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Need help interpreting brain CAT scan

An elderly person in my family has had several episodes of fainting
over a period of four or five years.  We’ve never been able to
pinpoint a cause. (more details and history follow the CAT scan
report).  

The obvious question about her fainting is whether she is having
TIAs or not. Her most recent CAT scan states the following:

"The ventricles and cortical sulci are moderately to markedly
enlarged consistent with atrophy and diffuse white matter disease.
The paraventricular white matter disease extending superiorly in the
corona radiata into the centrum semiovalae is nodular with the
appearance of numerous lacunar infarcts.  There is also a suggestion
of some ischemic changes in the brain stem.  There is no edema or
mass effect.  Specifically, there is no evidence of mass in the
right temporal lobe.  The visualized paranasal sinuses and orbits
are normal."

"Impression: Moderate to severe atrophy with extensive diffuse and
nodular symmetrical periventricular white matter disease, most
consistent with ischemic changes."

QUESTIONS:  

Does this mean she’s been having TIAs after all?

Should she take some kind of anticoagulant like aspirin?

Would this type of atrophy be expected to cause cognitive changes?
(She’s been slowing down a little lately, and repeats old stories,
but she’s oriented, memory for recent events is good and has nothing
else that would suggest Alzheimer’s or other dementia.)

Her balance is bad.  Would that be due to this kind of change?

HISTORY:

She has had three episodes of fainting. Episodes of fainting
previous to the most recent one involved her feeling dizzy and then
waking up on the ground looking up at a bunch of concerned faces.
One episode happened while standing in line for a long time.  This
caused the doctor to suggest it was vasodepressor syncope (she does
have swollen ankles and venous stasis).  Another episode, however,
occurred while she was sitting down.  She was at a homeless shelter
passing out food, felt "funny", and told people she had to go home
early.  She then got up, tried to walk to her car and keeled over a
few feet away.  The episodes seem to last about 10-15 seconds.

The most recent fainting spell was at the end of October. This
episode was markedly different from other ones.  Instead of just
outright fainting, she sat down suddenly because she felt weak.  She
then had a kind of "waking dream" where she thought she was helping
someone move furniture and called out for help.  This lasted 10-15
seconds, afterwards she was perfectly fine and there has not been a
repeat episode in 4 months.

We previously thought her fainting might be due to medication, since
she’s been on anti-cholinergics for a bladder problem.  At the time
of the first two episodes, she was on ditropan.  The dizziness
stopped when she discontinued the ditropan and had no further
episodes for about a year.  The most recent – and different –
episode occurred after she began taking imipramine for the same
bladder problem. She has had no repeat episodes since discontinuing
the imipramine; however, she’s only been off it for a couple of
months.

Physical findings:

Carotid doppler is normal.  Holter and regular EKG are normal except
for left bundle branch block of long standing. No arrthymias,
murmurs or obvious cardiac abnormalities. No other neuro signs. EEG
is normal.  

MEDICATIONS:

She takes levothyroxin for hypothyroidism, was a little hypothyroid
recently but the dosage was changed and she was euthyroid at the
time this fainting episode occurred.  Has recently discontinued HRT.
Takes ibuprofen for arthritis.  She also takes a variety of
antioxidant vitamins for macular degeneration and the herb bilberry.
 (There’s not a whole lot of research on bilberry, but it decreases
vascular permeability, suggesting that, if it has any effect at all,
it would counteract venous stasis.)

OTHER RELEVANT HISTORY:

She is 74 years old.

She just underwent radical hysterectomy and lymph node sampling for
endometrial cancer (last week, actually). We were concerned about
the possibility of a brain metastasis, but there doesn’t seem to be
anything to support that theory.   In addition to the CAT scan
stating there was no mass, the path report states that the cancer
was Stage I, grade 2.  The tumor was smaller than 3 mm and was less
than one sixth of the way into the myometrium, with no involvement
of the lower uterine segment.  Lymph nodes are clean.  

She survived septic shock from cellulitis in 1994, had a bout of
sepsis from a UTI in 1998 (did NOT lead to shock, fortunately).  Has
frequent UTIs.  She has slight osteoporosis on chest X-ray, for
which the doctor has recommended increased calcium intake since she
can no longer take estrogen.

I’m open to comments and ideas.

Please send me an e-mail copy of any replies you post to the
newsgroup.

Thanks.

