Etiology of Aphasia

[MasterDoc]

I am a 50 year old Emergency Physician. Seven months ago I insidiously (it seemed to me) developed aphasic symptoms. Semantic paraphasias, phonemic paraphasias, word finding difficulties, impaired repitition. Strangely, the frequency seems to vary significantly from day to day from extremely minimal (once or twice a day) to moderate (20 times a day maximum let me estimate).If I consciously greatly slow down my speech and attend VERY carefully to what I am saying the frequency of paraphasias diminishes (eliminated?) in initiated speech although I still may have difficulty with repetition (aluminum even with CAREFUL attention still might become "alunimum". Usually I notice the error although sometimes not until brought to my attention.  I have had a brain MRI with diffusion weighting which revealed only a small LEFT anterior TEMPORAL arachnoid cyst (no mass effect).EEG totally normal. My only medication when this started was Lipitor.Two possibly related points:1) In November I had an episode where, after donating blood, I ran for a bus. I then got very light-headed and had to get off the bus and passed out (very approx 5 minutes duration). For one hour afterward I was pale, cool and diaphoretic.NO focal symptoms. 2) I had a negative CT 12 years ago (no cyst).
1) Is there ANY additional neurorad test that might pick up ANYold stroke that the MRI misses? 2) Could the NON-congenital cyst cause FOCAL pressure? How prove/disprove? ANY suggestion re further workup/diff dx? Help me please (educationally speaking only of course). And could you check back so I could get one followup

[ill13632]

A related discussion, Horrific speech problems and APHASIA was started.

[vega1318]

You're insane.  Lyme disease does not cause arachnoid cysts or aphasia.  Period.   Stop with this nonsense already.

[ingcam]

If your arachnoid cyst was not on a prior study it may very well be enlarging. A post CT myelogram may help to determine if the cyst has a ball-valve effect.  The contrast gets in the cyst but not out.  The fact that your cyst is in an area consistent with your symptoms would be indication enough for me to warrent the risks (minimal) associated with the test.  I suffered for approx 2 years with an arachnoid cyst in my right cp angle (which was missed on two MRI's) before it was detected on a third scan.  Even then with objective neurologic findings(nystagmus, ataxia, hyperreflexia, vertigo, dysmetria) and a cyst 2.5CM in diameter (yes centimeters!) I was treated like a malingerer and told that "it isn't causing the problems." Eventual aniscoria, pappiledema, and a seizure led to the post ct myelogram which showed the cyst was enlarging and after a posterior fossa craniectomy with fenestration of the cyst I am fine. The fact that you are a doc and are posting on this forum tells me that you have heard many times that the cyst is benign, an incidental finding, not large enough to cause a problem, etc. Please continue to seek help.  You deserve to get your life back.  Also, the negative EEG may never show significant changes but a trial on an antiseizure med. to see if the aphasia abates may also r/o the cyst as the problem.  Good luck

[MasterDoc]

By the way at this point I am UNEMPLOYED because of this. I decided I was unsafe to work when I didn't notice that I had told a paramedic "Give the Dopamine if the blood pressure goes UP (emphasis added) at all." I could kill someone!

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

Keep in mind that I am unable to diagnose you, because I am unable to examine you, and this forum is for eduactional purposes.  The symptoms you describe are indicative of left temporal dysfunction.  The left temporal lobe contains the cortex involved in language generation.  Lesions to these areas, most notably the superior temporal gyrus cause a fluent aphasia (Wernickes) while more subtle damage can lead paraphasic errors, word substitutions and the general feeling of getting your words all jumbled up.  Arachnoid cysts for the majority of patients are present at birth and rarely expand during maturation and are incidental findings.  Rarely these cysts have been described to grow, cause localized mass effect and generate seizure activity.  It is very interesting that you had a negative CT 12 years ago, and could indicate that you have an expanding cyst.  That being said, I would reccomend a prolonged EEG with sleep and it should only be deemed adequate if your symptoms are captured while connected to the EEG. Your EEG may show temporal slowing (that would indicate dysfunction) or spike/sharp waves (would indicate epileptic activity) If you do not have your symptoms, It is reasonalbe that the EEG may be normal.  Temporal lobe dysfunction/language difficulty can originate from many sources besides the clues you presented, other causes are stroke (MRI with diffusion, flair and contrast is the best we have), tumor (occasionaly a cystic astrocytoma can mimic the appearance of an arachnoid cyst), infection (HSV etc, less likley), stress and primary progessive aphasia.  In addition to the Prolonged EEG (may need epilepsy monitoring unit stay) I would also suggest a PET scan to look for focal areas of hypometabolism in your left temporal lobe.
As far as your episode after pusrsuing the bus, That sounds to be pure syncope, you had just given blood, you were stressed and running then pale cool clammy...syncope. No need to worry about that one, however if this repeats you should have a cardiac stress echo and holter monitor.  I hope this has been helpful.