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Suggest Treatment For Severe Dizziness And Loss Of Balance
Question: I had a stroke on Thursday and was admitted to the hospital and given TPA. All symptoms of right leg paralysis resolved after the TPA and there was no brain damage seen on the MRI. I was confined to bed for 24 hours in the ICU. I was transferred to the telemetry unit where I have remained for three days. Since resuming walking I have recurrent weakness spells that come on suddenly after exertion. It starts with a sudden flush throughout my body, followed by an extreme drowsiness and lack of alertness, followed by immediate weakness in my legs, followed by extreme lack of balance and near fainting. I cannot take steps without assistance. A blood pressure check then shows 180-220. I sleep for an hour or more, after which I wake up feeling fine. My EKG and Echo Cardiogram were both normal. My cardiologist is doing a stress test in the morning and has ordered compression stockings for me to wear. She says my symptom description was pinpoint accurate. But for what diagnosis? She didn't say.
Brief Answer:
TIA last Thursday (not Stroke).
Detailed Answer:
Good evening.
I'd like to go through your presentation a bit and see if I can you understand some things what your condition.
You say that had a STROKE on Thursday, however, you also say that you were given TPA and that the right leg paralysis resolved immediately and that no damage was seen on MRI. That would say that the PERFUSION and DIFFUSION sequences did not show either lack of circulation or any type damage due to lack of oxygen. If that information is correct then, it would be most appropriate for you to refer to your event as a TRANSIENT ISCHEMIC ATTACK (TIA) and not a stroke. A STROKE by definition indicates BRAIN DAMAGE even though in some cases symptoms of weakness or other focal problems for all intents and purposes may have resolved...the fact that the MRI shows an abnormality is enough to make the call for a STROKE. Doesn't like that in your case.
Going on with your case....you refer recurrent spells of weakness after physical exertion since getting into rehab for your walking after spending 3 days on a tele unit. You report a sentinel FLUSHED sensation in the body and then, a wave of extreme drowsiness and loss of alertness, maybe a "brain fog?" Then, comes the weakness of the LEGS (now you say legS...plurals....both?). This is then, followed by lack of balance/equilibrium and near loss of consciousness which would call PRE-SYNCOPE. You cannot ambulate without assistance. Your blood pressure then, elevates to the numbers you mention. A short nap of 60 min. makes you feel back to normal. The cardiologist made a comment that your symptoms were on spot for some diagnosis but is keeping you in suspense by not telling you exactly what she is thinking. She has ordered you compression stockings.
Well, perhaps, in the future my recommendation would be, "Don't let that woman out of your room until she gives you the PUNCHLINE of the story....."
For now, as a neurologist I would say that the cardiologist is probably somehow thinking that your recurrent symptoms of weakness and loss of alertness may signify a form of cardiac arrhythmia that would cause a break in blood flow to the brain and this would explain your going nearly going to the ground and getting weak IN BOTH LEGS....as opposed to one leg which would then, make it more likely a circulation problem in the brain...since you really can't easily knock out 2 legs at the same time....unless you hit a part of the brainstem or both hemispheres at once which would cause either fainting or near fainting.
I certainly like the idea of the compression stockings to prevent against DVT's from forming since you were in such an immobilie state. I wish the neurologist would've thought of it first....it's bad form for the treating neurologist to not have ordered that care parameter right from the get go and wait until a cardiologist 2-3 days into your stay thinks about it.....WE SHOULD'VE recommended that nursing care detail first....oh well.....as far as the rest of it is concerned.....my thought is that typically after heavy exertion what happens is that there may a sudden relaxation in the vascular system (loss of tone) in the body due to the presence of chemical substances given off by muscles in response to the need for more oxygen...or too much carbon dioxide accumulating because of muscles that are exerting themselves more than usual. The problem though is that if enough of a signal is sent by the body's muscles in order to cause there to be this VASOVAGAL discharge to fire in order to DILATE blood vessels throughout the body in order to increase blood flow and oxygen to the muscles then, you will see this sudden FLUSHING FEELING followed by brain fog and weakness in the legs quite possibly since the brain will LOSE blood pressure when enough blood vessels open up for the muscles. However, in the immediate aftermath of that VASOVAGAL discharge there should be a NORMAL rebound of blood pressure and possibly heartrate since the body wants to regenerate the blood pressure it's lost to the brain.
The period of rest you then, take tends to give the body time to MOP UP these excess muscle chemicals that have spilled out into the system causing blood pressure to drop and things will tend to normalize within the intervening 1 hr. such that when you awaken all parameters including normal blood flow to the brain will have been restored.
The stress test may be a way of getting you to duplicate the physical exertion phenomenon which will then, get other internal systems stimulated to potentially reproduce the vasovagal attack so that the brain fog and REBOUND HYPERTENSION can be documented.
If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating? Again, many thanks for submitting your inquiry and please let me know how things turn out.
Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.
This query has utilized a total of 79 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
TIA last Thursday (not Stroke).
Detailed Answer:
Good evening.
I'd like to go through your presentation a bit and see if I can you understand some things what your condition.
You say that had a STROKE on Thursday, however, you also say that you were given TPA and that the right leg paralysis resolved immediately and that no damage was seen on MRI. That would say that the PERFUSION and DIFFUSION sequences did not show either lack of circulation or any type damage due to lack of oxygen. If that information is correct then, it would be most appropriate for you to refer to your event as a TRANSIENT ISCHEMIC ATTACK (TIA) and not a stroke. A STROKE by definition indicates BRAIN DAMAGE even though in some cases symptoms of weakness or other focal problems for all intents and purposes may have resolved...the fact that the MRI shows an abnormality is enough to make the call for a STROKE. Doesn't like that in your case.
Going on with your case....you refer recurrent spells of weakness after physical exertion since getting into rehab for your walking after spending 3 days on a tele unit. You report a sentinel FLUSHED sensation in the body and then, a wave of extreme drowsiness and loss of alertness, maybe a "brain fog?" Then, comes the weakness of the LEGS (now you say legS...plurals....both?). This is then, followed by lack of balance/equilibrium and near loss of consciousness which would call PRE-SYNCOPE. You cannot ambulate without assistance. Your blood pressure then, elevates to the numbers you mention. A short nap of 60 min. makes you feel back to normal. The cardiologist made a comment that your symptoms were on spot for some diagnosis but is keeping you in suspense by not telling you exactly what she is thinking. She has ordered you compression stockings.
Well, perhaps, in the future my recommendation would be, "Don't let that woman out of your room until she gives you the PUNCHLINE of the story....."
For now, as a neurologist I would say that the cardiologist is probably somehow thinking that your recurrent symptoms of weakness and loss of alertness may signify a form of cardiac arrhythmia that would cause a break in blood flow to the brain and this would explain your going nearly going to the ground and getting weak IN BOTH LEGS....as opposed to one leg which would then, make it more likely a circulation problem in the brain...since you really can't easily knock out 2 legs at the same time....unless you hit a part of the brainstem or both hemispheres at once which would cause either fainting or near fainting.
