Dad's diagnostic letter to PCP

December 21, 2007

Kenneth Crump, MD

3200 N Canyon Rd Ste E

Provo, UT 84604

RE: John E. Simpson

Date of visit: July 10, 2007

Dear Dr. Crump,

I had the pleasure of seeing your patient Mr. Simpson per your consultation. As you know he is a 44-year-old male with a recent diagnosis of cerebral vasculitis. the history was reviewed with the patient and mother as well as reviewing his past records.

Mr. Simpson has a history of a primary brain tumor at age 13. He was treated with whole-brain radiation with excellent response. He suffered from his first seizure (generalized) at age 22 and was teat with antiepileptic medications. He reports having about one seizure every seven years until five years ago when we began to have them more frequently up to 3 times a month resulting in the need for additional medications. In addition, he developed episodes of "surges" an ill-described sensation in his head heralding seizures. He underwent multiple AED trials. Ultimately all these symptoms have been controlled with his current regimen.

His recent neurologic symptoms began in December of 2006 when his wife first noted to have the gradual worsening of dysarthria, short-term memory difficulty, and poor balance. He then developed new severe frequent migraine headaches with nausea ultimately leading to the use of narcotics to alleviate. He denies any history of abrupt neurological deficits but has complaints of numbness of his feet.

He underwent an extensive workup which included negative factor V Leiden, CRP 2.3, ESR 2, normal PT, PTT, normal antithrombin activity, negative lupus anticoagulant, normal protein C and S, negative ANA, ANCA, RF, Anticardiolipan IGG 6 and IgM 22. CN: pupils equal and reactive, face symmetric normal sensation, palate symmetric. Motor: normal, tone and strength throughout. Sensory: patchy decrease. DTR: 2/4.

Impressions: This is a 44-year-old male now 30 years sp whole-brain radiation who has now had 8 months history of progressive headache multifocal neurological symptoms and diffuse angiographic changes not responsive to high dose steroids. I believe he suffers from radiation-induced vasculopathy, although rare this condition usually onset great than 20 years after whole-brain radiation and is manifest by multifocal small vessel stroke, vascular headaches, and progressive dementia. The vasculopathy is notoriously non-responsive to steroids. Unfortunately, this condition is generally considered progressive and incurable. There has been some discussion in the literature regarding the use of ACE- inhibitors, and statins for membrane stabilization.

I recommend starting an SSRI for mood stabilization.

Elaine J. Skalabrin, MD

Associate Professor of Neurology

CC: Joseph Watkins, MD

Stroke Center director at U's Clinical Neurosciences Center and Associate Professor of Neurology at the U Medical School.