What is the recommended workup for an elderly female with transient bilateral blurred vision, sore neck, and headache of over a month's duration?

Workup for Elderly Female with Transient Bilateral Vision Loss, Prolonged Neck Pain and Headache

This patient requires urgent evaluation for giant cell arteritis (GCA) with immediate ESR/CRP testing and consideration of empiric corticosteroids before diagnostic confirmation, as the combination of transient vision loss in an elderly patient with prolonged headache and neck pain represents a medical emergency that can lead to permanent blindness. 1

Immediate Laboratory Testing

• ESR and CRP must be obtained urgently, as elevated inflammatory markers in an elderly patient with visual symptoms and headache are highly suggestive of GCA 1
• Complete blood count with platelets to assess for thrombocytosis or anemia associated with GCA 1
• Comprehensive metabolic panel including glucose and renal function 1
• Fasting lipid panel 1

The EULAR guidelines emphasize that patients with both typical symptoms and increased CRP/ESR who present with acute visual disturbance should be treated with corticosteroids before diagnostic confirmation, as delaying therapy when visual loss is present is the strongest risk factor for permanent blindness 1.

Urgent Vascular and Cardiac Evaluation

• Electrocardiography should be performed immediately, as transient bilateral vision loss represents a potential retinal artery occlusion equivalent requiring stroke workup 1
• Noninvasive imaging of cervicocephalic vessels (carotid ultrasound/transcranial Doppler, CTA, or MRA) to evaluate for large vessel stenosis or occlusion 1
• Echocardiography (at least transthoracic) is reasonable to identify cardiac sources of emboli 1
• Prolonged cardiac monitoring (Holter or telemetry) if initial workup is unrevealing 1

Neuroimaging

• MRI brain without contrast is the preferred imaging modality, including DWI sequences to evaluate for acute cerebral infarction 1, 2
• If MRI is unavailable, head CT should be performed within 24 hours of symptom onset 1
• The American College of Radiology recommends MRI as superior for characterizing structural abnormalities and excluding secondary causes of headache 2

However, given the transient nature of bilateral vision loss that has completely resolved, combined with prolonged neck pain and headache in an elderly patient, GCA remains the primary concern and takes precedence over routine stroke workup 1.

Temporal Artery Evaluation

• Temporal artery biopsy (TAB) should be arranged urgently through a specialized center with fast-track access 1
• The biopsy remains diagnostic even weeks after corticosteroid initiation, so treatment should not be delayed to obtain biopsy 1
• Temporal artery ultrasound or other vascular imaging may show features of large vessel vasculitis 1

Ophthalmologic Consultation

• Urgent ophthalmologic evaluation is required to exclude other causes of sudden visual disturbance and assess for signs of arteritic anterior ischemic optic neuropathy 1
• Dilated fundus examination to evaluate for retinal artery occlusion, optic nerve head changes, or other vascular abnormalities 1

Critical Management Decision

If clinical suspicion for GCA is high based on age >50 years, elevated inflammatory markers, visual symptoms, and prolonged headache with neck pain, initiate high-dose corticosteroids (prednisone 40-60 mg daily or methylprednisolone 1g IV for severe cases) immediately without waiting for biopsy confirmation 1. The neck pain may represent cervical artery involvement in large vessel vasculitis 1.

Common Pitfalls to Avoid

• Do not delay corticosteroid treatment while awaiting temporal artery biopsy in patients with visual symptoms, as this is the strongest risk factor for permanent blindness 1
• Do not dismiss bilateral transient vision loss as benign migraine aura in an elderly patient without first excluding GCA and vascular causes 1
• Do not attribute prolonged headache and neck pain to cervical spine disease without excluding GCA in patients over 50 years 1
• Recognize that normal inflammatory markers do not completely exclude GCA, though they make it less likely 1

Timeframe for Evaluation

The entire diagnostic workup should be completed within 24 hours through a fast-track clinic or stroke center, as retrospective studies demonstrate that rapid referral and immediate treatment reduce the rate of permanent visual impairment 1.