A New Diagnosis or a Re-Diagnosis?
Walter Williams is a thin man with a mild demeanor. I met him in his home for a Medicare Wellness Visit. He was considering becoming a patient for primary care with us. He had a dramatic history of a couple of strokes with right sided paralysis lasting up to 24 hours without any remaining weakness. He also told me he had had several TIAs, transient ischemic attacks, between his strokes.
He lives in an area with minimal cell phone service and he has no internet in his home. He told me he’d had lots of CT scans that didn’t show anything. He didn’t think he’d had an MRI, but he was now scheduled for one because he had hearing loss in only one ear, which always makes you worry about an acoustic neuroma.
I asked him and his son to describe the spells to me. They always involved the right side of his body. The strokes involved the right side of his face as well as his right arm and leg and had lasted a day or more. The shorter spells usually involved only weakness of the right side of his face.
His neurological exam was normal except for numbness in his left 4th and 5th finger, which suggested that the ulnar release at the elbow he had several years ago had failed. He also had mild weakness in all the fingers of his left hand suggesting carpal tunnel syndrome.
“I’d like to get into the Maine Health InfoNet and look at all your hospitalizations, emergency room visits and x-rays you’ve had done. Then I’ll need to think about all this and come back to make a recommendation on what we should do next. Would that be all right with you”, I asked.
He agreed, and back home I pored over his big online dossier.
He had undergone two CT angiograms of the blood vessels in his neck and brain which were both normal. And two brain CTs were also normal. When his brain MRI then came in, it showed no acoustic neuroma and also no sign of a prior stroke.
It made no sense to me that someone could have several strokes with full recovery and TIAs with negative angiograms and brain MRI imaging. This had to be purely neurological and not vascular.
In my mind, this left only two options that could explain his symptoms, complicated migraine or some sort of seizures. I googled my question whether you could see paralysis during a seizure. The answer i found listed in my search was Todd paresis, something I had not heard of, but certainly matched his symptoms, multiple episodes of one-sided full or partial weakness lasting up to a few days and resolving completely on its own.
In follow-up I zeroed in on whether he’d experienced any kind of headache with his neurological episodes. He had , but not severe and only some of the time. As far as seizures went, most TIA and stroke-like episodes had occurred when he was alone, but his son had once or twice seen his father act a little spacey before the right sided facial weakness developed. He had certainly never had anything like a grand mal seizure. In my reading I saw that the seizure that precedes the paresis can sometimes be very subtle.
I explained my differential diagnosis to the two of them.
“The first time, when I was in the hospital in Boston, they put me on a seizure medicine, but I’m not sure why”, Walter said. “I took it for a few years but when my wife died and I moved up here, I stopped all my medications”.
“Why was that”, I asked.
“I went through a severe depression”, he answered.
“Did they do an EEG, where they put stickies and wires on your head, while you were in Massachusetts General”, I asked.
“No, I never had that done”, he answered.
I told him I’d like to order such a test and he agreed. It may be normal, and if so, I would probably still offer him a trial of seizure medications while we wait for a neurology consultation, which can take many months to get here in Maine.
I will also try to get the records from MGH to see if they made the diagnosis of Todd paresis on just the clinical history the way I am now considering, years later. A diagnosis made, lost and rediscovered?
(Why does this country have such fragmented medical records?)