brief episodes of inability to speak

[ingcam]

I am a 39yo female nurse.  The other day I was post call and had not slept in about 24hrs.  I was having breakfast with a friend (we were both post call) when I noticed some random movement of my left arm that I didn't seem to have control over.  My friend asked me about it but it really wasn't bothering me and seemed to abate quickly so I blew it off.  After I got home I was on the phone briefly and I became sort-of unaware of my surroundings and was unable to get my words out BUT I was aware of what was going on.  I did notice that my left arm was moving again- only my left arm.  This episode only lasted for a few minutes and has only happened a few other times.  I have noticed that sometimes when I go to say some words they come out wrong.  I notice it when It happens but by then it's too late. This does not happen that often but I seem to notice it happening after the brief episodes of not being able to get my words out at all.  I do seem to notice my left arm randomly moving at times without the speech difficulties.  I had an head MRI in the past for some hyperreflexia and left leg numbness which only showed a pineal region cyst- otherwise unremarkable.  Could this be stress related?  I am otherwise healthy except for mild hypertension HCTZ 25mg/day.  I don't feel more stressed but have not been getting "quality" sleep.  What could be causing my left arm mvmt?  Sometimes it is just the arm thing going on- and this seems to happen more often than my speech difficulties.  Could this me a movement disorder?  if so what tests can be done to r/o a disorder?

[CCF-Neuro-M.D.-SH]

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 possibly related to seizure, stress and/or a lesion causing alien hand syndrome.  
   Focal epilepsy can occur in the areas of language processing, temporal-parietal and inferior frontal cortex and the only manifestation may be speech arrest, inability to read, name objects, etc. These can occur without loss of conciousness, but people often get a strange feeling, or "seem different" during these seizures.  Sleep deprivation can exacerbate epilepsy by lowering your seizure threshold, (so if you have a tendency to have seizures, you are more likely to have one under stress, such as sleep deprivation).  An MRI can be normal in a patient with epilepsy.  The test of choice would be an EEG (electroencephalogram or brain wave test). I would recommend a 2 hour sleep deprived EEG in your case, to start with.  EEGs can be negative (falsely) if your spells do not happen while hooked up to the EEG, or if the seizure happens in a deep area of the brain that is not accessable to the scalp (where the electrodes are).  The arm movements, both complex and simple can be caused by seizure, but since the symptoms do not always occur together in a "spell", you should also consider other possibilities as well.

  Another possible cause would be alien hand syndrome.  This occurs when there is a lesion (stroke, tumor, demyelination, trauma, etc.) that affects the Corpus callosum (white matter that connects the 2 sides of your brain), the frontal lobe (motor processing) and/or parietal lobe (sensory integration).  The syndrome is characterized by the patients (usually Left) hand/arm does actions that do not appear to be under volitional control.  Sometimes these are complex or simple movements.  Occasionally the pateint also does not recognize the hand as their own.  I do not know when you MRI was done, but I would recommend a repeat MRI with Contrast to rule out a tumor that may be invading your corpus callosum, etc.  Alien hand syndrome would not explain your speech difficulties, but a lesion in the temoral lobe and invading the corpus callosum could cause both problems.
   A third possibility is that myoclonic jerks are occuring in your left arm.  Myoclonus is a brief jerk that can be caused by metabolic derangements, stress, and spinal cord lesions.  These are also seen in some epileptic syndromes (such as Juvenile Myoclonic Epilepsy). For this I would recommend a CBC, CMP, Ca (with ionized) magnesium, TSH, ESR, CRP, ANA, ammonia. It may be that the sleep deprivation is causing your encephalopathy (altered awareness) and myoclonic jerks, but I would still recommend the above testing to evaluate for more serious causes.
I hope this has been helpful.

[vega1318]

Please, have a full evaluation by a neurologist.  They might repeat your MRI or add some contrast to it to visualize your brain better.  You should also have an EEG, looking for possible seizures.  This may be completely benign, but needs to be evaluated to make sure nothing like a seizure is going on.  In the meantime, try to get better sleep hygiene as that can bring on these transient events.
Also have your doctor order carotid dopplers.

[Fionajnz]

is probably not helping what is happening.  The thing that struck me reading your post was that there is a type of seizure that can occur that affects only one arm, usually starting in the fingers and moving toward the shoulder - jacobson or jacobsonian is what I seem to recall from my college days.  It commonly occurs after concussion type injuries when the brain literally hits the opposite side of the skull during an accident or injury.

The other thing that I would investigate further is your pineal region cyst, that gland regulates the melatonin your body produces and controls circadian rythyms, and can produce muscle weakness, tremors and swallowing probs amongst other things - did you have the blood work done to determine it was benign?  I am going through that process now after a brain MRI for worsening tremors and muscle weakness beginning to affect swallowing. I have found the UCLA neuro website useful.  

At the minimum I would say you need another neuro workup. Speech is  controlled by a very specific part of the brain, as you are probably are aware.  Sleep deprivation can cause speech probs (at 41 I refer to it as Mommy brain) I can find myself mid sentence without recalling what I started saying and I often find myself struggling to find the word I need or I am talking notice something while speaking and suddenly the word is in my sentence - but for me I can relate it to sleep deprivation, multi tasking and my level of concentration.

I hope you get it sorted out soon.  You deserve the best of the best health wise working in your field.  BTW, in my before kids life I was an occupational therapist :-)

Fiona