Answer: C, transverse sinus stenosis
The patient in this prompt was diagnosed with idiopathic intracranial hypertension (IIH). Most cases do not present as florid as this and many times this is treatable with excellent outcomes. The classic presentation is a young, obese woman with recent weight gain, visual disturbance, and headache. Bilateral optic disc edema, called papilledema in cases of IIH, and elevated opening pressure on lumbar puncture are hallmarks of the diagnosis. MR Venography is useful for establishing the diagnosis, and at around 90%, the most sensitive finding is transverse sinus stenosis. Flattened posterior globe and empty sella have sensitivity of about 80% and 70%, respectively. Finally, her lacrimal gland swelling was an interesting finding and perhaps due to obstructed venous drainage. Because of the enlarged lacrimal gland, the initial differential diagnosis included autoimmune etiologies such as sarcoidosis and a comprehensive lab panel was unremarkable.
She was symptomatic with headache for nearly two weeks prior to the presentation and had presented to the ED on two separate occasions. The patient was treated for migraine at those presentations and later developed worsening symptoms as stated in the prompt. When IIH was suspected she was admitted and started on acetazolamide and Ophthalmology was consulted. Neurosurgery was also consulted and given the hand-motion vision she underwent VP shunt. Two weeks following the surgery her vision improved to 20/30 in the right eye and 20/60 in the left, with some persistent disc edema bilaterally and trace macular edema in the left eye.
For an overview of IIH, including discussion of MRI findings, check out this site: https://casebasedneuroophthalmology.pressbooks.com/chapter/idiopathic-intracranial-hypertension/
