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Do all small strokes show up on MRI's?
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Do all small strokes show up on MRI's?

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?
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Avatar_n_tn
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.
5 Comments
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Avatar_m_tn
I've brought up the possibility of a cerebral angiogram a couple times already with 2 different neurologists. They both told me it was too dangerous a procedure to undertake. What about a CT-angio?
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Avatar_f_tn
Basilar migraine is a very likely possibility and I would go with the doctor's suggestion of trying a preventative medication, such as Elavil.   Definitely see a headache specialist in your area.  There is no need for a CT angio at this time, most likely, especially, since these symptoms have been going on for a long time.   Your tortuous vertebral artery is unlikely the culprit but you should try to reduce your atherosclerotic risk factors, such as cholesterol, high blood pressure, any sugar problems -- if you have such.
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Avatar_m_tn
Doing all that. Trying to lead as healthy a lifestyle as I can.
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Avatar_n_tn
End of June I had a small seizure followed by weakness of the left hand side and was told after a spell in hospital that this was probably a small stroke.  Two weeks later I awoke with worsened LHS weakness.  Then I had an MRI which was normal I have also had an MRI on  my neck and neurologist has ordered a lumbar puncture, EEG VERs and SSERs which I haven't had done yet.
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 is better it still suffers greatly with tremor.  There is no history of epilepsy in my family.  I also suffer with high blood pressure as does my 83 yr old mother and my 58 yr old sister my father died at age 65 of an MI with no prior history.
If anyone can offer any answers I would be very grateful.
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