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What causes syncope as per the attached reports?

DOCTOR OF THE MONTH - Nov 2013
Nov 2013
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Answered by

Neurologist
Practicing since : 1994
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Question
Hi Doctor,

Many new year wishes.

I'm 39 years Male, 6 feet, 89 kgs, athletic built, single

A week ago I had a syncope and a fall.
After a dinner on my way to a trip, I had this episode and my friends told that I was unconscious for 15 minutes.
they took me to local hospital in channpatna( place en-route mysore), when they did a ECG after 30 minutes after syncope I had Atrial fibrillation.

The next day, I got a CT and ECG done in Bowring Hospital, XXXXXXX
ECG was absolutely normal and CT showed " calcified granuloma in the right parietal lobe" 7 mm and muliple ( provisional report attached)

Then I was advised to get an Brain MRI > which I got it done. It shows "calcified granuloma in the right parietal lobe > 7mm" and Pansinusitis. Report attached.

Previous History:

had syncope attacks during childhood, doctors mentioned as it was always because of a trigger and no seizures as not epilepsy, yet was on Tegretal 100 for 6 years till my teenage.
Previous Brain MRI done in Nimhans was back in 2010 " focal area of gliosis in right inferior frontal gyrus"
The report attached.

Other issues I have:

Erectile weakness > though the sexual inclination is fine and semen quantity is good, my penile strength is not hard enough even to wear a condom. This obviously has stress on me.

Developed twitching of right eye from past four years. overall the right limbs are slightly weaker than the left.
Good diet and healthy habits lessens the impact and it comes back sometimes.

had a wrist fall 6 years back and got corrected soon.

Have occassional bruxism.


Habits:

I do smoke. A pack a day (definitely cutting it down soon)
Occassional drinks.
South XXXXXXX food.
Normal stress ( which I can handle) but these health issues cause bigger stress ( as I'm health care professional involved in public health and I myself am unable to resolve some issues)

Look forward for your reply on:

a) Why did the syncope happen in first place (for 15 minutes, No seizures)?
b) Is Pansinusitis got to do something with syncope or the granuloma of the brain?
c) Is 7 mm too big, though calcified, does it exert pressure on near my regions? How to reduce or cure this calcified grauloma?
d) Is ED related to my brain condition? How to correct it?
b) Inference on above symptoms/condition and plan of approach to resolve it.
b) Lifestyle and other foods which can help to rebuild.

I eagerly look forward for your answers doctor. Thank you in advance.
Fri, 8 Jun 2018 in General Health
 
 
Answered by Dr. Sudhir Kumar 17 hours later
Brief Answer:
Calcified granuloma can cause seizuers

Detailed Answer:
Hi,

Thank you for posting your query. I have noted your current and past medical details.

1. Syncope could be related to atrial fibrillation. I have noted that repeat ECG is normal. However, I would request you to see a cardiac electrophysiologist (cardiologist, trained in heart rhythm disturbances). They may ask for further tests such as Holter monitoring, etc.

2. Pansinusitis is an ENT problem, and has no relation to granuloma of brain or your current problem.

3. Calcified granuloma is a healed infection. In XXXXXXX the commonest cause is a tapeworm infection (also known as neurocysticercosis). There is NO method to reduce or cure the calcified granuloma.

4. Even though the granuloma is healed, it can cause seizures in future. So, I would prefer that you are started on antiepileptic drugs such as oxcarbazepine. As mentioned in point 1, consult a cardiologist too.

5. ED is not related to brain condition. Treatment can be discussed with andrologist/endocrinologist/psychiatrist.

6. Normal diet and physical activity is permitted. Swimming should be avoided for at least six months.

Best wishes,

Dr Sudhir Kumar MD DM (Neurology)
Above answer was peer-reviewed by
 
Follow-up: What causes syncope as per the attached reports? 2 days later
Thank you for the answers. Request to answer some follow up questions/suggestions/ futher actions

1) I got a digital video EEG, 2d Echo done today ( they told it is normal) shall upload the reports tomorrow.
At this moment, I'm wearing the 24 hr holter monitoring device. I shall consider to go for HUTT test too ( kindly let me know if HUTT is essential if 2d echo and 24 hr holter shows normal).
Shall upload all the reports soon.


2) More clarity About the syncope episode:
The episode started suddenly with a vertical fall on the occipital bone....
No muscle spasms seen.....complete loss of consciousness seen for a period of 15 mins.....was not responsive to any verbal or physical stimulation
Tongue was slightly protruded out during the episode
Slowly consciousness was regained with requests for drinking water
However motor coordination was lacking for a period of 1.30 hours with requirement for support to stand and move around....
Speech was compromised.
However throughout the post episode period he would respond to name and was giving correct replies to questions asked
The pulse was feeble initially however picked up after a few minutes....breathing was slow but recovered after a few minutes.

a) I had slurring speech for the first two days following the syncope, and excess salivation. It is better now. Slight lightheadedness is also present. As I was moving around with these symptoms (took tegretal 100 for safety, shall change after your prescription)
I hope these symptoms shall disappear after the treatment.

b) Is it a seizure? Am I epileptic? Is it grandmal or something else?



