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What Causes The Inability To Speak In A Quadriplegic Patient?
Question: My father is a quadriplegic, has been for 33 years now. He was admitted to the hospital last week because of dehydration, low platelets, sent home after a week. Went back in for very low heart rate only in the 30s-40's..and blood pressure through the roof. He has now been diagnosed with a viral infection but they don't know the exact one yet. They did a spinal test to get fluid from his spine to see what is causing him not to speak now. He has not been able to talk for a week. Please I really hope you can help, the Drs are stumped and have no idea why he is not speaking.
Do you think this may be a neurological problem? They did a CAT scan and the results were good, nothing wrong they said. No blood on the brain, or swelling they said. or do you think it could of been a small stroke? We don't know, please help!!
Do you think this may be a neurological problem? They did a CAT scan and the results were good, nothing wrong they said. No blood on the brain, or swelling they said. or do you think it could of been a small stroke? We don't know, please help!!
Brief Answer:
Possible.
Detailed Answer:
I read your question carefully and I am sorry about the situation your father is in.
Since you say the doctors are stumped you mean that his general physical condition is stable, that there are no more hydration or other metabolic issues, blood pressure and heart rate have gone back to normal and there is no respiratory failure, is that correct. I am asking because any metabolic issue or lack of oxygen and blood flow to the brain would justify him not speaking.
It would also be useful to know what were the results of that spinal tap, were there any abnormalities in his cerebrospinal fluid. What about his condition, by not being able to speak do you mean that he is not awake at all, or is he awake and able to comprehend but unable to articulate words.
Whether it is possible to have a stroke not detected by a CAT scan which can leave one unable to speak...yes it is possible. Stroke involving the brainstem may not be detected by CAT scan and if affecting the pathways responsible for speech articulation may lead to inability to speak, even if it is a small stroke.
I remain at your disposal for other questions, possibly providing the information I mentioned.
Possible.
Detailed Answer:
I read your question carefully and I am sorry about the situation your father is in.
Since you say the doctors are stumped you mean that his general physical condition is stable, that there are no more hydration or other metabolic issues, blood pressure and heart rate have gone back to normal and there is no respiratory failure, is that correct. I am asking because any metabolic issue or lack of oxygen and blood flow to the brain would justify him not speaking.
It would also be useful to know what were the results of that spinal tap, were there any abnormalities in his cerebrospinal fluid. What about his condition, by not being able to speak do you mean that he is not awake at all, or is he awake and able to comprehend but unable to articulate words.
Whether it is possible to have a stroke not detected by a CAT scan which can leave one unable to speak...yes it is possible. Stroke involving the brainstem may not be detected by CAT scan and if affecting the pathways responsible for speech articulation may lead to inability to speak, even if it is a small stroke.
I remain at your disposal for other questions, possibly providing the information I mentioned.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
yes you are correct they said he is stable because of his blood pressure and HR are now normal, and he is not dehydrated anymore. His Saturation has been in the very high 90's even off the ventilator since he has been in the hospital. Although there was a time that it dropped to the 80's a couple times. The spinal tap results came back as a viral infection, but they are not sure yet exactly which one. He is fully awake, and is able to show some signs of facial expressions. However, if we ask him to stick out his tongue, or follow our finger, he is not able to. But if there are two people next to him he can hear them talking and make eye contact to the person that is talking to him. It's so frustrating, because it looks like he wants to talk but cant.
Brief Answer:
MRI is the next diagnostic step.
Detailed Answer:
Thank you for the additional information.
Given that information the situation can not be blamed to a secondary involvement of the brain by respiratory or metabolic issues.
In that situation I think the next necessary step is a brain MRI. It would detect the small stroke the possibility of which we discussed, as well as possible infection related findings which may be missed by simple CAT scan. Perhaps MRI hasn't been done till now because of the presence of the pace maker, but if the pace maker doesn't work as you say I suppose the device can be removed.
Let me know if I can further assist you.
MRI is the next diagnostic step.
Detailed Answer:
Thank you for the additional information.
Given that information the situation can not be blamed to a secondary involvement of the brain by respiratory or metabolic issues.
In that situation I think the next necessary step is a brain MRI. It would detect the small stroke the possibility of which we discussed, as well as possible infection related findings which may be missed by simple CAT scan. Perhaps MRI hasn't been done till now because of the presence of the pace maker, but if the pace maker doesn't work as you say I suppose the device can be removed.
Let me know if I can further assist you.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
So your saying because the pace maker does not work that they can indeed remove it to perform the MRI? His platlets are 36,000. Not falling or increasing they said. If they removed the pacemaker is there a high risk of death because of the low platlets? And your also saying that a MRI can give us an exact answer as to why he is not speeking?
is it possible that he may never speak again?
Did you get my last message? So your saying because the pace maker does not work that they can indeed remove it to perform the MRI? His platlets are 36,000. Not falling or increasing they said. If they removed the pacemaker is there a high risk of death because of the low platlets? And your also saying that a MRI can give us an exact answer as to why he is not speeking?
is it possible that he may never speak again?
