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Background: Fourth ventricular outlet obstruction is an infrequent but well-established cause of tetraventricular hydrocephalus characterized by marked dilatation of the ventricular system with ballooning of the foramina of Monro, Magendie, and Luschka. Multiple processes including inflammation, infection, hemorrhage, neoplasms, or congenital malformations are known to cause this pathological obstruction. However, true idiopathic fourth ventricular outlet obstruction is a rare phenomenon with only a limited number of cases reported in the literature. Case Description: A 61-year-old female presented with several months of unsteady gait, intermittent headaches, confusion, and episodes of urinary incontinence. Conventional magnetic resonance imaging demonstrated tetraventricular hydrocephalus without transependymal flow, but with ventral displacement of the brainstem and dorsal displacement of the cerebellum without an obvious obstructive lesion on pre- or post-contrast imaging prompting a diagnosis of normal pressure hydrocephalus. However, constructive interference in steady state (CISS) and half-Fourier acquisition single-shot turbo spin echo (HASTE) sequences followed by fluoroscopic dynamic cisternography suggested encystment of the fourth ventricle with thin margins of arachnoid membrane extending through the foramina of Luschka bilaterally into the pontocerebellar cistern. Operative intervention was pursued with resection of an identified arachnoid web. Postoperative imaging demonstrated marked reduction in the size of ventricular system, especially of the fourth ventricle. The patient’s symptomatology resolved a few days after the procedure. Conclusion: Here, we describe an idiopathic case initially misdiagnosed as normal pressure hydrocephalus. The present case emphasizes the necessity of CISS sequences and fluoroscopic dynamic cisternography for suspected cases of fourth ventricular outlet obstruction as these diagnostic tests may guide surgical management and lead to superior patient outcomes.

Background:Cauda equinasyndrome (CES) is an uncommon entity that presents acutely with all or some of the following symptoms; urinary incontinence from retention, fecal incontinence from loss of sphincter tone, saddle area hypoesthesia or anesthesia, and acute or progressive weakness in one or both lower extremities. The protean symptomatology is often mixed and is vulnerable to confounding comorbidities making the accurate and timely diagnosis of this syndrome uniquely challenging. Here, we present the case of a man who developed isolated sacral nerve dysfunction from CES in the midst of a diabetic crisis.Case Description:A 53-year-old male with a long history of uncontrolled Type 2 diabetes presented with acute-onset urinary and fecal incontinence, scrotal anesthesia, and a 3-day history of lower back pain with intermittent bilateral leg pain. This patient displayed no objective changes in leg strength, sensation, or reflexes. In addition, the patient tested positive for cocaine and had a blood glucose level of 800 mg/dL which confounded his clinical picture. The patient underwent bilateral laminectomies from L4–S1 with the removal of a large sequestered disc fragment from the S1–S2 disc space within 8 h of presentation with reasonable recovery.Conclusion:Highly variable presentations often confound the accurate and timely diagnosis of CES with severe implications on quality of life. Despite the limited functional recovery seen after surgical decompression, urgent or emergent intervention is paramount for treatment. Our patient’s presenting symptomatology and comorbidities highlight the need for practitioners to maintain a high index of suspicion in anyone with incontinence and back pain, regardless of distractors and even in the absence of other anticipated motor or sensory findings.