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What Causes Sudden Black Outs?
Question: My wife is 63. What could be causing her to seemingly black out. I say seemingly because although her eyes are closed and her body is limp, she can still hear what's being said and still feel if she is touched. She is totally unresponsive though. You could take a needle and poke her with it and she will not respond. When she snaps out of it her right eyeball floats up in her head. She has had MRI's, MRA's, MRV's. She has had cat scans, EEG,s, EMG,s. So far epilepsy is ruled out. She has a weakness on the right side of her body and has foot drop. Three times she was taken to the hospital (911) because I thought she had a stroke. Slurred speech, mouth cocked to one side, contorted arm and wrist on right side. Two different hospitals say she did not have a stroke although the physical therapists say that's what it looks like. She has had a complete work up on her heart and got a clean XXXXXXX of health. She has seen a psychiatrist and it is not conversion or depression. The only injury to her neck was a car accident almost 4 years ago. She had her seat belt on and snapped her neck but did not hit her head. She was seen by a surgeon for her neck and he said she does not need surgery. What could this possibly be?. She has had these episodes on and off since the time of the accident. So far nobody has been able to match it up with a diagnosis.
Brief Answer:
How are epilepsy and RULED OUT exactly?
Detailed Answer:
Good evening. My name is Dr. Dariush Saghafi and I am a neurologist in the XXXXXXX OH area.
I'm sorry that your wife's presentation has remained an enigma for so long. It certainly sounds like a lot of people have been trying very hard to discover what is going on. Please tell me a little more about the presentation. Does she SUDDENLY go out if you've witnessed any of these episodes? If she were standing for example, does she suddenly and without warning suddenly crumble to the ground and lose all tone or does she have a warning and a feeling that something is going to happen? Does she give you any description of feelings or sensations in her stomach, her head, ringing in the ears, does she get glassy eyes, is she drooling, is there heavy breathing while she is out? You say that the eyes are closed. Have you actually raised the eyelids to look at what the eyes are actually doing while she is out. You say that she "hears what is said and feels being touched." How do you know these things? Does she feel pain when it is applied such as a pinch or uncomfortable gripping pressure against her toe or thumb when squeezed? You say she doesn't respond to the pressure but I think it is important to know where things are at in terms of processing of all sensory information while she is out.
How long do these episodes last?
Have you been documenting these episodes since they began to see how they've been evolving with respect to frequency, duration, and associated symptoms (onset of headaches, nausea/vomiting, other funny symptoms or feelings, weird or strange thoughts?).
Have you asked her if she is trying to communicate but simply cannot? What is she feeling during the time you say she is "hearing" everything around her?
You say that stroke and epilepsy are ruled out. Yet she has a right sided weakness accompanied by slurred speech, dropped foot, and all the rest of these symptoms. Have the MRI studies been done within several hours of her going out? Have they been done using stroke protocol sequences meaning "diffusion and perfusion weighted imaging studies?" Has she had prolonged and/or sleep deprived EEG tests done as well as 24h in-house video monitoring for at least 3-5 days? Has she had interictal PET scans.
A standard EEG recording may only pick up seizure activity in the brain in 30% of individuals while getting a 2nd recording seems to improve the yield to about 50% of the time. With 3 studies the percentage of positive studies then, rises to over 80%. Have all her EEG studies been at least sleep deprived if not 60 min. prolonged studies? With those types of studies accomplished and read out as normal then, I would start to believe that seizures have been RULED OUT. Otherwise, I think there is still more to do. Also, if she is having brainstem types of seizure activity which would explain the lapse of consciousness, these are poorly detectable by surface EEG recordings using standard electrodes.
Have they performed Brainstem Auditory Evoked Potentials which can test the integrity of a large portion of the brainstem (BAER). A similar type of test is called a Somatic Sensory Evoked Potential (SSEP) which tests the integrity of the pathways from the peripheral nerveous system into the cortex itself. Unfortunately, none of these tests can test the PROCESSING ability of the brain..simply the integrity of the transmission systems.
When you say she "snapped" her neck please be more specific? Did she have a vertebral fracture of some sort and if so was there spinal cord damage or contusions that you are aware of or were there simply bony fractures without spinal cord or cervical nerve involvement?
Is the right sided weakness and dropped foot always present or just after an episode of unresponsiveness?
What are her vital signs during these episodes? Has she been checked for something called either orthostatic hypotension or autonomic dysfunction using a tilt table apparatus, sweat box, and had paced breathing exercises measured or performed?
Is she incontinent of bowel or bladder during any of these episodes? Is there any convulsing or limb twitching that you see, heavy breathing, deep snoring, and what type of response do her pupils have to light while she is in one of these "catatonic like" states?
Sorry for all the questions but I would like to know that some of these details have been performed as well as the other diagnostic studies. Is she followed at a teaching hospital type of institution or by community physicians and hospitals? In a complex and obviously challenging case such as this I would say that if the doctors have done their best to figure things out and they cannot that it's time to call in the "big boys" and that's were a teaching hospital or academic institution would be more likely to have the resources to really get information as I've outlined above.
I'm assuming that a 30 day Holter monitor has been done to absolutely rule out any sort of cardiac arrhythmia and I'm also further assuming that we definitely have no hormonal issues such as hypothyroidism, hypoadrenalism, or other endocrinological or metabolic issues?
If you would like to write back with some more of the information filled in that I've asked you for as well as get copies of diagnostic study reports and post them I'd be happy to take a look at what they've written.