I certainly like the idea of the compression stockings to prevent against DVT's from forming since you were in such an immobilie state. I wish the neurologist would've thought of it first....it's bad form for the treating neurologist to not have ordered that care parameter right from the get go and wait until a cardiologist 2-3 days into your stay thinks about it.....WE SHOULD'VE recommended that nursing care detail first....oh well.....as far as the rest of it is concerned.....my thought is that typically after heavy exertion what happens is that there may a sudden relaxation in the vascular system (loss of tone) in the body due to the presence of chemical substances given off by muscles in response to the need for more oxygen...or too much carbon dioxide accumulating because of muscles that are exerting themselves more than usual. The problem though is that if enough of a signal is sent by the body's muscles in order to cause there to be this VASOVAGAL discharge to fire in order to DILATE blood vessels throughout the body in order to increase blood flow and oxygen to the muscles then, you will see this sudden FLUSHING FEELING followed by brain fog and weakness in the legs quite possibly since the brain will LOSE blood pressure when enough blood vessels open up for the muscles. However, in the immediate aftermath of that VASOVAGAL discharge there should be a NORMAL rebound of blood pressure and possibly heartrate since the body wants to regenerate the blood pressure it's lost to the brain.
The period of rest you then, take tends to give the body time to MOP UP these excess muscle chemicals that have spilled out into the system causing blood pressure to drop and things will tend to normalize within the intervening 1 hr. such that when you awaken all parameters including normal blood flow to the brain will have been restored.
The stress test may be a way of getting you to duplicate the physical exertion phenomenon which will then, get other internal systems stimulated to potentially reproduce the vasovagal attack so that the brain fog and REBOUND HYPERTENSION can be documented.
If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating? Again, many thanks for submitting your inquiry and please let me know how things turn out.
Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.
This query has utilized a total of 79 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you, Dr. Saghafi. I will give you a fine review and five stars. I would like to get the results of the stress test to share with you for your feedback.
I think the nursing care I have received has been excellent. I wore automated leg compressors for three days after TPA, and only after that stopped because it hurt my legs did the compression stockings get recommended.
The cardiologist did mention possible arrhythmias but said none had been detected on the heart monitor I have been on for four days. The neurologist has cleared me of any neural problem in the brain. You are smart to pick up on these things.
Thanks for the explanation of the muscles releasing a chemical in response to the need for more oxygen due to exertion, which dilates the blood vessels to increase blood flow. The next time I feel the first warning sign which is the flushing, I will know it is because the blood vessels have suddenly opened up because my muscles are screaming for oxygen and my body replied big-time. Then, I will know that the drowsiness and brain fog plus the leg weakness will occur because my brain has lost blood pressure. The extremely high blood pressure they detect after this event is a rebound to the loss of brain blood pressure. My nap afterwards gives my body time to dissolve the muscle chemicals and normalize my blood pressure. Then I wake up perfectly refreshed. This all makes perfect sense to me. Thank you for explaining it in a way I can understand. I will remember it and not forget it.
Is it my deconditioning due to being immobile in the ICU that caused the extreme reaction to exertion? Or did having a TIA itself take a toll on my strength? Or did the TPA XXXXXXX my strength? Or maybe all three? Before the TIA, I walked a brisk mile every day and lifted 140 lb weights with NEVER a symptom of Vasovagal Attack. I hope to get back to that level of conditioning again. Any idea how long these attacks might last and how I can get them to stop quicker? Should I take hyperbaric oxygen treatments?
Can you please tell me what is the chemical that my muscles release to get me more oxygen?
I think the nursing care I have received has been excellent. I wore automated leg compressors for three days after TPA, and only after that stopped because it hurt my legs did the compression stockings get recommended.
The cardiologist did mention possible arrhythmias but said none had been detected on the heart monitor I have been on for four days. The neurologist has cleared me of any neural problem in the brain. You are smart to pick up on these things.
Thanks for the explanation of the muscles releasing a chemical in response to the need for more oxygen due to exertion, which dilates the blood vessels to increase blood flow. The next time I feel the first warning sign which is the flushing, I will know it is because the blood vessels have suddenly opened up because my muscles are screaming for oxygen and my body replied big-time. Then, I will know that the drowsiness and brain fog plus the leg weakness will occur because my brain has lost blood pressure. The extremely high blood pressure they detect after this event is a rebound to the loss of brain blood pressure. My nap afterwards gives my body time to dissolve the muscle chemicals and normalize my blood pressure. Then I wake up perfectly refreshed. This all makes perfect sense to me. Thank you for explaining it in a way I can understand. I will remember it and not forget it.
Is it my deconditioning due to being immobile in the ICU that caused the extreme reaction to exertion? Or did having a TIA itself take a toll on my strength? Or did the TPA XXXXXXX my strength? Or maybe all three? Before the TIA, I walked a brisk mile every day and lifted 140 lb weights with NEVER a symptom of Vasovagal Attack. I hope to get back to that level of conditioning again. Any idea how long these attacks might last and how I can get them to stop quicker? Should I take hyperbaric oxygen treatments?
Can you please tell me what is the chemical that my muscles release to get me more oxygen?
Brief Answer:
Be aware that all these phenomenon occurred in context of the TIA
Detailed Answer:
Thank you for your return message with a very nice summary and rephrasing of what I had said.....yes, I agree that some of this could've occurred because of deconditioning of being "couped up" in the ICU and not really being allowed to move around....but honestly 3 days in not that much time to be bedbound after something like this and perhaps in other institutions they might try to get you up a bit sooner but I would say that for the precautions and monitoring they were doing in order to assess your risks for having an embolic phenomenon which could've led to another event 3 days is reasonable followed by rehabilitation and as in this case a bit more testing.
Also, do be aware that everything you experienced occurred in the context of your initial TIA to begin with and so I doubt you'll feel these sorts of symptoms in the future if you stay active and simply go about your normal business. What would be nice to try and discover why you may have had that arterial blockage that required TPA in the first place so that they can figure out whether you were hypercoagulable due to something in your metabolic milieu that caused the blood to react and develop a clot, is it an inherent ability your blood has or somehow developed to become prone to forming clots, was it your heart that suffered a sudden "hiccup" in its its usual normal rhythmicity, was it dehydration, etc. etc. These are many of the questions we ask in a situation like this and why there's usually a lot of testing that goes on before releasing someone.
Obviously, the BEST person to tell you why you got the stress test.....would be the cardiologist herself....there may be an entirely different reason she was thinking...sometimes neurologists and cardiologists have different ideas of why certain things get done or not and so I encourage you to speak with her and then, you'll know for sure. But the best thing you can do going forward is follow your doctor's instructions on stroke prevention tips in terms of diet, exercise, and medications (if necessary....usually not if everything's in order).
Chemical mediators that signal that muscles are need of more oxygen can actually be many things and actually our body is constantly monitoring the blood for both levels of acidity, amount of carbon dioxide and oxygen present as well as other things such as levels of hydration etc. When muscles are asked to work there is an oxygen debt that begins to occur along with production of a substance called lactic acid. It is possible that either of these situations would be sufficient in a physically exerted muscle (which in the context of a TIA would not take much to amplify and be known to the patient) to trigger the sensors that monitor the status of the vascular flow that could then, trigger this phenomenon known as the vaso-vagal reaction that suddenly lowers blood pressure and vascular resistance allowing blood to flow into areas such as muscle tissue, etc.
