Transient Global Amnesia
In my Family Practice, once in a while, I would hear an interesting story related to a transient, hours-long episode of confusion and memory loss. The usual questions related to drugs and alcohol were always answered in the negative. In fact, these patients (there were not many over the 40 odd years) tended to be elderly but healthy people. I liked the diagnosis given for this syndrome because it has no downstream implications, unlike having a stroke, a tia, or angina. Until recently, I was not aware of any obvious risk factors for the diagnosis raised in these circumstances, Transient Global Amnesia (TGA).
I offer a hypothesis regarding a possible cause for this condition — vigorous exercise. The book, Breath suggests the possibility and the anecdotal stories that flow when one tells of this experience have a common thread as it relates to exercise. What follows is my story and experience with TGA and for desert, Kernie’s experience with a TIA.
I have studied aging; my 60,000 foot view on aging gracefully finds exercise as the most important focus or advice I give to those who want to be long-lived. As one gets closer to earth, there are other important things such as a good diet, keeping your mind active, have a good social network, having a loving spouse, moderating excesses, even having a dog……..but exercise is key. When we stop walking and moving through space, there are feedback cycles in our biology that lead to senescence, which is to say, deterioration.
Since my middle and late middle years I exercised regularly and with discipline. I dabbled with weights but my workout has been primarily walking and biking. I am competitive and at times, this causes lapses in judgement: I tried the exercise of jumping on and off a two foot high platform as many times as possible in 60 seconds (something I was really good at when I was 18) and damaged my left knee cartilage. I pushed for a bench press I had achieved ten years before, and strained a shoulder. I tried to run a six minute mile in my early 50’s and on the third lap (on track to my target) I felt my left achilles tendon cry out with determination that I stop. I did and limped for six weeks.
In the Fall of 2017, just five months from retirement at age 66, I had a week with Kernie in Mexico which was usually associated with daily aerobic exercise. This trip, I played beach volleyball and injured myself, gimping around on an arthritic knee which rendered my exercise anemic: modified yoga poses and “swimming”.
For me, swimming is not exercise—I don’t really know how to swim; I just know how to avoid drowning.
Back in the saddle at work, I was playing catch-up. When one is gone a week, things pile up and the first few days are busy: when not actually seeing patients, there are tests and correspondence from the week before. I had just such a day and came home with all the morning medical records needing to be completed. I needed a breather and my sense of exercise debt found me driving to the local LA Fitness where I went to the exercise cycle room. I had not ridden the stationary bike for almost two weeks. I plugged in my custom 60’s exercise play list. I pounded out an amazing half hour of aerobic exercise: The bike tracks the energy expended and in half an hour, I went into overdrive, generating an average reading of almost 200 Watts.
I remember the session, mostly, but things get very fuzzy as I left the gym. I went to the car, had a general sense that, “things were off.” My memory is not specific in this time-frame, but I have impressions that while knowing I was not quite right, I could safely drive, turn, brake, and guide myself home. I had no pain, dizziness, or loss of strength.
I parked the car, walked into the living room and met Kernie. Most of the following history is recounted from her point of view because I retain just a few glimpses of what happened over the next few hours.
“Well,” says Kernie, “You looked me in the eye and said, ‘Something is very wrong.’ When I asked what happened, you could not give a clear answer; you knew you were at the gym. I asked if you remembered to go to the store. You did not remember not only that task, but did not think you had made it to the store. Now I was paying attention.”
She asked if I had gone to work; I was not sure. At this point, she said, “I think we should go to Urgent Care; I am going to call Britt.” Britt is a good friend and long-term colleague; she explained my situation and he recommended we come right in.
I said, “no problem.” That is when Kernie knew we were in trouble. I would do anything to avoid going to urgent care or the emergency room. In the car, Britt called and told us to go straight to the Emergency Room; the stroke protocol would guarantee a timely workup. As we drove, Kernie attempted a cranial nerve examination; I looked at her, moved my eyes in different directions, raised my eyebrows, stuck my tongue out…….
The Emergency Room was everything I hate about modern American Medicine; the lobby was full of people who did not look very sick. There was no sense of urgency. Kernie assertively jumped ahead of the line: “My husband is here and Dr. Smith called ahead; my husband may be having a stroke.” The clerk looked down the line at me, seemed nonplussed, but picked up the phone and called someone. We were asked to sit. A male nurse came and got a few details and we were asked to wait. Despite my confusion, I was a little irritated that Kernie would jump the line so even with memory in question, my normal temperament remained on line.
Amber, my daughter, a nurse practitioner who works across the street came over. The three of us chatted amiably. I have a vague sense of appreciating their non verbal communications: glances and facial expressions.
We came to a bay in the ER and I sat on the gurney. I saw nurses, a resident, and the ER doctor. Kernie relates that I was quiet, passive, and used language that was childish and not in my usual vocabulary. Each doctor that saw me seemed to get pieces of the history and exam but it never felt comprehensive. The resident focussed on the motor exam. The ER doc seemed to refer to her notes and added on some of the Mini Mental Status Exam. In those days, I administered this exam typically three times a week. I had the advantage like the optometrist who is asked to read the eye chart which was memorized years before. I did struggle. I remember just giving up when asked to spell WORLD backwards. I tried two or three times, with hesitation and after the third time simply said, “I can’t.” More looks from daughter and wife that were unmistakeable and felt.
