Brief Answer: it was probably a minor stroke. MRI Brain required Detailed Answer: Hi there, Thanks for your query. Firstly, in order to PINPOINT the exact cause of your problems; give you a SOUND professional advice; and, TRUE VALUE FOR YOUR MONEY, may I request you to kindly provide additional information as follows :- # Have you been having headaches with nausea or vomiting, double vision prior to onset of vertigo 4 weeks back? # Are you a patient of high blood pressure, diabetes, heart disease or obesity?? # Did you vomit when you felt the room spinning, 4 weeks back? # Please share with me, any other problems, if any, in as much details as possible. Nevertheless, pending receipt of the additional information, vertigo and unsteady gait occur due to problem of either, internal ear, cerebellum (posterior part of the brain) or the brainstem (described below). As the onset of problems were abrupt, and still persisting, it was probably a minor stroke of either the cerebellum or the upper part of spinal cord (called brainstem) which connects to the brain. The possible causes of stroke are :- 1. A thromboembolism causing obstruction to blood flow in the artery supplying the cerebellum or the brainstem. 2. High blood pressure, causing a minor bleed. 3. High cholesterol levels promote deposition of cholesterol in the lumen of blood vessels (called plaques, which jut inside the arteries and consequent narrowing with obstruction to blood flow). Sometimes, a piece of the plaque- in the main arteries supplying the brain- dislodges, gets carried by the blood stream to arteries of the brain, cutting off the blood supply. 4. Diabetes is a potential risk for strokes. 5. Rarely, a tumor of the nerve which supplies the internal ear (tumor is called Accoustic neuroma), which produces both : vertigo and unsteady gait. I PERSONALLY AM OF THE OPINION THAT YOUR TREATING DOCTOR SHOULD HAVE ADVISED MRI OF BRAIN or Angio-MRI in the first instance to see for evidence of infarct/bleeding in the brain. Consult your doctor and apprise him of my opinion. I am certain that he will agree with my opinion; order required tests, and- based on the reports- will arrive at a certain diagnosis and prescribe suitable treatment as advised. It would however, be a pleasure to receive the additional information as requested, in addition to the test reports, which you must have received by now. Hope I have addressed to your concerns to your complete satisfaction and you find my response helpful and informative. I will be happy to answer further queries, if any. Fond regards and have a nice day, Dr. Rakesh Karanwal

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Brief Answer: Causes : minor stroke or internal ear problem Detailed Answer: Hi ma'am, Thanks for the prompt input. After analyzing the complete information, the possible causes narrow down to either a minor stroke, problem of the internal ear; or, lesion of the nerve which connects the internal ear with the brain. Hence, I expect your treating doctor to order MRI Brain at the earliest. Please do share with me, the reports of the tests carried out recently. Till then, Have a nice day Dr. Rakesh Karanwal

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Brief Answer: Stroke due to vertebro-basilar artery involvement Detailed Answer: Well ma'am, I am personally of the opinion that it was stroke due to disruption of blood supply in a branch of the vertebro-basillar artery. A vertebra-basilar and a carotid angiogram will give us the exact idea. Kindly discuss my entire opinion with your doctor during your next visit. Regards, Dr. Rakesh Karanwal

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Brief Answer: Test reports will give the exact cause of problem Detailed Answer: Yes. Off balance and feeling unsteady are same and called ataxia. Further, as mentioned earlier, the possible lesion is either * in the internal ear, * the nerve connecting internal ear to the brain; and, * cerebellum. Involvement of internal ear is called Labyrinthitis, while that of the nerve is called Vestibular Neuronitis. A SINGLE episode (without recurrence) of spinning sensation (vertigo) without nausea or vomiting, is unusual in Labyrinthitis. However, occurrence of unsteady feeling with head movement- as just brought out by you- does go in favor of Labyrinthitis or Vestibular neuronitis. Lastly, your neurologist and ENT Specialist are the best judge as they must have reached to a certain conclusion after carrying out thorough medical examination. It would therefore be advisable to wait for the test reports, which will localize the exact cause. Till then,Yes. Off balance and feeling unsteady are same and called ataxia. Further, as mentioned earlier, the possible lesion either in the internal ear, the nerve connecting internal ear to the brain; and, cerebellum. Involvement of internal ear is called Labyrinthitis, while that of the nerve is called Vestibular Neuronitis. A SINGLE episode (without recurrence) of spinning sensation (vertigo) without nausea or vomiting, reduces the possibility of Labyrinthitis Take care Dr. Rakesh Karanwal

