Neurological Work-Up and Management for Brief Slow-Motion Episodes with Sensory Symptoms
Given the normal cardiac evaluation and the specific symptom pattern of slow-motion perception with paresthesias and visual narrowing, this presentation is most consistent with panic attacks or anxiety-related symptoms rather than cardiac or neurological pathology, and the primary recommendation is psychiatric/psychological evaluation and treatment rather than extensive neurological work-up.
Clinical Reasoning
The symptom constellation strongly suggests a non-cardiac, non-neurological etiology:
- Brief duration (<30 seconds) with complete spontaneous resolution argues against structural neurological disease 1
- Normal cardiac testing including echocardiogram (EF 55-60%, normal chamber sizes, no valvular disease) and 30-day Holter monitoring with no arrhythmia correlation effectively rules out cardiac causes 2
- Symptom pattern of "slow motion" perception, chest/shoulder/hand paresthesias, and visual narrowing without loss of consciousness is characteristic of panic attacks or anxiety-related phenomena, particularly given her documented anxiety history 3, 4
- No room-spinning vertigo makes vestibular causes less likely 5
Recommended Approach
Primary Evaluation
Psychiatric/psychological assessment should be the first-line evaluation:
- Formal evaluation for panic disorder and anxiety disorders, as anxiety and depression are common in patients with history of PE (affecting approximately 20% of patients) and can manifest with these exact symptoms 3, 4
- The Hospital Anxiety and Depression Scale (HADS) can be used to quantify symptoms 3, 4
- History of PE itself is associated with increased anxiety and depression, with persistent symptoms over time 3
Limited Neurological Work-Up (If Pursued)
If neurological evaluation is deemed necessary despite low suspicion, focus on:
- Brain MRI to exclude structural lesions (particularly if any focal neurological signs develop or if episodes change in character)
- EEG only if there is concern for atypical seizure activity (though the symptom pattern is not typical for seizures)
- Carotid ultrasound may be considered given her age and hyperlipidemia, though symptoms are not typical for TIA 5
Important Caveats
Do not pursue extensive neurological testing without clear indication:
- The brief duration, stereotyped nature, and lack of focal neurological deficits make serious neurological pathology unlikely 5
- Extensive testing in the setting of anxiety can paradoxically worsen health anxiety and lead to further symptom focus 3, 4
- Her history of PE does not increase risk for these specific neurological symptoms, as PE-related neurological complications would present differently 1, 6
Symptomatic Management
Cognitive-behavioral therapy (CBT) and/or pharmacological treatment for anxiety:
- CBT is first-line for panic attacks and anxiety-related symptoms
- If pharmacological treatment is needed, SSRIs or SNRIs are appropriate first-line agents
- Benzodiazepines should be avoided for chronic management due to dependence risk
Reassurance is therapeutic:
- Emphasize the normal cardiac work-up results, as this addresses a common fear in patients with PE history 3, 4
- Explain that anxiety and panic can produce very real physical sensations including paresthesias and visual changes
- Patients with PE history have higher rates of anxiety (51% in incident cases), and mood disorders often improve with recognition and treatment 4
Follow-Up Considerations
Monitor for symptom evolution:
- If episodes increase in frequency, duration, or change in character, reassess
- If new focal neurological symptoms develop (true weakness, speech changes, persistent sensory loss), pursue neurological evaluation urgently
- Continue to monitor for late complications of PE (though her 3-4 year history of symptoms predating recent evaluation makes CTEPH unlikely) 2
Address cardiovascular risk factors:
- Continue management of hyperlipidemia
- Ensure appropriate anticoagulation management for PE history per guidelines 2