Dr. Abhijeet PLEASE RESPOND - I have posted and no one responds

I am really confused with my ongoing symptoms and would like any advice or direction.  These last few weeks have seemed like an eternity and I am still awaiting answers.  A few weeks ago I started having some visual changes and felt a little "out of body" while sitting on the couch. I awoke to my husband hovering over me telling me I just had a seizure.  It only last a few seconds and I only remember the odd feelings before (I have had these feelings before and I just thought it was something I ate)- vision changes, increased heart rate...  I did not lose control of bowel or bladder but was a little disoriented and sweating profusely and then I felt fine.  My husband forced me to the ER where they did a CT scan (it was normal), said they dont treat first time seizures and told me to follow up with the PCP.  

My PCP ordered an EEG results:
    
      Focally abnormal EEG indicative of left temporal lobae structural lesion.  Slow wave activity from left temporal
      phase reversal at T5.

MRI/MRA (no contrast) results:
MRA - A1 segment of left anterior cerbral artery is tortuous and hypoplasitc

MRI -  Few non-specific white matter T2/FLAIR hyperintense focci, possilby due to MS
     Small non-specific left retrocerebellar fluid collection of questional clinical significance, possibly communicating
     with a generous cisterna magna (7mm depth by 25-30 mm transversely by 5-6 mm in cephalocaudad dimension
     could be an arachnoid cyst although appearance not typical or epidermoid cyst but not likely)

A few days later I developed sudden vision loss in my left eye and went to ophthalmologist he sent me to see a neurologist on an emergent basis - was dx with optic neuritis and put on IV and oral steroids.  Vision is getting better.  He also did a spinal tap (which was negative), several other labs (said B12 was slightly low at 258) and another MRI with contrast.  I developed a spinal headache and when I went in for a blood patch the ER doctor said MRI results showed 10 different areas of demyelination.  I see a neuro in a few weeks.

I had a MRI/MRA in 2000 for some dizziness and nystagmus it showed:
MRA - aplasia or marked hypoplasia of A1 segement of the left supraclinoid carotid artery

MRI - 2 possible arachnoid cyst in posterior fossa, one in the midline and one posterolaterally on the left (2 by 1cm).

My father has epilepsy and MS but the neuro I saw for my neuritis says it does not matter that it is not hereditary.

The research I have done says it is rare to have seizures with MS.  I have some intermittent numbness/tingling in my hands and arms at times (very slight and go away very quickly), night sweats for over a year, and some chronic mildly enlarged lymphnodes in my groin and neck.  I had one bx in my groin and it showed as a reacitve node.  My concerns is that I had some minor symptoms eight years ago and they were dismissed and it was suggested I lose weight.  I have lost 150 pounds.  Is there any siginificance with the cysts and is it normal for demyelination to appear that way.  I do not have headaches or have had no head trauma.  Is there a corelation between the EEG and MRI?  The doctor also ordered a VEP but I do not know the results of it and am curious to how accurate it would be with the neuritis.  The neruologist I am scheduled to see next week is the same one I saw in 2000.  My only other choice was to be seen in August-the next available appointment for new patients with other physicians.  I realize my symptoms have changed a bit but I want to take control and not be dismissive.  I have already lost my driving privileges and am concerned with the affects of this on my career, I am a nurse and work 30 minutes from which is hard when my husband and I work opposite shifts to find someone to take me to work and pick me up.  Could you please give me any suggestions or any ideas as to what might be going on?  Could this be MS or epilepsy or could this have anything to do with the cysts and or the brain hypoplasia?  The neruologist dismissed these things (cyst and hypoplasia) when I had these issues earlier.  Should I consult a neurosurgeon for advice or second opinion?

[Abhijeet Deshmukh, MD]

Hello.

To start with the MRA, the hypoplastic left anterior cerebral artery does not seem to have affected the temporal lobe. It does not supply blood to temporal lobe. The hypoplasia could be a condition from birth and is probably not significant.

What is significant here is the white matter lesions and the EEG finding of a temporal lobe slowing. I was wondering if the MRI shoed any temporal lobe lesions. (I could not find it in the report).

I consider this scenario as strongly suggestive of a demyelinating pathology, most likely to be MS. The family history does play a big role here. There are a number of studies which have shown a positive correlation.

Coming back to the epilepsy part, I would like to know how your husband described your seizure to you when you had it. Was it a generalized seizure or a partial seizure? Temporal lobe seizures are partial seizures, as you know. Epilepsy is known to occur in MS. Have a look at these two articles -

http://www.msakc.org/Articles/UncommonSymptomsofMS.htm

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1528-1167.2008.01565.x

Overall, I guess you should further probe into MS. Find out if they did the IgG Index and oligoclonal band in CSF examination.

Let me know the VEP results. Now every test will be significant. Don't be anxious about future. Focus on the present. People with MS have a normal life span and quality of life when treated appropriately. Let me know.

Regards

[mb2815]

Thank you for your words of encouragement.  My husband described the seizure as more what I found to be a partial seizure.  I was sitting on the couch, my head went back and my eyes rolled back in my head.  He said my left arm was in the air and I was mildly jerking.  He called my name and when I did not respond did a sternum rub, which I still did not respond to.  I see the neruologist on Tuesday and will keep posted on what he says.  I am just a little anxious about things, especially not being able to drive.  Thank you for the article links.  I am awaiting on a copy of my MRI that was done with contrast and the VEP.  Do you feel the cysts are irrelevant?  Do you feel that I should seek a MS speicalist or stay with the neuro that dismissed by milder sx eight years ago?  I know there was minimal clinical significance then and thing have changed and the pictures is bigger I just want the best quality care and dont want to be just another number.  I have even looked into the Mayo clinic.  I know I am getting ahead of myself and should just relax and wait until I see the doctor.  Thanks again for you words of encouragement and I will keep you posted on my dx.

Best Regards

[mb2815]

I saw neuro this week and he says he is not convinced that my episode was a seizure.  He also says he is pretty sure I do not have epilepsy but he can not for sure rule out MS.  He feels that because the spinal tap came back negative and the areas of demyelination are more lateral (MS is typically medial or more towards the center) he is not sure.  He ordered some other tests to rule out heart condition to include:  TEE, cardiac labs (protein c, protein s, ....) 24h holter montior, and a tilt table test.  The dx he wrote on my chart was TIA and syncope.  Could the aplasia in the artery have caused the demyelination?  He did not seem at all concerned about the cyst.  My concern is that they are all on the left side I have:  temporal lobe lesion and slowing, cyst (not sure what type of cyst), several areas of demyelination, and an enlarged lymphnode on my neck(been there for about 2 years - hard and painless about 2cm - had groin lymphnode checked came back reactive and nothing else, did not check any others).  Today I went to the opthamologist for a follow up appointment he was amazed that I did not receive a diagnosis of MS.  He said optic neuritis alone is a very common presenting symptom of MS.  I talked recently with my dad, we are not very close and dont speak often, he told his diagnosis was basically the same.  His MRI showed symptoms of stroke, he had a negative spinal tap.  His diagnosis was delayed and he has suffered a huge coginitive decline and he continues to have a lot of trouble with his memory.  He thinks the delay in treatment did not work in his advantage.  Should I consult another neuro or just wait and see?  I am scheduled to see the neuro back in one month.  Could you please give me any advice?

[Abhijeet Deshmukh, MD]

Hello.

Can you confirm if your current Neurologist is an MS specialist? I don’t doubt his clinical skills, but having an MS specialist's opinion will always be valuable, especially when you have two different opinions about the brain lesions.

Regards