But remember, this theory I am presenting is in the context of the TIA and under normal circumstances vaso-vagal reactions resulting in sudden drops in blood pressures to cause these dramatic changes SHOULDN'T BE HAPPENING...so after your recovery and once you are back to normal activities and exercise capacity you should not be having these episodes anymore. If you continue to experience things like this then, additional testing should probably be done to discover another cause.
Once again, it was a pleasure to answer your questions and I look forward to hearing how you do down the road if you care to drop a line to me at: www.bit.ly/drdariushsaghafi or even ask direct questions on this or anything else I may be able to help with as a neurologist. Be well and all the best.
And many thanks for any fine words of feedback and that high STAR rating if you feel so moved?
This query has utilized a total of 100 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Be aware that all these phenomenon occurred in context of the TIA
Detailed Answer:
Thank you for your return message with a very nice summary and rephrasing of what I had said.....yes, I agree that some of this could've occurred because of deconditioning of being "couped up" in the ICU and not really being allowed to move around....but honestly 3 days in not that much time to be bedbound after something like this and perhaps in other institutions they might try to get you up a bit sooner but I would say that for the precautions and monitoring they were doing in order to assess your risks for having an embolic phenomenon which could've led to another event 3 days is reasonable followed by rehabilitation and as in this case a bit more testing.
Also, do be aware that everything you experienced occurred in the context of your initial TIA to begin with and so I doubt you'll feel these sorts of symptoms in the future if you stay active and simply go about your normal business. What would be nice to try and discover why you may have had that arterial blockage that required TPA in the first place so that they can figure out whether you were hypercoagulable due to something in your metabolic milieu that caused the blood to react and develop a clot, is it an inherent ability your blood has or somehow developed to become prone to forming clots, was it your heart that suffered a sudden "hiccup" in its its usual normal rhythmicity, was it dehydration, etc. etc. These are many of the questions we ask in a situation like this and why there's usually a lot of testing that goes on before releasing someone.
Obviously, the BEST person to tell you why you got the stress test.....would be the cardiologist herself....there may be an entirely different reason she was thinking...sometimes neurologists and cardiologists have different ideas of why certain things get done or not and so I encourage you to speak with her and then, you'll know for sure. But the best thing you can do going forward is follow your doctor's instructions on stroke prevention tips in terms of diet, exercise, and medications (if necessary....usually not if everything's in order).
Chemical mediators that signal that muscles are need of more oxygen can actually be many things and actually our body is constantly monitoring the blood for both levels of acidity, amount of carbon dioxide and oxygen present as well as other things such as levels of hydration etc. When muscles are asked to work there is an oxygen debt that begins to occur along with production of a substance called lactic acid. It is possible that either of these situations would be sufficient in a physically exerted muscle (which in the context of a TIA would not take much to amplify and be known to the patient) to trigger the sensors that monitor the status of the vascular flow that could then, trigger this phenomenon known as the vaso-vagal reaction that suddenly lowers blood pressure and vascular resistance allowing blood to flow into areas such as muscle tissue, etc.
But remember, this theory I am presenting is in the context of the TIA and under normal circumstances vaso-vagal reactions resulting in sudden drops in blood pressures to cause these dramatic changes SHOULDN'T BE HAPPENING...so after your recovery and once you are back to normal activities and exercise capacity you should not be having these episodes anymore. If you continue to experience things like this then, additional testing should probably be done to discover another cause.
Once again, it was a pleasure to answer your questions and I look forward to hearing how you do down the road if you care to drop a line to me at: www.bit.ly/drdariushsaghafi or even ask direct questions on this or anything else I may be able to help with as a neurologist. Be well and all the best.
And many thanks for any fine words of feedback and that high STAR rating if you feel so moved?
This query has utilized a total of 100 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dr. Saghafi,
Thank you for your expert advice so far. You have been very knowledgeable and helpful. I would like to give you an update on my condition and get further advice from you on my blood pressure, strokes and vasovagal attacks. These are my concerns that I would like your help with:
1. My BP varies between 220 and 90 but it is usually 140-165. I have a BP drop of 40-50 points when I stand. The cardiologist told me I have dysautonomia and should have more tests as an outpatient. What additional tests do you think might be helpful? What is the cause of dysautonomia, if that is indeed what I have?
2. My husband died of a sudden heart failure on April 1, 2015 and my first stroke was on May 1, 2015 (stress-induced?). I have had recurrent strokes/TIAs since then. I had MRI-documented strokes in April 2015, July 2015, October 2015 in the left basal ganglia, left centrum semiovale, right cerebellum, and left posterior limb internal capsule. I have stenosis of the right A1 segment, the proximal left A1 segment, the left P2/P3 segment, the bilateral M1 segments, and the distal basilar artery. I have had 20+ TIAs occurring every 2 weeks to 3 months since the first stroke. What is the cause of my multiple strokes, TIAs and stenoses? Each time I think it is the last, and then it happens again.
3. I have had frequent vasovagal attacks since my TIA on 3/9/2017. Thinking back, I now remember having had them after several previous strokes/TIAs and each time they did eventually stop (until the next time). They have become less frequent and severe in the last four days and I seem to be almost recovered.
For your review, below are all my most recent test results:
LABORATORY STUDIES:
Sodium 143, potassium 3.7, chloride 111, CO2 of 25.3, BUN
13, creatinine 0.78, glucose 105, A1c 6.0, and magnesium 2.22. TSH
2.438. Troponin is negative. Total cholesterol 246, LDL 156, HDL 66.
Triglycerides 121. WBC 6.9, hemoglobin 13.7, and hematocrit 40.2.
STRESS TEST XXXXXXX HR: 134 BPM 86% of Pred: 155 BPM XXXXXXX BP: 181/083 mmHG XXXXXXX Work Load: 8.1 METS
Exercise ThalliumN Stress done for 5:29 min. Peak HR-133. Sestamibi 33 mci injected during exercise, her legs felt too weak to walk to bed, her mind felt foggy.
Myocardial Perfusion Scan Nuc Med
Left ventricular size is within normal limits. There is moderate soft tissue and bowel attenuation artifact. The stress tomographic images demonstrate a normal pattern of perfusion. The resting tomographic images demonstrate a similar pattern. There is no evidence for reversible ischemia. Wall motion is normal. The ejection fraction is calculated at 79%.
MRA Angio Head
There is evidence of intracranial atherosclerotic disease with areas of mild to
moderate stenosis, most pronounced in the proximal A1 segment of the right anterior cerebral artery where there appears to be severe stenosis. There is also moderate stenosis within the distal basilar artery, where there is an estimated 50% stenosis.
MRI Brain
Mild-moderate chronic microvascular disease.
Chronic lacunar infarcts involving the left basal ganglia, left centrum semiovale,
right cerebellum, and left posterior limb internal capsule.
CTA OF THE BRAIN: Severe focal stenosis of the right A1 segment, mild stenosis of the proximal left A1 segment, mild narrowing of the left P2/P3 segment, mild to moderate multifocal narrowings the bilateral M1 segments, and severe focal narrowing of the distal basilar artery is similar to prior. No proximal large vessel occlusion is seen. The bilateral intracranial ICA and right PCA are patent.
