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Suffering from peripheral vestibular lesion with cerebral atrophy. ENG showed severe vestibular lesion

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Internal Medicine Specialist
Practicing since : 1980
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Hello Sir, As u r aware about my health condition, i have certain querries. I am a 35 year old male suffering from peripheral vestibular lesion with cerebral atrophy. the problem started from the month of May, 2012. I was having irregular heartbeats, severe sweating, getting collapsed while standing, sometimes total blackout, inability to stand for long time which i could earlier, giddiness, nausea, imbalance, tremor in legs while standing. I started visiting doctors around my workplace in Assam. They conducted several tests but the reports came normal. Lastly in the month of Nov,2012 they did a CT scan and the report was Cerebral/ Cerebellar atrophy. The doctor started the treatment in this line. To confirm the atrophy i came down to KOLKATA and visited a neuro hospital. There they conducted an MRI of my brain and denied the previous report of atrophy. the neurologist told that i am having peripheral vestibular disease and reffered me to an ENT . The ENT conducted some tests including ENG which says that i am having severe vestibular lesion in right ear. I was on Vertigon 25 , Paxidep CR 25, Zapiz 0.25 according to the suggestion of the ENT & Neurologists. I continued the medicine upto Feb, 2013. But on Mar,2013 the problem aggravated and i rushed to CMC Vellore and consulted with the doctor of Audio Vestibular Department there. They conducted some ENT tests and reported that my reflex of right ear is absent and i am having SNHL. From then only I am on Vertin 48, Prothiaden 75. While taking all this medicines throughout this period i was not getting cured completely. The problem was still there. I went for follow up check up again to CMC in the month of September, 2013. The doctors conducted ENG test and reported Bilateral Canal Paresis. They conducted an MRI of brain and cervical region and report is like : mild atrophy with ventricular prominence, Left PCA hypoplasty, Plaque at CCA bifurcation. From then i am on VERTIN 48, PROTHIADEN 75, NEUROBION FOURTE, FINATE 160( my triglyceride is 250), STALOPAM PLUS, FOURTTS B, ZYLORIC 100 ( my URIC ACID is 7.2). But my thing is not improving. I am still having extreme fatigue, i feel drowsy throughout the day, i feel very lethargic, i feel depressed, my eye lids become heavy, often i feel nausea, still i have balance problem, I cant walk for a long distance, i feel like i am floating in the air. I am doing yoga and vestibular exercises regularly. My question is are these problems only because of Vestibular Disease ?. Are these symptoms are related to atrophy too ? Is atrophy normal at my age ? What should be my next step for treatment? In this connection i would like to state that i had met with a bike accident in the year 2003 and was unconscious for more than 20 mins. what should be the precautions for cerebral atrophy ?
Posted Thu, 7 Nov 2013 in Ear, Nose and Throat Problems
Answered by Dr. Rakesh Karanwal 22 hours later
Brief Answer:
You are already on appropriate treatment

Detailed Answer:

Thanks for your query. I fully sympathize with the agony that you are passing through.

Firstly, I deeply apologize for the delay in replying to your query. I was blocked by the Company's System as I have already exceeded the allotted quota of Premium Queries. The moderator has finally increased my quota so as to enable to address to your query.

* I have thoroughly gone through the provided details. Unfortunately, your case has got complicated by conflicting CT/MRI interpretations and, conflicting opinions given by ENT specialist and Neurologist, at Kolkata and Vellore. Hence, I have no option but to take the interpretation reports of CT/MRI/ENG tests and doctors’ opinions at their face value.

* Firstly, Head injury with loss of consciousness in 2003 had, most likely, caused irreversible injury to the posterior part of brain (called cerebellum and occipital lobe of brain), thereby leading to atrophy of the injured areas. If that is so, it is unfortunately irreversible. Despite there being several drugs in the market, NONE OF THEM IS OF PROVEN VALUE for reversing/delaying the rate of brain atrophy.

* Further, atrophy may also be due to underdeveloped (a congenital anomaly) Left Posterior Cerebral Artery (PCA)- as reported in the latest MRI. PCA supplies blood to the Cerebellum. Poor/inadequate blood supply to cerebellum due to underdeveloped PCA, may be additional cause of cerebellar atrophy.

* Under normal circumstances, atrophy of any part of the brain is NOT seen at 35 years’ of age.

* Cerebellum – in close coordination, through connecting nerves, with inner ear- is responsible for maintenance of posture. Injury to cerebellum/ the connecting nerves (and, in your case, peripheral vestibular involvement/bilateral canal paresis) with associated defect of vestibular system cause imbalance, vertigo, nausea with or without vomiting.

* Hence, both- cerebellar atrophy (irreversible) with defective vestibular system are the cause of your following problems :- imbalance, giddiness and nausea.

* Your symptoms- particularly, extreme fatigue, drowsiness, lethargy, depression are due to depression, for which you have already been prescribed Prothiaden 75 and Stalopram. You may require increase/modification of anti-depressant drugs, as you still have ongoing symptoms of depression. The Psychiatrist will either modify the treatment or, titrate doses of the drugs so as to minimize the undesirable side effects.

* I will also suggest that you get Thyroid hormones levels done, to exclude Hypothyroidism (which is characterized by extreme fatigue, drowsiness, lethargy and mental depression).

* Drowsiness is also due- in part- to anti-depressant drugs (Prothiaden and Stalopram).

* There are no known precautions for atrophy, except for a balanced diet and adequate Vitamin B12 intake. (You are already on Neurobion Forte which contains adequate Vitamin B12).

