Primary angiitis of the central nervous system
B. Repeated lumbar puncture with serologies
Bilateral disc edema, transient vision loss, and elevated opening pressure on lumbar puncture are suggestive of intracranial hypertension, which may be idiopathic intracranial hypertension or secondary to a mass-occupying lesion, dural venous sinus thrombosis, or another underlying disease, including anemia, Addison disease, or systemic lupus erythematosus.1 While tighter blood pressure control (choice A) would be helpful in hypertensive retinopathy, elevated blood pressure medications do not mitigate elevated intracranial pressure. With negative laboratory findings for autoimmune or inflammatory disease, there is no indication to start high-dose corticosteroids (choice C). The patient had persistent visual field deficits despite acetazolamide use, which requires further investigation beyond monitoring with serial testing (choice D). A repeated lumbar puncture (choice B) revealed an opening pressure of 18 cm H2O, an IgG level of 6.6 mg/dL (normal range, 0.5 to 5.9 mg/dL; to convert to grams per liter, multiply by 0.01), and 4 oligoclonal bands (normal range, 0 to 1). Throughout this workup, the patient began to develop new neurological symptoms, including persistent left cranial nerve V numbness, paresthesia, fatigue, cold intolerance, throbbing headache, and bradyphrenia (ie, slowing of cognition).