A 43-year-old man comes to the physician due to a 1-month history of worsening frontal headaches, blurred vision, and occasional falls. The blurry vision is provoked when he leans forward. His symptoms are particularly bothersome as they interfere with his sleep. The patient has no history of head trauma or seizure. He says "I occasionally get a head cold at this time of year." He does not take any medications. His mother has a history of glaucoma. He works as a real estate agent and does not use tobacco or alcohol. His vital signs are normal. On physical examination, his pupils are equally round and reactive to light. Which of the following is the most likely cause of this patient's condition?

Question

A 43-year-old man comes to the physician due to a 1-month history of worsening frontal headaches, blurred vision, and occasional falls.  The blurry vision is provoked when he leans forward.  His symptoms are particularly bothersome as they interfere with his sleep.  The patient has no history of head trauma or seizure.  He says "I occasionally get a head cold at this time of year."  He does not take any medications.  His mother has a history of glaucoma.  He works as a real estate agent and does not use tobacco or alcohol.  His vital signs are normal.  On physical examination, his pupils are equally round and reactive to light.  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

This patient's symptoms are concerning for intracranial hypertension (ICH). Brain parenchyma, cerebrospinal fluid, and blood are contained within a rigid skull and increased volume of any of these 3 components may cause ICH. Potential etiologies include trauma, space-occupying lesions, hydrocephalus, impaired central nervous system venous outflow, and idiopathic ICH (pseudotumor cerebri). Patients typically present with headache (worse at night), nausea/vomiting, and mental status changes (eg, decreased level of consciousness, cognitive dysfunction). Patients may also have focal neurologic symptoms (eg, vision changes, unsteady gait) and seizure. Symptoms can worsen with maneuvers that further increase intracranial pressure (eg, leaning forward, Valsalva, cough). Signs may include papilledema and focal neurologic deficits. Cushing reflex (hypertension, bradycardia, respiratory depression) is a worrisome finding suggestive of brainstem compression. papilledema (Choice A) This patient's family history and symptoms of headache with decreased vision may be consistent with acute angle closure glaucoma (AACG). However, AACG usually occurs in individuals age >60, and examination findings typically include conjunctival erythema and a mid-dilated pupil that is poorly reactive to light. examination findings (Choice C) Temporal arteritis can present with headache and blurred vision; however, it rarely occurs in individuals age <50. Moreover, it is commonly associated with polymyalgia rheumatica, which is characterized by proximal muscle stiffness/tenderness. (Choice D) Signs of meningeal irritation (eg, headache, photophobia, nuchal rigidity) may be seen with acute meningitis or subarachnoid hemorrhage. This patient's progressive onset of symptoms and lack of photophobia/nuchal rigidity make these diagnoses less likely. (Choice E) Sinusitis can cause a frontal headache that worsens with leaning forward; however, it is typically associated with nasal congestion and purulent nasal discharge, not blurred vision and falls. Educational objective: The symptoms of intracranial hypertension include headache (worse at night), nausea/vomiting, and mental status changes. Papilledema and focal neurologic deficits may be seen on examination. Cushing reflex (hypertension, bradycardia, respiratory depression) is a worrisome finding suggestive of brainstem compression. References: Headache and facial pain: differential diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/24565480) Headache. (http://www.ncbi.nlm.nih.gov/pubmed/22377852)

A 43-Year-Old Man Comes to the Physician Due to a 1-Month