A 25-year-old woman is referred for bilateral disc swelling found incidentally. She has headache on bending but no other focal neurological deficits. Visual acuity is 6/6 bilaterally. Visual fields show enlarged blind spots. She is obese (BMI 38) and on oral contraceptives. MRI brain is normal; MRI venography is normal. LP opening pressure is 34 cm H₂O. What is the most likely diagnosis and recommended first-line pharmacological treatment?
- A Cryptococcal meningitis; intravenous amphotericin B
- B Idiopathic intracranial hypertension (IIH); acetazolamide ✓
- C Bilateral optic neuritis; IV methylprednisolone
- D Dural arteriovenous fistula; endovascular embolisation
Explanation
Idiopathic intracranial hypertension (pseudotumour cerebri) typically affects obese women of childbearing age on oral contraceptives or tetracyclines. Diagnostic criteria (modified Dandy criteria) include papilloedema, normal neurological examination, normal MRI (or empty sella/flattening of posterior globe/transverse sinus stenosis), elevated CSF opening pressure (>25 cm H₂O in adults), and normal CSF composition. First-line pharmacological treatment is acetazolamide (carbonic anhydrase inhibitor reduces CSF production) combined with weight loss. Surgical options (optic nerve sheath fenestration or CSF shunting) are reserved for progressive visual loss despite medical therapy.
Reference: Khurana Comprehensive Ophthalmology, 7th ed.
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Written and medically reviewed by the StethoPrep medical team.