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What Do These Lab Reports Indicate?
Question: If you saw the following reports. What would you do? I now have developed Meige Syndrome.
Brief Answer:
Meige Syndrome
Detailed Answer:
Good evening. I am an adult neurologist and would like to respond to your question in the following way.
Let's take each scan:
SCAN.pdf (performed 2011)- History reveals dysarthria and left arm weakness. Swallowing problems began 2 years ago. Has been receiving vocal cord stimulation at ENT service which has improved symptoms. Apparently ALS and MG have been ruled out in workup. There is a history of cervical laminectomy in 2011.
The study revealed the presence of mild oropharyngeal dysphagia without vocal cord penetration or evidence of aspiration. Findings are consistent with swallowing perturbations seen in ALS. The patient is at risk for aspiration and must be cautious with type of diet in order to minimize complications. Esophageal motility appears to be normal below the level of the epiglottis.
Therefore, based upon the results of the above scan I WOULD NOT make a diagnosis of ALS because the findings are merely noted to be consistent with the condition. Swallowing studies are entirely incapable of making diagnoses of ALS. I would recommend that the patient be seen for swallowing training and therapy with attention paid to the specific deficits to see if in combination vocal cord stimulation there may other exercises or positions that the patient can learn how to eat in order to minimize risks of aspiration. I wouldn't necessarily make major changes to the patient's diet at this point but I would have a serious talk with the patient and explain the findings in detail so they understand that it would be to their advantage to start thinking in terms of modified diets. Perhaps, something like a THICK IT diet would be acceptable at least for thin liquids since those tend to be easiest to swallow.
SCAN2.pdf- MRI of the brain without contrast. Performed 2010
The stated reasons for this study are TENSION TYPE headaches and meningismus.
Findings in a 49 year old patient are nonspecific white matter lesions in both frontal lobes. The vertebral and basilar arteries are slightly smaller in caliber than usually seen.
I wouldn't necessarily DO anything major with this study except perhaps think about getting a CONTRASTED study is I really believed the diagnosis of MENINGISMUS. The doctor who ordered the study must've been under the impression that you were having neck pain, stiffness of the neck, headaches, nausea, vomiting, perhaps, spasms in the neck, etc.
If the diagnosis of meningismus were that likely then, I would've gotten the study with gadolinium contrast instead of without. However, notwithstanding, the report as it stands and as it was read is not impressive to take any particular action except to correlate with clinical symptoms. In other words, I would have to know a little more about why this study was obtained in order to say more about it..or even whether or not, based upon symptoms and physical findings it was even necessary?
In other words, none of the findings would've helped predict or make a diagnosis of Meige's Syndrome. None of the findings would've helped predict or understand symptoms of left arm weakness. I'm assuming at this point that the laminectomy you got in 2011 in the neck was based on pain. Would that laminectomy have occurred AFTER this scan since the doctor had a diagnosis of MENINGISMUS which usually NECK PAIN. So instead of meningismus or anything else...you had some type of either arthritic process in the neck or narrowing of the spinal canal causing some pinching of nerves which resulted in some left arm weakness. Is that accurate?
The MRI does not contain any other pertinent or clinically useful information.
SCAN4.pdf- 4 vessel angiogram was done in 2003 but there is no set of symptoms or history provided in the report so as to know WHY this study was done.
Results of the study revealed a minor anatomic variation of your posterior cerebral arteries (PCA's) arising from both carotid arteries (which happens in a small percentage of the population; it is usually of no clinical importance). The caliber of the arteries is a bit smaller than expected. Normally the PCA's arise as terminal branches of the BASILAR artery which is why they are expected to be a bit bigger since the basilar is such a LARGE PIPE so to speak compared to the takeoff points in the carotid where these came from. This is another anatomic variation. About 5% of all left vertebral arteries come directly off the aortic arch instead of the subclavian artery.
However, again, seeing that in isolation as an anatomic variation without knowing WHY they got the study in the first place makes it impossible for me to know whether or not this anatomic variation could be of any significance. Most of the time it is not.