Did you get my last message? So your saying because the pace maker does not work that they can indeed remove it to perform the MRI? His platlets are 36,000. Not falling or increasing they said. If they removed the pacemaker is there a high risk of death because of the low platlets? And your also saying that a MRI can give us an exact answer as to why he is not speeking?
Brief Answer:
Read below.
Detailed Answer:
I received all your messages but because of time difference with Europe I got them once I had gone to sleep.
That platelet number is indeed very low and it might represent a risk. The choices would be either to wait for some more days hoping that those figures can improve or to try a platelet transfusion in order to raise the platelet count enough.
As to whether the MRI will give an exact answer, that I can't say before the exam. But I can say that it will detect any small stroke or brain lesion which may be missed by CAT scan, may also show inflammation of cranial nerve roots due to infection or autoimmune causes. So even if it shows nothing it will rule out some hypotheses for good and it can be moved on to thinking about other possibilities.
I can not say whether he will be able to speak since we are not clear about the cause, not only of him not speaking but of this platelet count and what initiated the event (dehydration seems not enough to explain everything). The fact that he is at least stable provides some hope, especially if there will be no additional findings on MRI. There can be no certainties though, especially given that he was already quadriplegic which makes it difficult to understand the extent of neurological damage given that muscular strength was already absent and can't be assessed.
Read below.
Detailed Answer:
I received all your messages but because of time difference with Europe I got them once I had gone to sleep.
That platelet number is indeed very low and it might represent a risk. The choices would be either to wait for some more days hoping that those figures can improve or to try a platelet transfusion in order to raise the platelet count enough.
As to whether the MRI will give an exact answer, that I can't say before the exam. But I can say that it will detect any small stroke or brain lesion which may be missed by CAT scan, may also show inflammation of cranial nerve roots due to infection or autoimmune causes. So even if it shows nothing it will rule out some hypotheses for good and it can be moved on to thinking about other possibilities.
I can not say whether he will be able to speak since we are not clear about the cause, not only of him not speaking but of this platelet count and what initiated the event (dehydration seems not enough to explain everything). The fact that he is at least stable provides some hope, especially if there will be no additional findings on MRI. There can be no certainties though, especially given that he was already quadriplegic which makes it difficult to understand the extent of neurological damage given that muscular strength was already absent and can't be assessed.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
The Dr's have not checked his thyroid, By checking it, do you think that would prove any reason to his speaking problem? Perhaps his serotonin is low,.. He was in a very depressive mode before entering the hospital. Do you think he could be partially catatonic due to that? We were also concerned about his neck We were wondering if transferring him from bed to wheelchair could of possibley misaligned his spine, causing him not to speak, is that even possible? We are still searching for answers. He seems to be improving a little more today, with more facial expressions, but is still not speaking. Have you ever worked with a patient that was speaking, then suddenly did not speak? and if so do you know how long it took for them to talk again?
Brief Answer:
Read below.
Detailed Answer:
I do not think thyroid function can be accused about it. However I would expect the doctors to have perhaps made a basic measurement of thyroid function, in most western hospital it is among the routine biochemical tests for the admitted patients.
The neck also shouldn't be responsible, the nerves which are responsible for speech are cranial nerves, situated inside the skull.
Psychogenic issues can mimic any neurological disorder, so if no other cause is found and every test is normal it may be taken into account. However given that there have been abnormalities found in his vitals, blood tests as well as lumbar puncture I wouldn't hurry into looking for depression as a cause, as I said it is considered when other causes have been excluded.
I have patients who present with inability to speak all the time, as a neurologist dealing with stroke speech issues are very common. As to how long it takes to recover that depends on the cause and extent of damage, in the case of a stroke may vary from a few days to never regaining it at all when there is a big stroke. But in this case we do not even know whether it is a stroke in the first place, let alone make predictions. However since the CT is normal I would be optimistic that it is not the case of a big stroke and there are good chances of recovery if other vitals remain stable, there are no infectious complications and his blood tests get better.
Read below.
Detailed Answer:
I do not think thyroid function can be accused about it. However I would expect the doctors to have perhaps made a basic measurement of thyroid function, in most western hospital it is among the routine biochemical tests for the admitted patients.
The neck also shouldn't be responsible, the nerves which are responsible for speech are cranial nerves, situated inside the skull.
Psychogenic issues can mimic any neurological disorder, so if no other cause is found and every test is normal it may be taken into account. However given that there have been abnormalities found in his vitals, blood tests as well as lumbar puncture I wouldn't hurry into looking for depression as a cause, as I said it is considered when other causes have been excluded.
I have patients who present with inability to speak all the time, as a neurologist dealing with stroke speech issues are very common. As to how long it takes to recover that depends on the cause and extent of damage, in the case of a stroke may vary from a few days to never regaining it at all when there is a big stroke. But in this case we do not even know whether it is a stroke in the first place, let alone make predictions. However since the CT is normal I would be optimistic that it is not the case of a big stroke and there are good chances of recovery if other vitals remain stable, there are no infectious complications and his blood tests get better.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Is it possible to do a cranial nerve procedure on his brain, If he has low platelets? How did the nerve even get damaged? If indeed it is damaged is there any hope of his ever speaking again?
