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How To Get An Magnetic Resonance Angiogram Done?
Question: Dear Dr Saghafi,
1) I'm in the process of ordering the MRA of 'everything' that supplies the brain with blood. Since I'm ordering it myself I'm not 100% sure that what I'm asking for is correct. Essentially, it's an MRA of carotids and vertebral arteries, right?
2) I got a phone call from the lab that the test for anti-streptolysin O came within normal range. I don't have the exact number yet though - I will give it to you next week. Still waiting for anti-DNA and anti-ENA antibodies.
3) CT scan of the neck + TMJ is ordered for 22nd of October the day after they take off my braces... Yupee! What's even better is that the insurance company will cover the CT.4) In our last conversation you asked about the EEG results. I think that some time ago I gave you my translation of the description which was probably inaccurate, nevertheless you concluded that the finding didn't indicate anything except that I was drowsy during the procedure. This time I'm enclosing the actual result if you're interested in that. (you'll find it as an attached report). Here is the description again:
===================================
Abnormal II., background Alpha 9-10 Hz, AD imperfect or missing. Native theta episodes, EV theta with a dominance biCTP up to biFCP, slight amplitude dominance on the right, more during HV, with a tendency to generalise up to occasional generalised episodes of irregular OV theta lasting 2-4 seconds. No other changes.
EKG reg, 60/min
BM A sym
BM F Co theta multiplied biFCTP, normal differentiation of other activities
FS without specific response
conclusion:
Mixed episodic changes (theta, OV theta) biFCTP with generalisation during HV, in the background labile Alpha.
====================
My Czech neurologist, based on this finding, sent me to a weekly EEG monitoring in hospital that will take place in about a month.
What I'm thinking is that this EEG made objective my subjective feeling of fatigue and drowsiness. I do feel drowsy all the time and the EEG just showed that. The question is what's causing the constant drowsiness....
Best,
XXXXXXX
1) I'm in the process of ordering the MRA of 'everything' that supplies the brain with blood. Since I'm ordering it myself I'm not 100% sure that what I'm asking for is correct. Essentially, it's an MRA of carotids and vertebral arteries, right?
2) I got a phone call from the lab that the test for anti-streptolysin O came within normal range. I don't have the exact number yet though - I will give it to you next week. Still waiting for anti-DNA and anti-ENA antibodies.
3) CT scan of the neck + TMJ is ordered for 22nd of October the day after they take off my braces... Yupee! What's even better is that the insurance company will cover the CT.4) In our last conversation you asked about the EEG results. I think that some time ago I gave you my translation of the description which was probably inaccurate, nevertheless you concluded that the finding didn't indicate anything except that I was drowsy during the procedure. This time I'm enclosing the actual result if you're interested in that. (you'll find it as an attached report). Here is the description again:
===================================
Abnormal II., background Alpha 9-10 Hz, AD imperfect or missing. Native theta episodes, EV theta with a dominance biCTP up to biFCP, slight amplitude dominance on the right, more during HV, with a tendency to generalise up to occasional generalised episodes of irregular OV theta lasting 2-4 seconds. No other changes.
EKG reg, 60/min
BM A sym
BM F Co theta multiplied biFCTP, normal differentiation of other activities
FS without specific response
conclusion:
Mixed episodic changes (theta, OV theta) biFCTP with generalisation during HV, in the background labile Alpha.
====================
My Czech neurologist, based on this finding, sent me to a weekly EEG monitoring in hospital that will take place in about a month.
What I'm thinking is that this EEG made objective my subjective feeling of fatigue and drowsiness. I do feel drowsy all the time and the EEG just showed that. The question is what's causing the constant drowsiness....
Best,
XXXXXXX
Brief Answer:
MRA orders
Detailed Answer:
The correct way to order an MRA to see all vasculature of relevance would be:
MRA of the Head and Neck.
DX: Topographic Survey of vascular patency of the carotid and vertebrobasilar systems. Rule Out Vertebrobasilar insufficiency.
