What are the red flags to watch for in a patient presenting with chest pain, neck pain, and headache, with incidental findings of an empty sella and arachnoid pits on a computed tomography (CT) scan, suggestive of idiopathic intracranial hypertension (IIH)?

Red Flags for Patients with Chest Pain, Neck Pain, and Headache with Incidental Empty Sella and Arachnoid Pits

The most critical red flag to watch for in a patient presenting with chest pain, neck pain, and headache with incidental empty sella and arachnoid pits on CT is subarachnoid hemorrhage, which requires immediate neuroimaging and intervention to prevent significant morbidity and mortality.

Key Red Flags Requiring Urgent Attention

Neurological Red Flags

• Thunderclap headache - described as "the worst headache of life" that reaches maximal intensity suddenly (within seconds to minutes) 1
• Altered mental status or decreased level of consciousness
• Focal neurological deficits including cranial nerve palsies
• Papilledema - a key finding in idiopathic intracranial hypertension (IIH) that requires prompt evaluation 1
• Visual disturbances - transient visual obscurations, blurred vision, or visual field defects
• Pulsatile tinnitus - common in IIH and may indicate increased intracranial pressure 2
• Neck stiffness or meningismus - suggesting meningeal irritation

Cardiovascular Red Flags

• Chest pain radiating to neck/jaw - may indicate serious cardiovascular pathology
• Irregular pulse or significant hypertension - can be associated with both cardiovascular disease and increased intracranial pressure
• Signs of heart failure or cardiovascular compromise

Significance of Empty Sella and Arachnoid Pits

The incidental finding of empty sella and arachnoid pits on CT scan is significant as these are radiological features commonly associated with IIH:

• Empty sella is present in approximately 44% of IIH patients 3 and results from herniation of subarachnoid cerebrospinal fluid through an absent or patulous diaphragma sellae 4
• Arachnoid pits/granulations have an inverse relationship with IIH severity - fewer granulations correlate with higher opening pressures and more severe radiological findings 5

Diagnostic Algorithm

1. Immediate neuroimaging:

   • If thunderclap headache is present, obtain urgent non-contrast head CT to evaluate for subarachnoid hemorrhage 1
   • If CT is negative but clinical suspicion remains high, proceed to lumbar puncture to evaluate for xanthochromia 1
   • Consider MRI with MR venography to evaluate for cerebral venous thrombosis, which can occur in up to 8% of cases 6

2. Ophthalmologic evaluation:

   • Fundoscopic examination to assess for papilledema
   • Visual field testing if papilledema is present

3. Cardiovascular assessment:

   • ECG and cardiac biomarkers to rule out acute coronary syndrome
   • Consider aortic imaging if dissection is suspected

Special Considerations

For Idiopathic Intracranial Hypertension

• Headache in IIH is often daily, located anteriorly, and more common in middle-aged overweight women 7
• Additional symptoms include radicular neck pain and pulsatile tinnitus 2
• MRI findings such as empty sella, perioptic subarachnoid space distension, optic nerve tortuosity, posterior globe flattening, and transverse sinus stenosis support the diagnosis 3

For Subarachnoid Hemorrhage

• 70% of non-traumatic SAH is caused by ruptured cerebral aneurysms 1
• A sentinel headache (warning leak) may precede catastrophic rupture by 2-8 weeks in up to 19.4% of cases 1
• Nausea, vomiting, and severe headache have high positive predictive value for neurosurgical lesions 1

Common Pitfalls to Avoid

1. Misdiagnosis or delayed diagnosis - SAH is misdiagnosed in up to 12% of cases, associated with a nearly 4-fold higher likelihood of death or disability 1

2. Failure to obtain appropriate neuroimaging - The most common diagnostic error in SAH is failure to obtain a non-contrast head CT 1

3. Dismissing symptoms as benign headache - Especially when incidental findings like empty sella are present, there may be a tendency to attribute symptoms to these findings rather than investigating more serious causes

4. Overlooking cardiovascular causes - The combination of chest pain with headache and neck pain should raise suspicion for aortic dissection or other serious cardiovascular pathology

5. Ignoring warning signs of impending aneurysm rupture - Severe, localized, unremitting headache, especially with homonymous hemianopsia, can indicate impending rupture of an intracranial mycotic aneurysm 1

Remember that while empty sella and arachnoid pits may be associated with IIH, these findings alone do not explain the triad of chest pain, neck pain, and headache, which requires comprehensive evaluation for potentially life-threatening conditions.