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Neurology (Expert Forum)
Do all small strokes show up on MRI's?
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Do all small strokes show up on MRI's?
by heart2heart, Aug 06, 2006 12:00AM
I'm a 54 yo non smoking female. After 30 years of symptoms I'm now convinced I'e suffered some kind of stroke that isn't showing up on MRI's. I've had vertigo attacks, double vision, numbness of my face (right side near mouth) tinnitus, drop attacks, alternating somnolence/insomnia, near fainting spells, amnesia attacks, nausea, and in the beginning ..headaches (located behind my eyes) I've been to a half dozen neuros. One dx is of BAM (basilar artery migraine) I've tried diiferent drugs, neuroleptics, beta blockers, verapamil, to no avail. How can BAM continue for 30 years? MRI is normal, MRA shows tortous but patent right vert.artery, COW is patent. Should I be on some kind of anti coagulant therapy? Will these symptoms lead to a horrible brainstem stroke?
Doctor's Answer
by CCF-Neuro-M.D.-SH, Aug 06, 2006 12:00AM
First of all, keep in mind that I am unable to diagnose you because I am unable to examine you, this forum is for educational purposes. The symptoms you describe are very complex, and there is a lot of information that I do not have. From the symptoms you decribe, basilar artery migraines is likely reasonable, but I would suggest extensive testing prior to stopping with that diagnosis.
Some small strokes can be missed on MRI scans, especially strokes in the lateral brainstrem (the so called Wallenberg syndrome) if they are very small. However it is unlikely to miss recurrent strokes, because the area affected would be larger. Recurent strokes in the same area of the brain (causing the same symptoms) is generally related to a vessel abnormality in that region, such as a stenosis or dissection.
Given that you have had these symptoms for 30 years it is unlikely that you are having brainstem strokes or something bad would have happened by now. However, the brainstem is a structure that has to be taken seriously and I would suggest an angiogram of your cerebral vessels to make sure that right vertebral artery is not dissected, or other vessel abnormalities do not exist (Cerebral angiogram is more sensitive than MRA).
Basilar artery migraines can cause the symptoms you describe and are also often refractory to treatment. A class of medications that you did not mention is the atypical anti-psychotics such as Zyprexa 5-10mg and Seroquel 25-50mg(at lower doses that used as psych meds) are often helpful with these type headaches. These medications work on the dopamine transmitter system and are similar other standard migraine drugs such as Reglan and Compazine. It is not uncommon for migraines to persist for 30 years, it would be VERY uncommon for brainstem strokes to persist for 30 years with a normal MRI. A good preventive medication that you did not mention is elavil 10mg-75mg taken each night. I would recommend that you see a neurolgist that specializes in headaches (such as a headache center) since there are many things that can contribute to poor headache control (food, sleep, over the counter medication overuse, etc).
I would not recommend anti-coagulation at this time (a baby aspirin 81mg is fine). Anti-coagulation (with coumadin) has many risks and there is no clear benefit in your case from what you have described. After you have had the cerebral angiogram, the final decision about anti-cogaulation can be made by your neurologist. Also given your history of amnesia, somnolence and drop attacks I would also recommend an EEG (electro-encephalogram-or "brain wave test") to evaluate for a seizure disorder.
I hope this has been helpful.
Some small strokes can be missed on MRI scans, especially strokes in the lateral brainstrem (the so called Wallenberg syndrome) if they are very small. However it is unlikely to miss recurrent strokes, because the area affected would be larger. Recurent strokes in the same area of the brain (causing the same symptoms) is generally related to a vessel abnormality in that region, such as a stenosis or dissection.
Given that you have had these symptoms for 30 years it is unlikely that you are having brainstem strokes or something bad would have happened by now. However, the brainstem is a structure that has to be taken seriously and I would suggest an angiogram of your cerebral vessels to make sure that right vertebral artery is not dissected, or other vessel abnormalities do not exist (Cerebral angiogram is more sensitive than MRA).
Basilar artery migraines can cause the symptoms you describe and are also often refractory to treatment. A class of medications that you did not mention is the atypical anti-psychotics such as Zyprexa 5-10mg and Seroquel 25-50mg(at lower doses that used as psych meds) are often helpful with these type headaches. These medications work on the dopamine transmitter system and are similar other standard migraine drugs such as Reglan and Compazine. It is not uncommon for migraines to persist for 30 years, it would be VERY uncommon for brainstem strokes to persist for 30 years with a normal MRI. A good preventive medication that you did not mention is elavil 10mg-75mg taken each night. I would recommend that you see a neurolgist that specializes in headaches (such as a headache center) since there are many things that can contribute to poor headache control (food, sleep, over the counter medication overuse, etc).
I would not recommend anti-coagulation at this time (a baby aspirin 81mg is fine). Anti-coagulation (with coumadin) has many risks and there is no clear benefit in your case from what you have described. After you have had the cerebral angiogram, the final decision about anti-cogaulation can be made by your neurologist. Also given your history of amnesia, somnolence and drop attacks I would also recommend an EEG (electro-encephalogram-or "brain wave test") to evaluate for a seizure disorder.
I hope this has been helpful.
I also suffer with coronary artery spasm and prior to the first attack at the end of june I had some bad angina pain my doc wanted to admit me to the local coronary care unit but i was unwilling. Prior also to this I had had a chronic chest infection with pneumonia and so had a high temperature.
My neuorlogist does not think I have had a stroke but I wonder if it is possible to have a small stroke that affects the left side ie., hand, arm and left leg and to still have a normal MRI. I have good use back into my arm and hand but my leg is still floppy and very shaky when i try to put any weight on it. I am now receiving physio and this is early days. I am confined to a wheelchair as I cannot walk at all, I cannot put any weight on my left leg it feels like jelly and is so shaky with tremors. Although my left hand