chronic paraventricular white matter changes; small vessel ischemic disease

50 year old female with 25 year history of hypertension; recently uncontrolled; 25 year history of pack & half smoking [quit December 2007 prior to this event]; prior to the event I'll describe, intermittent periods of speech problems [slurring], right eye vision distortion, right eye droopiness; clumsiness - falling.  12 year history of hypothyroidism. Five year history hyperlipidemia.  No prior history of syncope.
Day before this event had uncontrolled, unrelieved headache pain nearly all day that was nauseating.
Awoke around 3 ro 4 AM with "mid-epigastric" pain, walked to bathroom and tried to sit down on toilet.  Last thing remembered before awakening lying headfirst inside a basket in the bathroom, confused and not sure how got there at that time.  Able to get up and go back to bed, but had problems with right leg "feeling funny" and both arms hurting from landing on basket.  Not clear how long unconscious - best guess is just matter of minutes.  Confusion lasted and right leg symptoms persisted, had dizziness, imbalance with walking and nausea.  Confusional state was prolonged and there were memory issues - called a former employer from 4 years prior to report being ill instead of current employer.
Went to hospital and BP on arrival was 198/110, pulse 54 to 60.
Hospitalized four days, then released to home with persistent, intermittent dizziness and balance issues.  
EKG - normal sinues rhythm with rate of 55 and lsight ST elevation in 2,3 and aVF, V5 and V6.  CK 34 and serial testing negative
Other labs within normal limits
Neurological exam negative except for unsteady gait and equivical Romberg
MRI showed chronic paraventricular white matter changes consistent with small vessel ischemic disease; no acute ischemia; non-specific foci of T2 prolongation
Carotid Doppler found no hemodynamically significant stenosis; but left vertebral aratery was not well visualized.
2=D echocardiogram normal left ventricular systolic function, trace tricuspid regurgitation, but no indication of thrombus
Telemetry 3 days - negative
EEG was "nonspecific"
Tilt Table positive - became unresponsive, BP 75/50 and pulse 30
Medications on admit - Wellbutrin, Timolol, Zetia, Estratest HS, Synthroid
Eye exam found health of the right eye to be normal; however, vision correction/lenses prescription changed

Ongoing symptoms two months later - vision distortions right eye [blurriness]; intermittent dizziness with balance issues; memory issues - trouble remembering things that I commonly would use or I should know; occasionally having trouble with finding the right word when speaking, or saying the wrong word when speaking.  BP is well controlled now.

Have been advised I did not have a stroke; I may have had a seizure, but unconfirmed; Wellbutrin, Estratest stopped and Medications changed to Simvastatin, Atenolol and Vasotec; Low-dose aspirin therapy started.

[PaulMD]

Hi there.

These changes in the MRI reflect a chronic and ongoing process where some parts of the brain are being starved with blood supply and oxygen.  These can be considered as "small strokes" that don't have dramatic and classic symptoms of paralysis.  These small vessel problem may  a consequence of the hypertension, since prolonged increased pressure in the blood vessels cause injury to these small vessels and can lead to narrowing.  Another possibility is multiple sclerosis (MS) which is a chronic demyelinating condition.

It is important to really have the blood pressure controlled, as well as reporting to your doctor any new symptoms that might ensue.

REgards.