MRI white matter lesions
Many times I get consulted by patients or their relatives when their MRI brain report reads multiple scattered white matter lesions seen. The radiologist’s report usually further reads that these can be seen in primary demyelinating conditions like multiple sclerosis or in vascular disorders. Patient’s and caregivers are naturally worried when they get this MRI report and do not know what to do and how to proceed further. So I thought that here I shall talk about these white matter abnormalities seen on the MRI. What is their significance? Do they represent evidence of multiple sclerosis?
White matter signal changes on the MRI essentially means that on the MRI, the white matter showed some scattered bright spots. White matter in the brain refers to the fiber tracts that carry information to and fro from the brain.
My first question when somebody asks me what next and what does this mean is to ask them why was the MRI done in the first place. If the MRI was done because there was a clinical suspicion of multiple sclerosis then these white matter lesions may indeed have significance and may represent radiological evidence of MS plaques. Let me explain this with an example. You go to your doctor, you have signs and symptoms that suggest MS (example you may have had an attack of optic neuritis), when the doctor examines you he is able to elict signs in the examination compatible with a diagnosis of MS, then he orders an MRI to see if you do have evidence of white matter lesions in the brain. In a case like this the presence of white matter lesions/ signal changes in the MRI is obviously important. Here it likely does suggest the presence of MS. That said and done I again want to re-emphasize that the diagnosis of MS is made on the basis of clinical history of previous attacks, CSF (spinal fluid) examination and MRI, not just on the basis of the MRI alone. Also there are certain criteria which have to be satisfied on MRI to make a definite diagnosis of MS. These radiological criteria for MS include the number of lesions on the MRI, their location and their size.
Thus it is important to remember that a person who is noted to have white matter lesions on a brain MRI does not necessarily have MS. White matter lesions can be seen in numerous other conditions and they are more commonly seen as we grow older. The thinking behind this is that they represent microvascular ischemic changes in the brain (the smaller caliber blood vessels in the brain showing signs of ischemia or decreased blood flow). Hence these white matter abnormalities on MRI are more commonly seen in patients who have microvascular and macrovascular risk factors such as a history of hypertension, diabetes and high cholesterol (dyslipidemia/ bad lipid profile).
White matter signal changes on MRI may also be seen in patients who have infectious and other inflammatory conditions. They have been reported in the MRI of patients with a history of migraine headaches (migraine too is a vascular disorder and that may explain the connection).
So I want to end by saying that the presence of these white matter signal changes on brain MRI has to be correlated to the history, clinical examination and other ancillary investigations. Your doctor shall help you in going about this in a methodical manner. I repeat these white matter lesions do not suggest MS in each and every case they are found.
Dr. Sethi
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Tags: brain, infections, microvascular changes, migraine, MRI, MS, Multiple sclerosis, signal changes, small vessel disease, vascular disorders, white matter lesions
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Hi,
I have a query regarding the white matter lesion. I am having headache for the past 3 months. My primary pysician rdered for MRI scan of head without contrast.
Head MRI without contrast Results:
Scattered foci of increased T2 signal in the right frontal white matter, best appreciated on the FLAIR sequences. They are probably artifacts.
I was asked to see a neurologist. My neurologist did some physical exam and asked me to take MRI with contrast.
This MRI i did 22 days after the the first MRI.
Head MRI with contrast Results:
Normal MRI of the brain without and with gadolinium.
I am realy scared why different MRI results.
Also, I am very much worried whether it is related to tumor or not.
Could you please tell me is this not related to any major brain disease?
I am very much worried. Please help me.
Regards,
KP
Dear KP,
thank you for your email. Like I said in my post above a lot of people may have scattered white matter lesions on their MRI scan. As I took pains to detail above, they may or may not be of any significance. Most of the times these are seen in patients who have microvascular risk factors like diabetes and hypertension and hence are believed to represent small vessel ischemic changes on MRI. They have been reported in patients who have migraines too.
As your MRI scan with contrast was reported normal, I think that should be quite reassuring that you do not have a brain tumor.
These lesions are open to interpretation of the neuroradiologist who is reporting the MRI scan hence the reports may very slightly. Moreover MRI scans are at times done with different protocols and some of the MRI protocols are more sensitive to picking up these scattered bright spots better as compared to others.
I hope that helps to allay your anxiety. I would advise you to follow up with your neurologist.
