What is the most appropriate diagnostic test for a 50-year-old woman presenting with worsening daily headaches, blurred vision, feeling off balance, and a seizure, with vital signs showing hypertension (elevated blood pressure), bradycardia (low heart rate), and normal body temperature?

MRI of the Brain with and without Contrast is the Most Appropriate Diagnostic Test

MRI of the brain with and without contrast is the most appropriate diagnostic test for this 50-year-old woman presenting with worsening headaches, blurred vision, balance issues, and seizure.

Clinical Presentation Analysis

This patient presents with several concerning features:

• 2-week history of daily headaches that worsen in the morning
• Throbbing headache quality different from her previous migraines
• Visual symptoms (blurred vision)
• Balance disturbance ("off balance")
• Seizure in the emergency department
• Vital signs showing hypertension (150/80 mmHg) and bradycardia (55/min)

These symptoms and findings strongly suggest an intracranial process requiring comprehensive neuroimaging.

Diagnostic Test Selection

MRI Brain with and without Contrast

MRI with and without contrast is the preferred diagnostic test because:

• It provides superior detection of intracranial pathology including tumors, infection, inflammatory lesions, and vascular abnormalities 1
• It offers higher sensitivity for detecting ischemia, encephalitis, and subtle cases of subarachnoid hemorrhage compared to CT 1
• The combination of pre-contrast and post-contrast images allows for comprehensive evaluation of potential mass lesions, infection, edema, and vascular pathologies 1
• The patient's symptoms (morning headache, visual changes, balance issues, seizure) suggest a possible space-occupying lesion or other intracranial pathology best visualized with MRI 1

Why Other Options Are Less Appropriate:

1. Cerebral Angiography:

   • More invasive than necessary for initial evaluation
   • Should be reserved for cases where vascular pathology is strongly suspected after initial imaging 1

2. Electroencephalography (EEG):

   • While useful for seizure evaluation, it would not identify the underlying structural cause of the patient's symptoms
   • The ACR guidelines recommend neuroimaging first in patients with seizures and altered mental status 1

3. Lumbar Puncture:

   • Carries risk without prior imaging in a patient with possible increased intracranial pressure
   • Should be performed after neuroimaging has ruled out mass effect or herniation risk 1

4. CT Brain:

   • Less sensitive than MRI for many intracranial pathologies
   • While useful in emergency settings for rapid assessment, MRI provides more comprehensive evaluation 1
   • CT may miss subtle abnormalities that could explain the patient's symptoms 1

5. Transcranial Doppler Ultrasonography:

   • Limited utility as an initial diagnostic test in this clinical scenario
   • More appropriate for specific vascular evaluations after initial imaging 1

Clinical Decision Algorithm

1. Initial Assessment: Patient with new-onset headaches, visual changes, balance issues, and seizure

2. Immediate Considerations:

   • If patient is unstable: Consider non-contrast CT first for rapid assessment
   • If patient is stable (as in this case): Proceed directly to MRI

3. MRI Protocol:

   • MRI brain without and with contrast is optimal 1
   • Include sequences to evaluate for mass lesions, ischemia, hemorrhage, and inflammation

4. Additional Testing Based on MRI Findings:

   • If vascular abnormality suspected: Consider MRA/MRV
   • If infectious/inflammatory process suspected: Consider lumbar puncture after ruling out mass effect
   • If seizure etiology remains unclear: Obtain EEG

Important Considerations

• The morning headache pattern with visual changes raises concern for increased intracranial pressure, potentially from a mass lesion
• The combination of hypertension and bradycardia (Cushing's triad when combined with irregular breathing) can suggest increased intracranial pressure
• The seizure indicates significant brain irritation requiring thorough evaluation
• MRI provides the most comprehensive initial assessment for identifying the underlying cause of these concerning symptoms 1

MRI with and without contrast offers the highest diagnostic yield for identifying the etiology of this patient's concerning neurological presentation and should be the initial imaging study of choice.