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Suggest treatment for TIA while on Kreppa

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Posted on Sat, 23 May 2015
Question: Thank you. I had an event about two months ago, went to the ER, saw a neurologist at the ER and came away with a diagnosis of a TIA. A month after that, having a follow up apt with my neurosurgeon, a week later he said he'd like me to go back on kreppa. He never examined me, is PA did. She did the normal tests (hand/nose coordination, hand strength tests, etc) without incident and reported the results to the neurosurgeon. I've never had a diagnosis of seizures. I took kreppa for a short period of time after I was hospitalized for 2 brain bleeds that are non active and dissipating. Can you shed any light on this?
doctor
Answered by Dr. Olsi Taka (3 hours later)
Brief Answer:
Neurosurgeon thinks the event was a focal (partial) seizure.

Detailed Answer:
I read your question carefully and i understand your concern.

In order for me to better express my opinion it would have been useful to know some more details.
First I would like to know when did the brain bleeds happen, did they leave any neurological deficit behind or have you returned to normal activity, any idea on their location in the brain? Perhaps if you have a report you could upload it.
Second and more important, what do you actually mean by "an event", a description on preceding symptoms, the onset, its evolution, how long did it last are really crucial, so please do give some more details on that.

It is obvious that your neurologist and neurosurgeon share two different opinions on the nature of that event. The neurologist thinks it was due to a transient lack of blood flow in an area of the brain. The neurosurgeon in the meanwhile thinks it was a focal (partial) seizure, abnormal electrical discharges localized in an area of the brain causing the symptoms. It is a possibility after a brain bleed, even after a time because the bleed even when absorbing can leave behind a damaged area where new hyperexcitable synapses between brain cells are formed. Since the neurosurgeon thought that as the cause he gave you Keppra (I assume "kreppa" is a misspelling from you) to prevent other seizures, it's a very good drug choice if a focal seizure was the case.

It is at times very difficult to determine the difference between a TIA and a partial seizure (partial meaning it remains localized in an area without causing the classical generalized convulsion you might think of as seizure) as they both can cause a transitory event which leaves nothing behind for the doctor to find on the subsequent physical examination. So since history is all we have I suppose you understand why is needed a detailed description of the event.

I remain at your disposal for further questions.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka (5 hours later)
Thank you, Doctor. The brain bleeds happened in October and November of 2014. I believe they are on both the left and right side of the brain. .They were subdural hematomas. Both have dried up and reduced in size, but there are remnants of dried blood. I had returned to normal activity (mid-January 2015) and don't overdo it. I walk on a treadmill every day, (approx. 1.5 miles) an do about3-4 miles on a bike. I''ve uploaded two CT scans one on 3/3 and one on 4/1. The "event" was diagnosed on 3/3 as a TIA. Both bleeds happened as a result of being on warfarin and bumping my head. I had a left carotid bypass that occluded in 9/14 (thus the warfarin) but my right side is clear. I hope this helps. Yes, Keppra is a good choice for the right reason. What would an EEG show?
doctor
Answered by Dr. Olsi Taka (33 minutes later)
Brief Answer:
Read below.

Detailed Answer:
Thank you for providing some more info and for taking some time to scan and upload your report.
I wish you had said something about that event itself though. When I asked for some details I meant details coming from you, what you experienced on that day, there can be so many different types of focal seizures, with different manifestations. I did read on the CT report the event was right side numbness which indirectly gives me an idea, but still that doesn't tell me how long it lasted (seconds, minutes, hours), whether there was a pattern to the numbness. For example if it started in the distal part of one limb and spread progressively up your arm towards the face that would be typical of a focal seizure, what we call a Jacksonian march. To distinguish a TIA from a focal seizure can be hard even with having all info on our disposal, let alone if we don't.

When in doubt an EEG could be useful, however it is not enough alone. On an EEG due to the blood being on the brain surface there usually are some changes like reduced amplitude, asymmetry, lower frequency in 90% of patients with chronic subdural hematoma even in the absence of seizures so an abnormal EEG doesn't automatically mean a seizure.
Only when there are characteristic electric discharges that would be in the favor of a seizure, but outside the seizure itself those discharges are not always present all the time and a 20 minute EEG might miss them.
So if EEG shows discharges (spikes and sharp waves) it would confirm seizure diagnosis and we'd be sure, if it doesn't it doesn't exclude it though, there would still be uncertainty.

