Subtle Post Dive Neurological Symptoms

[CGE925]

Thank you for the update. If you have an opportunity to post after you see the diving medical specialist, we'd be interested to hear what he/she says.

Best regards,
DDM

UPDATE:

I've now had a consult with a local specialist who handles dive medicine cases, both recreational and commercial. After hearing the history, she said it did sound like a small embolism, but used the terms "deserved" and "undeserved". Deserved means I did it to myself through stupidity and newby incompetence, undeserved means my body did it to me and we have to find out why. She then sent me for the first test, a chest CT. Less than an hour after I left the CT lab, they had contacted her and she was on the phone to me, ordering me to the Emergency Room of my choice; the CT had disclosed a probable clot in the LH Innominate vein and extending into the Superior Vena Cava. After a full day in the ER, I am now under the care and direction of both the hospital's Thrombosis/Anticoagulation unit for the clot, and Neurology for the original stroke/brain issue. I'm now stabbing myself in the stomach for the next few days with Lovenox and taking Coumedin for the next three months to deal with the clot. The Neurology folks are scheduling me for a neck (doppler I assume?) and an Echocardiogram to see if they can figure out why the original accident happened in the first place. As they point out, lots of people have heart defects and don't know it. I get the feeling they don't seem to think that the clot in the neck/shoulder area leading into the heart is related to the brain fade, and no-one currently knows how old the clot is. They also don't think that my THA/hip replacement a few years ago would contribute to a clot in that area. The chest CT had also NOT shown any blebs, but did show what they referred to as "airway disease" at the base of both lungs. Interesting, given that my lungs feel otherwise very good and I've never smoked in my life. As a lifelong hobby furniture builder, I AM notorius for not wearing a mask and have inhaled tons of dust over the years.

Re the clot going into the heart, one of the thrombosis team asked, given the proximity of the clot to the left upper chest and shoulder, did I ever carry a lot of weight on my shoulders? I therefore assume she's never carried scuba gear. I dove a fair bit last year and dove pretty heavily loaded a few times, experimenting with a DUI weight harness which transmits the ballast weight from the waist belt to the shoulders. Could there be any connection, could 70 or 80 lbs on the shoulders be the cause of a clot in that location?

More to come. I'm now fearing for my dive life based on all this, though if I'm grounded, my wife, at least, will breath a sigh of relief. She's actually doubly happy, since I'm on blood thinners for a while, I also can't go near power tools either ;o(

 

[Duke Dive Medicine]

Whoa. Good thing they caught that (said obvious guy). See the link below for an interesting article on the pathogenesis of brachocephalic (aka innominate) vein thrombosis.

Upper-Extremity Deep Vein Thrombosis

Best regards,
DDM

 

[TSandM]

Yipes! Sounds as though, no matter the end of this story, having the post-dive symptoms prompt you into a work up was a good thing.

 

[flots am]

Re the clot going into the heart, one of the thrombosis team asked, given the proximity of the clot to the left upper chest and shoulder, did I ever carry a lot of weight on my shoulders? I therefore assume she's never carried scuba gear. I dove a fair bit last year and dove pretty heavily loaded a few times, experimenting with a DUI weight harness which transmits the ballast weight from the waist belt to the shoulders. Could there be any connection, could 70 or 80 lbs on the shoulders be the cause of a clot in that location?

(bold mine)

Any docs want to comment?

Is this an actual thing, or is it like when all the news reports list "oxygen tanks"?

flots

 

[Duke Dive Medicine]

Hi Flots,

Did you read the article?

Best regards,
DDM

 

[CGE925]

Whoa. Good thing they caught that (said obvious guy). See the link below for an interesting article on the pathogenesis of brachocephalic (aka innominate) vein thrombosis.

Upper-Extremity Deep Vein Thrombosis

Best regards,
DDM

Reading the article on UEDVT, and the reference to Paget-Schroetter Syndrome made me remember a recent episode of EXTREME heavy lifting that I endured, that makes carrying a 60 lb BPW and tank a complete non-event. I also completely forgot to mention it to the thrombosis team at the hospital last week, but I will tomorrow when go go back to get my INR number confirmed.

