What is the recommended initial testing and treatment for a 25-year-old patient with a history of migraines, who presents with a one-month history of pulsatile tinnitus (whooshing sound in the ear), vision changes in one eye, and a recent ER visit for right maxillary sinus disease, with normal blood pressure and no other neurological deficits?

Urgent Evaluation for Pulsatile Tinnitus with Vision Changes

This patient requires immediate imaging with CT angiography (CTA) of the head and neck with contrast as the first-line study, followed by urgent ophthalmology referral to evaluate for papilledema and idiopathic intracranial hypertension (IIH), which is the most likely diagnosis given the constellation of pulsatile tinnitus, vision changes, migraine history, and prior concern for optic disc swelling. 1, 2

Critical Diagnostic Considerations

This 25-year-old woman presents with a high-risk constellation of symptoms that demands urgent workup:

• Pulsatile tinnitus is never benign and requires imaging in nearly all cases, as over 70% have an identifiable structural or vascular cause 2
• Vision changes with prior optic disc swelling concern raises immediate red flags for papilledema from elevated intracranial pressure 2, 3
• Young overweight women with migraines and pulsatile tinnitus represent the classic demographic for IIH, which is the second most common cause of pulsatile tinnitus (after atherosclerotic disease) 2, 3
• Missing IIH can result in permanent vision loss, making this a time-sensitive diagnosis 4, 3

Immediate Testing Algorithm

First-Line Imaging (Order Today)

CT angiography (CTA) of head and neck with contrast is the appropriate initial study because: 1, 2

• Evaluates for life-threatening vascular causes including dural arteriovenous fistulas (8% of pulsatile tinnitus cases), arterial dissection, and arteriovenous malformations 2
• Assesses venous sinus anatomy for sigmoid sinus diverticulum/dehiscence and transverse sinus stenosis commonly associated with IIH 2, 3
• CTA source images can be reconstructed to create temporal bone CT images without additional radiation, evaluating for paragangliomas, jugular bulb abnormalities, and superior semicircular canal dehiscence 2
• A mixed arterial-venous phase (20-25 seconds post-contrast) captures both arterial and venous pathology in a single acquisition 1

Urgent Specialty Referrals (Within 1-2 Days)

• Ophthalmology referral for formal visual field testing and fundoscopic examination to document papilledema and assess for optic nerve damage 2, 3
• Comprehensive audiologic examination including pure tone audiometry, speech audiometry, and acoustic reflex testing to document any asymmetric hearing loss 5, 2

Additional Workup if Initial Imaging Negative

If CTA is negative but clinical suspicion remains high (which it should given the vision changes): 1, 2

• MRI brain with contrast and MR venography (MRV) to further evaluate for venous sinus abnormalities, cerebellopontine angle lesions, or subtle vascular malformations 1, 2
• Lumbar puncture with opening pressure measurement if imaging suggests IIH (empty sella, transverse sinus stenosis, optic nerve sheath distension) or if papilledema is confirmed on ophthalmology exam 3

Life-Threatening Causes to Rule Out

The imaging workup must exclude these catastrophic diagnoses: 2, 6

• Dural arteriovenous fistula (can cause hemorrhagic or ischemic stroke if untreated)
• Arterial dissection (stroke risk)
• Arteriovenous malformation (2-3% annual hemorrhage risk with 10-30% mortality from first bleed)
• Paraganglioma/glomus tumor (16% of pulsatile tinnitus cases)

Most Likely Diagnosis: Idiopathic Intracranial Hypertension

The clinical picture strongly suggests IIH: 2, 4, 3

• Young woman (mean age 41 in studies, but commonly affects 20s-30s)
• Chronic migraines (present in 90% of IIH patients)
• Pulsatile tinnitus (present in 48% of IIH patients)
• Vision changes with prior optic disc swelling concern (papilledema in 89% of IIH)
• Transverse sinus stenosis is identified in most IIH patients and causes the pulsatile tinnitus 3

Treatment Approach (Pending Confirmation)

If IIH is Confirmed

• Acetazolamide (carbonic anhydrase inhibitor) is first-line medical therapy to lower intracranial pressure 3
• Weight loss is critical for long-term management 3
• Serial ophthalmology follow-up to monitor for progressive vision loss 4
• Venous sinus stenting may be considered if medical management fails, with 93% resolution of pulsatile tinnitus and 97% improvement in papilledema in published series 4

If Vascular Lesion Identified

• Dural AVF or AVM: Endovascular embolization or surgical resection 2, 6
• Sigmoid sinus diverticulum: Surgical repair or stenting in severe cases 2
• Paraganglioma: Surgical resection, radiation therapy, or observation depending on size 2

Critical Pitfalls to Avoid

• Do NOT dismiss pulsatile tinnitus as benign migraine-related tinnitus without imaging—this is a common and dangerous error 2
• Do NOT delay ophthalmology referral—vision loss from papilledema can become irreversible 4
• Do NOT attribute all symptoms to the recent sinus disease—maxillary sinusitis does not cause pulsatile tinnitus or vision changes 1
• Do NOT order brain MRI alone without vascular imaging—standard brain MRI protocols miss most vascular causes of pulsatile tinnitus 1
• Do NOT perform lumbar puncture before imaging—must rule out mass lesions before LP 3

Blood Pressure Note

The BP of 136/76 is at the upper limit of normal but does not explain the symptoms. However, document this as it may be relevant if IIH is confirmed (though IIH is not caused by hypertension despite the name). 3