A 34-year-old woman presents to the clinic with several weeks of daily headaches that are worse in the morning and when she bends forward. She also reports transient episodes of blurred vision lasting a few seconds, particularly when standing up quickly. Her medical history is notable for obesity, and she recently started taking an oral contraceptive. On physical examination, visual acuity is normal, but funduscopic examination reveals bilateral optic disc swelling with blurred margins. Neurologic examination is otherwise normal. MRI of the brain shows no mass lesion or ventricular enlargement.
Which of the following is the most appropriate next step in management?
The correct answer is:
D) Lumbar puncture with opening pressure measurement
This patient’s presentation is consistent with papilledema due to increased intracranial pressure, most likely idiopathic intracranial hypertension. Symptoms include morning headaches, transient visual obscurations, and bilateral optic disc edema with preserved visual acuity. After neuroimaging has excluded a mass lesion or obstructive hydrocephalus, the next step is lumbar puncture to measure opening pressure and confirm the diagnosis. Cerebrospinal fluid removal may also provide temporary symptomatic relief.
Answer choice A: Acetazolamide therapy, is incorrect. Acetazolamide is first-line treatment for idiopathic intracranial hypertension but should be initiated only after confirming elevated intracranial pressure with lumbar puncture.
Answer choice B: High-dose intravenous corticosteroids, is incorrect. Corticosteroids are not first-line therapy for idiopathic intracranial hypertension and are reserved for specific inflammatory or demyelinating conditions.
Answer choice C: Immediate optic nerve sheath fenestration, is incorrect. This procedure is reserved for patients with progressive vision loss despite medical therapy, not as an initial diagnostic or therapeutic step.
Answer choice E: Surgical decompression of the posterior fossa, is incorrect. Posterior fossa decompression is indicated for structural abnormalities such as Chiari malformation, not idiopathic intracranial hypertension.
Key Learning Point
Papilledema due to intracranial hypertension presents with headaches and transient visual obscurations. After normal neuroimaging, lumbar puncture with opening pressure measurement is required to confirm the diagnosis before initiating treatment.
