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Syncope and MRI for interpretation

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My husband has been feeling pretty terrible the for the last year or so, miscellaneous pains and illnesses. He has been having terrible pain at the base of his skull and sinus area, and has "passed out" twice. This past week he had an EEG, and on Saturday an MRI with and without contrast. The hospital said his doctor will probably receive the results on Thursday, but we received a call today from the nurse that his "EMG" and "MRI" were normal. He did not have an EMG, he had an EEG. I am looking at low res images of the MRI, and I can see what appears to be polyps in the sinus area.
I asked the nurse if there were any remarks regarding the polyps, and she said "all that I know is that the MRI was normal. I am wondering what would be deemed as normal? Are polyps and evidence of infection considered normal on an MRI? The right side of his head, behind his ear, is where he has what feels like a constant muscle cramp, and he said when he pushes on it it seems to relieve pressure in his sinuses. The size of that area has physically enlarged over the last year. What could cause this? Failing to mention I have known my husband for over 20 years, and he has never passed out until this year. HIs BP and heart rate during all of his doctor visits have been normal.


Category: Radiologist

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Category: Radiologist
Dr. Rohit Malik is online now

Expert:  Dr. Rohit Malik replied 4 Days.

Hello, Thank you for your consult at DoctorSpring.com and for the detailed history .

By "pased out " I have a few queries

1)Do u mean he was unconscious , then for how long or did he have a transient black out.

2) How big is the swelling behind the right ear?

3) Does he have any cardiac ailment ..Did his 2d Echo show any thrombus or vegetation on the valves . Has he had a carotid doppler to look for atherosclerotic plaques or emboli ??

I have gone through the MRI images which are of reasonable quality. These are my observations

1) Mucosal oedema & polyps noted in the right maxillary sinus arising from the right postero-lateral aspect of the roof.

2) Mucosal oedema leading to partial blockage of both Osteo-meatal units.

3) Significant deviation of the bony nasal septum having angulation & convexity to the left.

Hope this helps, look forward to your follow-up.

Regards


Patient replied :

Unfortunately I was not present when the loss of consciousness occurred. I was advised by his coworkers of both episodes. The first episode occurred a week after he had taken a tumble on a patch of ice. He emailed me at work complaining of severe pain in his right side (serratus anterior muscle). The pain was severe enough that he was becoming sweaty and nauseated. He stood up, began to walk to his supervisor's desk, and collapsed. The ambulance was called, which took him to the nearby ER where they ran a CT scan of his abdomen without contrast. His glucose level was checked, heart rate, and BP by the EMT, but nothing more was done in the ER, no blood tests or even a urinalysis. The CT scan found a cyst on the left kidney. He was released, and followed up with his doctor the following day. At that time he had a CBC, Chem Panel, and CT of the abdomen with contrast.
With the most recent episode I received more exact information from his coworkers. That particular morning before work, he complained of his left hand hurting. The last thing he recalled prior to "passing out" was that he was holding his hand above his head. I asked his coworkers to describe to me what exactly happened, and they said "he did the same thing he did the last time. He took two really deep guttural sounding breaths, which is why we knew to check on him." That was the first time that I had been made aware of his breathing changes prior to the episode. I asked where they found him, and they told me the following: "he was sitting in his chair, his legs stretched out and his body stiff." The EMT did the same thing they did the last time: glucose check, BP, and heart rate. I asked him if he noticed any dizziness prior to the episode, and he did not. I asked if he had any tunneling of his vision, "sparklies", of visual fuzziness, and he had none of those symptoms. He has not had an echo cardiogram, nor a full 12 lead EKG, nor a holter monitor.
We have been told that his CBC, SED rate, ANA, and c-reactive protein were all within normal range. Apparently his EEG was normal as well.
Here is what we do know. The right occipital and mastoid region of his skull is double the size of the left side. The enlargement is palpable and visible, but it does not feel nor appear to be lymph glands, as the enlargement is smooth and consistent, not lumpy. That is why the MRI was performed, and to rule out seizure activity (along with the EEG).
Both episodes occurred shortly after being outside, both days the temps were in the 15-19 degrees Fahrenheit range, and he walks a few blocks from his parking area to where he works. On average he walks around 3+ miles each day (he is asthmatic, so he does not run). So, I don't think the walk caused the issue, but anything is possible.
He had a benign thyroid tumor in 2007, which required the remove of the entire thyroid isthmus to obtain clean non-macrophage pocked margins.
*** WE BOTH VOLUNTEER AT AN ANIMAL SHELTER***. We are regularly exposed to zoonotic illnesses and a wide variety of parasites. I have told the doctor this repeatedly, but he doesn't seem to think the infections, "passing out", or sudden development of kidney cysts could be related. That being said, the infection that he had in his hand several months ago was due to a cat scratch. Apparently, the only report that was received by his doctor regarding the MRI was "Normal". I could clearly see the polyp activity in his sinuses, and inquired about that, and was told there weren't any remarks about his sinuses, just that the radiologist said it was normal. I forgot to mention that he was treated for what was thought to be an ear infection and sinus infection in March, July, and August. So, he has been on several rounds of antibiotics.
The first image is T1 SAG pre-contrast. All of the additional images are post contrast T1 COR.

I have requested that he have an echocardiogram or at least an event monitor to determine whether he is having issues with his heart. He does have a family history of Factor 8, as well as mitral valve prolapse, aneurysm, etc. However, he has not presented with any of the same issues that his family has. Unlike his family members, he has a normal blood pressure, normal heart rate, and normal to slightly elevated cholesterol.

Thank you for your assistance!

Happy holidays,

Anna


Expert:  Dr. Rohit Malik replied 3 Days.

Dear Anna,

Thanks for the detailed history. It really helps to have patients like you, who have an in depth knowledge about the problem. But I must say that unfortunately , your husband seem to have too many co-morbid illnesses at the young age of 37 yrs. My best wishes for his good health. From the history it is apparent that this look more like a non-neurological cause for the syncopy.

I am a Radiologist & my expertise is medical image interpretation & this is my opinion on the new set of attached images , besides the findings I previously mentioned.

1) The right post auricular area where the swelling is , cannot be seen on the attached images.

2)The limted pre & post contrast images of the brain given for opinion, do not show any significant abnormality.

3) There is no evidence of intracranial infection noted ( zoonotic or otherwise)


I request to get a detailed cardiac workup for yr husbands syncopy .

I cannot comment about the origin of the swelling on the right occipital region, not sure if it is related to his present condition .

Hope this helps you further, Please feel free to get back to me with any further queries .

Thanks


Dr. Rohit Malik
Category: Radiologist
Experience: 
Residency, Fellowship: DNB, DMRD, DMRE, Diagnostic Radiology Residency Program, Seth G.S. Medical College & KEM Hospital, 1997 – 2001
 
Medical School: MBBS, Bachelor of Medicine, Bachelor of Surgery (MBBS), Lokmanya TIlak Muncipal Medical College, 1991 – 1997
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