Abstract
Sitting in my office, drinking coffee and studying another patient's images, I all of a sudden spotted something interesting. Inspired by a musical hero of mine, I saw what appeared to be a wolf head inside this patient's brain.
James Hetfield from Metallica used to wear a wolf head pendant on his chest (Figure A). Strikingly, my patient's ventricles had the exact same shape of a wolf's head when viewed in a coronal plane at the level of the foramen of Monro (Figure B).
Following this notion, I further examined the anatomic details. I found that the eyes of the animal were extremely dilated fornices, bilaterally opening to the body of the fornix.
The head of the wolf was formed by a dilated cyst of the septum pellucidum, with a maximal diameter of 25 mm. Lateral bowing of the septum pellucidum's leaflets together with distant caudate nuclei create the animal's cheeks.
Bowed lateral ventricles form the ears. The patient's third ventricle forms the muzzle of the wolf, and on the muzzle, the shade of the anterior commissure creates a picture of a wolf baring its teeth.
An anatomically perfect image of a wolf's head. I searched the internet and found that no-one else seems to have noticed this sign before-the wolf sign-the sign that corresponds to a large cyst of the septum pellucidum and perhaps a clear-cut indication for endoscopic fenestration of the cyst, certainly in a symptomatic patient.
Our patient was symptomatic, suffering with acute episodic headaches and memory impairment with a decline in scholastic performance along with other neuropsychologic symptoms and thus was indicated for neuroendoscopic fenestration of the cyst. Due to a very low incidence of this type of cyst, around 0.04%,1 we might never see such a perfect and complete wolf sign again, but it does show that being a fan of Metallica has all sorts of educational benefits.