Bottom line is that the studies you've attached do not raise a red flag when looked at in the context of why they were obtained for anything really bad....EXCEPT for the swallowing study. In that study there are clear abnormalities that need to be addressed and explained. However, neither the angiogram in 2003 nor the MRI in 2010 say anything that could predict that you would've needed the swallowing study later.
Please feel free to fill in some gaps if you'd like.
I hope these answers satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
The query has required a total of 60 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Meige Syndrome
Detailed Answer:
Good evening. I am an adult neurologist and would like to respond to your question in the following way.
Let's take each scan:
SCAN.pdf (performed 2011)- History reveals dysarthria and left arm weakness. Swallowing problems began 2 years ago. Has been receiving vocal cord stimulation at ENT service which has improved symptoms. Apparently ALS and MG have been ruled out in workup. There is a history of cervical laminectomy in 2011.
The study revealed the presence of mild oropharyngeal dysphagia without vocal cord penetration or evidence of aspiration. Findings are consistent with swallowing perturbations seen in ALS. The patient is at risk for aspiration and must be cautious with type of diet in order to minimize complications. Esophageal motility appears to be normal below the level of the epiglottis.
Therefore, based upon the results of the above scan I WOULD NOT make a diagnosis of ALS because the findings are merely noted to be consistent with the condition. Swallowing studies are entirely incapable of making diagnoses of ALS. I would recommend that the patient be seen for swallowing training and therapy with attention paid to the specific deficits to see if in combination vocal cord stimulation there may other exercises or positions that the patient can learn how to eat in order to minimize risks of aspiration. I wouldn't necessarily make major changes to the patient's diet at this point but I would have a serious talk with the patient and explain the findings in detail so they understand that it would be to their advantage to start thinking in terms of modified diets. Perhaps, something like a THICK IT diet would be acceptable at least for thin liquids since those tend to be easiest to swallow.
SCAN2.pdf- MRI of the brain without contrast. Performed 2010
The stated reasons for this study are TENSION TYPE headaches and meningismus.
Findings in a 49 year old patient are nonspecific white matter lesions in both frontal lobes. The vertebral and basilar arteries are slightly smaller in caliber than usually seen.
I wouldn't necessarily DO anything major with this study except perhaps think about getting a CONTRASTED study is I really believed the diagnosis of MENINGISMUS. The doctor who ordered the study must've been under the impression that you were having neck pain, stiffness of the neck, headaches, nausea, vomiting, perhaps, spasms in the neck, etc.
If the diagnosis of meningismus were that likely then, I would've gotten the study with gadolinium contrast instead of without. However, notwithstanding, the report as it stands and as it was read is not impressive to take any particular action except to correlate with clinical symptoms. In other words, I would have to know a little more about why this study was obtained in order to say more about it..or even whether or not, based upon symptoms and physical findings it was even necessary?
In other words, none of the findings would've helped predict or make a diagnosis of Meige's Syndrome. None of the findings would've helped predict or understand symptoms of left arm weakness. I'm assuming at this point that the laminectomy you got in 2011 in the neck was based on pain. Would that laminectomy have occurred AFTER this scan since the doctor had a diagnosis of MENINGISMUS which usually NECK PAIN. So instead of meningismus or anything else...you had some type of either arthritic process in the neck or narrowing of the spinal canal causing some pinching of nerves which resulted in some left arm weakness. Is that accurate?
The MRI does not contain any other pertinent or clinically useful information.
SCAN4.pdf- 4 vessel angiogram was done in 2003 but there is no set of symptoms or history provided in the report so as to know WHY this study was done.
Results of the study revealed a minor anatomic variation of your posterior cerebral arteries (PCA's) arising from both carotid arteries (which happens in a small percentage of the population; it is usually of no clinical importance). The caliber of the arteries is a bit smaller than expected. Normally the PCA's arise as terminal branches of the BASILAR artery which is why they are expected to be a bit bigger since the basilar is such a LARGE PIPE so to speak compared to the takeoff points in the carotid where these came from. This is another anatomic variation. About 5% of all left vertebral arteries come directly off the aortic arch instead of the subclavian artery.