CTA OF THE NECK: Tortuosity of the proximal internal carotid arteries with abrupt turns identified. No evidence of a hemodynamically-significant stenosis or vessel dissection of the bilateral common carotid, bilateral internal carotid, or bilateral vertebral arteries. Degenerative changes of the spine.
CT HEAD
Patchy hypoattenuation of the cerebral white matter is most consistent with mild chronic microvascular ischemic changes. Chronic left basal ganglia lacunar infarct. Atherosclerotic calcifications of the cavernous segments of the internal carotid arteries are seen. The ventricles are stable size.
FINAL DISCHARGE DIAGNOSES:
1. Aborted cerebrovascular accident with tPA.
2. Hypertension.
3. History of cerebrovascular accident without any residual deficits.
Sincerely,
Deborah XXXXXXX
Thank you for your expert advice so far. You have been very knowledgeable and helpful. I would like to give you an update on my condition and get further advice from you on my blood pressure, strokes and vasovagal attacks. These are my concerns that I would like your help with:
1. My BP varies between 220 and 90 but it is usually 140-165. I have a BP drop of 40-50 points when I stand. The cardiologist told me I have dysautonomia and should have more tests as an outpatient. What additional tests do you think might be helpful? What is the cause of dysautonomia, if that is indeed what I have?
2. My husband died of a sudden heart failure on April 1, 2015 and my first stroke was on May 1, 2015 (stress-induced?). I have had recurrent strokes/TIAs since then. I had MRI-documented strokes in April 2015, July 2015, October 2015 in the left basal ganglia, left centrum semiovale, right cerebellum, and left posterior limb internal capsule. I have stenosis of the right A1 segment, the proximal left A1 segment, the left P2/P3 segment, the bilateral M1 segments, and the distal basilar artery. I have had 20+ TIAs occurring every 2 weeks to 3 months since the first stroke. What is the cause of my multiple strokes, TIAs and stenoses? Each time I think it is the last, and then it happens again.
3. I have had frequent vasovagal attacks since my TIA on 3/9/2017. Thinking back, I now remember having had them after several previous strokes/TIAs and each time they did eventually stop (until the next time). They have become less frequent and severe in the last four days and I seem to be almost recovered.
For your review, below are all my most recent test results:
LABORATORY STUDIES:
Sodium 143, potassium 3.7, chloride 111, CO2 of 25.3, BUN
13, creatinine 0.78, glucose 105, A1c 6.0, and magnesium 2.22. TSH
2.438. Troponin is negative. Total cholesterol 246, LDL 156, HDL 66.
Triglycerides 121. WBC 6.9, hemoglobin 13.7, and hematocrit 40.2.
STRESS TEST XXXXXXX HR: 134 BPM 86% of Pred: 155 BPM XXXXXXX BP: 181/083 mmHG XXXXXXX Work Load: 8.1 METS
Exercise ThalliumN Stress done for 5:29 min. Peak HR-133. Sestamibi 33 mci injected during exercise, her legs felt too weak to walk to bed, her mind felt foggy.
Myocardial Perfusion Scan Nuc Med
Left ventricular size is within normal limits. There is moderate soft tissue and bowel attenuation artifact. The stress tomographic images demonstrate a normal pattern of perfusion. The resting tomographic images demonstrate a similar pattern. There is no evidence for reversible ischemia. Wall motion is normal. The ejection fraction is calculated at 79%.
MRA Angio Head
There is evidence of intracranial atherosclerotic disease with areas of mild to
moderate stenosis, most pronounced in the proximal A1 segment of the right anterior cerebral artery where there appears to be severe stenosis. There is also moderate stenosis within the distal basilar artery, where there is an estimated 50% stenosis.
MRI Brain
Mild-moderate chronic microvascular disease.
Chronic lacunar infarcts involving the left basal ganglia, left centrum semiovale,
right cerebellum, and left posterior limb internal capsule.
CTA OF THE BRAIN: Severe focal stenosis of the right A1 segment, mild stenosis of the proximal left A1 segment, mild narrowing of the left P2/P3 segment, mild to moderate multifocal narrowings the bilateral M1 segments, and severe focal narrowing of the distal basilar artery is similar to prior. No proximal large vessel occlusion is seen. The bilateral intracranial ICA and right PCA are patent.
CTA OF THE NECK: Tortuosity of the proximal internal carotid arteries with abrupt turns identified. No evidence of a hemodynamically-significant stenosis or vessel dissection of the bilateral common carotid, bilateral internal carotid, or bilateral vertebral arteries. Degenerative changes of the spine.
CT HEAD
Patchy hypoattenuation of the cerebral white matter is most consistent with mild chronic microvascular ischemic changes. Chronic left basal ganglia lacunar infarct. Atherosclerotic calcifications of the cavernous segments of the internal carotid arteries are seen. The ventricles are stable size.
FINAL DISCHARGE DIAGNOSES:
1. Aborted cerebrovascular accident with tPA.
2. Hypertension.
3. History of cerebrovascular accident without any residual deficits.
Sincerely,
Deborah XXXXXXX
Brief Answer:
Multiple strokes/TIA's
Detailed Answer:
1. My BP varies between 220 and 90 but it is usually 140-165. I have a BP drop of 40-50 points when I stand. The cardiologist told me I have dysautonomia and should have more tests as an outpatient. What additional tests do you think might be helpful? What is the cause of dysautonomia, if that is indeed what I have?
>>>> At this point and without full autonomic function testing I wouldn't diagnose DYSAUTONOMIA but instead would simply state that you are very ORTHOSTATIC upon standing. I always do a careful review of medications as those are often the major culprits to such blood pressure drops. I would make sure that you were fully hydrating with lots and lots of fluids if you don't have that habit anyways and would get some compression hose for you to wear.....I'd make them at least 30-40mm Hg of compression...not just the ones you get from the pharmacy....those won't do anything for that type of BP drop. If you were to get testing done, however, I would first ask to be referred to a neurologist to determine the necessity of going through all that because it's a LOT OF TESTING....you won't necessarily be comfortable doing all of it and in the end it may be useless if the reason turns out to be something metabolic or because of overmedication for your BP. If on the other hand you are not on any medications and you're having these types of BP swings upon postural changes then, maybe you do have dysautonomia that needs to be elaborated.
2. My husband died of a sudden heart failure on April 1, 2015 and my first stroke was on May 1, 2015 (stress-induced?). I have had recurrent strokes/TIAs since then. I had MRI-documented strokes in April 2015, July 2015, October 2015 in the left basal ganglia, left centrum semiovale, right cerebellum, and left posterior limb internal capsule. I have stenosis of the right A1 segment, the proximal left A1 segment, the left P2/P3 segment, the bilateral M1 segments, and the distal basilar artery. I have had 20+ TIAs occurring every 2 weeks to 3 months since the first stroke. What is the cause of my multiple strokes, TIAs and stenoses? Each time I think it is the last, and then it happens again.
>>>>>The way strokes operate is that once there's been 1 then, the 2nd, 3rd, etc. occur more easily and under less conditions of physical duress since there is what we call "at risk" tissue after a stroke. But we also know that NOT ALL perceived or even DIAGNOSED TIA's are strokes are actually as billed as opposed to being exacerbations of previously suffered strokes. In other words, if there are already several lacunar infarcts that are being seen in your basal ganglia then, future events you refer to may not be NEW as much as they are exacerbations of previously suffered suffered. There are many reasons exacerbations can happen such as hyper or hypoglycemia, hyper or hypotension, metabolic problems with hormonal fluctuations, etc.