If ASO titers are normal then, that's all we really need to know. Don't particularly need the numbers. Are you still having any of those problems you were describing before of sort of jumpy or jittery hands/arms when trying to activate the microwave, etc. What about eyes "jumping" or having a difficult time seeing all words on the page?
Good news on the CT. Can't get them to splurge on the MRA, huh?
Thanks for the EEG and I agree that there are elements that are present which can be seen during periods of drowsiness. I'm afraid I wouldn't be quite as excited about the results of this EEG to be sending you each week to a hospital for monitoring. Please be careful that people don't take financial advantage just because they know you are ordering a lot of these things on your own, you're willing to spend your money, and have a bit of an issue perhaps with overthinking medical issues.
For example, exactly why does this neurologist think it is so necessary to get WEEKLY monitoring of your EEG? I've never seen nor heard of such a thing in all the years I trained and have been in clinical practice. You clearly don't have a seizure disorder, waves in an EEG demonstrating some occasional elements of drowsiness is of absolutely no clinical importance, nor is it even that sensitive necessarily for the condition of drowsiness.
I know you are looking for answers but the limitations of these tests are quite significant. Nobody uses an EEG (let alone weekly monitoring) to work up a case of fatigue. Surface EEG has no validity in that type of clinical scenario EXCEPT to rule out seizure disorder (if the suspicion is even there to begin with...which I'm not even sure there was any real clinical index of suspicion that you ever suffered from such a problem). I really think that is overkill and you may check to see what the doctor is getting in return from wherever or whomever he's sending you to for this very expensive proposition if he can't even tell you what's causing your problem?
My apologies if I'm seeming a bit harsh on the neurologist but unless he can really justify that bizarre action of weekly EEG monitoring I think he's taking advantage of you and I'd look for another neurologist because this guy is likely to run you through all sorts of unnecessary tests without having a clue as to where he really wants to go with any of it...including invasive procedures such as a lumbar puncture, angiograms, and the use potentially of even neurosurgical procedures to treat imaginary problems such as a narcolepsy, etc. etc.
If I were you I'd stop the train with that last EEG. It's perfectly fine and needs no repetition for your situation. Repeat studies are going to add nothing to your workup. It would be like taking blood pressures every minute and trying to determine why each and every reading is a few mm. off this way or that way and then, somehow using that information to diagnose somthing like ADD or ADHD.....nobody would do such thing since blood pressure changes minute to minute under normal circumstances. The same thing with EEG readings. They are constantly in flux and cannot be used predictably or diagnostically when it comes to anything really other than seizure disorders or distinguishing people who are truly encephalopathic vs. not.
Be aware that doctors can be just as likely to take advantage of patients who "flash the cash" as any other unscrupulous professional (lawyers, sales people, and of course, politicians!).
Stay in touch.
MRA orders
Detailed Answer:
The correct way to order an MRA to see all vasculature of relevance would be:
MRA of the Head and Neck.
DX: Topographic Survey of vascular patency of the carotid and vertebrobasilar systems. Rule Out Vertebrobasilar insufficiency.
If ASO titers are normal then, that's all we really need to know. Don't particularly need the numbers. Are you still having any of those problems you were describing before of sort of jumpy or jittery hands/arms when trying to activate the microwave, etc. What about eyes "jumping" or having a difficult time seeing all words on the page?
Good news on the CT. Can't get them to splurge on the MRA, huh?
Thanks for the EEG and I agree that there are elements that are present which can be seen during periods of drowsiness. I'm afraid I wouldn't be quite as excited about the results of this EEG to be sending you each week to a hospital for monitoring. Please be careful that people don't take financial advantage just because they know you are ordering a lot of these things on your own, you're willing to spend your money, and have a bit of an issue perhaps with overthinking medical issues.
For example, exactly why does this neurologist think it is so necessary to get WEEKLY monitoring of your EEG? I've never seen nor heard of such a thing in all the years I trained and have been in clinical practice. You clearly don't have a seizure disorder, waves in an EEG demonstrating some occasional elements of drowsiness is of absolutely no clinical importance, nor is it even that sensitive necessarily for the condition of drowsiness.