However, again, seeing that in isolation as an anatomic variation without knowing WHY they got the study in the first place makes it impossible for me to know whether or not this anatomic variation could be of any significance. Most of the time it is not.
Bottom line is that the studies you've attached do not raise a red flag when looked at in the context of why they were obtained for anything really bad....EXCEPT for the swallowing study. In that study there are clear abnormalities that need to be addressed and explained. However, neither the angiogram in 2003 nor the MRI in 2010 say anything that could predict that you would've needed the swallowing study later.
Please feel free to fill in some gaps if you'd like.
I hope these answers satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
The query has required a total of 60 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hello Dr Saghafi
I will describe events leading up to reports.
In 2003 I was having headaches. I was refered to a neurologist. He did a MRI on my XXXXXXX with contrast. It reveal the abnormality in the my viens.
He order the aniogram to take better look. Because of small vessals, he wanted be sure there no blockes.
Begining in 2009. I started to have promblems swallowing. Food getting hung my throat. In 2010 I was refered to different neurologist. I reported to him headaches, touge
spasmes, teeth chattering, hand tremors and left arm/hand tingling. He ignored all symptoms accept the headaches and hand tremors. He order the XXXXXXX MRI. My insurance
approved to have with contrast. I assumed that want I was to get. When the technican didn't put contrast in. I asked wasn't I suppose have contrast. She said wasn't ordered.
Follow up he said everything was normal. I that he new what he doing, so didn't question the MRI.
In 2011. I contiued to increasing promblems of swallowing. I went to my ENT, who I had previosly for things. He ordered the first swallowing study. It showed my epigottis promblems. And order swallowing
terapy with a speech therapist. She did e-stem and had me do excersizes. This improved my swallowing. I had learn how to get food pass my epigottis. She was concern that I had bulbar ALS. In May I had to have
a ACDF at C3-C4. Of course this didn't help swallowing. But it only lasted 3 or 4 weeks. Than back to my normal promblems. I speech terapist wanted another swallowing study after the surgery. It reveal no difference
than first one. I went back to my ENT. He wanted to do an endoscope, because I was also having adcid reflux. That decovered that I had significasnt gastroparesis with very minimal peristalsis. He said my esophagus appeared
normal.
My ENT wanted me go see another neurologist. He sent me to a ALS clinic for review of bulbar ALS.
I spent the last 4 years going that clinic. The doctor there order a EMG. And another swallowing study, this is one I sent you. They tested only left arm and leg. It was normal. 2.5 years she notice my voice was gettin weaker. But could firgure out want was wrong. I try drug for
parkinson. but had no effect. She would have come back evey 6 months to check if delvoped any other systoms of ALS. I have not, I guess.
She left. So I a new neurogist. Who saw my dystonia in my eyes (they blink a lot) and neck. Now he has sent a movement doctor. Who only going treat my dystonia. I have a started trial of Levadopa. To see if does anything.
The movement doctor sending me another ENT for swallowing. I started with an ENT.
So here I am seeking advice online.
I also did to add to my systems. I having problems with short term memory, this just started about 4 months ago. And my signature has changed in the last 4 months.
You need know also. I was in a depression state from Oct. 2009 till April of this year. I have been and still are being treated by a Psychiatric Mental Health Nurse Practitioner. We have tried several
medications. I'm now taking Lamital. It is not clear if this is bought me out depression. Also I took Trazadone for sleep, 16 years. I came off of it at same time I started the Lamital.
I had sleep apnea in 1998. And had upper and lower jaw advancement. Which solve my apnea. Until 2009. I had a sleep study 2009. Now I am on a c-pap. I am having another sleep study on August 14. Because I keep waking up.
I will describe events leading up to reports.