Now, let me point out one inconsistency in the MRA that contradicts the side of leg paralysis you suffered for which tPA apparently made you well. The MRA points to a severe A1 segment stenosis in the RIGHT ACA but you are saying that it was your RIGHT leg that was affected on this latest TIA. Therefore, the affected blood vessel where the blood clot would've had to have been visualized would be the LEFT ACA where apparently there is no evidence of occlusion or stenosis. Of course, you could've also had a BLOOD CLOT form somewhere and lodge in the LEFT ACA causing your paralysis and that the tPA cleared that......but the right A1 stenosis is not the cause of your latest symptomatology.
You say also that the MRI scans failed to show any damage but did they do what we call PERFUSION/DIFFUSION weighted imaging which for your latest episode would've shown abnormalities in the territory of the LEFT A1 ACA before they unplugged it.
Bottom line is that you would be best advised to work closely with your neurologist to reduce as much possible your risk factors for both small and large vessel strokes but looking for causes of clots...such as with cardiac scans (transesophageal echocardiograms), metabolic workups for possible factor deficiencies, or other problems that can cause your blood is to be HYPERcoagulable, make sure you drink plenty of fluids (water is best).
I'd be very careful about stenting any of these lesions since I also suspect you have developed a sufficient amount of collateral circulation which could be shown by way of other types of studies. I'd also consider doing an MRA with DOUBLE CONTRAST which can often times give even a higher resolution and better NONINVASIVE picture of what's going on with the cerebrovasculature than a catheter based 4 vessel angiogram. I like MRA's also better than CTA's (less radiation for one thing) and higher resolution. That goes for MRI vs. CT scan.
Once again, it was a pleasure to answer your questions and I look forward to hearing how you do down the road if you care to drop a line to me at: www.bit.ly/drdariushsaghafi or even ask direct questions on this or anything else I may be able to help with as a neurologist. Be well and all the best.
And many thanks for any fine words of feedback and that high STAR rating if you feel so moved?
This query has utilized a total of 159 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Multiple strokes/TIA's
Detailed Answer:
1. My BP varies between 220 and 90 but it is usually 140-165. I have a BP drop of 40-50 points when I stand. The cardiologist told me I have dysautonomia and should have more tests as an outpatient. What additional tests do you think might be helpful? What is the cause of dysautonomia, if that is indeed what I have?
>>>> At this point and without full autonomic function testing I wouldn't diagnose DYSAUTONOMIA but instead would simply state that you are very ORTHOSTATIC upon standing. I always do a careful review of medications as those are often the major culprits to such blood pressure drops. I would make sure that you were fully hydrating with lots and lots of fluids if you don't have that habit anyways and would get some compression hose for you to wear.....I'd make them at least 30-40mm Hg of compression...not just the ones you get from the pharmacy....those won't do anything for that type of BP drop. If you were to get testing done, however, I would first ask to be referred to a neurologist to determine the necessity of going through all that because it's a LOT OF TESTING....you won't necessarily be comfortable doing all of it and in the end it may be useless if the reason turns out to be something metabolic or because of overmedication for your BP. If on the other hand you are not on any medications and you're having these types of BP swings upon postural changes then, maybe you do have dysautonomia that needs to be elaborated.
2. My husband died of a sudden heart failure on April 1, 2015 and my first stroke was on May 1, 2015 (stress-induced?). I have had recurrent strokes/TIAs since then. I had MRI-documented strokes in April 2015, July 2015, October 2015 in the left basal ganglia, left centrum semiovale, right cerebellum, and left posterior limb internal capsule. I have stenosis of the right A1 segment, the proximal left A1 segment, the left P2/P3 segment, the bilateral M1 segments, and the distal basilar artery. I have had 20+ TIAs occurring every 2 weeks to 3 months since the first stroke. What is the cause of my multiple strokes, TIAs and stenoses? Each time I think it is the last, and then it happens again.
>>>>>The way strokes operate is that once there's been 1 then, the 2nd, 3rd, etc. occur more easily and under less conditions of physical duress since there is what we call "at risk" tissue after a stroke. But we also know that NOT ALL perceived or even DIAGNOSED TIA's are strokes are actually as billed as opposed to being exacerbations of previously suffered strokes. In other words, if there are already several lacunar infarcts that are being seen in your basal ganglia then, future events you refer to may not be NEW as much as they are exacerbations of previously suffered suffered. There are many reasons exacerbations can happen such as hyper or hypoglycemia, hyper or hypotension, metabolic problems with hormonal fluctuations, etc.
Now, let me point out one inconsistency in the MRA that contradicts the side of leg paralysis you suffered for which tPA apparently made you well. The MRA points to a severe A1 segment stenosis in the RIGHT ACA but you are saying that it was your RIGHT leg that was affected on this latest TIA. Therefore, the affected blood vessel where the blood clot would've had to have been visualized would be the LEFT ACA where apparently there is no evidence of occlusion or stenosis. Of course, you could've also had a BLOOD CLOT form somewhere and lodge in the LEFT ACA causing your paralysis and that the tPA cleared that......but the right A1 stenosis is not the cause of your latest symptomatology.
You say also that the MRI scans failed to show any damage but did they do what we call PERFUSION/DIFFUSION weighted imaging which for your latest episode would've shown abnormalities in the territory of the LEFT A1 ACA before they unplugged it.
Bottom line is that you would be best advised to work closely with your neurologist to reduce as much possible your risk factors for both small and large vessel strokes but looking for causes of clots...such as with cardiac scans (transesophageal echocardiograms), metabolic workups for possible factor deficiencies, or other problems that can cause your blood is to be HYPERcoagulable, make sure you drink plenty of fluids (water is best).
I'd be very careful about stenting any of these lesions since I also suspect you have developed a sufficient amount of collateral circulation which could be shown by way of other types of studies. I'd also consider doing an MRA with DOUBLE CONTRAST which can often times give even a higher resolution and better NONINVASIVE picture of what's going on with the cerebrovasculature than a catheter based 4 vessel angiogram. I like MRA's also better than CTA's (less radiation for one thing) and higher resolution. That goes for MRI vs. CT scan.
Once again, it was a pleasure to answer your questions and I look forward to hearing how you do down the road if you care to drop a line to me at: www.bit.ly/drdariushsaghafi or even ask direct questions on this or anything else I may be able to help with as a neurologist. Be well and all the best.
And many thanks for any fine words of feedback and that high STAR rating if you feel so moved?
This query has utilized a total of 159 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dr. Saghafi,
Thank you for your reply. It was very informative. You have told me more that my doctors have in two years. I will follow up with my neurologist and cardiologist on following points. Let me know if I missed anything.
1. Autonomic testing for orthostatic hypotension. In the last five days this has reduced to a 10-20 point drop or no drop when standing, so it may be resolving on its own.
