March News and Reports

The last half of March brings significant information.

Excerpts from neuropsychologist's report:

• Mr. Garner's responses on the WAIS-III indicate that he is functioning in the high average range of intelligence, but there is significant difference between verbal and performance intelligence scores.
• His processing speed score is significantly low, which is consistent with organic brain dysfunction and visual disturbances.
• Kyle Garner performed in the high averge to superior range on tests of verbal concentration and attention. He performed in the impaired range on tests that require quick visual scanning and shifting the focus of his attention, but these scores probably misrepresent his abilities because of his complaints about double visioin. His Trail Making Test, Part A score was below the 1 percentile.
• Kyle Garner demonstrated some difficulties in memory functions, primarily in visual memory.
• His scores on the Rey Complex Figure were at the 1 percentile for immediate recall and at the 3 percentile for delayed recall. His delayed recall was actually better than his immediate recall. He demonstrated more significant memory problems on the WMS-III.
• Kyle Garner did not demonstrate any problems with expressive or receptive speech during the interview or evaluation. At times he seemed to have problems organizing his thoughts, but he consistently performed in the high average to superior range on tests of word retrieval, verbal reasoning and verbal comprehension.
• Kyle Garner complains of significant problems with double vision and he used a magnifying glass to assist in perceiving some of the test stimuli. He performed in the impaired range on tests of visuomotor functioning. His scores on the Grooved Peg Board were at the 2 percentile for his right (preferred) hand and at the 1 percentile for his left hand. His finger tapping scores were at the 33 percentile for his right hand and at the 19 percentile for his left hand.
• Kyle Garner appears to have problems in higher level cognitive skills. His speed of processing score was only at the 8 percentile, but the problems with double vision probably contributed to this low score. He performed in the average range on the WCST, except he required a significant number of presentations to achieve the first category (6 - 10 percentile). His Category Test score was at the 18 percentile. His Stroop Color - Word score was at the 3 percentile. His FAS score was at the 15 percentile His Trail Making Test, Part B score was below the 1 percentile.
• The neuropsychologist gave an extensive and not-so-favorable sounding report on emotional state based on MMPI-2 results. He suggests emotional factors may be adding to the motor and cognitive difficulties. Kyle's response is: "Duh! You really think so? Why would anyone be emotional about something like this?"
• Diagnostic Impresion: 1. Vascular Dementia, uncomplicated 2. Somatoform Disorder

Recommendations from the neuropsychologist:

• 1. Referral to Idaho Division of Vocational Rehabilitation for assistance in returning to work.
• 2. Ophthalmology Evaluation and recommendations for the visual problems.
• 3. Mr. Garner will have problems in occupations that require visual scanning, interpretation of visual stimuli, quick decision-making and abstract reasoning.
• 4. He will also have severe p roblems in any occupations that require a rapid motor response or average level manual dexterity.
• 5. Although psychological factors appear to be contributing to his problems, he does not appear to be a good candidate for psychological treatment. He might benefit from treatment with a SSRI, although this apparently has not bee effective int he past. I would discourage any treatment that focuses on symptoms that are not objectively validated.

These tests were performed in early December, 2000, but the results weren't made available until March, 2001. There has been some improvement during that period of time. The report was taken to a Neuro-Ophthamologist at the Moran Eye Center in Salt Lake City, where further testing was performed. Following are excerpts from the report from the doctor who performed that evaluation. The extensive medical and social history in the report was much more accurate than the same histories in the neuropsychological report.