In 2003 I was having headaches. I was refered to a neurologist. He did a MRI on my XXXXXXX with contrast. It reveal the abnormality in the my viens.
He order the aniogram to take better look. Because of small vessals, he wanted be sure there no blockes.
Begining in 2009. I started to have promblems swallowing. Food getting hung my throat. In 2010 I was refered to different neurologist. I reported to him headaches, touge
spasmes, teeth chattering, hand tremors and left arm/hand tingling. He ignored all symptoms accept the headaches and hand tremors. He order the XXXXXXX MRI. My insurance
approved to have with contrast. I assumed that want I was to get. When the technican didn't put contrast in. I asked wasn't I suppose have contrast. She said wasn't ordered.
Follow up he said everything was normal. I that he new what he doing, so didn't question the MRI.
In 2011. I contiued to increasing promblems of swallowing. I went to my ENT, who I had previosly for things. He ordered the first swallowing study. It showed my epigottis promblems. And order swallowing
terapy with a speech therapist. She did e-stem and had me do excersizes. This improved my swallowing. I had learn how to get food pass my epigottis. She was concern that I had bulbar ALS. In May I had to have
a ACDF at C3-C4. Of course this didn't help swallowing. But it only lasted 3 or 4 weeks. Than back to my normal promblems. I speech terapist wanted another swallowing study after the surgery. It reveal no difference
than first one. I went back to my ENT. He wanted to do an endoscope, because I was also having adcid reflux. That decovered that I had significasnt gastroparesis with very minimal peristalsis. He said my esophagus appeared
normal.
My ENT wanted me go see another neurologist. He sent me to a ALS clinic for review of bulbar ALS.
I spent the last 4 years going that clinic. The doctor there order a EMG. And another swallowing study, this is one I sent you. They tested only left arm and leg. It was normal. 2.5 years she notice my voice was gettin weaker. But could firgure out want was wrong. I try drug for
parkinson. but had no effect. She would have come back evey 6 months to check if delvoped any other systoms of ALS. I have not, I guess.
She left. So I a new neurogist. Who saw my dystonia in my eyes (they blink a lot) and neck. Now he has sent a movement doctor. Who only going treat my dystonia. I have a started trial of Levadopa. To see if does anything.
The movement doctor sending me another ENT for swallowing. I started with an ENT.
So here I am seeking advice online.
I also did to add to my systems. I having problems with short term memory, this just started about 4 months ago. And my signature has changed in the last 4 months.
You need know also. I was in a depression state from Oct. 2009 till April of this year. I have been and still are being treated by a Psychiatric Mental Health Nurse Practitioner. We have tried several
medications. I'm now taking Lamital. It is not clear if this is bought me out depression. Also I took Trazadone for sleep, 16 years. I came off of it at same time I started the Lamital.
I had sleep apnea in 1998. And had upper and lower jaw advancement. Which solve my apnea. Until 2009. I had a sleep study 2009. Now I am on a c-pap. I am having another sleep study on August 14. Because I keep waking up.
Brief Answer:
Craniocervical dystonia
Detailed Answer:
Thank you for your updates. Now, some things are clearer. I don't quite understand how you could've spent 4 YEARS?? at an ALS clinic before someone finally decided to get an EMG on you? Typically when doing EMG's it is not necessary to do both sides of the body. Only if the test ordered directly calls for BOTH SIDES to be done. What is found on one side is assumed to occur on the other. If the EMG is normal then, ALS (after 4 years) is virtually impossible.
I also understand now why the diagnosis of Meige Syndrome or Meige's Syndrome or more descriptively CRANIOCERVICAL DYSTONIA was given to you....the forceful eye closures and other muscular contractions of the facial and neck muscles. That certainly sounds much more plausible than ALS.
