A 22-year-old woman comes to the physician with headaches for the last 6 weeks. The headaches are pulsatile in quality and associated with nausea. They are worse at night and awaken her from sleep. She has no photophobia, weakness, sensory abnormalities, or history of trauma. The patient takes no medications. Her body mass index is 33 kg/m². Neurologic examination is unremarkable. Funduscopy shows papilledema. Computed tomography scan of the brain shows no abnormalities. Lumbar puncture shows an elevated opening pressure with otherwise normal cerebrospinal fluid analysis. Which of the following is the most appropriate next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: This patient's presentation suggests idiopathic intracranial hypertension (IIH) or pseudotumor cerebri. Diagnosis is considered in patients with the following: Features of increased intracranial pressure in an alert patient Absence of focal neurologic signs except for sixth nerve palsy No evidence for other causes (eg, tumors) of increased intracranial hypertension on neuroimaging Normal cerebrospinal fluid (CSF) examination except for increased CSF opening pressure Treatment goals for IIH are prevention of vision loss, reduction of intracranial pressure, and symptomatic relief of headaches. Funduscopy and routine monitoring of visual acuity and visual fields are required to prevent vision loss. IIH can be caused by certain medications (eg, tetracyclines, isotretinoin), which should be avoided in this patient population. Weight loss may help with resolution of symptoms. Acetazolamide is the first-line medical treatment for IIH. It inhibits choroid plexus carbonic anhydrase, thereby decreasing CSF production and IH. Furosemide can be added for patients with continued symptoms on acetazolamide. For patients with symptoms refractory to medical therapy or those with progressive vision loss, surgical intervention with optic nerve sheath decompression or lumboperitoneal shunting is recommended (Choice E). Short-term use of corticosteroids or serial lumbar puncture (LP) can serve as bridging therapy for patients awaiting definitive surgical treatment (Choice C). These are not recommended as primary intervention due to side effects associated with long-term corticosteroid use and the complications associated with LPs. (Choice B) Mannitol is an osmotic diuretic used to reduce intracranial pressure associated with cerebral edema. It is an intravenous infusion and requires careful monitoring of renal function and electrolytes. Mannitol is used in the inpatient setting for those with severely elevated intracranial pressure (obtunded patients). It is not used in the management of IIH. (Choice D) Oral sumatriptan is used to treat migraine headaches. It is not used in the treatment of IIH. (Choice F) Timolol eye drops are used to treat glaucoma. CSF opening pressure is not elevated in glaucoma. Educational objective: Acetazolamide +/- furosemide is the first-line medical treatment for idiopathic intracranial hypertension. Optic nerve sheath decompression or lumboperitoneal shunting is recommended for patients refractory to medical therapy. Corticosteroids and serial lumbar punctures are not recommended as long-term primary treatments. However, they may be used as bridging therapies for patients awaiting definitive surgical treatment. References: Idiopathic intracranial hypertension (pseudotumor cerebri): recognition, treatment, and ongoing management. (http://www.ncbi.nlm.nih.gov/pubmed/23136035)

A 22-Year-Old Woman Comes to the Physician with Headaches for the Last