History
Ms. Hui was a 45-year-old lady. She was a non-smoker and social drinker.
She had a past medical history of impaired fasting glucose, moderate obstructive sleep apnea. She did not have a family history of headache / cognitive impairment.
She presented with a 5-year history of episodic visual obscurations, described as a white, bright halo over her left or right visual fields. These episodes were precipitated by bright light and were associated with eye pain upon eye movement.
These visual symptoms have increased in frequency over the past year, accompanied by episodic occipital headache.
She also reported a forgetfulness that had come on gradually since contracting COVID-19 4 years ago.
She initially sought medical attention from an ophthalmologist. Ocular examination was deemed to be normal. There was no mention of papilledema or elevated intra-ocular pressure. She was referred to the neurology clinic on the clinical impression of migraine with aura.
Physical examination
Neurological examination was unremarkable. There was no relative pupillary defect, and visual fields were full.
Thought process
Ms. Hui presented with a syndrome of chronic episodic visual obscurations with recent worsening associated with eye pain, headache, and cognitive symptoms.
She was a female of child-bearing age with a background of obesity.
The pathology was likely localized to the cerebral level.
The most likely etiology was idiopathic intracranial hypertension. The absence of bilateral papilledema was an atypical feature.
Transient toxic-metabolic disturbances and epileptic events were more remote considerations.
Next steps
A lumbar puncture was arranged to document the CSF opening pressure.
A contrast MRI brain and MRV brain were arranged to search for features of idiopathic intracranial hypertension and exclude cerebral venous thrombosis.