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Brief Answer: VNG and ENG test reports are inconclusive. Detailed Answer: Hi there, Firstly, I am really sorry for the delay WHICH WAS DUE TO ERRATIC INTERNET CONNECTIVITY. I have gone through the reports, which- I am afraid- could not interpret. I will therefore request you to kindly quote the "interpretation" of the test. Further, the entire sequence of events indicate a "mixed " type of vertigo. Incidentally, there are two types of vertigo : * "Peripheral" (due to involvement of internal ear and the nerve). It is associated with nausea + vomiting (BUT YOU DID NOT HAVE EITHER OF THESE SYMPTOMS). It recovers within a few days to few weeks). * " Central" (due to involvement of posterior brain(CEREBELLUM) and/or brainstem. Vomiting, nausea is uncommon (AS IN YOUR CASE). The unsteadiness or off-balance feeling persists for months. Your feeling of unsteadiness is still persisting, though 4 weeks have elapsed. Hence, I STILL FEEL THAT YOUR PROBLEMS ARE DUE TO BRAINSTEM / CEREBELLUM. Further, a minor/minimal stroke (affecting either the brainstem or cerebellum) is still a possibility. Proceeding further, the inner ear’s vestibular organs (internal ear) and the associated nerves and brain centers form a complex system that serves many functions and can be affected by a number of outside systems. VNG and ENG tests diagnose the involvement of internal ear or nerve. In your case are inconclusive/equivocal. HENCE, I WILL STILL RECOMMEND MRI of brain, focusing particularly on cerebellum and brainstem, TO diagnose/rule out lesions of these regions of the brain. Regarding Epley Maneuver, it is curative only in a particular type of "Peripheral" problem, called Benign Paroxysmal Positional Vertigo (BPPV). This condition is characterized by breaking off of minute particles (in the internal ear) and floating/drifting into other parts of the internal ear. Epley maneuver relocates the particles in their original site. IN YOUR CASE, THE PROBLEMS ARE NOT DUE TO BPPV. HENCE, IT WILL NOT BE EFFECTIVE IN YOUR CASE. Lastly, I hope you meant "electromanography" which is carried out to diagnose glaucoma. Prescription of Diamox suggests that your ENT doctor has also found evidence of co-existing Glaucoma. Lastly, I cannot comment on the cause of similar symptoms in your mother. Similar tests, as in your case, along with MRI Brain will conclusively pinpoint the cause. I will therefore suggest that you take Betahistine tablets till such time you are perfectly normal. Your doctor will titrate its dose. Hope I have addressed to your concerns to your complete satisfaction and you find my response helpful and informative. I will be happy to answer further queries, if any. Fond regards and have a nice day, Dr. Rakesh Karanwal

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Brief Answer: Please intimate MRI findings to me if possible Detailed Answer: Well ma'am, Its nice to know that you are finally going in for MRI tomorrow. Please request your doctor to include BRAINSTEM for scan. May I elaborate the word "stroke" further : Signs and symptoms of an infarct depends on its size, the nerves/centers representing a particular function in the body. For example, very small infarct (stroke) affecting ONLY a small area- called cerebello-pontine angle (representing or containing nerves that coordinate balance of the body) will produce SIMILAR SYMPTOMS AS YOURS. Further, after thorough medical examination of a patient, doctors/specialists narrow down the number of possibilities to the minimum (called differential diagnosis). Thereafter, relevant investigations are carried out to rule out/confirm each possibility, one by one. And I am sitting thousands of miles away from you; have not medically examined you, but have, nevertheless, given you the likeliest possibilities, SOLELY on the basis of information and test reports provided. I MAY BE COMPLETELY WRONG in pinpointing the EXACT diagnosis. However, as a thorough professional with vast experience, it is my ethical duty to rule out every short-listed possibility. THE ONLY AIM IS TO CLEAR ALL DOUBTS once for all, which may otherwise, haunt the doctor as well as the patient in future. Please continue with Diamox as advised. I would certainly be curious to know about the MRI findings- a learning experience, indeed. Lastly, I have already expressed my agreement regarding the internal ear problem as the cause of "off-balance" feeling. It is just that the quoted report does not conclusively prove-beyond doubt- about the defect limited SOLELY to the internal ear. Looking forward to hearing from you after MRI report is received. Fond regards, Dr. Rakesh Karanwal