I know you are looking for answers but the limitations of these tests are quite significant. Nobody uses an EEG (let alone weekly monitoring) to work up a case of fatigue. Surface EEG has no validity in that type of clinical scenario EXCEPT to rule out seizure disorder (if the suspicion is even there to begin with...which I'm not even sure there was any real clinical index of suspicion that you ever suffered from such a problem). I really think that is overkill and you may check to see what the doctor is getting in return from wherever or whomever he's sending you to for this very expensive proposition if he can't even tell you what's causing your problem?
My apologies if I'm seeming a bit harsh on the neurologist but unless he can really justify that bizarre action of weekly EEG monitoring I think he's taking advantage of you and I'd look for another neurologist because this guy is likely to run you through all sorts of unnecessary tests without having a clue as to where he really wants to go with any of it...including invasive procedures such as a lumbar puncture, angiograms, and the use potentially of even neurosurgical procedures to treat imaginary problems such as a narcolepsy, etc. etc.
If I were you I'd stop the train with that last EEG. It's perfectly fine and needs no repetition for your situation. Repeat studies are going to add nothing to your workup. It would be like taking blood pressures every minute and trying to determine why each and every reading is a few mm. off this way or that way and then, somehow using that information to diagnose somthing like ADD or ADHD.....nobody would do such thing since blood pressure changes minute to minute under normal circumstances. The same thing with EEG readings. They are constantly in flux and cannot be used predictably or diagnostically when it comes to anything really other than seizure disorders or distinguishing people who are truly encephalopathic vs. not.
Be aware that doctors can be just as likely to take advantage of patients who "flash the cash" as any other unscrupulous professional (lawyers, sales people, and of course, politicians!).
Stay in touch.
Above answer was peer-reviewed by :
Dr. Bhagyalaxmi Nalaparaju
Hi,
you really got on a rant there :-) But I appreciate the information. You're right or at least it seems to me that my neurologist has no clue what's going on. She said that she doesn't think it's completely psychological but she doesn't know what it is. Depression and temporal lobe epilepsy are what she suggested. As I said before, I disagree with depression - my only current wish is to get over the fatigue and other problems so I can restart doing all my hobbies and interests and there are plenty. I'm not sad in any way and don't have any issues with parents, friends, relationships or the world or my academic career or whatever... Everything's just fine. All doctors I've been to so far except you have tried to put me on drugs that I'd have to take for the rest of my life (from their favourite drug company....ehm ehm....) without having a clue what's going on.
This leads me to overthinking of medical issues. Well, the thing is that I have absolutely no trust in Czech socialist healthcare system where if your condition is not a clear one you're left to your own devices or worse to die. 3 members of my family died of neglect in hospital with treatable conditions. One of them had a broken leg and they kept opening windows on him in cold winter until he got pneumonia and died (they do it purposefully). My cousin was told he had tonsilitis and sent home until he got so bad that my mother - a teacher - diagnosed him with mononukleosis and yada, she was right... This is my rant :-) and I won't go on... It's true I'm extremely cautious when it comes to health but that's just because I have absolutely no trust whatsoever into czech doctors... none at all...
As for temporal lobe epilepsy and the suggested EEG monitoring, I have had since last year several days (once in six weeks) where I get some sort of dream while being awake (5 times on that day); where I don't lose consciousness but I get an electric sensation from my stomach which starts as very pleasant and at the end of this 30-second episode I feel quite sick and exhausted. The dream is very vivid but I can still see the room around me while dreaming it, and consists of a combination of past memories and some imaginary things... In all honesty, it feels like getting connected with my alter identity in an alter reality... Voodoo! I got first such and episode after 2 of my wisdom teeth were taken out...
Fortunately, for the last 3 months I've been 'seizure'-free (at least during the day, I can't say if anything happens during the night), maybe because I've drastically lowered the amount of stress and stopped working haha.
