What could be causing my persistent pressure and balance issues despite having clear MRI (Magnetic Resonance Imaging) and CT (Computed Tomography) scans?

Evaluation of Persistent Pressure and Balance Issues with Normal Neuroimaging

Your symptoms of persistent pressure sensation and balance problems despite clear MRI and CT scans warrant systematic evaluation for non-structural causes, with particular attention to vestibular disorders, medication effects, cardiovascular factors, and functional neurological conditions. 1, 2

Initial Clinical Assessment

Critical Red Flags to Exclude

Even with normal imaging, specific symptom patterns require immediate attention:

• Rapidly worsening symptoms or headaches that awaken you from sleep suggest evolving pathology requiring urgent re-evaluation 1
• Headaches worsened by Valsalva maneuver (coughing, straining) indicate possible elevated intracranial pressure that may not yet show structural changes 1
• Any focal neurological deficits (weakness, numbness, vision changes) significantly increase likelihood of pathology even with normal initial imaging 1, 2
• Pulsatile tinnitus or visual obscurations suggest idiopathic intracranial hypertension, which can occur with normal or subtle imaging findings 1

Cardiovascular Evaluation

Blood pressure assessment is essential, as hypertension commonly causes both pressure sensations and balance disturbances:

• Measure blood pressure in both arms and assess for orthostatic changes (standing vs. sitting measurements) 3
• Dizziness and unsteadiness are recognized manifestations of impaired cerebral autoregulation in hypertension and may indicate evolving hypertensive encephalopathy 2
• If blood pressure is significantly elevated (>180/120 mmHg) with neurological symptoms, this constitutes hypertensive urgency requiring immediate laboratory workup including hemoglobin, platelets, creatinine, electrolytes, LDH, and urinalysis 2

Common Non-Structural Causes

Vestibular Disorders

Peripheral vestibular dysfunction is the most common cause of balance problems with normal brain imaging 4, 5:

• Benign paroxysmal positional vertigo (BPPV) - "loose ear crystals" - accounts for 7.9% of diagnosed balance disorders in elderly patients 5
• Inner ear infection or labyrinthitis represents 11.0% of balance disorder diagnoses 5
• These conditions require specific bedside testing (Dix-Hallpike maneuver, head impulse test) rather than imaging 4

Medication-Related Causes

Medication side effects are the single most common diagnosed cause of balance disorders (11.3% of cases) 5:

• Review all current medications, particularly diuretics (used in 36.5% of treated balance disorder patients), anxiolytics (25.1%), and meclizine (21.4%) 5
• NSAIDs, oral contraceptives, sympathomimetics, and neuropsychiatric agents can all cause or worsen balance problems 3

Sensory Deficits

Multiple sensory impairments commonly contribute to balance dysfunction 6:

• Reduced vision - ensure current eye examination and corrected vision 6
• Peripheral neuropathy - assess for diabetes, vitamin B12 deficiency, or other causes of nerve damage 6
• Vestibular dysfunction - may require formal vestibular testing if suspected 6

Functional and Psychological Factors

Fear of falling and functional neurological disorders are important considerations 6:

• Anxiety about balance can perpetuate and worsen symptoms independent of structural pathology 6
• These diagnoses require positive identification of specific features, not simply exclusion of other causes 6

Recommended Diagnostic Pathway

If Pressure Sensation Predominates

Consider lumbar puncture with opening pressure measurement if headache pattern suggests elevated intracranial pressure 1:

• Opening pressure >250 mm H₂O confirms idiopathic intracranial hypertension even with normal or subtle imaging findings 1
• Removal of 20-30 mL CSF during the procedure may provide immediate symptom relief if pressure is elevated 1
• This is particularly relevant if you have any visual symptoms, as declining visual function requires urgent surgical management 1

If Balance Issues Predominate

Structured clinical balance assessment should precede extensive testing 4:

• Timed Up-and-Go Test is the simplest and most reliable office-based assessment 4
• Unipodal Stance Testing (standing on one foot) is a good predictor of fall risk 4
• Abnormal results warrant referral to physical therapy or vestibular rehabilitation 4

Laboratory Screening

Basic metabolic and endocrine evaluation is warranted given the incidental finding of empty sella (if present on your imaging) 1, 7:

• Thyroid function tests (TSH, free T4) to exclude hypothyroidism 3
• Morning cortisol and ACTH if fatigue is prominent 7
• Complete blood count and comprehensive metabolic panel 2

Management Algorithm

1. Immediate (within 1 week):

   • Blood pressure measurement and cardiovascular assessment 3, 2
   • Medication review with elimination of potentially causative agents 5
   • Ophthalmologic examination if any visual symptoms present 1, 7

2. Short-term (within 1 month):

   • Vestibular function testing if peripheral vestibular disorder suspected 4, 5
   • Lumbar puncture with opening pressure if pressure headaches persist 1
   • Physical therapy evaluation for balance training 4

3. Ongoing:

   • Weight loss if overweight, as this effectively treats idiopathic intracranial hypertension in many patients 1
   • Structured balance rehabilitation program 4
   • Serial clinical assessments rather than repeat imaging unless new symptoms develop 1, 7

Critical Pitfalls to Avoid

• Do not assume normal imaging excludes all significant pathology - many balance disorders and some causes of elevated intracranial pressure have normal structural imaging 1, 2
• Do not attribute symptoms to "stress" or "anxiety" without positive evidence for functional disorder and thorough exclusion of treatable causes 6
• Do not order repeat MRI or CT without new symptoms or clinical change - this provides low diagnostic yield and unnecessary cost 7, 5
• Do not dismiss unsteadiness as "benign dizziness" without systematic evaluation, as this symptom pattern increases likelihood of underlying pathology 2