3) Previous Brain MRI in 2010 shows " focal area of gliosis in right inferior frontal gyrus"

Present Brain MRI just a few days back shows "calcified granuloma in the right parietal lobe > 7mm"

Has the previous " focal area of gliosis in right inferior frontal gyrus" disapperared? ( as there is no sign in the present MRI)
Approximately how old can be this granuloma ( it was not seen in Brain MRI 2010)


4) Doctor As mentioned by you "There is NO method to reduce or cure the calcified granuloma"
Do I have to take anti epileptic for rest of my life?
How to confirm that the old clacified granuloma is because of "neurocysticercosis"?
Doctor, please also mention if 7mm is too big and how it can affect the other surrounding parts and alter my lifestyle
Should I take albendazole? What should be the dosage of Oxcarbapazine? Please give brand name.

5) Life style: I read on this site, that people with similar situation should avoid cabbage, salads .. etc. Should I, what are other precautions I need to take. Some sources say no to milk and non veg too. Any allergy tests to be done?

6) I have twitching of right Eye ( with discomfort and slight pain of right neck) from over 4 years, sometimes it subsides and sometimes it is annoying. Is it related to this condition? How to cure this?

7) I have ringing noise in ears (tinnitus?) and less control of holding urine. Kindly advice.

I look forward for your valuable answers.

Have a good day.

Best Regards.
 
 
Answered by Dr. Sudhir Kumar 9 hours later
Brief Answer:
Alcohol can trigger seizures.

Detailed Answer:
Thank you for getting back with 10 follow up queries. My replies are below:

1. Yes, HUTT is required for complete evaluation of causes of syncope.

2. a. These symptoms would get better with time.
b. Yes, it is seizure, and you have epilepsy. It was a generalised type of seizure.

3. Previous gliosis is not seen (a better quality MRI would show it, as it does not disappear). Calcified granuloma is probably a few years old.

4. Yes, you would require antiepileptic drugs for life.
There is no method to confirm whether it is because of neurocysticercosis.
7 mm is small and it would not impact surrounding areas or lifestyle.
Albendazole is not needed as the tapeworm is dead.
Oxcarbazepine is started at a dose of 10 mg per kg body weight in two divided doses.
Brand name is oxetol.

5. All food items can be consumed by you. No allergy tests are needed.

6. Twitching of eye is unrelated and would go away with rest and proper sleep.

7. You can consult ENT for ringing ears, and urology for bladder control symptoms.

8. Neurocysticercosis occurs due to eating infected food (with tapeworm). No lifestyle changes are needed.

9. Cigarettes can not, however, alcohol can trigger seizures.

10. You can continue to travel and speak, however, you should avoid driving.

Best wishes,

Dr Sudhir Kumar MD DM
Above answer was peer-reviewed by
 
Follow-up: What causes syncope as per the attached reports? 2 days later
1) I have attached the reports of tests >

Digital EEG
2d Echocardio
24 hr holter monioring

All seem normal.
a) Kindly have a look and let me know your diagnosis and inference on my present condition.

b) Doctor > how can you in one word objectively call my episode as 1) Seizure 2) Mild stroke or 3) syncope


2) Considering the present scars are healed and wont affect me, How to avoid seizures and/or syncope for rest of my life? Apart from taking anti-epileptic drug, are there any useful tips?
what are other precautions I need to take NOT to magnify this issue or similar issues to brain going forward.


3) I have symptoms of
slurred speech (high during the morning) , light head ache and generalized weakness. How to cure them soon?


4) I started with oxetol 150 mg twice a day. As per your suggestion,
I need to increase it to 900 mg ( as I'm close to 90kg). Shall I increase it gradually.


5) One question still is hanging around doctor, If my Old calcified granuloma is a few years old and if I had a syncope just a week back ( that too when i temporarily had to change to unhealthy lifestyle)
Still I need to go with antiepileptics for rest of my life?


6) I don't remember eating pork from years, but I have eaten good outside food. Really worried what caused and what to avoid going forward. Any light on this?


7) Can stress cause seizure/syncope? Could you suggest some medication for chronic stress and anxiety?

8) Is there a breathing exercise or yoga or meditation or any thing which you would recommend me to do, so that it helps my nervous system. Hope it is one specific exercise, so that I can practice daily.

I'm really grateful for all your answers. Looking forward for the answers to above questions.

Will be happy to leave a good review.

Many thanks!