2. MRA with double contrast to see my brain better and figure out why I have had so many strokes in so many different parts of my brain. My MRIs show strokes on these dates: 5/2/2015 left internal capsule, left thalamus, left mesial temporal lobe; 6/22/2015 dorsal thalamus; 10/7/2015 left cerebral peducle, left mid-brain; 10/22/2015 right cerebellum, bilateral frontal lobes, left temporal lobe, right splenum of corpus collossum, left basal ganglia; 10/28/2015 right posteria corpus collossum; 11/14/2015 left frontal centrum semiovale, left and right corpus collossum.
3. Studies to prove if there is sufficient collateral circulation in areas of severe stenosis, so no surgery is needed.
4. Reduce risk factors for small and large vessel strokes; look for metabolic causes of clots and HYPERcoagulable state.
I will give you a good rating and five stars.
By the way, I play the violin, too. I studied at The XXXXXXX Institute of Music.
Sincerely,
Deborah XXXXXXX
Thank you for your reply. It was very informative. You have told me more that my doctors have in two years. I will follow up with my neurologist and cardiologist on following points. Let me know if I missed anything.
1. Autonomic testing for orthostatic hypotension. In the last five days this has reduced to a 10-20 point drop or no drop when standing, so it may be resolving on its own.
2. MRA with double contrast to see my brain better and figure out why I have had so many strokes in so many different parts of my brain. My MRIs show strokes on these dates: 5/2/2015 left internal capsule, left thalamus, left mesial temporal lobe; 6/22/2015 dorsal thalamus; 10/7/2015 left cerebral peducle, left mid-brain; 10/22/2015 right cerebellum, bilateral frontal lobes, left temporal lobe, right splenum of corpus collossum, left basal ganglia; 10/28/2015 right posteria corpus collossum; 11/14/2015 left frontal centrum semiovale, left and right corpus collossum.
3. Studies to prove if there is sufficient collateral circulation in areas of severe stenosis, so no surgery is needed.
4. Reduce risk factors for small and large vessel strokes; look for metabolic causes of clots and HYPERcoagulable state.
I will give you a good rating and five stars.
By the way, I play the violin, too. I studied at The XXXXXXX Institute of Music.
Sincerely,
Deborah XXXXXXX
Brief Answer:
Kinda Sorta- Allow me to clarify.
Detailed Answer:
Thanks for the little summary of your understanding....gives me something to sink my teeth into so I don't have to improvise in a 12/8 bar that modulates from the key of F# min. to C Maj. directing you to go Sul D where the string is actually tuned a quarter step flat by composer's direction! And yes, that was a crazy piece that I had to play at a recital back in the early part of this century.....modern music...sheesh! So pray tell, who would you have studied with.....During our era at CIM there was my teacher Mr. XXXXXXX Loebel, My UCYO director XXXXXXX XXXXXXX (who still composes and conducts), XXXXXXX McCoppin, XXXXXXX Cerone, and of course, XXXXXXX Majeske who I never studied with but of course, heard many a story of how he tried to impress people such as Heifetz who would barely give him the time of day.
And of course, I must know if you still play and if you still practice your Flesch Scales and Rode Etudes? And can you still play from memory the Kreutzer Etude #2...even if you haven't picked up the instrument in 40 years? I'm still rather active and perform regularly in shows, gigs, recitals, chamber and sub in for orchestral members of professional groups....NOT TCO of course, but professional all the same....I'm a card carrying AFM member....that's how! HA!
So, first let me clarify just a couple of the points up top to make sure we're on the same page. Hopefully, there's a neurologist leading the charge on these strokes and their management, right?
1, If your ORTHOSTASIS is resolving it would be nice to know whether it was of central or peripheral origin.....so again, TESTS for autonomic dysfunction ONLY IF there is a high index of suspicion that it is NOT because of metabolic or overmedication disturbances, or significant dehydration, and/or poor physical deconditioning because of you being immobilized for X number of days in bed due to the tPA thing and recovery.......so if they can rule everything else out then, it makes sense to do a full battery of AUTONOMIC FUNCTION TESTING.....but you will need an Autonomic specialist for that who is generally a neurology with fellowship training and a fully equipped lab because there are a number of tests that should be done.
2. MRA with double contrast may have the utility of outlining a little more precisely degrees of stenosis of some of the LARGER pipes in your head such as the BASILAR ARTERY, the ANTERIOR CEREBRAL ARTERY, the CAROTIDS, and the VERTEBROBASILAR SYSTEM which will show us cerebellar penetration or lack thereof. This would be instead of CTA's and instead of actual XXXXXXX procedures so that we can remain NON-INVASIVE until that's not possible anymore. This suggestion is NOT to see the brain better but to see the vascular system that feeds the brain a little more robustly. Depending on the experience of the radiologist (such as if they are a NEURORADIOLOGIST or not) they may or may not get the potential utility of this procedure.
BTW, before you get the double contrast have them get a CREATININE along with an EGFR. You need to clear >=60 cc/min. from the kidneys in order to safely do the study. If not, then, I wouldn't go to that test...not worth the risk of hurting your kidneys. I also am noticing that your A1C is at 6.0 which could be slightly trending on the higher side of normal (depending on your lab limits) even though the glucose seems to be pretty good at 105 (i.e. no PREdiabetic state...though 6.0 is slightly pushing that upper limit for some institutions....but it ain't bad for sure).
The MRA's (even when double contrasted) may not explain why the numerous lacunar or small vessel infarcts as much as studying your RISK FACTORS for small vessel disease (diabetes, smoker, hypercholesterolemia, family history, HYPERTENSION, hypertriglyceridemia, etc). As well as evaluating risk factors for thrombotic as well as small embolic disease. For that you need to do blood work (i.e. stroke in the young workup.....although typically when neurologists say "stroke in the young" they are referring to folks under the age of 55......Please don't be offended....that's just the way it is...but I STILL CONSIDER you a candidate for stroke in the young ESPECIALLY if you fail to have significant risk factors for all the pockshots that your brain has been taking.....so yes, I think something on the order of a TEE of the heart, possible 4 vessel angiogram (unless repeat MRA with double contrast fails to show anything).
You should consider coming back to XXXXXXX bring your fiddle as Mr. Loebel would always say, and I'll order the workup for you if they don't want to do it out in LALA Land!
Try and get a TEE if you haven't already as well as a 30 day event monitor for the heart to take home with you.
3. Studies to prove collateral circulation (4 vessel angiogram) may or MAY NOT be worth the risk (approximately 2.5% nationwide for thromboembolic complications....meaning more strokes which may or may not compromise brainstem function....that is NOT a good thing)
I would definitely be careful and hesitant about any recommendation for surgeries or stent placements BEFORE doing everything possible to see about collateral circulation. There is also a very sensitive ULTRASOUND of intracerebral circulation that can be done but the technician needs to be experienced to determine degree of stenosis, reversal of flow dynamics, etc. etc.....so I don't know what sorts of facilities they're working with out there.....but if they don't have it.....you know we've got those toys back here in XXXXXXX at the academic centers.
Cheers my dear! And ROCK ON- Go XXXXXXX Luc and XXXXXXX Grapelli!
This query has utilized a total of 209 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Kinda Sorta- Allow me to clarify.