Ah f*** - my English has failed me again - I meant a week-long not weekly monitoring.... Sorry about that. But I guess it doesn't change much about that fact that you deem additional EEGs unnecessary, right? So I haven't spoilt your rant that much? :-)
The EEG monitoring will also be covered by the insurance company so I don't think it's necessarily an attempt by my neurologist to take advantage of me. I also stress that it was not my suggestion and I'm not very keen at all on eating hospital 'food' for the whole week.
Yes I am still having the problem with missing buttons on microwave and tremor in hands when making certain movements; also reading is quite difficult. What's strange though is that one day it's slightly better, on another day it's bad. Especially with the reading. All the problems correlate with each other (the worse the fatigue, the more sluggish thinking and the more memory problems, the more clumsiness and the more difficult reading). I would also dare say that these things correlate with how much spasm I have in my neck muscles etc on a particular day. That's why I'm ordering MRA and MRI of the whole spine. On the whole, I must say that I'm feeling 10% better in everything compared to before I started physiotherapy. It DOES help - especially with urination.
Speaking of MRA, thank you for the MRA description. I'll also be ordering MRI of the whole spine to rule out nerve compression or whatever (because of the urination problems and the suggested CB syndrome and vertebral algic syndrome) - basically I want to see a nice picture of my spine :-)... how childish... Anyway, is there anything specific to say when ordering an MRI of the spine?
Thanks again!
Best,
XXXXXXX
you really got on a rant there :-) But I appreciate the information. You're right or at least it seems to me that my neurologist has no clue what's going on. She said that she doesn't think it's completely psychological but she doesn't know what it is. Depression and temporal lobe epilepsy are what she suggested. As I said before, I disagree with depression - my only current wish is to get over the fatigue and other problems so I can restart doing all my hobbies and interests and there are plenty. I'm not sad in any way and don't have any issues with parents, friends, relationships or the world or my academic career or whatever... Everything's just fine. All doctors I've been to so far except you have tried to put me on drugs that I'd have to take for the rest of my life (from their favourite drug company....ehm ehm....) without having a clue what's going on.
This leads me to overthinking of medical issues. Well, the thing is that I have absolutely no trust in Czech socialist healthcare system where if your condition is not a clear one you're left to your own devices or worse to die. 3 members of my family died of neglect in hospital with treatable conditions. One of them had a broken leg and they kept opening windows on him in cold winter until he got pneumonia and died (they do it purposefully). My cousin was told he had tonsilitis and sent home until he got so bad that my mother - a teacher - diagnosed him with mononukleosis and yada, she was right... This is my rant :-) and I won't go on... It's true I'm extremely cautious when it comes to health but that's just because I have absolutely no trust whatsoever into czech doctors... none at all...
As for temporal lobe epilepsy and the suggested EEG monitoring, I have had since last year several days (once in six weeks) where I get some sort of dream while being awake (5 times on that day); where I don't lose consciousness but I get an electric sensation from my stomach which starts as very pleasant and at the end of this 30-second episode I feel quite sick and exhausted. The dream is very vivid but I can still see the room around me while dreaming it, and consists of a combination of past memories and some imaginary things... In all honesty, it feels like getting connected with my alter identity in an alter reality... Voodoo! I got first such and episode after 2 of my wisdom teeth were taken out...
Fortunately, for the last 3 months I've been 'seizure'-free (at least during the day, I can't say if anything happens during the night), maybe because I've drastically lowered the amount of stress and stopped working haha.
Ah f*** - my English has failed me again - I meant a week-long not weekly monitoring.... Sorry about that. But I guess it doesn't change much about that fact that you deem additional EEGs unnecessary, right? So I haven't spoilt your rant that much? :-)
The EEG monitoring will also be covered by the insurance company so I don't think it's necessarily an attempt by my neurologist to take advantage of me. I also stress that it was not my suggestion and I'm not very keen at all on eating hospital 'food' for the whole week.
