Clinical Images

The “Wrinkle Sign” in Time-of-Flight Magnetic Resonance Venography is a Hallmark of

Idiopathic Intracranial Hypertension
Zhouyang Jiang, Wenyu Shao, Wenyan Li

Key words Idiopathic intracranial hypertension (IIH) is usually caused by sinus stenosis,
- Endovascular intervention which manifests in magnetic resonance venography (MRV) as occlusion or
- Idiopathic intracranial hypertension
- TOF MRV
intraluminal webbing. We present the case of a 27-year-old patient with IIH, and
time-of-flight (TOF) MRV only exhibited a rare “wrinkle sign,” which was
Abbreviations and Acronyms eventually proved to indicate sinus obstruction. The patient received venting and
IIH: Idiopathic intracranial hypertension
recovered. The TOF MRV provides a nonradioactive approach to identify IIH
MRV: Magnetic resonance venography
TOF: Time-of-flight patients who potentially need intervention.

Department of Neurosurgery, Southwest Hospital, Third

Military Medical University, Chongqing, China
To whom correspondence should be addressed:
Wenyan Li, M.D.
[E-mail: lwy243@tmmu.edu.cn]
Zhouyang Jiang and Wenyu Shao contributed equally to this
work.
Citation: World Neurosurg. (2024) 183:204e205.
https://doi.org/10.1016/j.wneu.2023.12.093
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2023 Elsevier Inc. All
rights reserved.
CLINICAL IMAGE
Idiopathic intracranial hypertension (IIH)
is a rare neurologic disorder that is often
seen in obese women aged 20e24 years
with a prevalence of approximately 19/
100,000. Common symptoms of IIH
include headache, transient blurred vision,
optic papilledema, diplopia, and pulsatile
tinnitus. The currently accepted diagnostic
criteria include clinical signs and symp-
a cerebrospinal fluid pressure of 360 mm
H2O indicated IIH (Figure 1A).
Meanwhile, time-of-flight (TOF) MR
venography (MRV) revealed no significant
findings but a heterogeneous signal dis-
tribution of the right transverse sinus,
which we described as the “wrinkle sign”
that has rarely been reported (Figure 1C).
Obtaining his informed consent,
venography and venous sinus manometry
were performed to confirm a pressure
gradient of 18 mm Hg within the right
transverse sinus under awake setting
(Figure 1D). Following the stenting, the
pressure within right transverse sinus
dropped to 6 mm Hg, with gradually
relieved diplopia and headache
(Figure 1E and B).
This case demonstrates an easily
neglected “wrinkle sign” with TOF MRV,
which implies functional obstruction of
the venous sinuses, leading to uneven
distributed signals.1 It is presumably
CRediT AUTHORSHIP CONTRIBUTION
STATEMENT
Zhouyang Jiang: Investigation, Visualiza-
tion. Wenyu Shao: Writing e original
draft. Wenyan Li: Supervision, Writing e
review & editing.
REFERENCES
1. Sundararajan SH, Ramos AD, Kishore V, et al.
Dural venous sinus stenosis: why distinguishing
intrinsic-versus-extrinsic stenosis matters. AJNR Am
J Neuroradiol. 2021;42:288-296.
2. Markey KA, Mollan SP, Jensen RH, Sinclair AJ.
Understanding idiopathic intracranial hyperten-
sion: mechanisms, management, and future di-
rections. Lancet Neurol. 2016;15:78-91.
Conflict of interest statement: Chongqing medical scientific
research project (Joint project of Chongqing Health
Commission and Science and Technology Bureau)
(2024MSXM010, 2023MSXM102). Senior Medical Talents
Program of Chongqing for Young and Middle-aged.
Received 29 July 2023; accepted 16 December 2023

toms of elevated intracranial pressure, due to intracavity segmentation, which Citation: World Neurosurg. (2024) 183:204e205.

lumbar puncture pressure >25 cm H2O, causes fluid obstruction yet without https://doi.org/10.1016/j.wneu.2023.12.093

imaging features of magnetic resonance apparent morphologic changes.2 Journal homepage: www.journals.elsevier.com/world-

imaging, normal cerebrospinal fluid find- Therefore the “wrinkle sign” in TOF neurosurgery

MRV is suggested to be an important Available online: www.sciencedirect.com

ings, and exclusion of other causes of
hallmark of IIH, also proving TOF MRV 1878-8750/$ - see front matter ª 2023 Elsevier Inc. All
increased intracranial pressure.
as a nonradioactive approach to identify rights reserved.
Our image is of a 27-year-old man who
presented with diplopia and headache for potential IIH patients who require
2 months. Negative magnetic resonance stenting.
imaging findings, optic papilledema, and

204 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2023.12.093


ZHOUYANG JIANG ET AL.
Figure 1. Images of a 27-year-old man who presented
with diplopia and headache for 2 months. Time-of-flight
magnetic resonance venography (TOF MRV)
demonstrated a “wrinkle sign,” which is easily
neglected. Being diagnosed with idiopathic intracranial
hypertension, venography and venous sinus
manometry further confirmed the obstruction within
the right transverse sinus. (A) Fundus photography
WORLD NEUROSURGERY 183: 204e205, MARCH 2024
CLINICAL IMAGES
“WRINKLE SIGN” IMPLIES POOR SINUS DRAINAGE
before treatment. (B) Fundus photography after
venting. (C) TOF MRV exhibits a “wrinkle sign” in the
right transverse sinus, as indicated by a red arrowhead.
(D) Venography and venous sinus manometry before
venting. Arrows indicate the positions where
manometry is performed. (E) Venography and venous
sinus manometry after venting. Arrows indicate the
positions where manometry is performed.
www.journals.elsevier.com/world-neurosurgery 205