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Jane is a 22-year-old who presents with a headache that has been worsening over the past 3 months. Generally, it is worse when she wakes up and settles during the day. Last Friday, 5 days ago, the headache suddenly got worse for several hours. She described it as 10 out of 10. She takes the OCP, and her weight is 100 kg, and she is 150 cm tall. She has also noted that the sight in her right eye has become more blurred. She is not pregnant. Her LMP was 10 days ago. She has no other past history and is a student in her final year studying law.
She has Intracranial hypertension and papilloedema. What other tests would you now request?
1. What would you like to do next
2. What are your key suspicions and your differential?
3. However, the next 2 tests should be what
She needs a CT head
She then needs an LP with measuring of opening pressure and CFS analysis
She did report worst ever headache on Friday, so wise to check for xanthochromia
4. Question
Her CT scan is normal
Opening pressure was 35 cm
CSF analysis was normal
5. what other tests would you now request
She should have an MRI venography to ensure she does not have cerebral venous thrombosis which could cause identical symptoms. This a cause of intracranial hypertension and stroke and if it is diagnosed needs anticoagulation.
The MRV is normal
CSF analysis is normal
Who should also see the patient
6. Who should also see the patient
Ophthalmology document papilloedema in both eyes and slightly reduced visual acuity. Who would you discuss with next?
7. Who would you discuss with next.
The diagnosis is IIH
8. What would you do next
She needs to be started on Acetazolamide
She should stop the OCP and consider another choice of contraception
Refer to the acute neurology clinic for ongoing assessment
Ongoing care between ophthalmology and neurology is usual
9. Question
10. Question
References
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Case #15 Headache
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A thorough examination. You are able to dilate the pupils to look at the retina and note that the left optic disc appears swollen. Her visual acuity in her left eye has reduced such that she cannot read small print, which she can do with her right eye.
This could be a brain tumour with a morning headache and what appears to be papilloedema which suggests raised intracranial pressure. Alternative diagnoses could be Idiopathic Intracranial hypertension. Less likely should be considered is a chronic tension headache, atypical migraine, subarachnoid haemorrhage, cerebral venous thrombosis and others.
She needs an eye examination by Ophthalmology to confirm the papilloedema and to formally document her visual acuity. Damage to vision is the most worrying complication.
Answer
Answer
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