Subdural bleeds do have a high potential for seizures, higher then other types of brain bleeds, so in the doubt I understand your neurosurgeons decision to opt for treatment as a generalized seizure with a potential fall might have serious consequences.

I hope to have been of help.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka (2 hours later)
I apologize for not understanding the initial question. The symtoms that caused me to go to the ER, was a numbing sensation in my right hand of the middle finger, ring finger and pinky finger. I rubbed those fingers thinking I pinched a nerve and then the numbness moved to the index finger and then thumb. Shortly thereafter I felt the same sensation in the right lower part of my face. I checked the smile, eyes, hands to nose, speech and everything was fine. The ER neurologist diagnosed it as a TIA. I didn't question that because I've had TIAs before, approx. 4 of them and it was fairly familiar. I'm questioning the surgeon, since he never saw me, didn't do any other tests, except at CT scan when I saw his PA, and this was 40 days after. As I said, the CT scan was similar to the one done at the ER. At the ER that night, the only test that wasn't done was an EEG.

I certainly appreciate your time in reviewing this.

doctor
Answered by Dr. Olsi Taka (5 hours later)
Brief Answer:
Read below

Detailed Answer:
Thank you for completing the info. I have to be honest and say I can't be completely sure whether it's a seizure or not. I am more prone to side with it being a seizure due to the way it has spread and the high seizure probability in your particular type of bleed.
So I would side with the neurosurgeon if you aren't feeling particular side effects. While I understand the frustration of him never personally examining you, physical exam is not vital in this case, it's more the history taking, CT and EEG helping the decision on whether Keppra is necessary. I would recommend the EEG even though as I said it could not be conclusive, it's a safe and rather non expensive test, if discharges are found it would reinforce the decision for Keppra, if not conclusive nothing is lost anyway.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka (53 minutes later)
Thank you for your opinion, and, I would agree with that if an EEG was done after the first bleed, but, certainly after the second bleed or during the next four appointments I had. It seems to me, as one who analyzed financial statements, management systems for over 40 years, etc that is just occurred to them and it's a system of covering oneself. It now get down to a matter of trust and whom will the EEG benefit - their patients or their own. With all these symptoms, it would have more creditability if done earlier and trust or lack thereof on my part would not be there.

Again, Doctor, thank you for your time and objectivity.
doctor
Answered by Dr. Olsi Taka (41 minutes later)
Brief Answer:
You're welcome.

Detailed Answer:
You're welcome. I hope things will work out for the best.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Olsi Taka

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Suggest treatment for TIA while on Kreppa

Brief Answer: Neurosurgeon thinks the event was a focal (partial) seizure. Detailed Answer: I read your question carefully and i understand your concern. In order for me to better express my opinion it would have been useful to know some more details. First I would like to know when did the brain bleeds happen, did they leave any neurological deficit behind or have you returned to normal activity, any idea on their location in the brain? Perhaps if you have a report you could upload it. Second and more important, what do you actually mean by "an event", a description on preceding symptoms, the onset, its evolution, how long did it last are really crucial, so please do give some more details on that. It is obvious that your neurologist and neurosurgeon share two different opinions on the nature of that event. The neurologist thinks it was due to a transient lack of blood flow in an area of the brain. The neurosurgeon in the meanwhile thinks it was a focal (partial) seizure, abnormal electrical discharges localized in an area of the brain causing the symptoms. It is a possibility after a brain bleed, even after a time because the bleed even when absorbing can leave behind a damaged area where new hyperexcitable synapses between brain cells are formed. Since the neurosurgeon thought that as the cause he gave you Keppra (I assume "kreppa" is a misspelling from you) to prevent other seizures, it's a very good drug choice if a focal seizure was the case. It is at times very difficult to determine the difference between a TIA and a partial seizure (partial meaning it remains localized in an area without causing the classical generalized convulsion you might think of as seizure) as they both can cause a transitory event which leaves nothing behind for the doctor to find on the subsequent physical examination. So since history is all we have I suppose you understand why is needed a detailed description of the event. I remain at your disposal for further questions.