A sinking feeling

<h3></h3> A 60 year old women with a previous high functioning career had a 2 year change in personality, inability to work, impulsivity, apathy, disinhibition. She presented with dysarthria, dysphagia, difficult walking. She would sit in the hospital bed lyng forward onto her legs. Cognitive testing revealed a dysexecutive syndrome and impulsivity. MRI brain scan showed Frontal Brain Sag. A SPECT scan showed frontal lobe hypoperfusion. An MR myelogram did not reveal any leak from the spine. She was managed with support and carers but had a community Deprivation of Liberty for over 2 years due to lack of capacity and putting herself at risk living on her own; leaving gas ovens on, eating food that has started to go off and not maintaining personal hygiene. Approximately 2 years after presentation a dynamic CT myelogram revealed a CSF to vein fistula. This was surgically excised in January 2023. In January 2024 the structural MRI shows almost complete resolution of the brain sag. Clinically she has improved with more rational approach, calmer but still has difficulty planning. We will present neuroimaging MRI, SPECT, CT myelogram, surgical video and follow-up data to April 2024.