P HEADACAHE WITH B/L PAP

 A

This 16-year-old girl presents with bilateral papilledema, headaches, light and sound sensitivity, nausea, and brief double vision. These symptoms suggest increased intracranial pressure (ICP), and the presence of papilledema is a red flag indicating potential intracranial pathology. The recent weight gain following oral contraceptive use and the family history of migraine and a relative with a brain aneurysm further contribute to the complexity of the case.

Key considerations:

• Bilateral papilledema is a sign of increased intracranial pressure, which can be caused by a variety of conditions, including intracranial mass lesions, venous thrombosis, or idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri.

• The headaches, nausea, double vision, and weight gain in the setting of oral contraceptive use raise concern for idiopathic intracranial hypertension (IIH), which is a condition where there is increased ICP without a structural lesion, and it can be triggered or exacerbated by oral contraceptives.

Given the symptoms and clinical findings, the most appropriate next step in diagnosis would be to assess for increased intracranial pressure and to rule out secondary causes.

Most appropriate diagnostic test:

• MRI of the brain with venography or CT scan of the brain with venography (in cases where MRI is not available) to rule out structural abnormalities, such as tumors, venous thrombosis, or other causes of increased intracranial pressure.

In addition to imaging to rule out masses or other structural causes, a lumbar puncture (LP) could be considered to measure the opening pressure and analyze cerebrospinal fluid (CSF) in suspected IIH.

Thus, the most appropriate diagnostic test to perform in this patient would be an MRI of the brain with or without MR venography, to evaluate for any intracranial mass or other causes of increased intracranial pressure. If the MRI is normal, a lumbar puncture to assess opening pressure and CSF characteristics would be the next step in confirming a diagnosis of idiopathic intracranial hypertension (IIH).