Personal Regards,
Dr. Sethi
thank you very much for clarifying…
The word artefacts or artifacutual usually means interference from anonther cause. I.E not an abnormality in the patient but a problem with the machine or environment.
You make a good point CH. Thank you for writing in.
Personal Regards,
Nitin Sethi, MD
I recently had an unenhanced MRI because I have been having rather persistent and sometimes very severe neck pain with headaches. This is how the report read:
Impression: Multiple focal white matter abnormalities bilaterally of high level of concern for MS. Evidence for sinusitis also seen at this time.
Can you help?
I recently had an unenhanced MRI because I have been having rather persistent and sometimes very severe neck pain with headaches. This is how the report read:
Can you help?
I’ll try this again! Not all of my message worked.
Can you shed some light?
hello,dont know really why or what im looking for…long story short ive had two brain scans done back in feb 2008 7 days apart…had gone to my doctor thinking id had a mild stroke,im 33yrs and female,i started to notice little things about myself,dropping things,burning myself,then in oct.2007 i forgot which finger my wedding rings went on,then while at the gym one day i couldnt move my left leg or arm…i had to keep telling my brain to ask my left side to move…i just gave up..tired and scared i went home and slept for hours…and couldnt move for nearly three weeks…then came christmas and i just put things down to christmas time busy time,until in jan 2008 i just couldnt take anymore,my joints and muscles started hurting at first the odd day,then i had to start crawling up the stairs till one day i just couldnt i sat on the bottom step looking at the stairs like it was mt everest and cried like a baby,at this stage i knew something was wrong and rang my doc.he saw me at once and i had an mri the next day and the second 7 days later…they both showed scattered white matter/white blood cell all over the brain..ive been to see a general consultant in april who has mentioned possible ms,he said with my symthoms it is a possibility,i dont know the mri results in med. terms ,i suppose i just wanted to share my story…thank you for listening
I had an MRI to investigate possible acoustic neuroma. Luckily no neuroma, but according to the doctor, “some small spots”. He didn’t show me the radiologists report. I asked my doctor about the “spots” and he said that if we took 100 people off the street and gave them MRIs at least one would have “spots”. I didn’t find this helpful – my goofy side wondered – if we took 100 people off the street where would we put them? and would they get their MRIs faster than I did (3 1/2 months wait for the MRI plus 1 for the results!) as for my symptoms, he said – for my hearing loss – get amplification and for the facial numbness, disequilibrium & pain – see my GP or a neurologist. Oh, and follow up with an MRI in 6 months. Hopefully my GP will actually let me see the radiology report.
I too understand what it is like to not know what is happening with yourself and what the MRI/MRA results mean. In December of 2007 out of nowhere I woke up one morning with severe dizziness, nystagmus, and weakness. I went to the ER and was told I probably had an ear infection (even though the doctor never looked in my ears at all). They gave me an antibiotic and Antivert for the dizzizness and sent me on my way. A few days later when taking the Antivert wasn’t helping I went to the ER again. This time they felt I needed to be seen by neurology. Neurology decided I needed an MRI. After getting the results of the MRI they felt that I needed to follow up with a neurologist right away. In the meantime I had made an appointment with an ENT who completely cleared me from an ENT standpoint. I went to see the neurologist (now mind you this has been going on for over 2 weeks now non stop) who tells me that the foci seen in white matter on the MRI are not “significant” and to go back to the ENT. Altogether I had continuous dizziness, double vision, and muscle weakness for 3 weeks, then it just went away. I just had a follow up MRI and the results this time read “more conspicuous foci of signal abnormality most notably within the deep right parietal white matter”. I have no idea what this means but I will be seeing a different neurologist to make sure I have 2 opinions on this. It is really scary when you don’t know why you are having the problems you are having, and it doesn’t help when doctors make you feel like you are imagining things.
Dear Sher,
thank you for your comment and for sharing your medical history with us. You are right, it can be very taxing for the patient trying to figure out what exactly is wrong with me especially when the doctors are not able to give you a definitive answer.
I think though you are on the right track. Get a second opinion from another doctor, someone who is willing to spend some time on you. Read my post on “how to get a second opinion a patient’s perspective”, you may find it informative.
I wish you the very best.
