Dr. Aida Abaz Quka
Neurology
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Patient's Query
Hello doctor,
I keep having episodes of presyncope. I have been to the local emergency room (ER) four times and was admitted on the last time. During the course of those four visits, I had all my basic blood work done which came out normal. I had a computed tomography (CT) scan without contrast that was normal. An ultrasound of my carotid arteries that was normal, we checked for historic hypotension and the test did not show anything abnormal, and I was cleared by a cardiologist. So, it is not cardiac related. I was released from the hospital saying everything looked fine and was told to follow up with a neurologist. My question is, from a neurological standpoint, what neurological things could be causing my pre-syncopal episodes? Again CT scan without contrast was normal and I had a basic neurological exam from a regular doctor that said everything was fine. What could it be? I do not believe I am having seizures.
Hello,
Welcome to icliniq.com. I read carefully your question and would explain that your symptoms could be related to different possible causes: A metabolic disorder. Vasovagal syncope. Cardiac arrhythmia. Seizures may mimic this symptomatology too. Coming to this point, I would recommend performingfurther tests to investigate the possible causes: 1. An electrocardiogram (ECG) 24 to 48 hours Holter monitoring to investigate for cardiac arrhythmia. 2. An electroencephalography (EEG). 3. A head-up tilt test for vasovagal syncope. 4. Thyroid hormone levels for possible thyroid dysfunction. 5. Glucose tolerance test.
Patient's Query
Hello doctor,
Thanks for the answer. So, I have already had all the metabolic causes ruled out. My thyroid and everything is normal. Tilt table came back normal and I am not dehydrated or anything. All the tests have come back normal so far. I have also already been placed on a Holter monitor and had an echo of my heart that came out normal. The cardiologist said it is not cardiac related. What neurological causes besides seizures can cause this?
Hello,
Welcome back to icliniq.com. Thank you for the additional information. Considering all your performed tests, there are just a few disorders to consider: Seizures. Panic attacks. An inner ear disorder. Coming to this point, I would recommendperforming an EEG (possibly during sleep) and consulting with an ENT specialist. Performing labyrinthine tests is also necessary to exclude an inner ear disorder. I would also recommend checking cortisol plasma levels for possible adrenal gland dysfunction. Meanwhile, I would recommend you tomonitor your blood pressure values and heart rate during those episodes. You should discuss with your doctor on the above tests. If you have any other questions, please do not hesitate to ask me again.
Patient's Query
Thank you doctor,
Here are my follow up questions to your answer. During these episodes, my blood pressure is normal or slightly elevated, but never low. Would it not be low if I was going to faint? Is it possible that I could have a vascular problem in the brain causing ischemia or would that cause different symptoms? My computed tomography (CT) scan w/o contrast came back normal. I also had an ultrasound of my carotid artery but not my vertebral artery in the back of my neck. My main worry is some kind of vascular issue. Besides seizures, are there no other neurological disorders that could cause near syncopal episodes like I am feeling? Keep in mind I have no other neurological symptoms. My only symptoms are feeling like I am going to faint. (Breaking out in a sweat, dizzy, faint feeling).
Hello,
Welcome back to icliniq.com. Normal blood pressure during these episodes excludes orthostatic hypotension or low blood pressure as possible causes. But it does not exclude seizures or an inner ear disorder. Low fasting glucose or anxiety cannot be excluded either. I would exclude any vascular disorders related to this clinical situation as you had a brain computed tomography (CT) scan and a Doppler ultrasound. Anyway, a brain magnetic resonance imaging (MRI) and angio MRI (with gadolinium enhancement) of the brain would help to definitely exclude any vascular disorders (and also examine the blood flow in the vertebral arteries and in the small arteries inside the brain). You should discuss with your doctor on this test. There are no neurological disorders, besides possible seizures and vertebrobasilar insufficiency (which can be excluded by performing a brain angio CT scan or angio MRI). A vasovagal syncope has been excluded, considering the normal head up tilt test. If all these tests result normal (ENT consult, angio MRI of the brain), you should consider panic attacks as a possible cause of your complaints. Hope to have clarified some of your uncertainties.
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