Abdominal pressure as a trigger?

[freaked-out]

Male. Age 35. For 4.5 years I am struggling with losses of consciousness. I had several MRIs and EEGs done. Apart from cavum septi pellucidi (which was NOT considered to be the cause of my problems either by radiologists or neurologists) no irregularity was found. EEGs did not indicate any paroxysmal outbursts. In 2004 I underwent thorough diagnostic examinations in Vienna, Austria. The longest periods between losses of consciousness were 9.5 months; 8.5 months and 5 months. Now the periods between attacks have decreased to 3; 2 and 1 month between attacks. Initially under therapy with Lamictal, then Lamictal and Valproic Acid (both excluded by physicians in Vienna as they attributed my problems to job related stress). Roughly a year and a half ago prescribed diazepam pills a 5 mg 1,1,1 to be supplemented, six months ago, by Tegretol CR (controlled release) 0,0,1 (initially 400 mg, now 600 mg per day, after liver and EMIT tests). During the past 4.5 years I have bitten my tongue on two occasions, both times laterally and while asleep. In 90% of cases the losses of consciousness were experienced while seated (having lunch, twice in the car – as a passenger), behind laptop etc. A feeling (aura?) usually precedes the attack (?). It manifests as a special (hard to describe) feeling in the area of diaphragm and xiphoid process. In most cases my shoulders were slouched and I was exercising unintentional pressure on my abdomen. Witnesses estimated the loss of consciousness to last between 15 and 60 seconds where I would first turn pale (white as a sheet) and just before regaining consciousness my face would turn intensely red. Could it be that my posture is triggering or contributing towards the attacks, and if so do you have any advice on the possible remedy?

[Abhijeet Deshmukh, MD]

Hello.

Neurodermatitis syndromes are known to be associated with seizures. I don't see the tongue biting episodes as normal incidences. Stress does play a role in "triggering" certain neurological issues, especially seizures. But stress is not the root cause.

Your "seizures" appear to be related to changes in the blood circulation. The unintentional pressure on the abdomen alters the pressures in the chest cavity, which pushes blood out of the mediastinum. And you also turn pale during the episode. Had it not been for the tongue biting, I would also not have considered seizures.

Regards

[freaked-out]

Thank you for your prompt response.

The tongue bitting episodes occurred on both occasions while asleep (I wasn't aware of it until morning) , both times laterally on the right-hand side (the side I sleep on) and more to the back of the tongue (I suppose I bit the tongue with my molars). This has happened only on these two occasions.

I have never had any heart problems. During the above mentioned examinations in Vienna I underwent ECG tests (including 24 hrs recording) plus ultrasound examination of the heart and periphery blood vessels (neck and feet). All findings were normal.

As a background info: I am a nonsmoker and a nondrinker and have never used any drugs; I was involved in sports almost my entire life; I am 6.2'' and weigh between 195 and 198 lbs. All of the losses of consciousness occurred in relation to some stressful episode (tight deadlines at work, VIP visits at work, unresolved private issues etc.). I admit that I tend to set the bar rather high when it comes to my work performance as well as private life.

The Vienna physicians concluded that stress was triggering these episodes. I argued that I had been exposed to a fair share of stress throughout my life but never with such results. However, they emphasized the cumulative nature of stress and warned me against underestimating the negative effects of stress.

If it is of any value to you another piece of information: I suffer and have been suffering all my life from neurodermatitis which did not result in any serious problems but in situations when I am exposed to stress tends to visibly worsen and needs ointment treatment. Could it be that stress is the root cause of my problems?    

I highly appreciate your time and effort.

[Abhijeet Deshmukh, MD]

Hello.

Could you describe the tongue biting episodes? Were they during episodes of unconsciousness? You don't bite your tongue during syncope. We need to check upon this part.

Have you had any heart conditions? Have you been referred to a cardiologist?

Regards

[freaked-out]

Your answer is much appreciated. I would need your opinion on another related issue. I am afraid that I may have been misdiagnosed and have been reading up, for quite some time now, on the possible different causes of my condition. This is when I started focusing on syncope as a possible cause of my problems. However, I do not know if I am able, as a patient, to maintain objectivity. Nonetheless, a number of symptoms fit this diagnosis: pallor, bradycardia, drop in blood pressure, losses of consciousness of under 60 seconds, epigastric discomfort, the fact that I am aware of my surroundings and fully oriented the moment I regain consciousness, the fact that I never recall hitting the ground (or sofa), normal EEGs, the fact that I was not taking any medications when I was problem free for periods of 8.5 and 9.5 months etc. I underwent head-up tilt test in 2005 but the result was negative. I know that it is not an easy job to differentiate between these conditions but I would hate to discover that I was being stuffed with medications that had nothing to do with my condition. Could you recommend any differential diagnostic method that would be of help in my case in order to confirm beyond doubt the nature of my condition given that my diagnosis is still epi susp.? Your comments and views on anything stated above are welcome and highly valued. Much obliged.  

[Abhijeet Deshmukh, MD]

Hello.

Hope you are still visiting this forum. It's been a long time since you have posted your query.

What you have described fits in the picture of generalized seizures with aura. The abdominal pressure is actually part of the aura. I do not think your posture is related.

Now the episodes are occurring more frequently. This suggests that the cause of epilepsy has not been touched. Epileptic seizures are known to increase in frequency if not treated.

The fact that you have bittern your tongue rules out any non epileptic seizures (pseudo seizures). You need to get the dose of the medication right.

Regards