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Welcome to the neuro transmitters, a podcast about everything neurology with the goal of reducing your neur a phobia. I'm your host, Dr Michael Ken Trees. And today we are joined by a special guest doctor Right Zhangke Jaw. Hello everyone. Doctor Jaw. Thank you for coming on. We had an interesting case a little while back and I know one of the things we've talked about on the show before is talking about some case reports. So if you would do us the honors of kind of leading us into it and walking us through this case. Absolutely, Doctor Kendra's. Well, first of all, thank you for having me on this podcast. I am a PDY two resident Internal Medicine and I have had the opportunity of seeing some pretty interesting cases with Dr Kendricks here. So the case I'm going to be discussing uh about he is very healthy and he presents with a near syncopal event and this is followed by period of memory loss. So our patient turns out that he is an endurance runner and he had recently started following this youtube group called Wim Hof. And he follows this uh this technique called us the Wim Hof method, which is, which are these techniques to increase the body's wiggle tone. So the story is that the night before admission, he developed pickups like one does. Um, he tried several maneuvers including holding his breath that are very similar to like a Valsalva technique if you will. And right after that, he had a near syncopal event, he dropped to his knee. Um he did not really come back up pretty quickly. So he ended up calling his wife to get the EMS. He went to the er and at this point, um the primary concern was ruling out a stroke. Now, the imaging findings, uh the CT Scan MRI S were actually negative for any kind of stroke. However, there was a certain development in the patient's symptomology for the next 12 hours after being admitted, he kept asking repetitively questions including when did you arrive or did I do something wrong? After receiving the answer to the same, he would repeat those questions back in the next hour or so. His family was pretty worried, they thought that he was having some kind of memory loss. The pattern that we're seeing is a uh the pattern of an anterograde memory loss. This went on for about 12 hours after which the patient did recover and went back to his normal mental state. Now, the last 12 hours, he did not recall much of what was happening. All the questions he was asking and it was only kind of told to us or reiterated by his wife and some of his family members. Now, the the imaging findings were pretty interesting, especially the CT perfusion images. They did show that there was a small area with a T max of more than six seconds which shows an area of hyperperfusion which was kind of located in the left temporal region. There was also an area with less than 30% CBF that relates to lie an ischemic court and the penumbra was calculated to be about eight CCS. Now, the location is in the left temporal region pretty close to where we consider the hippocampus to be this patient. Basically, I'm going to be presenting this case at several different places and I call it hiccups in a 12 hour long memory black hole. Uh because because the last 12 hours, we're pretty much a black hole in his memory that he recalled. Nothing of the imaging findings were pretty consistent with what we see in transient global amnesia. And uh that's pretty much what our case was. Yeah, clinically, uh his symptoms fits pretty well. And you know, fortunately on the MRI, there was no evidence of ischemic stroke correct is good, especially in uh man as young as he was. Yeah, so tell us a little bit more about transient global amnesia if you'd be so kind. So transient global amnesia, it's a reversible condition which is, which is pretty interesting. Usually the patient's will have a period of anterograde amnesia. Um And the inciting factors are sometimes hyperperfusion, sometimes the low BP, valsalva maneuvers. Um The path of physiology behind it, there have been multiple different etiologies that's been considered, but none really conformed. So far, we have considered arterial is scheme. IA'S, we've considered venous insufficiencies even like a migrainous or epileptiform folk. I but none of them really have been proven to be the cause behind it. The important thing is the patient uh still remains oriented to sell. And after the end of this, usually 12 to 24 hour period, they go back to their complete mental state without any uh change in their orientation or uh any neurological function. Their neurological exam is usually completely normal. And I think that that point with remaining oriented itself is important because that is actually something that we'll see sometimes in functional or psychologic disorders where you have that uh loss of autobiographical data, right? But our patient was, you know, he completely fit the picture in that he knew who he was. But these questions kind of kept coming back um within this 12 hour period. So tell us a little bit more about this profusion study. I know you mentioned things like penumbra, right, which we typically, you know, I am a big linguistic fan but uh basically referring like Umbra, the shadow. So kind of the shadow of the stroke is how I think of it. Absolutely. I love that. I love that correlation. Um Usually we use these terms um to understand stroke, uh let's say ski mix strokes. So when we're looking at the blood flow, we calculate an area of uh we know there's something called the cerebral blood flow. So an area that's getting less than 30% of the usual cerebral blood flow. That is an area that we kind of correlate with a court infarct. Another term we use is T max um uh T max of more than six seconds. So the area that corresponds to that usually means an area of hyperperfusion. Now, you got these two areas which is the total hyperperfusion area and a court infarct, which is within it. So basically, if I subtracted one from the other, the remaining area is going to be the pin number, right? And that's kind of what some of these um these AI protocols are based off of is calculating this