Teaching NeuroImages: Transependymal Oozing of Intrathecal Contrast Mimicking Intracerebral Hemorrhage

A 58-year-old woman presented with headache and nausea after resection of a craniocervical junction meningioma. CT head showed acute hydrocephalus (figure, A). CT ventriculogram showed no concern for CSF leak. Contrast remained in the ventricles on first postprocedure image (figure, B), but repeat CT head showed transependymal movement of contrast into brain parenchyma over the next several days (figure, C–F). Glymphatic clearance of intrathecal contrast has been shown to be reduced in patients with idiopathic normal-pressure hydrocephalus, which may facilitate intraparenchymal oozing.1 It may linger after intrathecal contrast has washed out and is indistinguishable from blood without dual-energy CT.2

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