Headaches and Transient Bi-lateral Vision Loss in a 29-year-old Woman
A 29-year-old woman presents complaining of headaches for the past two months. She describes the headache severity as 5 to 6 on a 10-point scale; she has not had vomiting associated with the headaches. She has noticed occasional tinnitus that seems to be syncopated with her pulse. Upon rising from a seated or lying position, she experiences transient bilateral loss of vision.
Past medical history is unremarkable, and the patient is otherwise healthy. Family history is unremarkable. The patient reports no allergies to medications. The only medication she currently uses is topical retinoic acid for acne.
Blood pressure is normal, as is the general physical exam. At 5 feet 3 inches tall and 225 lbs., she is at least 75 lbs. overweight. Visual acuity is 20/25 in the right eye; 20/20 in the left. She has an increased blindspot and arcuate scotoma on automated perimetry. Pupils are normal; no afferent pupillary defect is evident. Her ocular motility is normal. Her funduscopic exam reveals marked elevation of both optic nerves, suggesting papilledema. Her neurologic exam is otherwise normal.
What is the likely diagnosis? What tests would you order?
The patient’s current complaints are suggestive of idiopathic intracranial hypertension (IIH), commonly known as pseudotumor cerebri. It is critical to confirm this diagnosis and rule out an actual tumor. Consultation with an ophthalmologist or neuroophthalmologist to assess the presence of papilledema from IIH or other causes is helpful. CT scan with and without contrast or MRI should be performed to rule out an actual tumor. Magnetic resonance venography can help to rule out venous sinus obstruction.
The modified Dandy criterion for increased intracranial pressure (ICP) is an ICP greater than 250mm water. Certain medications are known to induce pseudotumor cerebri, including oral contraceptive pills, tetracycline, sulfa antibiotics, and retinoic acid/vitamin A derivatives. Studies suggest that weight loss can lead to improvement of papilledema. There is no treatment for drusen. Patients should be counseled about the condition. Typically, the patient must understand that there is no treatment and the condition is not typically progressive, but they should return for regular evaluations.
Excerpted with permission from Practical Neurology, October 2009; practicalneurology.net
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