It is not unreasonable to try levodopa medication or other medications which are similar because some patients with Meige syndrome can respond to LEVODOPA. If that medication doesn't work or works poorly then, there is a literature that supports the use of an antiepileptic medication called KEPPRA (Leviteracetam). However, the most successful treatments that I have seen and which I use in my patients with Meigs is BOTULINUM TOXIN. ENT could (if they wished) do injections into the vocal cords which has about a 50/50 chance of improving spastic paralysis so that your voice improves. Not sure why exactly they're doing the electrical stimulation since BOTOX is so much more direct and well known to work. I've had a number of patients who've either gotten very little improvement or if they do it's rather short lived and then, they have to return for another 6-10 week course of therapy. I also tend to inject BOTOX into the spasming muscles and get very good results within about 7 days after injection and these can last for up to 3 and when I'm lucky, 4 months. I also have a regimen (cocktail) of Klonopin and Lyrica that can work when other drugs fail. Ambien is another drug with anecdotal case reports of important in Meig's. There are a number of other medications which I've tried on my patients but they don't seem to be very effective but if necessary I can throw those out to you as well.
Be on the watch for medications that the psychiatrist may choose to prescribe that can also be an EXACERBANT of your abnormal and dystonic muscle contractions. If the medications are clearly not helpful then, my recommendation is to not take them due to the Meig's. That's what I always tell my own patients because these psych meds are so notorious for interfering with people who have movement disorders...anyways....
I've had a handful of patients who have not responded well to any medication (including BOTOX) but who have gotten relief from Deep Brain Stimulation (DBS). That is a neurosurgical procedure but its usefulness in these types of patients has been well studied and documented so that's something else to think about.
I hope these answers and recommendations satisfactorily address your questions. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
The query has required a total of 85 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Craniocervical dystonia
Detailed Answer:
Thank you for your updates. Now, some things are clearer. I don't quite understand how you could've spent 4 YEARS?? at an ALS clinic before someone finally decided to get an EMG on you? Typically when doing EMG's it is not necessary to do both sides of the body. Only if the test ordered directly calls for BOTH SIDES to be done. What is found on one side is assumed to occur on the other. If the EMG is normal then, ALS (after 4 years) is virtually impossible.
I also understand now why the diagnosis of Meige Syndrome or Meige's Syndrome or more descriptively CRANIOCERVICAL DYSTONIA was given to you....the forceful eye closures and other muscular contractions of the facial and neck muscles. That certainly sounds much more plausible than ALS.
It is not unreasonable to try levodopa medication or other medications which are similar because some patients with Meige syndrome can respond to LEVODOPA. If that medication doesn't work or works poorly then, there is a literature that supports the use of an antiepileptic medication called KEPPRA (Leviteracetam). However, the most successful treatments that I have seen and which I use in my patients with Meigs is BOTULINUM TOXIN. ENT could (if they wished) do injections into the vocal cords which has about a 50/50 chance of improving spastic paralysis so that your voice improves. Not sure why exactly they're doing the electrical stimulation since BOTOX is so much more direct and well known to work. I've had a number of patients who've either gotten very little improvement or if they do it's rather short lived and then, they have to return for another 6-10 week course of therapy. I also tend to inject BOTOX into the spasming muscles and get very good results within about 7 days after injection and these can last for up to 3 and when I'm lucky, 4 months. I also have a regimen (cocktail) of Klonopin and Lyrica that can work when other drugs fail. Ambien is another drug with anecdotal case reports of important in Meig's. There are a number of other medications which I've tried on my patients but they don't seem to be very effective but if necessary I can throw those out to you as well.
Be on the watch for medications that the psychiatrist may choose to prescribe that can also be an EXACERBANT of your abnormal and dystonic muscle contractions. If the medications are clearly not helpful then, my recommendation is to not take them due to the Meig's. That's what I always tell my own patients because these psych meds are so notorious for interfering with people who have movement disorders...anyways....
I've had a handful of patients who have not responded well to any medication (including BOTOX) but who have gotten relief from Deep Brain Stimulation (DBS). That is a neurosurgical procedure but its usefulness in these types of patients has been well studied and documented so that's something else to think about.
I hope these answers and recommendations satisfactorily address your questions. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
The query has required a total of 85 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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