Lab and Xrays were completed over the next few hours and I was feeling more and more normal. The conclusion now that a stroke had been ruled out was that I had experienced transient global amnesia. I was oriented enough to see that a this fit and was a victory of sorts—no harm, no foul, no stroke.
I went home and spoke with Britt. I got on line and completed ten chart notes that were in need of completion. In each case, my notes found me recalling the interaction and I was able to summarize and bless each note with confidence.
My follow up was to be with a neurologist; a precursor to that visit was an MRI, my first. The horror stories about claustrophobia attached to the test were over-rated and my only complaint with the testing was the position of my throat was such that swallowing was difficult and only relieved by flexing my neck which was forbidden. I managed the test without aspirating spit.
The results of the test showed swelling (reflecting a “soft” injury, like bruising in the skin) in the left hippocampus which is the brain’s center for organizing and storing memory. I had no idea this test could be done to confirm the diagnosis. I had my visit with the neurologist six weeks after the event and knew the results of the MRI. He and I knew the conclusion and I was confident about the visit as I felt extremely functional in those weeks having returned to work and performing without any apparent problem. He had me perform his version of the Mini Mental State Exam.
My confidence was shaken: despite all my “back to normal” sense, I could not remember the name of the state’s governor. I could spell words backward, but he timed me and asked how many animals I could name that started with the letter “P.” Seconds without speaking pass very very slowly. He asked me to write a sentence at the end of the test and I smartly wrote one that identified, correctly, the name of the state’s governor. He then asked me to draw a clock face with the hands at quarter past one. I drew a circle and makes the compass points with 1, 3, 6, and 9. Only when I tried to put the hands in did I see my error.
To his credit, the neurologist was reassuring, gave me confidence that I was safe to work, reviewed my medications and blood pressure control and asked me to follow up in six months with a repeat MRI to precede that visit.
The follow up MRI was normal and to this day, I practice random trials of naming animals with different first letters every so often, just to stay in shape. I am an expert at drawing clock faces. I am managing the check book and birthdays, and whatever else I need to worry about just fine. I made sure my living will and power of attorney for healthcare forms are in my medical record……
This association of heavy exercise and “improper breathing” in Breath gets made once more in my life within a year. I was at the gym, in a spin class and on my way to coffee with someone very dear to me. She noted an unusual sensation in the right arm. She then noted not only the arm felt funny, but she had trouble opening the car door. When she exclaimed her frustration, there was some slurring of her speech. What follows is problematic in that it is a common response.
“Shit! You are having symptoms of a stroke; we need to get you to the ER as soon as possible.”
“No, hold on,” the voice sounding clear, “I think it is going away. Let’s get coffee and go home.”
We drove home and again, she fumbled at the door handle. “We are going to the ER now!”
“Naw….What if I just lie down for awhile, this will pass.”
We were in the ER within an hour of the onset of symptoms. The symptoms had passed by the time we got there and in fact, the testing done to demonstrate a clear diagnosis was done quickly and with negative results.
A neurologist was seen in follow up weeks later. The drill in that visit was to review risk factors for a stroke as the clinical diagnosis was that she had a classic TIA. Family history? negative. Blood pressure? Low, consistently. Past history of vascular disease? None. Cholesterol? Excellent profile. Diabetes? None; all testing normal. The “exercise hypothesis” was not discussed with the neurologist as we were ignorant of the possibility.
In the end, the neurologist could not stand it; he had to do something. He prescribed a 5 mg dose of atorvastatin. It was a compromise given her cholesterol value but he could not have her leave the office without some anti-stroke intervention. And a homeopathic dose of atorvastatin is what they settled on along with a small dose of daily aspirin.
For a long time, the lesson to me was that “shit happens.” There was no predictability to what happened with this TIA or my TGA but then again, Breath offers up some empiric observations that link heavy duty aerobic exercise with arteriospasm and symptoms as noted above. When I tell people about my TGA experience, other people come forward with another case and exercise is not uncommonly associated with those experiences. Lesson learned; we exercise but no longer compete with our younger selves when setting goals. Slow and steady wins the race………
Lastly, if there is a recurring theme about people having strokes or heart attacks, it is the psychological operational system that takes over: denial. If I could have a dollar for every man heading for the Cath lab for his heart attack muttering to me that, “it’s just gas…..” I could have retired a year earlier. It astounds me to recall the degree of neurological deficit that people brush off in the middle of a stroke as something that will pass. This includes not being able to use an arm or a leg, to not be able to speak, to have intractable dizziness or double vision. These are not things that just go away—unless you turn out to be really really lucky. The window for reversing a stroke with drugs is four hours from the onset of those symptoms. Both cases I outline above were in the emergency room within an hour. Despite disbelief and denial, we got checked out and can brag about our mileage cycling this year, instead of writing from a nursing home bed.
Cheers!
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