images: PMC7265414_01_SNI-11-98-g008.jpg
case_images: F8
case_images: During her admission, the VP Codman Certas shunt settings were changed from 4 to 5 which gave her marked improvement with nystagmus, postural symptoms, and the ability to move her eyes above midline when looking up, however, not full resolution of the upgaze palsy [Figures 7-9].
case_images: Five months postshunt adjustment attempting to look upward. Persistent upgaze limitation with lateral deviation of the left eye.
case_images: SNI-11-98-g009.jpg
case_images: PMC7265414_01_SNI-11-98-g009.jpg
case_images: F9
case_images: During her admission, the VP Codman Certas shunt settings were changed from 4 to 5 which gave her marked improvement with nystagmus, postural symptoms, and the ability to move her eyes above midline when looking up, however, not full resolution of the upgaze palsy [Figures 7-9].