• On examination, blood pressure is 128/80 and heart rate is regular at 70 beats per minute. He is fully oriented. He is of very pleasant affect and seems entirely cooperative. Visual acuity is 20/30 on the right and 20/40 on the left and does not improve with pinhole. Color vision is normal in both eyes but is slower on the left. Stereo vision is mildly reduced. His pupils are large and equal and I could not detect an afferent pupillary defect. He has generalized constriction of the Amsler grid on the left and a left superior defect on the right. Visual fieldsshow scattered defects on confrontation. On Goldmann visual field testing, he has a right inferior quadratic defect, which is very clearly delineated. In addition, he has generalized constriction worse on the left than the right. Flicker fusion is of poor sonsistency. Extraocular movements are full in range and I could not detect any phorias or tropias at distance. He has a mild exophoria at near. Slit lamp examination is normal. Corneal sensation is intact. Dilated fundus examination shows small full optic nerves with a tilted nasal fullness. The vessels are markedly attenuated. I could not see any areas of occlusion of the bessels. Venous pulsations were not seen. The maculae showed mild epiretinal membrane worse on the left than the right. There did seem to be mild papllor to the left optic nerve compared to the right. General neurologic examination shows that he is able to read somewhat haltingly. His facial recognition was excellent, although he had some difficulty putting together the full cookie-theft scene. He has some left/right discrimination difficulties.
• Mr Garner has a right inferior quadratic defect as well a generalized constriction. Review of the records indicates the he had quite marked papilledema postoperatively, suggesting a bout of elevated intracranial pressure due to a disruption of venous drainage. It also sounds as if he had vascular attenuation pior to the surgery, which could be the result of very longstanding hypertension but could also be the result of vascular insufficiency because of a steal phenomenon. Fortunately, his papilledema has resolved and his optic nerves look relatively healthy. Reviewing his scans, he has a small area of abnormality in the right occipital lobe and also an abnormality of the corpus callosum, indicating that while his language function is relatively intact, his visual processing would be likely to be very impaired. Review of his neuropsychological evaluation indicates that this is the case.
• Mr. Garner was encouraged to understand that there were true neurologic defects that explain the severe difficulty he has been having with his vision. Fortunately, it sounds like he is improving without intervention. I woudl recommend a follow-up MRI scan because of some of his recent return of symptoms. If there is any question, a spinal tap should be performed to rule out elevated intracranial pressure because of the ongoing fullness of his optic nerves. I see no evidence of papilledema bad enough to cause progressive optic nerve dysfunction but that could certainly change at any time. He is going to be continuing to work on his vision and on his visual p rocessing. I suggested the possibility of speech or occupational therapy, but given his very high level of functioning they may not have that much to offer him. In the meantime, he is currently disabled from work because of his visual processing, although this may not be the case for the indefinite future.

The doctor further explained that the flickering areas were in the areas of no or poor vision. These could be caused by 1. a return of the avm, 2. seizures limited to the damaged areas of brain tissue, and 3. brain cells generating random data to make up for the lack of input.

A subsequent MRI scan that same day showed no surprising results, except for some scar tissue in the occipital lobe. Shrinkage and hardening or that scar tissue may also be causing symptoms.

There was some discussion of visual hallucinations. I described the shadowy, ghost like figures I would see for about 10 weeks following surgery. If anyone walked acros my field of view, even though I could barely see them there would be a trail of strobe-like copies following, but only if the action were from left to right. Other times, I would see a faint circle move from left to right, followed by a square, then triangle, then a ghostly ball would roll by, followed by a slowly tumbling block, then rotating pyramid. Then a faint, whispy dog would chase a ball across the visual field from left to right, followed by a faint, ghostly woman I had never before seen. There would be a pause, the the whole process would repeat. It seemed like my brain was takin basic shapes and building on them. This was apparently my brain's attempt to activate damaged cells, and to give data to brain centers starving for input in my near blind state.

The doctor was confident that the functioning fibers in the corpus callusom would take over the functions of the damaged ones. She emphasized that it would be a slow process taking 3 to 5 years.

It was interesting to note that, during the Goldmann test, I was asked if I could see a moving light. I could not see the light in certain areas at all, but knew that there was motion. The fibers communicating information about movement are apparently undamaged. The right brain, though, could not pass on information to the left brain about seeing a light through the left eye.

Visit with the surgeon.

I saw the surgeon for a 6 month check up right after the testing at the eye center. He had just gotten off the phone with the Opthamologist, and seemd a little agitated. He described the Alien Hand Syndrome and other problems with the left side as apparent damage to the nerve roots at the level of the brain stem. He felt that damage was unrelated to the surgery. He had no explanation, and ordered an MRI, which was done a few minutes later. The results showed scar tissue in the occipital lobe. The doctor did not suggest any more follow up for the surgery.

It appears the surgery was completely successful. The avm is gone and staying gone. No major problems remain as a result of the surgery. I am on my own for determining the cause of and recovery from the other problems and damage.

There have been several suggestions that I have experienced bleeds (strokes) several times in the past. We can identify at least 3 likely occasions. The swelling after the surgery may have caused some problems. A CT scan and MRI within the first 6 weeks after surgery confirmed the swelling, but there was no followup locally or in Salt Lake City.

I am more active and getting more exercise, and still slowly loosing weight. My social involvement is increasing, and I am looking for some part time volunteer work for a few hours per week. So far, no one is comfortable having me, but the search just started. It will probably take some time.

Issues of Alien Hand Syndrome and disassociation will be covered next month, the one year anniversary of the discovery of the AVM.

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