A few months ago, I had managed to work myself into a position of having to manhandle a 350 lb machine tool into my home workshop, including getting up and down two flight of stairs, all by myself. I was absolutely at the limit of my physical strength and was completely knackered at the end, though I don't recall any specific acute pains at the time, just some very sore muscles in the upper body. I do know that I have never lifted like that in my life. I wonder if such a clot, which seems to be only a partial blockage of the brachiocephalic vein, could have been there for a few months. And this lifting episode was just a few weeks prior to the diving incident/brain fade.

 

[flots am]

Hi Flots,

Did you read the article?

I did, but it referred to young athletes " . . . usually in their dominant arm, after strenuous activity such as rowing, wrestling, weight lifting, or baseball pitching, but are otherwise young and healthy", not middle age guys who carry gear up a ladder now and then.

flots.

 

[Duke Dive Medicine]

I did, but it referred to young athletes " . . . usually in their dominant arm, after strenuous activity such as rowing, wrestling, weight lifting, or baseball pitching, but are otherwise young and healthy", not middle age guys who carry gear up a ladder now and then.

flots.

This is the part I was talking about: "Significant thrombosis may occur with repeated insults to the vein wall, especially if mechanical compression of the vessel is also present.⁵ "

The reference talks about a case report of a woman who had a recurrence of thrombosis after carrying a shopping bag.

Best regards,
DDM

 

[DocVikingo]

Neurology folks are scheduling me for a neck (doppler I assume?) and an Echocardiogram to see if they can figure out why the original accident happened in the first place.

Hi CGE925,

The safest, least expensive, easiest and generally most frequently preferred technique for imaging the carotids is duplex ultrasonography, a procedure that combines traditional with Doppler ultrasound. The former uses sound waves that bounce off blood vessels to create pictures. The latter records sound waves reflecting off moving objects, such as blood, and measures their speed and direction. Under certain circumstances, CT, MRI or direct angiography may be applied.

Your echocardiogram will most likely, and hopefully, be a transesophageal echocardiogram (TEE) with saline contrast.

Best of luck.

DocVikingo

 

[CGE925]

Hi CGE925,

The safest, least expensive, easiest and generally most frequently preferred technique for imaging the carotids is duplex ultrasonography, a procedure that combines traditional with Doppler ultrasound. The former uses sound waves that bounce off blood vessels to create pictures. The latter records sound waves reflecting off moving objects, such as blood, and measures their speed and direction. Under certain circumstances, CT, MRI or direct angiography may be applied.

Your echocardiogram will most likely, and hopefully, be a transesophageal echocardiogram (TEE) with saline contrast.

Best of luck.

DocVikingo

You hit it right on the head, Doc. The two next tests in the planned intervention were the stated Neck Doppler, and what I believe was referred as a "bubble" echocardiogram, which I believe uses a saline solution infused with tiny bubbles as the contrast agent. Not sure if it will be transesophageal. I did have the neck done yesterday, still waiting on the echogardiogram. The senior neurologist who is taking my case was on hand for the entire ultrasound test. RH showed some plaque, and an abnormality of the topology of the neck veins and arteries under the jaw (to use my own terminology as a former engineer and mathematician ;o). Lots of abnormal crossovers and strange routings of the blue and red flows which took them a while to sort out, but they seemed happy with the flow rate. LH, more problematic. I had surgery and radiation 15 years ago to kill off a Mucoepidermoid carcinoma on the deep lobe of the left parotid gland. Totally successful treatment, but but it left me with permanent stiffness, soreness and radiation burns in the entire LH jaw and neck area. The Doppler showed, in addition to the usual plaque, a complete blockage of one of the major vessels on the left side posterior/towards the back. Concerning, but the neurologist was satisfied that the Coumadin I'm (hopefully) temporarily taking will address that the same time it resolves the clot into the superior vena cava.

On a brighter note, he also reviewed my brain MRI for the first time. He instantly found the small lesion on the occipital lobe, which explains the vision issues during the original dive event, but he considered the lesion quite minor. Through it all, I'm still not sure if this issue is getting resolved, I guess I'll have to wait until all the pieces are put together by the neurologist and the thrombosis team to sort out whether this was a one-time event or is more long-term and dive-life ending. Why I had the mini-stroke in the first place is still a mystery.