* Incidentally, you have mentioned that at the time of onset of problems, you used to have irregular heart beats (called Arrhythmias). Arrhythmias too manifest with the similar symptoms, such as, dizziness, giddiness, imbalance, blackouts, sweating, ‘weak legs’. If you STILL GET IRREGULAR HEART BEATS, I will suggest that you also consult a Cardiologist, who will carry out ECG and if required, 24-hours Holter monitoring of the heart rates (which will reveal arrhythmias). If the tests suggest presence of arrhythmias, then anti-arrhythmic drugs will be of great help.

* Lastly, being a Physician, I cannot comment on the course of treatment for Vestibular lesions/bilateral canal paresis or SNHL : the ENT Specialists are best people to provide you with the options.

Hope I have answered your query. If you need further clarifications, I will be happy to answer them.

Wish you a good health

Fond regards and best wishes,

Dr. Rakesh Karanwal
Above answer was peer-reviewed by
Follow-up: Suffering from peripheral vestibular lesion with cerebral atrophy. ENG showed severe vestibular lesion 46 hours later
I had done ECG & 24 hrs holter tests which came out normal. I want to know what can be probable complications in future if the atrophy progresses? At what interval should i do next Mri?
Answered by Dr. Rakesh Karanwal 2 hours later
Brief Answer:
No chances of progression of brain atrophy

Detailed Answer:

Thanks for seeking more information.

As mentioned earlier, the atrophy was primarily due to head injury in 2003. It is NOT likely to progress. Further, even with hypoplastic Left PCA, the brain develops collateral vessels to maintain blood supply to the affected part of the brain. So, there is no likelihood of progression of atrophy due to abnormal PCA.

Hence, from neurological point of view and in view of the reasoning given in the previous paragraph, I do NOT foresee further progression of atrophy until old-age. By inference, you are NOT likely to have further complications.

MRI is therefore NOT required in near future. Repeated MRIs for follow-up are not recommended.

You may therefore be reassured that there would be no progression of atrophy.

Lastly, exclusion of potentially XXXXXXX arrhythmias through Holter Monitoring is a good sign. However, I would still recommend Thyroid hormone levels test.

Hope I have answered your query.

Fond regards,

Dr. Rakesh Karanwal
Above answer was peer-reviewed by
Follow-up: Suffering from peripheral vestibular lesion with cerebral atrophy. ENG showed severe vestibular lesion 18 hours later
Thank you Doctor for nice & detailed clarification. I would like to mention some recent behavioral change in my mentality which was pointed out by my wife. Firstly i am becoming very aggressive in behavior. In simple conversations I am becoming very angry as if i can do any harm to anybody.But I cool down in next second. Secondly I am becoming inattentive sometimes e.g. if someone very much known to me passes in front of me I cant recognize him for sometime, until he calls my name. this often let me in embarrassing position letting him to think that I am ignoring him, but the reality is I am noticing him but failing to recognize. Are these related to atrophy too?
Answered by Dr. Rakesh Karanwal 14 hours later
Brief Answer:
Your behavioral changes are due to depression

Detailed Answer:

It's nice that you have brought out more facts regarding behavioral change.
Having gone through the changes thoroughly, these, including a momentary inability to recognize a face, to are more likely attributable to depression than to cerebellar atrophy. The MRI has not shown atrophy of the part of the brain which governs human behavior.

Cerebellum has no role in modulating behavior. May I apprise you here that behavioral changes are due to imbalance between the chemicals (called neurotransmitters), such as Dopamine and Serotonin in the brain. The imbalance occurs in Depressive illness. Hence, as already suggested earlier, you need modification of treatment for depression, in terms of dosages/change in the combination of medicines.

I therefore recommend that you discuss the entire matter with Psychiatrist who knows what would be best for you.

Dr. Rakesh Karanwal
Above answer was peer-reviewed by
Follow-up: Suffering from peripheral vestibular lesion with cerebral atrophy. ENG showed severe vestibular lesion 9 hours later
Thanks Sir for giving me relief. I have tested couple of times my Thyroid levels, but the parameters are within normal limits. what could be the cause of this extreme fatigue and lethargy. I cant do any hard work, any exertion, travelling by bus or train is becoming nightmare, little bit of walking is tiring me havoc, ascending or descending stairs makes me tired. This type of situation was not there 2 years before. I was a hard worker in my work place. If I think deeply about something I feel mild pain in my head specially in the backside and upperside of my head. I feel more relaxed with closed eyes than with eyes open. I feel irritated with eyes open.
Answered by Dr. Rakesh Karanwal 40 minutes later
Brief Answer:
Anti-depressants will restore your normal status

Detailed Answer:

Thanks for reposing your faith in me.

May I reassure you that these symptoms are NOT due to brain damage or the unfortunate accident of 2003. Its a good sign that your thyroid reports are within normal range. Please let me know the TSH level (it should be less than 5).

Severe depression with associated lack of self-confidence and misplaced apprehensions, manifest in the form of extreme fatigue and lethargy, lack of concentration, thought-block, poor memory, sense of pending doom etc...

Apart from the anti-depressants, you have to reassure yourself the following:-

* that, your brain atrophy is NOW STATIC: it will NOT affect your day-to-day activities or curtail your longevity or aggravate in future.

* that, there is NO PHYSICAL DISABILITY to account for your problems highlighted above

* that, it's just your state of mind.

Bring back your self-confidence! I have several patients who were passing through EXACTLY the same condition as yours. They have improved so remarkably with anti-depressants over a period of time. Now, they are BACK TO NORMAL.

Hence I suggest that you see a really good Psychiatrist who would understand your problems and treat you with compassion; effective anti-depressants.

Other possible causes of these symptoms are anemia, which has already been excluded. Further, you do not have any heart problem.


I wish you a speedy recovery and good health.

Fond regards,

Dr. Rakesh Karanwal
Above answer was peer-reviewed by
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