information, making it readily available to clinicians like in an acute ischemic stroke and that sort of situation. Right. Absolutely. Because that's what is important for us to know because the penumbra is your area that's salvageable. And we want to know the court, in fact, because that's your non salvageable area, right? And not necessarily related to this case. But, you know, there as uh Praveen and I've mentioned previously on one of these recordings, there may be that trend towards tailoring you moving more away from like a strict time limit and more towards a imaging functional capacity type of paradigm for acute stroke. But for this guy, so you mentioned whim the Wim Hof method, which I I had encountered actually uh a couple of years ago in my research on seizures as there were some reports. But tell me what you learned when you're researching this case about, about Wim Hof and the Wim Hof method. Well, the Wim Hoff, the person, it sounds like very interesting person. Um He has a very big following. He is a youtube grew. He has these techniques which include cold immersion techniques as well as wiggle maneuvers and his ideologies. A is that by increasing your body's wiggle pone, you'll live a better healthier life and they kind of use the term superhuman quite often. Yeah, like I'll include some links in the show notes, but there are some, there's very interesting documentary showing him and some of his followers hiking through like mountain passes in their underwear and swimming through frozen rivers. Quite remarkable feats of endurance. Oh, absolutely. I'm pretty sure Wim Hof himself has set many world records. Yeah. In one of those feats, right? I don't remember. I think it was swam. Uh Somebody of water. I can't recall exactly what it is. I'm afraid. Hey, everybody, Michael from the future here. Uh Wim Hof actually has multiple previous world records related to uh swimming under ice uh times with half marathons, barefoot on ice and snow, uh Climbing Mount Everest, wearing nothing but shorts and shoes to a height of 7400 m. So essentially multiple events related to his ability to endure uh extreme temperatures. But it kind of is interesting because, you know, we do know that the increased vagal tone could theoretically put you at more risk for transmitting global amnesia. Uh Like I, I've had patient's who have had it after, you know, have you been constipated and straining or even people uh after Coitus have had an episode which as you can imagine for their partner was quite unnerving. Um I have a feeling there are case reports on this. Yeah, I mean, there are, that's out there. But yeah, I hadn't encountered this particular breathing technique as, as a potential precipitant. So I thought it was kind of just a little interesting story. Yeah, when we began our conversation um with the patient, the story about the hiccups happened much later. And then he told us about all these techniques that he's used to doing and that took us to Wim Hof method, which the patient was very enthusiastic about and that kind of he'd been going after it pretty, pretty aggressively in terms of his training outside of even the Wim Hof, like you mentioned earlier, the endurance running physical training, very fit individual. Yeah. So after we've made this diagnosis in an individual, right, we have this sort of repetitive goldfish as a type of memory episode, we don't find any evidence of seizures or stroke on MRI. How do we, how do we typically manage these folks? So um the management is pretty straightforward because you do consider this as if not a stroke, there is some imaging evidence of uh low blood flow or hyperperfusion. You don't want these episodes to repeat and you would usually send these patient's with the baby aspirin. So 81 mg of aspirin taken daily and of course, with advice about not to over or do the techniques, the vasovagal maneuvers because if he continues to do them, there is a possibility of repeat, right? So there are some case series showing uh a small percentage of these patient's can have recurrence, although it's typically thought to be kind of a one and done type situation. And that is, that's an excellent point is that if we're having recurrent episodes of quote unquote TG A, then it really should make you question if you have the right diagnosis to begin with, you know, maybe there were seizures that weren't captured. We know the routine eg sensitivity is only about 50% give or take. So, so yeah, always got to make sure you don't anchor to your initial diagnosis too hard if the clinical picture evolves and doesn't really bear up to scrutiny down the road. So rich hockey, where can people find you online? And do you have anything that you would like to plug today. Oh, absolutely. Thank you for the opportunity. Um Well, I am on Twitter. Uh and my Twitter ID is at Rush Yankee underscore J that's Rishank, I underscore JJ as in judge and we'll, we'll include that uh Lincoln and Notes there. Thank you. And yes, I do have a book that I wrote a couple of years back. One of my interests is poetry. Uh and this was way back when I had just finished medical school. Um and I did do my medical school in India. So that was right after that. Um And the book is called uh Modern Miseries and My Bottle of cough syrup. So if you're interested in poetry, it's available on Amazon as well as Barton Noble. Very excellent. Who is your favorite poet? Oh my God, that is so difficult. It's like asking a mother to choose between his Children. She can't do that fair enough. Well, Doctor John, thank you again for coming on. I appreciate you taking the time to discuss this interesting case with us and hopefully our listeners also found it interesting. Well, thank you so much, Doctor Ken Trees for having me. It was a really great experience. I'm glad to hear that. If you enjoyed this podcast, please don't hesitate to leave us a five star review on Apple itunes, Spotify or wherever you get your podcast and please subscribe and share for future episodes. You can also reach me on Twitter at Doctor Ken Trees. That's drkentris or by email at the Neuro transmitters podcast at gmail dot com. See you all next time.