Personal Regards,
Nitin Sethi, MD
I saw my family doctor today and he printed out the radiologist’s report for me. It confirms that there was no acoustic neuroma, but an “incidental finding in the left petrous apex”, most likely a “cholesterol granuloma”. I don’t what defines a lesion as “small” or “large”, mine is 12.8mm X 4.2 mm X 10mm. The follow up MRI is to confirm a static appearance. I’ve read that sensori-neuro hearing loss, tinnitus, facial numbness, vertigo and deep ear-ache are symptoms of cholesterol granuloma, so I’m baffled by my ENT’’s dismissal of my symptoms. My family doctor has requisitioned the 6-month MRI since the ENT wanted me to book an appointment with him in November in order to book the MRI. Based on past experience that would put the MRI at Feb/March (9 or 10 months). It’s probably not urgent, but it is my brain, so I’m going with the earlier option. Good luck unraveling the mystery of your symptoms, Sher. I hear you. (Well, I hear you on the right side, the left is deaf)
Dear Robin,
a cholesterol granuloma, i think you mean a cholesteatoma in the cerebellopontine angle (which is near the apex of the petrous part of the tmeporal bone) can behave very much like an acoustic neuroma and press on the vestibular portion of the VIII cranial nerve (auditory nerve) and present clinically with complaints of vertigo and dizziness. It also leads to sensorineural hearing loss. Cholesteatoma’s are usually locally aggressive and invade surrouding tissue so have yourself checked out earlier rather than later.
Personal Regards,
Nitin Sethi, MD
Thanks for the information. Hopefully the 2nd MRI will clarify exactly what we are dealing with. The initial radiology report indicated that an epidermoid process was possible but considered unlikely (that would be a cholesteatoma, right?) and a cholesterol granuloma most likely. There seems to be some confusion in the literature about which is which (or is it just me?). In either case, I would think that by the time symptoms appear some intervention would be indicated. I am going to go back to the doctor and ask for a referral to an expert. Should that be a neurologist or back to the ENT? I am still baffled about why the ENT didn’t discuss these findings with me and note a correlation with my symptoms…
Robin
I would say get the MRI done Robin. You should ask your doctor whether it should be with or without contrast. You can then follow with either a neurologist or a ENT specialist. Depending upon what this is and whether it is growing in size, your PMD may request a neurosurgical opinion.
I agree the management and follow up depends upon finding out what exactly is this lesion.
Personal Regards,
Nitin Sethi, MD
I am a 49 year old female who grew up in northern Alberta, Canada. I had an MRI (without contrast) a few months ago which showed a number of lesions scattered throughout the white matter (the MRI was done to investigate possible osteoarthritis in the cervical spine). The radiology report made no mention of any pathogenic disease process.
However, I have been experiencing tremors of the right hand and arm; fatigue that is exacerbated by heat and which does not resolve with sleep; muscle spasms and stiffness of the neck, shoulders, and upper back, which do not resolve with rest or OTC muscle relaxants; numbness and tingling in my feet, sometimes also in my arms and hands (both sides); muscle weakness in right arm & hand, also in legs; problems with balance and occasional vertigo; mild nystagmus; bowel problems; and cognitive problems (forgetfulness). Parkinson’s has been ruled out, as has IBS. I have primary immune deficiency, polymyalgia rheumatica, Hashimoto’s thyroiditis, osteoarthritis, rheumatoid arthritis, and asthma – all of these are being treated and, for the most part, being well controlled (with IVIG, methotrexate, prednisone, plaquenil, synthroid, singulair, and symbicort). I had one episode of optic neuritis about 30 years ago which resolved after a period of 3 weeks. I have one cousin, 9 years older than me, who was diagnosed 5 years ago with progressive MS. I am concerned that I may have also have MS – a concern shared by my psychologist who has a couple of patients with MS who have similar symptoms.
I realize that you cannot diagnose anything, but I would like to have your opinion as to whether or not I should be seeking a second opinion and further testing for MS – i.e. MRI with contrast, spinal fluid analysis, evoked potentials.
Thank you for your assistance.
Dear Connie,
your history is complicated. Though there are aspects in your history and MRI findings that do raise the suspicion of MS, many other diseases in your case complicate the history.
My advice to you would be to seek a second opinion from a neurologist. Most of the times a good neurologist would be able to get a fairly good idea if you have MS from a thorough history and physical/ neurological examination. Then if needed he can ask for further tests like MRI brain, visual evoked potentials and spinal fluid analysis.
Get a second opinion, your past history of optic neuritis is a thing of concern but I would go about this systematically. Invasive tests should come last.
