Subtle Post Dive Neurological Symptoms

[DocVikingo]

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.

Hi CGE925,

Yes, yours is turning out to be a relatively complex case and patience is an excellent rx while the various specialties gather and sort out the findings and plan and monitor tx. On the bright side, it does sound like you have appropriate and interested experts involved and that matters are off to a good start.

As to why you had the mini-stroke in the first place, the description of study results thus far indicates the possibility of anastomosis, tortuosity, stenosis, and varying degrees of plaque formation within the greater carotid arterial system. This is a picture of an anatomically fertile field for the formation and trapping of emboli that can obstruct vessels that deliver blood to the head and brain.

Best of luck and please keep us posted.

DocV

 

[CGE925]

Hi CGE925,

Yes, yours is turning out to be a relatively complex case and patience is an excellent rx while the various specialties gather and sort out the findings and plan and monitor tx. On the bright side, it does sound like you have appropriate and interested experts involved and that matters are off to a good start.

As to why you had the mini-stroke in the first place, the description of study results thus far indicates the possibility of anastomosis, tortuosity, stenosis, and varying degrees of plaque formation within the greater carotid arterial system. This is a picture of an anatomically fertile field for the formation and trapping of emboli that can obstruct vessels that deliver blood to the head and brain.

Best of luck and please keep us posted.

DocV

Given what I well remember about the actual 45 minutes underwater, it was a very easy dive, and I've never really thought that a high ascent rate and gas bubble were to blame for the mini-stroke. Based on what they are finding with the various tests so far, I guess a physical blockage from a blood clot or plaque would be a better alternative. I can't wait for the Echocardiogram, hopefully a PFO is not in play.

If a clot was somehow dislodged from somewhere between the upper chest and neck, how long would it take for it make its way upwards into the lower aft area of the brain in the Occipital lobe, and manifest it's arrival with those mild symptoms? I'd say that between the time I hit the surface, contorted myself into a pretzel to remove the gear, climbed the ladder, removed the BP/W and tank, and then noticed the symptoms, was probably 3-5 minutes, if that. Could the stroke have happened that quickly and originated on the surface? There was nothing remotely strenuous about the dive before that point.

Thanks very much to everyone for all the feedback, it's very much appreciated

 

[DocVikingo]

If a clot was somehow dislodged from somewhere between the upper chest and neck, how long would it take for it make its way upwards into the lower aft area of the brain in the Occipital lobe, and manifest it's arrival with those mild symptoms? I'd say that between the time I hit the surface, contorted myself into a pretzel to remove the gear, climbed the ladder, removed the BP/W and tank, and then noticed the symptoms, was probably 3-5 minutes, if that. Could the stroke have happened that quickly and originated on the surface? There was nothing remotely strenuous about the dive before that point.

Hey CGE925,

Assuming that your sxs were the result of a thromboembolic event, that event may or may not have been influenced by dive or immediately post-dive related factors. It may just have been time for it to occur--it could have happened topside while you were kicking back sipping a cold one. At any rate, in the absence of discovery of a PFO I’m quite skeptical that any of your treating sources will ever be able to establish a really plausible causal link between your dive and your complaints.

Cheers,

DocV

 

[TSandM]

The transit time between the clot in the vein and your brain could be anywhere from a few seconds to a minute or two, depending on the flow rate through the particular vessels involved.

This is a much more complicated situation than it looked like at first, with the anatomic abnormalities, the radiation history, and the venous thrombosis. But I suspect, in the end, that none of it will have much to do with diving.

 

[CGE925]

The transit time between the clot in the vein and your brain could be anywhere from a few seconds to a minute or two, depending on the flow rate through the particular vessels involved.

This is a much more complicated situation than it looked like at first, with the anatomic abnormalities, the radiation history, and the venous thrombosis. But I suspect, in the end, that none of it will have much to do with diving.

My major concern (aside from resolving the fundamental health issue, of course) is that a physician somewhere will say "Since we don't where this originated from, diving is prohibited". But then, if diving is prohibited, presumably so would a host of other physical activities as well.

I'll just ride this out and see what transpires after the Echocardiogram and the findings of the Neurologists and Thrombosis team are available. At least I still have a few months before the ice melts ;o)

 

[CGE925]

The transit time between the clot in the vein and your brain could be anywhere from a few seconds to a minute or two, depending on the flow rate through the particular vessels involved.

This is a much more complicated situation than it looked like at first, with the anatomic abnormalities, the radiation history, and the venous thrombosis. But I suspect, in the end, that none of it will have much to do with diving.

It's proving to be quite a challenging and complicated case all right. Five months in and the ongoing testing, not to mention the delays between the tests, is almost certainly going to cost me the 2015 dive season.

I'm being handled by two different specialties, thrombosis and neurology, and neither is sure of the initial cause of the TIA, despite a battery of tests. As has been stated before, we'll probably never know. A CT in March showed a clot poised at the entry to the superior Vena Cava. 4 months of Coumadin, and the followup CT a few weeks ago showed the clot had disappeared. An external Echo showed a normal heart with no obvious problems and no PFOs. A 24 hour Holter showed perfectly normal heart rhythms, no SVCs or stoppages, etc. However...

The diligent Cardiologist, who handled the initial Echo, learned that this started out as a diving incident, and decided, despite the normal external Echo, to order a followup TEE, and that's when my excellent progress back into diving ground to a halt. The TEE, while still showing no PFOs, did suggest a thickening of a wall inside the heart. The Neurologists' referral note states "...still unclear if clot in LV" When I met with the Neurologist and he dropped this bomb on me, I didn't have the presence of mind to ask him why the two CTs showed that the clot entering the superior VC had resolved, and so why wouldn't the same before and after CTs have shown a clot in the left Ventricle also resolving. The last "all is clear" CT and the TEE suggesting an LV clot were only two weeks apart. Another of the tests the Thrombologist conducted on me determined that I had no blood conditions predisposing me to clotting, so I can't imagine a clot inside the heart happened so quickly. Is it the case that a clot inside the heart is not visible on a CT, when a clot in the superior Vena Cava is visible?

