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Dr. Rick, MD
Dr. Rick, MD, Board Certified MD
Category: Neurology
Satisfied Customers: 11242
Experience:  20+ years as a doctor. Internal Medicine Internship in NYC
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I am suffering from severe debilitating treatment resistant

Customer Question

I am suffering from severe debilitating treatment resistant depression since 2013, accompanied by a tormenting sensation of acid/numbing of the left frontal part of my brain. This diagram shows my pharmacological history: https://tinyurl.com/2015jg
I have done an MRI scan on 2014 and although the report came normal at the time, I just noticed some possible artifacts, which I designate in red circles in this video: https://www.youtube.com/watch?v=RkB6TsswW9s
Images of the same artifact from other sequences: http://tinyurl.com/mri2014artifact
I would like to ask for the opinion of a experienced neurologist in the interpretation of this data.
If you want to take a look to the overall exam sequences, I've placed a video of the complete 3 sequences of the MRI for your full brain inspection at: https://www.youtube.com/watch?v=pj-t6e8wqnA
Submitted: 1 year ago.
Category: Neurology
Customer: replied 1 year ago.
As a complement to my question I would like to get a recommendation on which further exam I should make to study my persisting symptoms on the left frontal side of my brain, which are accompanied by quite significant cognitive and working memory impairments that render me disabled, bedridden and unable to work. Which exam should be appropriate in my case (fMRI, SPECT, SPECT, EEG?) to further investigate on the severe functional impairment and permanent numbing/burning symptomatology on the Left-DLPFC ?
Customer: replied 1 year ago.
Errata:
Where it says: "(fMRI, SPECT, SPECT, EEG?)",
Should be: "(fMRI, SPECT, PET, EEG?)"
Expert:  Dr. Phil, MD replied 1 year ago.

can I help?

any other medical issues?

Customer: replied 1 year ago.
I could use some help yes... but need an insightful opinion from an experienced neurologist, and your ratings don't exactly inspire me. Besides, your picture was stolen from the internet.I suffer from extreme fatigue/exhaustion and all symptoms of extreme severe and debilitating melancholic depression, I am a M38,230lbs(104Kgs),don't have other diagnosed comorbidities so far.
Some blood test data:
Vitamin D: 24 ng/mL.
Testosterone: 373 ng/dL (had a varicocele surgery at age 14)
Thyroid check:
TSH : 2.5 uUI/mL (normal range: 0.27 - 4.2)
T3: 1.99 mmol/L (normal range: 1.3 - 3.1)
FT3: 5.62 pmol/L (normal range: 3.1 - 6.8)
T4: 56 ug/dL (normal range: 60 - 120)
FT4: 11.36 pmol/L (normal range: 12 - 22)
Expert:  Dr. Phil, MD replied 1 year ago.

No problem. I can opt out for you if you like.

However, you may need an endocrinologist and not a neurologist

Just let me know how you want to proceed

Customer: replied 1 year ago.
I need the help of a neurologist to interpret the MRI artifact as described in my post.
The blood test data was only complementary information to your answer.
I would prefer that you opt out and will wait for an experienced neurologist that can interpret my MRI.
Thank you
Expert:  Dr. Rick, MD replied 1 year ago.

Hi. My name is***** and I am online and available to help you today. I see that your expert has opted out.

Question and answer is just one of the services I offer. I can also provide you with additional services, such as live telephone or skype consultation, at a small additional cost. Let me know if you are interested.

How can I assist you?

Do you have any other medical problems or take any medications?

This is not an answer, but an Information Request. I need this information to answer your question. Please reply, so I can answer your question. I look forward to helping you.

Customer: replied 1 year ago.
Hello,
I have described my concern regarding the MRI exam in the description in the context of an intractable extreme melancholic depression. I would like to get help regarding that.
Expert:  Dr. Rick, MD replied 1 year ago.

I am unable to see the video you uploaded with enough detail to give an opinion on the artifact you have circled. When these sorts of files are interpreted by the radiologist a specialized program with advanced hardware is used to enlarge and highlight areas like this.

As such, from the limited viewing I can get, and knowing that the doctor who read your film had access to the latest hardware and software, I would have to say that these areas do not have any clinical significance.

That being said if you want a better reading then all you have to do is request that the data be sent to a different radiologist for a second opinion. If you choose to go this route I'd recommend sending the films (actually data disks.... no one uses actual film anymore ;) to a University Teaching Hospital.

Why a teaching hospital? Because At an institution like that you could be evaluated and treated by a team of sub-specialists who are at the cutting edge of their respective fields. The best thing about these large teaching hospitals is that consultations are available with Professors and leaders in their field by just walking a few steps down the hall.