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Brief Answer: You have none of the symptoms of Meniere's disease Detailed Answer: There are several conditions of different etiology, affecting the internal ear and, causing more-or-less similar symptoms in different combinations. As mentioned earlier, some of the conditions are : BPPV, Labyrinthitis, Vestibular neuritis and, Meniere's disease. Further, the medical treatment is almost the same in all these conditions. Incidentally, Meniere's Disease is characterized by :- - Recurring episodes of vertigo. Feeling of spinning around or the whole rooms spins around you. YOU HAD ONLY ONE EPISODE OF VERTIGO. - Hearing loss. You have NEVER complained of hearing loss, although your tests indicate a mild hearing loss. - Ringing in the ear (tinnitus). Tinnitus is the perception of a ringing, buzzing, roaring, whistling or hissing sound in your ear. However, you do NOT have these symptoms. - Feeling of fullness in the ear. People with Meniere's disease often feel aural fullness or increased pressure in the ear (which YOU don't have). You can therefore conclude yourself whether your symptoms fit into Meniere's disease. Further, in internal ear diseases, imbalance occurs during/following VERTIGO. You have not had a recurrence of vertigo AFTER the initial episode of the feeling of room spinning around you. You may have, by now, realized why I had thought of other causes of your problems. Have a nice day, Dr. Rakesh Karanwal

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Brief Answer: It's a minor condition:will fade in few weeks time Detailed Answer: PLEASE RELAX, MA'AM!! There is NOTHING to worry AT ALL!! There is nothing serious. Your problems are likely to fade away in a few weeks' time. Also, your condition DOES NOT HAVE ANY CORRELATION WITH YOUR LONGEVITY and well-being. I AM SURE THAT YOU HAVE FAITH IN WHAT I AM SAYING IS PROFESSIONALLY SOUND AND CORRECT. I do NOT believe in false or misleading assurances. As an afterthought, it can also be a variant of migraine. If I were your treating Specialist, I would have recommended the following course of action:- (a) A regular course of a combination of anti-depressant, such as, Serteraline or Citalopram + an anti-anxiety drug, such as, clonazepam or Alprazolam + Beta-blockers (to curb your anxiety, mental stress and frustration, as well as, preventive treatment of migraine). (b) A regular course of Vitamin B12 (methylcobalamin) 1500mcg/day (c) Betahistine in appropriate doses (to control imbalance). I once again re-iterate that IT IS A MINOR PROBLEM : the symptoms will fade in a few weeks' time. SO, PLEASE RELAX!! Take care Dr. Rakesh Karanwal

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Brief Answer: I still stand by my statement Detailed Answer: Well ma'am, I STILL STAND BY MY EARLIER STATEMENT. A very minor stroke (possibly in the Brainstem or Cerebellum) is STILL a strong possibility. However, the symptoms disappear gradually as some of the nerves ( in the affected area, that is, infarct), that sustained partial AND reversible damage, recover completely. It was just an afterthought that, a rare variant of migraine, too produce similar symptoms and, therefore, a rare possibility of your symptoms. The combination of anti-depressant + anti-anxiety drugs was advised PRIMARILY for curbing mental stress, anxiety, frustration, sense of helplessness and possible depression. HOWEVER, its a sheer coincidence that THIS COMBINATION IS ALSO THE BEST PREVENTIVE TREATMENT OF ALL VARIANTS OF MIGRAINES

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Brief Answer: Possibilities+recommended treatment remains same Detailed Answer: Hi Ma'am, The new information provided reinforces my suspicion of the involvement of vertebra-basilar artery (located at the back of the neck and supplies blood to Brainstem), leading to either * a very minor stroke (of Brainstem/cerebellum, which has always been on top of my possibilities). Or, the stroke could have been either predominantly reversible or there is simply an intermittent, transient cut-off of blood supply to these structures. Intermittent lack of blood supply is due to compression over this artery, as in cervical spondylosis. * The possibility of Basilar migraine (a variant type of migraine, as mentioned earlier) also increases. This migraine is also due to involvement of vertebra-basilar artery. In a nutshell, NOTHING HAS CHANGED : The most possible cause(s) still stand as valid as before. Hence, I will strongly recommend that you start the advised treatment IMMEDIATELY (anti-depressant + anti-anxiety drugs + Beta Blockers, such as Metoprolol), WITHOUT EVEN WAITING for MRI report. Also, take Vitamin B12 as advised. Trust my instincts: Consult your doctor, discuss my latest opinion with him. I am sure he will agree with me and prescribe the advised medicines in appropriate doses. I am very confident that you will start showing gradual improvement within 2 weeks of starting the treatment. In addition, continue with your doctor's advice to take Diamox.

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