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“Face of the giant panda” and hydrocephalus

      Highlights

      • The face of the giant panda is a MRI sign in Wilson’s disease.
      • Non-pathological age-related iron accumulations is frequently seen in the red nuclei and the substantia nigra.
      • Due to a flow void in the aqueduct in NPH patients, the MRI looks very similar to the face of the giant panda.

      1. Case description

      A 67-year-old man presented with a 6-months-history of marked gait disturbance referred to as magnetic gait. There were no other complaints. His medical history was insignificant, and he had no family history of neurological disorders. Routine bloodwork and CSF were unremarkable. The CSF opening pressure was 17 cm H2O. MRI scan of the brain showed a communicating hydrocephalus, but also “the face of the giant panda” (Fig. 1).
      Figure thumbnail gr1
      Fig. 1T2-weighted MRI reveals an hydrocephalus and a face of the giant panda in the brainstem.
      The most likely diagnosis is:
      • (A)
        Parkinson’s disease
      • (B)
        Wilson’s disease
      • (C)
        Normal pressure hydrocephalus
      • (D)
        Progressive supranuclear palsy

      2. Answer

      After tapping 30 cc cerebrospinal fluid, the gait disturbance improved remarkably for a short period of time. The diagnosis of normal pressure hydrocephalus (NPH) was made. After placement of a lumbar peritoneal shunt the gait improvement became permanent.
      The face of the giant panda has generally been described in Wilson’s disease [
      • Gupta A.
      • Chakravarthi S.
      • Goyal M.K.
      ‘Face of giant panda’: a rare imaging sign in Wilson's disease.
      ]. However, the clinical presentation of our patient was not suspicious for this disease, and copper and ceruloplasmin values were normal. The face of the giant panda in Wilson’s disease is caused by T2 hyperintensity in the midbrain tegmentum with relative sparing of the red nuclei (eyes), the pars reticulata of the substantia nigra (ears) and the superior colliculus (mouth). In this case the “eyes” and “ears” of the panda are non-pathological age-related iron accumulations in the red nuclei and the pars reticulate of the substantia nigra respectively [
      • Aquino D.
      • Bizzi A.
      • Grisoli M.
      • Garavaglia B.
      • Bruzzone M.G.
      • Nardocci N.
      • et al.
      Age-related iron deposition in the basal ganglia: quantitative analysis in healthy subjects.
      ]. The “mouth” of the panda is actually a flow void in the aqueduct caused by higher than normal flow velocity of cerebrospinal fluid. This flow void is frequently present in patients with NPH [
      • Krauss J.K.
      • Regel J.P.
      • Vach W.
      • Jüngling F.D.
      • Droste D.W.
      • Wakhloo A.K.
      Flow void of cerebrospinal fluid in idiopathic normal pressure hydrocephalus of the elderly: can it predict outcome after shunting?.
      ]. The combination of non-pathological age-related iron accumulations and a flow void creates an image almost similar to the face of the giant panda, however in our case it is more a pseudo face of the giant panda, because there is no association with Wilson’s disease.

      Appendix A. Supplementary data

      The following are the Supplementary data to this article:

      References

        • Gupta A.
        • Chakravarthi S.
        • Goyal M.K.
        ‘Face of giant panda’: a rare imaging sign in Wilson's disease.
        QJM. 2014; 107: 579
        • Aquino D.
        • Bizzi A.
        • Grisoli M.
        • Garavaglia B.
        • Bruzzone M.G.
        • Nardocci N.
        • et al.
        Age-related iron deposition in the basal ganglia: quantitative analysis in healthy subjects.
        Radiology. 2009; 252: 165-172
        • Krauss J.K.
        • Regel J.P.
        • Vach W.
        • Jüngling F.D.
        • Droste D.W.
        • Wakhloo A.K.
        Flow void of cerebrospinal fluid in idiopathic normal pressure hydrocephalus of the elderly: can it predict outcome after shunting?.
        Neurosurgery. 1997; 40: 67-73