Does this make sense to you?

I hope this information was helpful for you. But I do work for tips so I want to make sure you are happy with me before rating me. If you have another question on this or a related issue feel free to fire away. You may also receive an email survey after our chat, if you don’t feel that I have earned the top rating in all areas, please let me know what I can do to meet your expectations.

Thanks in advance,

Dr. Rick MD FACS

Customer: replied 1 year ago.
Thank you Dr. Rick.Thank you for your answer. I was very detailed and uses good common sense. I liked it.Before rating you I would like to ask a second advice regarding what exam I can try next to try to clarify the symptoms I have.Since what I consider to have been a Zoloft adverse reaction, I feel the left frontal part of my brain is as if under anesthesia (if you ever had anesthesia in a dentist, and had your jaw and face feeling numb, it's a very similar feeling, but in the left frontal part of my brain, a fist size. That MRI was made to rule out the chances of stroke, ischemia, tumors or anything that could be structurally detectable there. But to my frustration nothing shows there, so I have no way of understanding why do I feel like this, as this is simply paralyzing and has me bed ridden for 3 years.It's like I felt I was neurology case study of Phineas-Gage, with my left frontal cortex destroyed by a metal rod, but nothing could be shown in structural exams. Since my adverse reaction to Zoloft 3 years ago, and every single day since then, nothing has changed in this paralyzing sensation in that region of my brain.I've seen many psychiatrists and neurologists in Portugal and all of them refused to look further with functional imaging exams. But this sensation is so incapacitating and permanent that I'm really willing to do a functional exam, like a PET, fMRI, SPECT or EEG to substantiate my claims that something went miserably wrong in this part of my brain.But I don't know what exam is indicated for this investigation.The neurologists I've seen here so far, refuse to consider my symptoms a neurological symptom and push me to psychiatry, calling this symptom consequence of anxiety of sensory hallucinations. Which is a huge mistake. The feeling I have in my brain is uniquely related to neurology alone, as sleeping for nearly 3 years with complete failure of 20 medications, unable to think or feel any fear or any emotion, I am sure this is the result of neurotoxic reaction to an SSRI.I have memory recall deficits, verbal fluency deficits and disordered memory, which neurologists ignore as they say I talk too eloquently and seem all knowing and wise. It's hard not to take that as an insult, as all I'm trying to have is genuine interest in digging further in this symptom.I am complaining about this symptom uninterruptedly since 2013 and every time I enter in a new neurologist office I am never taken seriously about this. But This symptom (together with the symptoms of untreatable severe depression), are literally killing me, as I'm bedridden and my body is falling apart as I barely can leave the house 1 day per month and walk 100 yards.The feeling of having this anethesia/acid in the left side of my brain, which appeared overnight in 2013 simply drives me insane, I suffer from no psychosis. My baseline condition is melancholic severe depression that renders me bedridden. I never heard voices but the times I went panicking it's because I can't stand this anesthesia/acid feeling in the left frontal cortex.I couldn't stress this more anywhere I go. Yes I have an unresolved extreme depression with score 37 in HAMD and score 57 in BECK-2, but there is no place in both questionnaires to complain for feelings of having a part of the brain with a brick lodged on it or acid pouring over it. It's a total physical sensation. I have it, regardless if I try psychiatric medication (any kind) or not.My disappointment with the psychiatrists and neurologists I've seen so far is that they never decided to further study this symptom, and I would agree with them that they had to try other pharmacological approaches before they decided on a functional imaging exam.I reached the point where I am willing to do a functional exam with our without consent of a doctor. And I have a place I can ask to do either a PET, SPECT, fMRI or EEG without direct medical prescription, if I support all costs. I simply don't know what to ask for as they told me it has to be specific, so I may try to ask that to a neurologist here but even neurologists I have seen here don't seem to know much about functional imaging, which is just a sad picture of Portugal's neurology landscape.In any case, what I would like to get from you was a recommendation on what specific functional exam I should get: PET, SPECT, EEG or fMRI, or other.. in order to investigate the agonizing and permanent symptoms I have in my Left-DLPFC.And if possible, some guidelines on how that exam should be made: which connectivity areas to test, in resting state or task activation. Something alongside that axis.I can't understand why this is Chinese to Neurologists that insist in looking at the basics: the structural imaging exams.I know medical science has limitations, but all I'm asking from Neurology is the chance of performing a functional imaging exam.I just need to know what to look for.
Expert:  Dr. Rick, MD replied 1 year ago.

Thank you for that detailed reply. After going over all you have posted I'm afraid I have to agree with your doctors: Additional neuroimaging in the form of PET, SPECT, EEG of fMRI is not really going to shed any light on you cause of your feelings or symptoms.