Yes I am still having the problem with missing buttons on microwave and tremor in hands when making certain movements; also reading is quite difficult. What's strange though is that one day it's slightly better, on another day it's bad. Especially with the reading. All the problems correlate with each other (the worse the fatigue, the more sluggish thinking and the more memory problems, the more clumsiness and the more difficult reading). I would also dare say that these things correlate with how much spasm I have in my neck muscles etc on a particular day. That's why I'm ordering MRA and MRI of the whole spine. On the whole, I must say that I'm feeling 10% better in everything compared to before I started physiotherapy. It DOES help - especially with urination.
Speaking of MRA, thank you for the MRA description. I'll also be ordering MRI of the whole spine to rule out nerve compression or whatever (because of the urination problems and the suggested CB syndrome and vertebral algic syndrome) - basically I want to see a nice picture of my spine :-)... how childish... Anyway, is there anything specific to say when ordering an MRI of the spine?
Thanks again!
Best,
XXXXXXX
Brief Answer:
Ahhh! You've restored MY faith in Czech Neurology
Detailed Answer:
Yes, both of us did get off on a bit of a tirade. So, I stand corrected then, ONE week long of monitoring. Now, that's an idea I can live with...inhouse monitoring with you hooked up? I concur....good move Ms. Czech Neurologist. I can tell you a couple of stories of patients I've had with what is called (do I dare say for fear of your looking it up and thinking you've got it? I shall cuz you're a smart guy...and you realize this is just a story..not a diagnosis). Anyways, I've had patients with complex partialis continuo epilepsy who were first diagnosed as psychiatric cases....and they were for all the world rather normal sounding, appearing, and functioning with the exception of just a couple of things here and there that didn't seem right to their husbands and/or family members who were with them 24/7. To anybody else (such as doctors, teachers, coworkers, neighbors) not a problem to mention.....but then, when hooked up to the EEG, all hell broke loose. I wish I could predict such a possible outcome in you but I'm not sure about that so much given your 1st EEG.
But--- I think that 1 week of an inhouse EEG is worthwhile doing if there is any chance temporal epilepsy could be an explanation for any of your symptoms. Enjoy the hospital food!
As far as the spine is concerned. Here's how I'd order it (are you doing it with contrast-- really not necessary):
MRI (with contrast) of the cervical, thoracic, and lumbar spines
DX: Degenerative disc Disease, CB syndrome
That should cover the spinal MR.
Go get 'em Tiger! But don't scare 'em too much. LOL.
Ahhh! You've restored MY faith in Czech Neurology
Detailed Answer:
Yes, both of us did get off on a bit of a tirade. So, I stand corrected then, ONE week long of monitoring. Now, that's an idea I can live with...inhouse monitoring with you hooked up? I concur....good move Ms. Czech Neurologist. I can tell you a couple of stories of patients I've had with what is called (do I dare say for fear of your looking it up and thinking you've got it? I shall cuz you're a smart guy...and you realize this is just a story..not a diagnosis). Anyways, I've had patients with complex partialis continuo epilepsy who were first diagnosed as psychiatric cases....and they were for all the world rather normal sounding, appearing, and functioning with the exception of just a couple of things here and there that didn't seem right to their husbands and/or family members who were with them 24/7. To anybody else (such as doctors, teachers, coworkers, neighbors) not a problem to mention.....but then, when hooked up to the EEG, all hell broke loose. I wish I could predict such a possible outcome in you but I'm not sure about that so much given your 1st EEG.
But--- I think that 1 week of an inhouse EEG is worthwhile doing if there is any chance temporal epilepsy could be an explanation for any of your symptoms. Enjoy the hospital food!
As far as the spine is concerned. Here's how I'd order it (are you doing it with contrast-- really not necessary):
MRI (with contrast) of the cervical, thoracic, and lumbar spines
DX: Degenerative disc Disease, CB syndrome
That should cover the spinal MR.
Go get 'em Tiger! But don't scare 'em too much. LOL.
Above answer was peer-reviewed by :
Dr. Prasad
Answered by
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