Interestingly, when I first learned of the original clot, I asked the Thrombologist whether I should take it easy and refrain from serious exercise. Silly me, I wondered whether increased cardiac activity could cause the clot to become dislodged and enter into the heart. I was surprised when she said no, you can exercise all you want. I have been VERY active this summer and have had the heart working in overdrive many times. Given I have no holes in the heart and no arrhythmias, I really have to wonder why can't I dive when I can abuse my body on land.

The referral with the Cardiologist who will review the TEE results in detail and decide on this mysterious ventricular artifact won't happen for a few months, so I will be well into the fall before I get closure. If she orders an MRI, it will be next year.

Keeping my fingers crossed...

 

[CGE925]

Hi CGE925,

Yes, yours is turning out to be a relatively complex case and patience is an excellent rx while the various specialties gather and sort out the findings and plan and monitor tx. On the bright side, it does sound like you have appropriate and interested experts involved and that matters are off to a good start.

As to why you had the mini-stroke in the first place, the description of study results thus far indicates the possibility of anastomosis, tortuosity, stenosis, and varying degrees of plaque formation within the greater carotid arterial system. This is a picture of an anatomically fertile field for the formation and trapping of emboli that can obstruct vessels that deliver blood to the head and brain.

Best of luck and please keep us posted.

DocV

It's now early November, and we seem to be entering the end game, to use the chess analogy. I'm not optimistic. Summary so far: Mid-50s male in reasonable shape had a very mild TIA/mini-stroke about 2 minutes after leaving the water from a simple ocean dive. Depths and duration were well short of any NDL. Surfacing, I had a lot of trouble contorting and twisting to remove my fins in the moderately choppy surf, and probably hyper-extended my upper body and neck. Two minutes after climbing the ladder, I noticed a definite brain "fuzziness" and very minor vision issues (double vision and reduced field of view on one side) Symptoms were quite gentle and had completely disappeared a few hours later. No other symptoms whatsoever, and no-one on the boat was aware of my situation as I appeared and acted perfectly normal. MRI revealed two small lesions in the LH Occipital and Parietal lobes, and a clot entering the Superior Vena Cava was observed via CT. Three months on Coumadin completely resolved the clot. This clot is probably unrelated to the dive as it probably happened as the result of a few hours of dangerously heavy lifting I engaged in AFTER the dive but before the CT. I am on low dose ASA permanently, and off Coumadin. I had both a TTE and a TEE, and both echos showed no heart issues at all, valves fine and no PFOs. A 24 hour Holter was also perfectly fine. Blood tests to check for blood disorders pre-disposing me to clotting were also completely negative. The only problem was a neck Doppler, which showed some tortuous vasculature on the RH side, with slight plaque blockage, and moderate plaque blockage of the vertebral artery on the LHS. Enough for concern and monitoring, but not enough to warrant surgical intervention. So far, the only treatment has been a doubling of my Crestor dose, and my cholesterol levels are smack in the middle of the normal range. I am to have another neck Doppler in a few months to see how my arteries are doing.

My problem is that the dive doctor handling my case seems reluctant to help me find a way to get back diving. Her words to me, after all these tests, were "We don't know exactly what caused this, so you shouldn't dive any more". I have not been told that I am under any other physical restrictions, and could theoretically go and play rugby right now if I wanted to, but I can't dive. I fully understand that the true cause of my TIA won't ever be known, but are there any other tests I can ask for that would help narrow the lists of possible causes, and are there any other treatments for a "plaque-y" neck artery that I can ask for. I am nowhere near blocked up enough for an endarterectomy, and I have to admit I don't know enough about hyperbaric medicine to understand why diving is so dangerous to me, but other physical activities with potentially even more adverse effects on the body are not. She is planning to discuss my case with a noted Cardiologist with tremendous dive medicine experience in the coming weeks, but I am not optimistic. Needless to say, I VERY much want to get back diving, and if she can't help, my next step may be to go for a second opinion and try to find someone who is prepared to dig deeper.

I fully realize that since the cause of my TIA will remain indeterminate, diving would always be at risk. I am certainly prepared to assume some reasonable risk

Thoughts, comments and suggestions for possible ways forward would be greatly appreciated.

 

[Duke Dive Medicine]

In the absence of any explanation for your transient dizzy spells, neurological changes and venous thrombosis, the diving physician's hesitance is understandable. You said the 24-hour Holter monitor didn't show anything. Did you experience any dizzy spells while you were wearing it?

Best regards,
DDM

 

[CGE925]

In the absence of any explanation for your transient dizzy spells, neurological changes and venous thrombosis, the diving physician's hesitance is understandable. You said the 24-hour Holter monitor didn't show anything. Did you experience any dizzy spells while you were wearing it?

Best regards,
DDM

As luck would have it, I did actually experience one of those episodes while wearing the Holter. The timing was impeccable, as I hadn't had one in months. I assume that the cardiologist who reviewed the record believed it to be unimportant, unless he missed it completely, as he made no mention of it in his report.

Channeling Conan Doyle here: Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth. Surely there must be other tests which I can ask for which would eliminate at least some of the possible causes. Given my gunked-up neck arteries, would an angiogram be useful, for example? I guess I'm taking the overly simplistic attitude that there must be only a small number of possible causes tor that event, and that there must be ways to narrow down the list and eliminate some of them.

 

[Jax]

UPDATE:
<snipped>

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.

Any chance you were assigned to the Middle East for a while?



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