————————————————————-
"The trick is to keep an open mind, without it being so open
                   that your brain falls out"

                    Camilla Cracchiolo
                     Registered Nurse
                  Los Angeles, California
                          USA

cami…@primenet.com         http://www.primenet.com/~camilla

.
posted by admin in Uncategorized and have Comments (3)

3 Responses to “Need help interpreting brain CAT scan”

  1. admin says:

    On 2 Feb 2000 04:03:42 GMT, cami…@primenet.com (Camilla Cracchiolo,

    - Hide quoted text — Show quoted text -

    R.N.) wrote:
    >"The ventricles and cortical sulci are moderately to markedly
    >enlarged consistent with atrophy and diffuse white matter disease.
    >The paraventricular white matter disease extending superiorly in the
    >corona radiata into the centrum semiovalae is nodular with the
    >appearance of numerous lacunar infarcts.  There is also a suggestion
    >of some ischemic changes in the brain stem.  There is no edema or
    >mass effect.  Specifically, there is no evidence of mass in the
    >right temporal lobe.  The visualized paranasal sinuses and orbits
    >are normal."

    >"Impression: Moderate to severe atrophy with extensive diffuse and
    >nodular symmetrical periventricular white matter disease, most
    >consistent with ischemic changes."

    >QUESTIONS:  

    >Does this mean she’s been having TIAs after all?

    Can’t say. They don;t sound like classical TIAs.  She has had
    ischaemic events and tiny lacunar infacts, which most commonly leave
    people with isolated small neurological deficits.  Does she have
    hypertension? Its the most common risk factor for strokes.  It sounds
    like chronic ischaemia with multiple small strokes.  Whether the
    anatomical changes in her brain are causing her falls, it is
    impossible to say.  

    >Should she take some kind of anticoagulant like aspirin?

    Depends what has caused the infarcts.  It can be an age-related
    change, and with anticoagulants your risk precipitating a cerebral
    haemorrhage which could be a more devastating neurolgical problem.
    Aspirin may have a role if the small strokes are embolic or associated
    with atrial fibrillation.  Consensus seems to suggest that although
    there is no evidence aspirin alters the progression of multiple white
    matter infarcts, known vascula risk factors should be treated, and
    aspiring has a role in that.

    >Would this type of atrophy be expected to cause cognitive changes?

    It can be associated with ‘multi-infarct dementia’, which is a step
    wise deterioration in function, cognitive and neurological.

    >(She’s been slowing down a little lately, and repeats old stories,
    >but she’s oriented, memory for recent events is good and has nothing
    >else that would suggest Alzheimer’s or other dementia.)

    Slowing down and repeating old stories is common too :-)

    >Her balance is bad.  Would that be due to this kind of change?

    Balance is an inner ear and largely cerebellar function.  Where there
    cerebellar changes?  Does she have any inner ear problems?  Does she
    have problems with her gait, with speech, with coordination, problems
    with her gaze?

    >HISTORY:

    >She has had three episodes of fainting. Episodes of fainting
    >previous to the most recent one involved her feeling dizzy and then
    >waking up on the ground looking up at a bunch of concerned faces.
    >One episode happened while standing in line for a long time.  This
    >caused the doctor to suggest it was vasodepressor syncope (she does
    >have swollen ankles and venous stasis).  Another episode, however,
    >occurred while she was sitting down.  She was at a homeless shelter
    >passing out food, felt "funny", and told people she had to go home
    >early.  She then got up, tried to walk to her car and keeled over a
    >few feet away.  The episodes seem to last about 10-15 seconds.

    Does she have postural hypotension? It is extremely common in older
    people, especially if they are on diuretics or antihypertensive drugs,
    or even just because they are old.  Losing balance when moving from
    lying to sitting or standing.

    Does she have intermittent arrhythmias of her heart?

    Does she lose consciousness?  Does she just lose her balance?  Does
    she go white and pale?  Does she have palpitations?

    >The most recent fainting spell was at the end of October. This
    >episode was markedly different from other ones.  Instead of just
    >outright fainting, she sat down suddenly because she felt weak.  She
    >then had a kind of "waking dream" where she thought she was helping
    >someone move furniture and called out for help.  This lasted 10-15
    >seconds, afterwards she was perfectly fine and there has not been a
    >repeat episode in 4 months.

    A TIA produces distinct neurological deficits, just like a stroke,
    that resolve and disappear within 24 hours.  Does she have
    cardiovascular disease?  Does she have any narrowing of her carotid
    arteries?  Has this been investigated?