Detailed Answer:
Thanks for the little summary of your understanding....gives me something to sink my teeth into so I don't have to improvise in a 12/8 bar that modulates from the key of F# min. to C Maj. directing you to go Sul D where the string is actually tuned a quarter step flat by composer's direction! And yes, that was a crazy piece that I had to play at a recital back in the early part of this century.....modern music...sheesh! So pray tell, who would you have studied with.....During our era at CIM there was my teacher Mr. XXXXXXX Loebel, My UCYO director XXXXXXX XXXXXXX (who still composes and conducts), XXXXXXX McCoppin, XXXXXXX Cerone, and of course, XXXXXXX Majeske who I never studied with but of course, heard many a story of how he tried to impress people such as Heifetz who would barely give him the time of day.
And of course, I must know if you still play and if you still practice your Flesch Scales and Rode Etudes? And can you still play from memory the Kreutzer Etude #2...even if you haven't picked up the instrument in 40 years? I'm still rather active and perform regularly in shows, gigs, recitals, chamber and sub in for orchestral members of professional groups....NOT TCO of course, but professional all the same....I'm a card carrying AFM member....that's how! HA!
So, first let me clarify just a couple of the points up top to make sure we're on the same page. Hopefully, there's a neurologist leading the charge on these strokes and their management, right?
1, If your ORTHOSTASIS is resolving it would be nice to know whether it was of central or peripheral origin.....so again, TESTS for autonomic dysfunction ONLY IF there is a high index of suspicion that it is NOT because of metabolic or overmedication disturbances, or significant dehydration, and/or poor physical deconditioning because of you being immobilized for X number of days in bed due to the tPA thing and recovery.......so if they can rule everything else out then, it makes sense to do a full battery of AUTONOMIC FUNCTION TESTING.....but you will need an Autonomic specialist for that who is generally a neurology with fellowship training and a fully equipped lab because there are a number of tests that should be done.
2. MRA with double contrast may have the utility of outlining a little more precisely degrees of stenosis of some of the LARGER pipes in your head such as the BASILAR ARTERY, the ANTERIOR CEREBRAL ARTERY, the CAROTIDS, and the VERTEBROBASILAR SYSTEM which will show us cerebellar penetration or lack thereof. This would be instead of CTA's and instead of actual XXXXXXX procedures so that we can remain NON-INVASIVE until that's not possible anymore. This suggestion is NOT to see the brain better but to see the vascular system that feeds the brain a little more robustly. Depending on the experience of the radiologist (such as if they are a NEURORADIOLOGIST or not) they may or may not get the potential utility of this procedure.
BTW, before you get the double contrast have them get a CREATININE along with an EGFR. You need to clear >=60 cc/min. from the kidneys in order to safely do the study. If not, then, I wouldn't go to that test...not worth the risk of hurting your kidneys. I also am noticing that your A1C is at 6.0 which could be slightly trending on the higher side of normal (depending on your lab limits) even though the glucose seems to be pretty good at 105 (i.e. no PREdiabetic state...though 6.0 is slightly pushing that upper limit for some institutions....but it ain't bad for sure).
The MRA's (even when double contrasted) may not explain why the numerous lacunar or small vessel infarcts as much as studying your RISK FACTORS for small vessel disease (diabetes, smoker, hypercholesterolemia, family history, HYPERTENSION, hypertriglyceridemia, etc). As well as evaluating risk factors for thrombotic as well as small embolic disease. For that you need to do blood work (i.e. stroke in the young workup.....although typically when neurologists say "stroke in the young" they are referring to folks under the age of 55......Please don't be offended....that's just the way it is...but I STILL CONSIDER you a candidate for stroke in the young ESPECIALLY if you fail to have significant risk factors for all the pockshots that your brain has been taking.....so yes, I think something on the order of a TEE of the heart, possible 4 vessel angiogram (unless repeat MRA with double contrast fails to show anything).
You should consider coming back to XXXXXXX bring your fiddle as Mr. Loebel would always say, and I'll order the workup for you if they don't want to do it out in LALA Land!
Try and get a TEE if you haven't already as well as a 30 day event monitor for the heart to take home with you.
3. Studies to prove collateral circulation (4 vessel angiogram) may or MAY NOT be worth the risk (approximately 2.5% nationwide for thromboembolic complications....meaning more strokes which may or may not compromise brainstem function....that is NOT a good thing)
I would definitely be careful and hesitant about any recommendation for surgeries or stent placements BEFORE doing everything possible to see about collateral circulation. There is also a very sensitive ULTRASOUND of intracerebral circulation that can be done but the technician needs to be experienced to determine degree of stenosis, reversal of flow dynamics, etc. etc.....so I don't know what sorts of facilities they're working with out there.....but if they don't have it.....you know we've got those toys back here in XXXXXXX at the academic centers.
Cheers my dear! And ROCK ON- Go XXXXXXX Luc and XXXXXXX Grapelli!
This query has utilized a total of 209 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I studied private violin with XXXXXXX XXXXXXX (Cerone's wife) and chamber music with XXXXXXX Cerone and music composition with XXXXXXX Erb. Yes, I can still play the standard scales, arpeggios, etudes and repertoire from memory. I'm not performing any more, but I used to be first stand second violin in the Fort XXXXXXX Philharmonic for eight years, and took private lessons with the concertmaster. I was an AFM member at the time, of course. Later, I became a Suzuki violin teacher at a private music school in XXXXXXX I taught private and group violin lessons to ages 3-12. This talk of violin makes me want to play again. I admire you for keeping up with it. I should do the same. I used to practice 4-6 hours a day when I was really into it. It was a way of life. Oh, what memories! And yes, I loved XXXXXXX Luc Ponty and XXXXXXX Grapelli. I have quite a library of violin CDs.
As for the medical stuff, I will take all your suggestions to share with the neurologist I am seeing for a hospital follow-up visit tomorrow. He is at USC as well as Good Samaritan where I saw him, so I expect good things from him. If not, I just may have to pay a visit to XXXXXXX and solicit your help. I was born and raised in Ohio, and haven't been back in quite a while.
Thanks again for everything. I will let you know what the new doc says to your suggestions.
Regards,
Deborah
As for the medical stuff, I will take all your suggestions to share with the neurologist I am seeing for a hospital follow-up visit tomorrow. He is at USC as well as Good Samaritan where I saw him, so I expect good things from him. If not, I just may have to pay a visit to XXXXXXX and solicit your help. I was born and raised in Ohio, and haven't been back in quite a while.
Thanks again for everything. I will let you know what the new doc says to your suggestions.
Regards,
Deborah
Brief Answer:
I took a lesson or 2 with XXXXXXX Cerone as well
Detailed Answer:
When Mr. Loebel would go on tour with the orchestra I remember taking lessons from Mrs. Cerone as well. I liked her a lot. Her husband was terrific as well but of course, at that time I was a goofy teenager who hated doing scales and so of course, a woman teacher was easier to have to explain things to if I had been a "bad student" that week....than her husband, who of course was a top man at CIM at that time. I don't think he'd become President yet for a few years....but still....
I'm very impressed at your musical docier and would ENCOURAGE you wholeheartedly to tune up the instrument....take her in the local shop and have them give it a once over and DO THE SAME THING I tell people who've had strokes and suffer from dementia to do with their brains...... USE IT FROM WHAT IT WAS DESIGNED TO DO.....in the brain's case, solve problems, improve function of the body through mastering precision eye/hand coordination tasks. In the violin's case....PLAY HER to her fullest amount.....my goodness...with all that training and talent....your violin must be screaming to be pulled out....the bow.....you MUST restart playing.
