Clinical Reasoning: A 65-Year-Old Woman With New Headache, Pulsatile Tinnitus, and Visual Disturbances

A 65-year-old previously healthy woman noticed new-onset, gradual, blurry vision in her left eye with perceived loss of peripheral vision and pulsatile tinnitus in the left ear for the past 2 weeks. In the past year, she visited 3 different emergency departments for new nonpulsatile and nonthunderclap headaches, which she described as “searing” pain. The headaches were accompanied by nausea without phonophobia or photophobia, were not worsened or triggered by recumbency and Valsalva, and did not wake her from sleep. There were no associated neurologic or systemic symptoms. A noncontrast CT scan of the brain was interpreted as normal. Visual acuity was 20/25 bilaterally. There was no relative afferent pupillary defect. On ophthalmoscopy, she had bilateral severe optic nerve head edema (Figure, A). Formal visual field testing (Humphrey 24-2) showed enlargement of the blind spots in each eye (Figure, B). The remaining neurologic examination was normal.