    Does she ever have tinglings, numbness or paralysis/loss of
    function/sensation of any part of her body , or part of her face?

    >We previously thought her fainting might be due to medication, since
    >she’s been on anti-cholinergics for a bladder problem.  At the time
    >of the first two episodes, she was on ditropan.  The dizziness
    >stopped when she discontinued the ditropan and had no further
    >episodes for about a year.  The most recent – and different –
    >episode occurred after she began taking imipramine for the same
    >bladder problem. She has had no repeat episodes since discontinuing
    >the imipramine; however, she’s only been off it for a couple of
    >months.

    I think I’ll stop now.  What does her doctor think?

    Any other medications?

    >Physical findings:

    >Carotid doppler is normal.  Holter and regular EKG are normal except
    >for left bundle branch block of long standing. No arrthymias,
    >murmurs or obvious cardiac abnormalities. No other neuro signs. EEG
    >is normal.  

    Asked and answered

    Does she have no neurological deficits at all?  Have any neurological
    signs ever been seen?

    Postural hypotension has to be pretty high on the list for a lady of
    this age.  It is very common.  Especially given some degree of venous
    stasis and decreased venous return, or if on any antihypertensives or
    diuretics.  Is she on any cardiovascular medications?

    Arrythmias up there too, but the Holter may lessen that as a likely
    cause, how often are the spells though, and how long did she wear the
    Holter, did she wear it during any of these episodes?

    They don;t sound like TIAs, and the good carotid dopplers tend to
    place this lower on the list, but never say never.

    >OTHER RELEVANT HISTORY:

    >She is 74 years old.

    >I’m open to comments and ideas.

    Well some ideas.  On the basis that common things happen commonly I’d
    investigate postural hypotension first, with standing and lying blood
    pressures.  I am surprised it isn;t mentioned here before CT scans.

    She obviously has cerebrovascular disease, with multiple white matter
    infarcts, this is most commonly associted with hypertension, and that
    is most commonly associated with advancing age. There is often a
    stepwise progression over years, and cognitive function my not be
    affected early on. She doesn;t have stenosis of her carotids, which is
    where most TIAs arise, unless they arise in the heart.  You don’t
    describe these falls as being associated with neurological symptoms
    like paralysis, or altered sensation, or inability to speak or
    swallow, or looking like strokes.

    She may have several processes going on, or drug effects, or postural
    hypotension, or autonomic dysfunction producing her falls.  Or the
    falls may be cause by being older and a bit frail and poor eyesight or
    inadequate glasses.  Many possible causes of falls, and the
    cerebrovascular disease may have nothing to do with it.

    This would be a good job for a really good gerontologist to get to the
    bottom of.  Falls are their bread and butter, or should be!

    Just some thoughts

    Kerry

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
    It’s easier for a man to enter a camel
    if he stands on a box.
    -Johnathon Creek
    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

  2. admin says:

    These, to me, sound like questions that need to be asked to the doctor
    taking care of your relative. It is clearly a complicated case, and these
    questions can, IMHO, only be answered by the physician who knows her best.

    Jeffrey Peter
    Camilla Cracchiolo, R.N. wrote in message

    <878aau$ke…@nnrp02.primenet.com>…

    - Hide quoted text — Show quoted text -

    >An elderly person in my family has had several episodes of fainting
    >over a period of four or five years.  We’ve never been able to
    >pinpoint a cause. (more details and history follow the CAT scan
    >report).

    >The obvious question about her fainting is whether she is having
    >TIAs or not. Her most recent CAT scan states the following:

    >"The ventricles and cortical sulci are moderately to markedly
    >enlarged consistent with atrophy and diffuse white matter disease.
    >The paraventricular white matter disease extending superiorly in the
    >corona radiata into the centrum semiovalae is nodular with the
    >appearance of numerous lacunar infarcts.  There is also a suggestion
    >of some ischemic changes in the brain stem.  There is no edema or
    >mass effect.  Specifically, there is no evidence of mass in the
    >right temporal lobe.  The visualized paranasal sinuses and orbits
    >are normal."

    >"Impression: Moderate to severe atrophy with extensive diffuse and
    >nodular symmetrical periventricular white matter disease, most
    >consistent with ischemic changes."

    >QUESTIONS:

    >Does this mean she’s been having TIAs after all?

    >Should she take some kind of anticoagulant like aspirin?