It will positively impact function of the brain and could help with things that are going on electrically in areas that have suffered some of these strokes. Think about it...remember, I spoke of AT RISK AREAS of the brain that are close to or in the general vicinty of stroked tissue. The way to keep these AT RISK areas from suffering damage is to make sure blood supply stays high and perhaps, even gets distributed a bit more is possible. Kind of like asking for a BUDGET from your boss.....you want MORE money for a project? Well, you have to show proof of both need and productivity. Same thing with the brain and the violin. You can use the instrument to force the brain to hone FINE MOTOR SKILLS in parts of the body that REQUIRE FUNCTION of the basal ganglia circuitry and white matter tracts which may have been stroked or are at risk. When you play a scale or when you play double stops....and you are commanding your body to do things requiring BILATERAL INTEGRATION of brain circuits and tissue....you are forcing electrical signals to go down pathways that need to be either "opened" up or if obstructed...REROUTED....make sense?
I use these principles all the time with my patients who have a variety of neurodegenerative conditions....I've encouarged patients with dementia to definitely pick up instruments they've not played in years...decades.....and in some cases I've encouarged children to get their parent to LEARN A NEW INSTRUMENT...in one case the children got a piano and harp teacher to come to give lessons at home (from CIM of course!) to their mother who was a former pianist and who over a period of 1 year learned how to do the Twinkle Twinkle sequence...she was 89 at the time and suffering with moderately advanced dementia at that time....but not only did she accomplish that....but she also composed a piece on piano with lyrics. She was exemplary in all my patients who I've supervised in this way using music.
In your case, I know you'd perhaps prefer a more SCIENTIFIC explanation of biomarkers and newest best treatments....but honestly, I can't think of anything more "getting to the root of the problem" than just practicing the fiddle and that my dear will do your brain WONDERS.
You CAN get back into it and you really should.....you're young and bright and I hope your neurologist is a musician as well because I'm sure he would concur. You should read XXXXXXX Sacks's books. He was a brilliant neurologist and accomplished musician and he wrote extensively on the relationship between music and the brain. I believe it needs to be TAUGHT in medical school......let's not even get started on my philosophies of how I believe EVERYBODY should be thoroughly trained in the art of music making...be it voice, instrument, composition......it should be more than just liking a tune on the radio....because that is innate......Our brains are actually much better in its wiring and function when speaking the language of MUSIC than it is when using verbal and other forms of symbolism.....little known fact.
At any rate, please do consider a trip out to XXXXXXX and bring the Ax (that's what XXXXXXX Patti from the renowned Patti Family in XXXXXXX used to call my instrument--- I knew him and studied orchestra in school from the 6th grade).....It might do you a bit of good as well to see the CIM......you wouldn't recognize it if you passed it on East Blvd....don't know if you've been keeping up with all the capital improvements going on in the University Circle area....but it's A LOT! Even the Music Settlement has begun to compete in some ways with CIM....and they don't like it! HAHA! Be well my dear. You will tell me next how your shoulders, arms, and neck felt after practicing for 30 minutes....60 if I've really inspired a reaction! LOL!!
I took a lesson or 2 with XXXXXXX Cerone as well
Detailed Answer:
When Mr. Loebel would go on tour with the orchestra I remember taking lessons from Mrs. Cerone as well. I liked her a lot. Her husband was terrific as well but of course, at that time I was a goofy teenager who hated doing scales and so of course, a woman teacher was easier to have to explain things to if I had been a "bad student" that week....than her husband, who of course was a top man at CIM at that time. I don't think he'd become President yet for a few years....but still....
I'm very impressed at your musical docier and would ENCOURAGE you wholeheartedly to tune up the instrument....take her in the local shop and have them give it a once over and DO THE SAME THING I tell people who've had strokes and suffer from dementia to do with their brains...... USE IT FROM WHAT IT WAS DESIGNED TO DO.....in the brain's case, solve problems, improve function of the body through mastering precision eye/hand coordination tasks. In the violin's case....PLAY HER to her fullest amount.....my goodness...with all that training and talent....your violin must be screaming to be pulled out....the bow.....you MUST restart playing.
It will positively impact function of the brain and could help with things that are going on electrically in areas that have suffered some of these strokes. Think about it...remember, I spoke of AT RISK AREAS of the brain that are close to or in the general vicinty of stroked tissue. The way to keep these AT RISK areas from suffering damage is to make sure blood supply stays high and perhaps, even gets distributed a bit more is possible. Kind of like asking for a BUDGET from your boss.....you want MORE money for a project? Well, you have to show proof of both need and productivity. Same thing with the brain and the violin. You can use the instrument to force the brain to hone FINE MOTOR SKILLS in parts of the body that REQUIRE FUNCTION of the basal ganglia circuitry and white matter tracts which may have been stroked or are at risk. When you play a scale or when you play double stops....and you are commanding your body to do things requiring BILATERAL INTEGRATION of brain circuits and tissue....you are forcing electrical signals to go down pathways that need to be either "opened" up or if obstructed...REROUTED....make sense?
I use these principles all the time with my patients who have a variety of neurodegenerative conditions....I've encouarged patients with dementia to definitely pick up instruments they've not played in years...decades.....and in some cases I've encouarged children to get their parent to LEARN A NEW INSTRUMENT...in one case the children got a piano and harp teacher to come to give lessons at home (from CIM of course!) to their mother who was a former pianist and who over a period of 1 year learned how to do the Twinkle Twinkle sequence...she was 89 at the time and suffering with moderately advanced dementia at that time....but not only did she accomplish that....but she also composed a piece on piano with lyrics. She was exemplary in all my patients who I've supervised in this way using music.
In your case, I know you'd perhaps prefer a more SCIENTIFIC explanation of biomarkers and newest best treatments....but honestly, I can't think of anything more "getting to the root of the problem" than just practicing the fiddle and that my dear will do your brain WONDERS.
You CAN get back into it and you really should.....you're young and bright and I hope your neurologist is a musician as well because I'm sure he would concur. You should read XXXXXXX Sacks's books. He was a brilliant neurologist and accomplished musician and he wrote extensively on the relationship between music and the brain. I believe it needs to be TAUGHT in medical school......let's not even get started on my philosophies of how I believe EVERYBODY should be thoroughly trained in the art of music making...be it voice, instrument, composition......it should be more than just liking a tune on the radio....because that is innate......Our brains are actually much better in its wiring and function when speaking the language of MUSIC than it is when using verbal and other forms of symbolism.....little known fact.
At any rate, please do consider a trip out to XXXXXXX and bring the Ax (that's what XXXXXXX Patti from the renowned Patti Family in XXXXXXX used to call my instrument--- I knew him and studied orchestra in school from the 6th grade).....It might do you a bit of good as well to see the CIM......you wouldn't recognize it if you passed it on East Blvd....don't know if you've been keeping up with all the capital improvements going on in the University Circle area....but it's A LOT! Even the Music Settlement has begun to compete in some ways with CIM....and they don't like it! HAHA! Be well my dear. You will tell me next how your shoulders, arms, and neck felt after practicing for 30 minutes....60 if I've really inspired a reaction! LOL!!
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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