What is the next best step in establishing a diagnosis for a patient presenting with symptoms of a panic attack and papilledema?

MRI of the Head and Orbits is the Next Best Step for a Patient with Panic Attack Symptoms and Papilledema

For a 39-year-old female presenting with anxiety, panic attacks, diaphoresis, tachycardia, hypertension, and papilledema, an MRI of the head and orbits is the next best diagnostic step to evaluate for elevated intracranial pressure. 1, 2

Significance of Papilledema in This Case

• Papilledema (optic disc swelling due to elevated intracranial pressure) is a critical physical finding that distinguishes this case from a typical panic disorder 3
• The presence of papilledema is never normal and requires immediate investigation, regardless of other symptoms that may mimic panic attacks 2, 4
• While the patient's symptoms of diaphoresis, tachycardia, and hypertension could be consistent with panic disorder, the finding of papilledema indicates a potential neurological emergency 5

Diagnostic Approach

First-Line Imaging

• MRI of the head and orbits is the most useful imaging modality for evaluating suspected elevated intracranial pressure 2, 1
• MRI provides higher resolution of intracranial and intraorbital structures compared to CT, making it more effective for detecting signs of elevated ICP 2, 1
• MRI can detect key neuroimaging findings associated with elevated ICP, including:
  • Empty or partially empty sella 1
  • Posterior globe flattening (56% sensitivity, 100% specificity) 2, 1
  • Intraocular protrusion of the optic nerve (40% sensitivity, 100% specificity) 2
  • Horizontal tortuosity of the optic nerve (68% sensitivity, 83% specificity) 2
  • Enlarged optic nerve sheath 2

Additional Imaging Considerations

• MR venography (MRV) should be included to evaluate for venous outflow obstruction or stenosis 1, 6
• CT venography (CTV) may be an alternative if MRI is contraindicated 2, 6

Differential Diagnosis to Consider

Idiopathic Intracranial Hypertension (IIH)

• Most common in women of childbearing age with elevated BMI 2, 1
• Presents with headache (90% of patients), visual disturbances, pulsatile tinnitus, and papilledema 1, 7
• Requires exclusion of other causes of elevated intracranial pressure 2

Other Causes of Elevated Intracranial Pressure

• Cerebral venous sinus thrombosis 2, 8
• Intracranial mass lesions 3, 4
• Meningitis or other intracranial infections 3
• Hydrocephalus 3

Why Not Other Tests First?

• Lumbar puncture should only be performed after neuroimaging to rule out mass lesions or hydrocephalus that could lead to herniation 2, 4
• Psychological evaluation alone would miss the underlying neurological condition suggested by papilledema 5
• Basic laboratory tests would not identify the structural causes of elevated intracranial pressure 4
• CT scan of the head is less sensitive than MRI for detecting subtle findings associated with elevated intracranial pressure 2, 1

Clinical Pitfalls to Avoid

• Mistaking symptoms of increased intracranial pressure for primary panic disorder or anxiety 9
• Failing to recognize papilledema as an urgent finding requiring immediate investigation 5
• Proceeding with lumbar puncture before neuroimaging, which could be dangerous if a mass lesion is present 2
• Treating with anxiolytics like alprazolam without investigating the papilledema, which could mask symptoms while allowing progression of the underlying condition 10

By following this approach, you can establish the correct diagnosis and initiate appropriate treatment for this patient whose symptoms suggest a serious neurological condition rather than a primary psychiatric disorder.