    >Would this type of atrophy be expected to cause cognitive changes?
    >(She’s been slowing down a little lately, and repeats old stories,
    >but she’s oriented, memory for recent events is good and has nothing
    >else that would suggest Alzheimer’s or other dementia.)

    >Her balance is bad.  Would that be due to this kind of change?

    >HISTORY:

    >She has had three episodes of fainting. Episodes of fainting
    >previous to the most recent one involved her feeling dizzy and then
    >waking up on the ground looking up at a bunch of concerned faces.
    >One episode happened while standing in line for a long time.  This
    >caused the doctor to suggest it was vasodepressor syncope (she does
    >have swollen ankles and venous stasis).  Another episode, however,
    >occurred while she was sitting down.  She was at a homeless shelter
    >passing out food, felt "funny", and told people she had to go home
    >early.  She then got up, tried to walk to her car and keeled over a
    >few feet away.  The episodes seem to last about 10-15 seconds.

    >The most recent fainting spell was at the end of October. This
    >episode was markedly different from other ones.  Instead of just
    >outright fainting, she sat down suddenly because she felt weak.  She
    >then had a kind of "waking dream" where she thought she was helping
    >someone move furniture and called out for help.  This lasted 10-15
    >seconds, afterwards she was perfectly fine and there has not been a
    >repeat episode in 4 months.

    >We previously thought her fainting might be due to medication, since
    >she’s been on anti-cholinergics for a bladder problem.  At the time
    >of the first two episodes, she was on ditropan.  The dizziness
    >stopped when she discontinued the ditropan and had no further
    >episodes for about a year.  The most recent – and different –
    >episode occurred after she began taking imipramine for the same
    >bladder problem. She has had no repeat episodes since discontinuing
    >the imipramine; however, she’s only been off it for a couple of
    >months.

    >Physical findings:

    >Carotid doppler is normal.  Holter and regular EKG are normal except
    >for left bundle branch block of long standing. No arrthymias,
    >murmurs or obvious cardiac abnormalities. No other neuro signs. EEG
    >is normal.

    >MEDICATIONS:

    >She takes levothyroxin for hypothyroidism, was a little hypothyroid
    >recently but the dosage was changed and she was euthyroid at the
    >time this fainting episode occurred.  Has recently discontinued HRT.
    >Takes ibuprofen for arthritis.  She also takes a variety of
    >antioxidant vitamins for macular degeneration and the herb bilberry.
    > (There’s not a whole lot of research on bilberry, but it decreases
    >vascular permeability, suggesting that, if it has any effect at all,
    >it would counteract venous stasis.)

    >OTHER RELEVANT HISTORY:

    >She is 74 years old.

    >She just underwent radical hysterectomy and lymph node sampling for
    >endometrial cancer (last week, actually). We were concerned about
    >the possibility of a brain metastasis, but there doesn’t seem to be
    >anything to support that theory.   In addition to the CAT scan
    >stating there was no mass, the path report states that the cancer
    >was Stage I, grade 2.  The tumor was smaller than 3 mm and was less
    >than one sixth of the way into the myometrium, with no involvement
    >of the lower uterine segment.  Lymph nodes are clean.

    >She survived septic shock from cellulitis in 1994, had a bout of
    >sepsis from a UTI in 1998 (did NOT lead to shock, fortunately).  Has
    >frequent UTIs.  She has slight osteoporosis on chest X-ray, for
    >which the doctor has recommended increased calcium intake since she
    >can no longer take estrogen.

    >I’m open to comments and ideas.

    >Please send me an e-mail copy of any replies you post to the
    >newsgroup.

    >Thanks.

    >————————————————————-
    >"The trick is to keep an open mind, without it being so open
    >                   that your brain falls out"

    >                    Camilla Cracchiolo
    >                     Registered Nurse
    >                  Los Angeles, California
    >                          USA

    >cami…@primenet.com         http://www.primenet.com/~camilla

  3. admin says:

    In <xxem4.65$59.8…@news1.epix.net> "Jeffrey Peter, M.D."

    <kidsdoc2…@hotmail.com> writes:

    >These, to me, sound like questions that need to be asked to the doctor
    >taking care of your relative. It is clearly a complicated case, and
    these
    >questions can, IMHO, only be answered by the physician who knows her
    best.

    >Jeffrey Peter

       I would say that such questions can be answered best probably by the
    physician taking care of the relative.  Probably, but not necessarily.
    If the only medical questions we ever considered on this forum where
    those which some doctor or other on the spot had not already
    considered, it would be a rather ininteresting forum.