If I've helped you with valuable information to answer your question then, your written feedback as well as a STAR RATING to this question are greatly appreciated. Also, CLOSING THE QUERY on your end so that the network may process, archive, and properly credit this case for future reference as well garners my thanks.
If you have further questions or comments on what I've written, please do not hesitate to contact me directly by looking me up on this network and sending questions to my specific attention (Dariush Saghafi, M.D.).
You may also get to my specific webpage at:
http://doctor.healthcaremagic.com/doctors/dr-dariush-saghafi/68474
This case required 57 minutes physician specific time for review, research, and final draft documentation for envoy.
All the best to you and your wife.
How are epilepsy and RULED OUT exactly?
Detailed Answer:
Good evening. My name is Dr. Dariush Saghafi and I am a neurologist in the XXXXXXX OH area.
I'm sorry that your wife's presentation has remained an enigma for so long. It certainly sounds like a lot of people have been trying very hard to discover what is going on. Please tell me a little more about the presentation. Does she SUDDENLY go out if you've witnessed any of these episodes? If she were standing for example, does she suddenly and without warning suddenly crumble to the ground and lose all tone or does she have a warning and a feeling that something is going to happen? Does she give you any description of feelings or sensations in her stomach, her head, ringing in the ears, does she get glassy eyes, is she drooling, is there heavy breathing while she is out? You say that the eyes are closed. Have you actually raised the eyelids to look at what the eyes are actually doing while she is out. You say that she "hears what is said and feels being touched." How do you know these things? Does she feel pain when it is applied such as a pinch or uncomfortable gripping pressure against her toe or thumb when squeezed? You say she doesn't respond to the pressure but I think it is important to know where things are at in terms of processing of all sensory information while she is out.
How long do these episodes last?
Have you been documenting these episodes since they began to see how they've been evolving with respect to frequency, duration, and associated symptoms (onset of headaches, nausea/vomiting, other funny symptoms or feelings, weird or strange thoughts?).
Have you asked her if she is trying to communicate but simply cannot? What is she feeling during the time you say she is "hearing" everything around her?
You say that stroke and epilepsy are ruled out. Yet she has a right sided weakness accompanied by slurred speech, dropped foot, and all the rest of these symptoms. Have the MRI studies been done within several hours of her going out? Have they been done using stroke protocol sequences meaning "diffusion and perfusion weighted imaging studies?" Has she had prolonged and/or sleep deprived EEG tests done as well as 24h in-house video monitoring for at least 3-5 days? Has she had interictal PET scans.
A standard EEG recording may only pick up seizure activity in the brain in 30% of individuals while getting a 2nd recording seems to improve the yield to about 50% of the time. With 3 studies the percentage of positive studies then, rises to over 80%. Have all her EEG studies been at least sleep deprived if not 60 min. prolonged studies? With those types of studies accomplished and read out as normal then, I would start to believe that seizures have been RULED OUT. Otherwise, I think there is still more to do. Also, if she is having brainstem types of seizure activity which would explain the lapse of consciousness, these are poorly detectable by surface EEG recordings using standard electrodes.
Have they performed Brainstem Auditory Evoked Potentials which can test the integrity of a large portion of the brainstem (BAER). A similar type of test is called a Somatic Sensory Evoked Potential (SSEP) which tests the integrity of the pathways from the peripheral nerveous system into the cortex itself. Unfortunately, none of these tests can test the PROCESSING ability of the brain..simply the integrity of the transmission systems.
When you say she "snapped" her neck please be more specific? Did she have a vertebral fracture of some sort and if so was there spinal cord damage or contusions that you are aware of or were there simply bony fractures without spinal cord or cervical nerve involvement?
Is the right sided weakness and dropped foot always present or just after an episode of unresponsiveness?
What are her vital signs during these episodes? Has she been checked for something called either orthostatic hypotension or autonomic dysfunction using a tilt table apparatus, sweat box, and had paced breathing exercises measured or performed?
Is she incontinent of bowel or bladder during any of these episodes? Is there any convulsing or limb twitching that you see, heavy breathing, deep snoring, and what type of response do her pupils have to light while she is in one of these "catatonic like" states?
Sorry for all the questions but I would like to know that some of these details have been performed as well as the other diagnostic studies. Is she followed at a teaching hospital type of institution or by community physicians and hospitals? In a complex and obviously challenging case such as this I would say that if the doctors have done their best to figure things out and they cannot that it's time to call in the "big boys" and that's were a teaching hospital or academic institution would be more likely to have the resources to really get information as I've outlined above.
I'm assuming that a 30 day Holter monitor has been done to absolutely rule out any sort of cardiac arrhythmia and I'm also further assuming that we definitely have no hormonal issues such as hypothyroidism, hypoadrenalism, or other endocrinological or metabolic issues?
If you would like to write back with some more of the information filled in that I've asked you for as well as get copies of diagnostic study reports and post them I'd be happy to take a look at what they've written.
If I've helped you with valuable information to answer your question then, your written feedback as well as a STAR RATING to this question are greatly appreciated. Also, CLOSING THE QUERY on your end so that the network may process, archive, and properly credit this case for future reference as well garners my thanks.
If you have further questions or comments on what I've written, please do not hesitate to contact me directly by looking me up on this network and sending questions to my specific attention (Dariush Saghafi, M.D.).
You may also get to my specific webpage at:
http://doctor.healthcaremagic.com/doctors/dr-dariush-saghafi/68474
This case required 57 minutes physician specific time for review, research, and final draft documentation for envoy.
All the best to you and your wife.
Above answer was peer-reviewed by :
Dr. Shanthi.E
Answered by
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