An 18-year-old woman with a history of acne comes to her primary care physician because of headaches for the past 3 months. The headaches are holocranial and pulsatile in quality. They are worsened by lying flat and improved by sitting up. She also experiences blurry vision and a "whooshing sound" occurring with the headaches. She denies photophobia, fever, nausea, and vomiting during the headaches. The headaches occur daily and fluctuate in intensity. Her current medications include isotretinoin for her acne. She has no known drug allergies. She does not use alcohol, tobacco, or illicit drugs.
Her blood pressure is 130/70 mm Hg and pulse is 70/min. Her BMI is 34 kg/m².
Which of the following should be closely examined during the neurologic evaluation of this patient?

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Quizplus · Accepted Answer

11ec193a_9873_8e5c_853d_55092450ec83_MD0002_00 This patient presents with idiopathic intracranial hypertension (IIH) (i.e., pseudotumor cerebri). The clinical symptoms of IIH are summarized in the above table and include a chronic pulsatile and holocranial headache worsened by lying flat and ameliorated by sitting up. IIH is likely caused by either excess cerebrospinal fluid (CSF) production or inadequate CSF absorption. The presence of normal imaging and elevated CSF opening pressure (>250 mm H2O) confirms the diagnosis. Although IIH is frequently seen in young obese women, it has also been associated with certain medications/vitamins (e.g., isotretinoin, tetracyclines, growth hormone, and vitamin A). Patients frequently complain of visual symptoms associated with the headaches (e.g., transient visual obscurations and blurry vision). The optic nerves are at risk of being damaged secondary to the increased intracranial pressure, and should be closely examined by funduscopy and confrontational visual field testing. Ocular motility should also be examined to rule out abducens nerve palsy. Patients who exhibit symptoms of impending visual loss need to be emergently evaluated by neurosurgery for ventriculoperitoneal shunting or optic nerve fenestration. (Choice A) Coordination with finger-to-nose and heel-to-shin maneuvers is used to test for cerebellar function and is usually normal in IIH. (Choice B) Myotatic stretch reflexes are usually normal in IIH and usually affected by either cortical disease or spinal cord injury. (Choice D & E) Pain and temperature sensations and tandem gait are usually unaffected by IIH. Educational objective: Idiopathic intracranial hypertension (i.e., pseudotumor cerebri) presents with a chronic, holocranial, and pulsatile headache worsened by lying flat and ameliorated by sitting up. The diagnosis requires normal imaging and elevated cerebrospinal fluid opening pressure (>250 mm H2O). The optic nerves are frequently affected; therefore, dedicated visual field testing and funduscopy need to be performed to rule out impending visual loss. __________ References: Pseudotumor cerebri (http://www.ncbi.nlm.nih.gov/pubmed/20721668) Update on idiopathic intracranial hypertension. (http://www.ncbi.nlm.nih.gov/pubmed/21696699)

An 18-Year-Old Woman with a History of Acne Comes to Her