I wish things were different but, at this point, I feel you have reached the limits of what modern medicine can offer....

Make sense to you?

I realize that this was not the answer you were hoping to hear but it would be unfair to you and unprofessional of me were I provide you with anything less than truthful and honest information.

Surely, you prefer that I tell the truth rather than what you wish to hear. Because it reflects very poorly on me unless you press one of the top three feedback choices, keep this in mind when rating my answer and please do not punish me for being honest. I understand that this may not be easy to hear, and I empathize.

Even though my answer was not quite what you were hoping for, please understand that my priority was to provide you with the most honest information. With that in consideration, I hope that you found my answer useful. Please click the excellent feedback button so that I can receive credit for my efforts.

Dr. Rick MD FACS

Customer: replied 1 year ago.
Thank you Dr. Rick.I understand your need to provide an honest opinion.But your answer assumes that functional brain imaging is not useful in psychiatry. Which is not always the case as it can at least be used to evaluate dementias. And considering I exhibit cognitive and memory symptoms there is at least some degree of cognitive impairment present. The degree to which it can be or not detected on a functional imaging exam would be better than not looking at all.Similarly, there are noticeable changes in brain activity in drug addicts, and what I feel 24/7 for 3 years in a localized reason of my brain brain since Zoloft, can eventually be result of neurotoxicity and that abnormality could potentially show somehow in brain activity scans.Suspicious brain activity with possible relation with neurotoxicity can be a powerful asset to a patient that suffers successive aggressions from psychiatric medications that don't work and make the baseline condition much worse.I believe that there are chances to learn more about the patient from such an exam, than doing nothing it at all, specially when the patient doesn't care if he lives or dies, as all he tries just pushes him more to the edge of the abyss.You will not question the usefulness of a functional exam in oncology, stroke, ischemia, alzheimer's once the disease has been diagnosed. The same way I wouldn't see the need or potential use of a functional imaging exam in the vast majority of depression cases. But for 3 years I have crawled the web back and forth and have found nobody (except Mitch Bartlet, which I met on a FB drug support group, that killed himself in August after having similar symptoms to mine, also after 10 years of Zoloft exposure. Strikingly similar case: http://www.dailymail.co.uk/tvshowbiz/article-3198765/Kylie-Minogue-posts-heartfelt-message-Locomotion-backing-dancer-close-friend-Mitch-Bartlett-tragically-passes-away.html
Nobody told that to the press but a small group in FB knows it as he was one of our suffering buddies there)People with severe depression don't usually complain of feeling a part of their brain burning in acid 24/7, for years on end, to the point of banging their heads against the walls and screaming in agony.I simply can't believe that a functional imaging exam will not detect any abnormal activity on the patient's brain affected regions. Something with such extreme severity in the pain scale, that nearly has me jumping of buildings for feeling my brain melting in acid, no matter what meds I try, or don't try, has to have minimal expression in physiological markers used in the tracers of PET or SPECT for instance. Even if it doesn't show directly, something has to show up. If a brain region dies, no activity will show for sure. And in that case I'm sure there's no use to make any exam, that is guaranteed.http://www.slideshare.net/swapnilagrawal92/neruoimaging-finalI understand what you mean: Even if some suspicious activity differences from controls shows, that does not provide guidance to the available treatments. However, for someone that is non responsive to treatments it can be a eye-opener, giving hints to the doctor, helping him determine if there's probably more neurotoxic potential on the non-useful Rx meds, than hypothetical therapeutic potential.https://www.youtube.com/watch?v=esPRsT-lmw8We probably lack the right radio tracers for inspecting things like receptor densities of several neurotransmitter systems, but the technology for inspecting brain activity is there. Saying functional imaging is of no use for psychiatric illness or neurotoxicity or dementia assessment is probably something that cannot be stated so boldly.It may all depend on the case severity.How can we be so sure that getting an insight on the brain activity in particular in the brain frontal-left brain region where all my symptomatology resides, will not give an experienced radiologist clues about what may be going on?How many severely depressed patients are bedridden for 3 years, constantly complaining about their agonizing sensation of acid burning in the left frontal part of their brains? Quitting their engineering careers, becoming totally incapacitated and depending on relatives to survive, and constantly complaining about that left region and being systematically ignored?My hairdressed paid most attention to it than any doctor did so far, as she noticed the scars I have on the left side of my forehead for banging my the left side of my head agaisnt the doors, in total agony.This appeared overnight in 2013 and never went away nor gave me a second of peace ever since. I googled and googled, and networked and networked an nobody relates to this.I can't believe that in cases so extreme like mine a brain imaging scan will conclude exactly nothing. I simply can't believe.