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Suggest treatment for memory loss, incoherent speech and tonsillar ectopia

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Neurologist, Surgical
Practicing since : 2007
Answered : 830 Questions
I had a recent MRI that stated "There is a mild cerebellar tonsillar depression below the foramen magnum although not sufficient to consider it a Chiari Malformation". Basically everything else is unremarkable.
Age      :      36-45 years
Gender      :      Female
Symptoms      :      Headache for the last 5 months following a rear end accident which resulted in me having shoulder surgery. Severe memory loss, falling, losing words, or over all feeling somewhat "stupid" when I talk (I am a VP of Operations at a manufacturing company). I am used to being the smart one and quick with my words and actions, neither of which is true now. Balance issues, severe pain at the very base of my head that radiates behind my eyes, swollen optic nerves, hand tremor which I have had for 5 years (other symptoms have come and gone but this is the worst they have been and longest). I have had steroid injections and nerve blocks in my occipital nerves as well as Facet Joints, had a Cervical (C5-6) Rhizotomy which did not last. I am so frustrated and feel I need someone who specializes in possibility of a Chiari being a cause even though an MRI said it was only a mild depression. I never heard of a Chiari until I received my MRI and I have been convinced that I had the beginning syptoms of MS so it isn't psychosomatic.
Medications      :      Oxycodone 10 mg x 4/day (occipital neuralgia and chronic shoulder pain (4 shoulder surgeries). Effexor 75 mg/day, Wellbutrin 150 mg/day, Was just put on a Prednisone dose pack x 2. , Klonopin 2mg and Gabapentin 300mg x 3/day.
Known Allergies      :      Reglan
Medical History      :      History of Rotator Cuff injuries, 2 concussions, H. Pylori, 3 right shoulder surgeries and 1 left. Shoulder, cervical spine and occipital injections.
Thu, 24 May 2018 in Brain and Spine
Answered by Dr. Ishu Bishnoi 2 hours later
Brief Answer:
Chiari Malformation and other possible differential diagnosis

Detailed Answer:
Hi XXXXXXX thanks for asking from HCM.

I can understand your concern. You are suffering from chronic headache, poor higher mental functions like memory/language, tremors. MRI brain is almost non-remarkable except minimal tonsillar herniation (not suspecting Chiari). I will first explain you about Chiari and then discuss possible differential diagnosis.

Chiari malformation is a birth defect which causes cerebellar tonsils (lowermost end of cerebellum) to descend in cervical spine (neck). In a normal healthy individual, tonsils are contained in skull (bony cover of brain) and do not descend. But Chiari malformation does not consider less than 5mm descend in it. So a descend between 1-5mm is not considered. It is known as "Tonsillar ectopia", a normal radiological finding which does not carry any significance.

You are having "Tonsillar Ectopia". Usually tonsillar descend of 12mm is required to cause spinal cord compression and other features of Chiari malformation. It rules out "Chiari malformation". If still not convinced, you can get "Cine flow MRI brain" to rule out it.

Your symptoms are suggestive of brain damage, not detectable on MRI brain. The possible differential diagnosis can be

- Concussion syndrome - If you are having history of repeated concussion in past, it can cause concussion syndrome. It manifests as repeated headache, poor memory, language, tremors, irritability, insomnia.

- Diffuse axonal injury - Diffuse axonal injury is a type of severe head injury which is not seen on CT/MRI brain. Its diagnosis is based on symptoms. Please confirm it with your treating neurosurgeon who treated you after accident. If yes, it can be the cause.

- Multiple sclerosis - You have mentioned about it. I also agree with it. But normal MRI brain finding is against it. You should consider nerve conduction velocity, EMG and CSF electrophoresis to rule it out.

- Post-traumatic stress disorder - It is a psychological dysfunction which occurs after major accident as a result of shock. It can be suspected of every investigation is normal. It should be kept as a last possibility. You need a psychiatric consultation to rule it out.

Hope it will help you. If you have any doubts, do let me know.
Thanks. Take care.
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