Brief Answer:
Read below.
Detailed Answer:
I think that you misread my last post. I said that cranial nerves are NOT damaged by a neck spinal damage. I never said they were damaged in the first place, so naturally we can't speak of procedures.
And again, before making predictions about the future we should find the cause, then we can speak of prognosis and treatment.
So to resume if there is a primary neurological lesion, it could be a stroke in the brain stem, or an infection which potentially can damage the brain or the nerves as they leave the brain. It can also be an autoimmune reaction directed to nerves.
With the information at hand it is impossible to differentiate between those, more tests would be advised, starting with a MRI (and possibly results of other current tests apart from the platelet count - up to now I've been assuming all the rest is fine). In any of those cases it is not a question of any surgical procedures though.
Read below.
Detailed Answer:
I think that you misread my last post. I said that cranial nerves are NOT damaged by a neck spinal damage. I never said they were damaged in the first place, so naturally we can't speak of procedures.
And again, before making predictions about the future we should find the cause, then we can speak of prognosis and treatment.
So to resume if there is a primary neurological lesion, it could be a stroke in the brain stem, or an infection which potentially can damage the brain or the nerves as they leave the brain. It can also be an autoimmune reaction directed to nerves.
With the information at hand it is impossible to differentiate between those, more tests would be advised, starting with a MRI (and possibly results of other current tests apart from the platelet count - up to now I've been assuming all the rest is fine). In any of those cases it is not a question of any surgical procedures though.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
The Drs said he can not have an MRI because he has a pace maker. with such low platelets it would be risky to remove it to perform the MRI. Trust me I really wish they could, so we can get down to the cause of all this. That is why they did the spinal tap instead they said. Unless you know of a way of removing the pacemaker a different way, I don't know. I thought maybe they could give him platlets to perform the removal of his pacemaker, but I don't know. They did a sonogram on his heart and it was good. He is holding his own with stable vitals. Why do you think he is not producing more platlets? why are they just staying at a steady 36,000. Do you think he is bleeding internally somewhere and they just can detect where its coming from? God, I just wish he could get the MRI..It would ease everyones minds.
Brief Answer:
Read below.
Detailed Answer:
I am sorry, I understand the anguish you must be in. Technically the MRI is feasible with a platelet transfusion and pacemaker removal. However the decision to go through with that depends on how high a degree of suspicion your doctors have, they are the ones who have examined cranial nerve functions (pharyngeal reflexes, facial weakness, pupillary asymmetries and ocular movements etc), if they have found no strong indicators they might not want to perform procedures which aren't vital. Remember that MRI is a test, not a cure. Even if we were to admit that say there is a stroke that wouldn't change the immediate management, the lesion is already there and it can't be reverted after the first few hours, improvements is expected by the organism itself compensating with time not by drugs which a only to prevent recurrences. Even in the case of a viral infection, MRI or not treatment is the same. So from a practical point of view while the MRI is important to make a point about the situation and prognosis, in terms of immediate action it wouldn't change so much, for that reason they are choosing not to go the path of urgent transfusions and pacemaker removal for the moment, with the condition being stable. At times anguishing as it may seem it may be better to wait for a few days, you say yourself that he's looking slightly better today.
As for the cause of thrombocytopenia, there is a long long list of potential causes like liver and spleen conditions, blood malignancies, nutritional deficiencies, infections etc etc. So I can not judge without knowing more on the other tests he's had. I can say that it is not due to internal bleeding, rather the other way round, low platelet count puts him in danger of bleeding, but is not due to it (I am sure they've thought about checking it though, would be visible starting with the low hematocrit in his blood count).
Read below.
Detailed Answer:
I am sorry, I understand the anguish you must be in. Technically the MRI is feasible with a platelet transfusion and pacemaker removal. However the decision to go through with that depends on how high a degree of suspicion your doctors have, they are the ones who have examined cranial nerve functions (pharyngeal reflexes, facial weakness, pupillary asymmetries and ocular movements etc), if they have found no strong indicators they might not want to perform procedures which aren't vital. Remember that MRI is a test, not a cure. Even if we were to admit that say there is a stroke that wouldn't change the immediate management, the lesion is already there and it can't be reverted after the first few hours, improvements is expected by the organism itself compensating with time not by drugs which a only to prevent recurrences. Even in the case of a viral infection, MRI or not treatment is the same. So from a practical point of view while the MRI is important to make a point about the situation and prognosis, in terms of immediate action it wouldn't change so much, for that reason they are choosing not to go the path of urgent transfusions and pacemaker removal for the moment, with the condition being stable. At times anguishing as it may seem it may be better to wait for a few days, you say yourself that he's looking slightly better today.
As for the cause of thrombocytopenia, there is a long long list of potential causes like liver and spleen conditions, blood malignancies, nutritional deficiencies, infections etc etc. So I can not judge without knowing more on the other tests he's had. I can say that it is not due to internal bleeding, rather the other way round, low platelet count puts him in danger of bleeding, but is not due to it (I am sure they've thought about checking it though, would be visible starting with the low hematocrit in his blood count).
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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