Had an EKG, EEG, head CT, CT angiogram with dye, echo, one wk holter, blood work and just today a stress echo with no diagnosis yet for the following symptoms: syncope, numb, intensely painful feet ball to toes(progressed from tingling only at night over past 2 yrs), pressure in left side of face near nose along with metallic taste that precedes the faint.(facial pressure/metallic taste also occurring without subsequent faint). Faints occurred in May 2013 when standing, July when seated & again in Sept 2013 when standing+ 30 min later when driving. Voided bladder in May, July only. Extreme fatigue follows. No convulsions. No headache.Wringing wet shirt after Sept faint with sweat running down face.Alert after faints. Dizzy when leaning over, vision slightly blurs but corrects after standing a few seconds-Started occurring shortly before Sept 10, 2013 & continues. No sex drive.Fatigue I'm a working 56 yr male.Blood work shows slight vit D deficiency. on BP med, thyroid (slight hypo)& D. Ideas?
Hi, I am Neuro Doctor, an American Board Certified Neurologist with vast clinical experience.
Have you received the stress echo report?
No that was just completed.
Okay I see
I will ask few more questions
Have you had a test by name "Tilt table testing"?
not yet but I'm aware of that possibility and how it works
Okay I see, I will explain now
First of all about the diagnosis;
Your symptoms are suggestive of a type of Syncope
There are myriad kinds of syncope
What is causing syncope is our main question
One type of syncope is neurocardiogenic syncope
That can cause your symptoms
It is also called as Vasovagal syncope
Are you familiar with this condition?
yes I've read and been told about that but just haven't found out cause. I don't have panic attacks or anything other than the symptoms I've listed
Panic attacks are not necessary for this type of syncope
it can happen spontaneously too
The episodes weren't related to specific events or with common conditions like seeing blood, etc
ok I see
Yes I agree with your points
Some of these syncope can occur randomly too
generally there is some obvious or specific trigger
but not always
these syncope occur in standing or sitting positions like in you
this possibility we need to explore
there are treatments for this condition
the test for this condition is;
Tilt table test
This will help in confirming the diagnosis
If this test was not done then this possibility is not yet ruled out
If the diagnosis is confirmed then the treatment options are as follows;
Before discussing the treatment options let me ask a question
Have you already tried any treatments so far?
nothing as they haven't made any suggestions yet
Okay I got you
I will discuss now about the treatment options;
Commonly used meds are;
SSRI agents like Fluoxetine
Beta blockers like Propranolol
Other meds tried are Florinef , or Proamatine
There are non-medication options too like;
Tilt training procedures
If nothing helps then;
There are surgical options too like;
Cardiac radiofrequency neuroablation OR
Cardiac pacemaker placement etc
But most patients never require any surgeries
the non-surgical above options are sufficient
You may discuss the above points with your doctors (the diagnostic possibility, investigation & the treatment options)
Please go through the above information and let me know if you have any further questions.
ok thanks. We have discussed the potential for the tilt table test if the stress echo shows no cause. I've read quite a bit about treatment options as well but appreciate your time in listing out the various options to consider. I wonder specifically about the facial pressure and metallic taste. Neuro said it scenario doesn't exactly fit seizure but also doesn't fit simple faint. So I guess I'll just have to proceed with tests until a diagnosis can be made.
You are welcome!
I am going through these additional info now
I will be with you shortly
Yes, we can proceed step by step
First let us get the report of stress echo test
if normal then the tilt table test is a strong consideration
And one more test I can suggest is;
Long duration EEG monitoring like video EEG or Ambulatory EEG, have you had one of them?
no, aware of that and how it's done but no suggestion to do so as yet
Okay I will explain now
Yes I agree, symptoms like facial pressure & metallic taste too are concerning
with these symptoms & presentations we need to think about out of the box possibilities
they do not easily fir to seizures or syncope
but they do have features of both
so this could be rare manifestation of syncope or seizure
about long duration EEG;
it is like EKG to holter
routine EEG to long duration EEG
the duration is considerably longer
the routine EEG because of short duration can miss seizure activities
the long duration EEG is more 24 hours, or 48 hours or even more as necessary
this will optimize our chances of picking abnormal findings
ambulatory EEG is easy
it is a home monitoring like holter
for video hospital admission is needed
generally we start with ambulatory EEG
this will help in showing any out of the box possibility of seizure
similarly the tilt table test will help in showing if there is a rare variant of vasovagal syncope
so the above tests may be considered in my strong opinion
if the stress echo does not help
ok, will there be potential benefit to the ambulatory EEG if faints only happen every two months though?
This is great question!
Yes it can still help
And does foot numbness and pain and no sex drive even sound remotely connected?
because there are what is called as interictal changes
The interictal seizure changes occur in between the seizures
oh I see
and routine EEG can easily miss these EEG findings
Do these symptoms occur along with these syncope like attacks?
just current symptoms but not sure there is any connection, undiagnosed
I agree with you
thereare two sets of symptoms
one set of symptoms are syncope vs seizures
the other set of symptoms occurring in between these attacks too
have you had MRI of the brain?
no mri just a CT head scan I believe they called it
MRI is the one where they put you inside a tube like machine
no I haven't had that
You definitely need brain MRI
To be honest I am surprised
they did not order MRI
shows things EEG does not then I assume?
CT scan miss certain things
no mri ordered
which are easily seen on the MRI
The EEG, MRI, Tilt table tests all show different findings
For your symptoms an MRI of the brain is definitely needed
the head ct was done in ER after my first fall and I was very upset and tired but I sure don't remember it being the mri with the tube etc. quite sure it was called ct.
So I will inquire about that for sure and confirm I'm correct
MRI is not usually done in the ER
ER most often just CT is done
MRI is arranged after the CT
Ok that fits with my memory too
Yes please confirm on this point
Most likely it was CT then
So brain MRI, long duration EEG, Tilt table test
after the report on stress echo
if MRI is done obviously no need to repeat it
but if it was not done you certainly need it
Ok, I will definitely confirm that
Do you have further questions now?
Not that I can think of I guess
Thank you for all the time tonight
Okay, Please try to get those tests
You are very welcome!
I am very glad to be of help!
This is life changing due to no driving and constant wonder about if I'll faint again. I go down so hard. Thanks again
wishing you a quick definitive diagnosis
I appreciate that
Yes I can fully understand your concerns and frustrations
Wishing you a quick and complete recovery, all the best!
Ok, good night
Good night to you too, all the best!
Please let me know if you have any further questions. And if you feel you have received the answer to your question please rate my answer to compensate me for the time and effort put by me in answering your question.