 
 
Answered by Dr. Sudhir Kumar 21 hours later
Brief Answer:
Most likely diagnosis is seizure

Detailed Answer:
Thank you for getting back with 8 follow up queries. Replies are below:

1. a) I agree the EEG, Echo and Holter reports are normal.
b) Seizure

2. Anti-epileptic drugs are the only method to reduce the chance of seizure recurrence.

3. No specific medicine is available for that. They usually improve on own over time.

4. Yes, the dose should be 450 mg twice daily, as per your body weight.

5. Yes, anti-epileptic drugs are needed as maintaining a healthy lifestyle alone may not be enough to prevent seizures in future.

6. Outside food can not be "certified" as good, as the worms are small and can not be seen by naked eye. Tapeworm eggs can be found in vegetarian food also, due to contamination by stool of pork eaters (farmers, cook, etc).

7. Stress does not cause seizure. For stress/anxiety medicines, consult a psychiatrist.

8. There is no special exercise for nervous system. Any exercise would help, such as running, cycling, etc. I do not have any knowledge of yoga or meditation.
Nadi shodhan pranayam can be helpful.

Best wishes,

Dr Sudhir Kumar MD DM
Above answer was peer-reviewed by
 
Follow-up: What causes syncope as per the attached reports? 4 hours later
Doctor, Thank you for the answers. They are very clear and precise. Hope you co-operate with definite last set of questions :)

1) As I remember I did have some these episodes (seizures) in 2010 and some years back. But each time I also remember I was back to full normalcy in maximum 30 minutes. This is only time when I had slurred speech, light headededness and general weakness for days.
Are the prior episodes different from the last one?


2) The old calcified granuloma may have caused by outside food after 2010. As they dont appear in my 2010 brain MRI done (high resolution) in Nimhans.
Am I correct?


3) Do you recommend to take another Brain MRI( high resolution) after taking Oxetol for a couple of months or so ?
to confirm if gliosis (2010) is still present and to check the size of old calcified granulomas.
May I know the specific MRI standard I should go for?


4) AS mentioned anti-epileptic drugs help in maintaining healthy life style, but not seizure proof. If I get any symptoms of pre seizure, what are precautions I need to take ( apart from sitting dowm or lying down)
what should I advice people around me during seizure? and what should I do post seizure to regain full normalcy soon?
Are there any cases who have gone completely seizure free and how did they manage to do so?


5) I had a few episodes of seizures during childhood and my last episode before the latest one was in the year 2010 (and I'm on NO medication),Can seizures be so rare?


6) Should I give up alcohol (beer) forever or can I have it in moderation once in a while?

7) In the year 2004, I had intra oral anesthesia for RCT, after anesthesia I was unconscious (Is that seizure too?) I felt I have needle phobia(dates back to my childhood). I have become unconscious couple of times after consumption of alcohol too.
Deep physical pain, witnessing a very traumatic site like an accident, sight of my blood deep cuts), drawing of more blood ... has trigerred these episodes for sure during childhood and they are not many now (yet, the thought of these episodes plays in my mind)
What should I do before these incidents to avoid them. How to overcome or provide cover before these events ( like need to provide blood for a tests or donation, sometimes this stops me from having a intercourse) ?

8) A doctor in XXXXXXX told me that if your episodes have definite trigger then it is not a seizure. Seizures happen without a trigger and can often quite often. I probably sticked to it, should I change my perception?

9) Even the last episode, I had a unhealthy lifestyle for a week before it happened. I accept with you that it is "most likely a seizure" could you kindly mention what could be the other possible reasons( like anxiety attacks, food allergies, or something else)

dear doctor, I'm in a effort to remove as many doubts as possible, hence so many questions. Some questions like 7) plays a big role in contributing to chronic stress. Kindly answer. I'm here resolve or clearly manage it effectively with your help.

Best Regards,
 
 
Answered by Dr. Sudhir Kumar 6 hours later
Brief Answer:
The severity of episodes were different earlier (less severe)

Detailed Answer:
Thank you for getting back with 9 follow up queries, the replies are below:

1. Prior episodes were probably less severe.

2. You may be correct, however, difficult to be sure.

3. Repeat MRI brain is usually not needed. In any case, oxetol has no effect on calcified granuloma.

4. In most cases, seizures come without warning. However, if you feel aura (symptoms prior to seizure), you can lie down in a safe place. People around you should place you in a safe position and avoid giving water by mouth, while you are unconscious.

5. Yes, seizures can be rare.

6. Alcohol has no good effect (it only harms brain) on brain and nervous system, hence, it is better to stop completely.

7. These events are more likely syncope. If you lie down, you can avoid syncope episodes in these situations.

8. Seizures can have triggers.

9. I can not think of any other cause than seizure in this case.

I love people who have questions. I am sure you would still have many more questions. I would be pleased to answer them. So, never hesitate before asking a question. I would be waiting for more follow up queries.

Best wishes,

Dr Sudhir Kumar MD DM
Above answer was peer-reviewed by
 
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