Please keep me posted.
Personal Regards,
Nitin Sethi, MD
It takes a long time to get in to see a neurosurgeon where I live so I persuaded my doctor to make a referral now – the results of my 2nd MRI will be available long before I get an appointment for sure and I can cancel if we decide a consult isn’t necessary. My family doctor is not at all concerned about my MRI findings. His reasoning:
- “it” (the lesion) was not what they were looking for in the original MRI.
- “it” might not be causing my symptoms.
- I may have had “it for the past 20 years.
- “it” is not malignant.
- don’t pay attention to internet information because it is all driven by advertising.
I had a number of counter arguments:
- with my symptoms differential diagnosis includes a number of things & MRI found 1 of them.
- my symptoms are consistent with what is described in the literature.
- just because it’s not malignant doesn’t mean it’s not serious.
- I didn’t diagnose myself by internet, I just looked up the words from my radiology report to find out what they meant.
I am going to adopt my doctor’s position (“don’t worry”) until I have new results, meanwhile like a true hypochondriac I am keeping a log of my symptoms.
Thanks for your feedback so far.
Robin
Dear Robin,
good to hear from you again. While I agree with what your doctor has said and that this “lesion” may very well be an incidental finding and have nothing to do with your symptoms, I do share your concerns as many of your symptoms do “fit” with it.
There is at times a grey zone between “not worrying” and been “hypochondriac”. I call it the “intelligent educated patient”. I would do what you and your doctor have decided. Wait for the results of the second MRI and then get a second opinion in consultation with your current doctor. Read my post on ” How to seek a second opinion” either here or on my website http://braindiseases.info and I feel you shall find it helpful.
If you go about it systematically, nothing “serious” would be missed.
Keep in touch.
Personal Regards,
Nitin Sethi, MD
My 16 year old daughter got an mri of the brain for severe fatigue, depression and complete hair loss. Scattered white matter lesions on mri.Allopecia areata, thought to be autoimmune. All other workup including bloods and csf negative for lymes, lupus, ms. Physically no signs of any other disease including ms.5 years later same mri very tired. sleeps most of her life, takes large doses of adderall to wake up and to stay up. Depressed, anxious, paranoid and very very tired.Most meds dont work. No social drugs. Neurologists, including those specializing in MS have no clue. Told her age group should not have these lesions. No migraine history. I would like to take her to NIH or CHOP but to whom?
I know that this is a very late reply, but this could be an extended b12 deficiency. B12 can cause lesions, and the hair loss, depression and extreme anxiety are also symptoms of a b12 deficiency. If she is still having issues you should get a serum b12, MMA and homocysteine test done prior to any type of b12 supplementation (if she is not already supplementing).
Dear Dave,
thank you for writing in. Vitamin B12 deficiency can cause a myriad of neurological signs and symptoms as you have indicated. You can read more about Vitamin B12 deficiency and its neurological manifestations on my website http://braindiseases.info.
Personal Regards,
Nitin Sethi, MD
Dear Laura,
thank you for writing in. Your daughter’s clinical presentation is indeed unique. It might be a good idea to take her to NIH. I recently read an article where in the NIH was asking physicians to refer “difficult” cases to them.
Your daughter’s doctor shall be the best person to initiate this referral and would be the most informed with respect to all the investigations already done.
Personal Regards,
Nitin Sethi, MD
hi can u help please i had a brain scan in feb 2007 and it came back with high signal lesions t2 weight non-sparfic in nature but could be consistent with ms ive had all the test vep lumper punch all was negative but the latery wave one was long mmy nero says no to ms at this stage since then iam hot all the time i suffer this pain in the rite side of my head the lesionn are on the left in the fronal and the parieral lobe and the paritrigion region the pain i fell is like if u drink some thing cold and it catches a tooth sharp my eye gos cloudy and my face drops i work for a bank so i have lots of paper to do when i write some thing down wot iam thinking is not going down on the paper i have toulbe with numbers alot and this past month ive been suffering alot of cramp in my left leg please could u tell me wot is going on with my boby thanks
sorry i forgot iam now 47
Dear Kym,
thank you for witing in. Like I said in my post not all white matter lesions on MRI signify multiple sclerosis. These may also be seen in patients who have vascular risk factors like diabetes and hypertension. They are more commonly seen as we age and have also been reported in migraine patients.
From what I gather, you say that one of the visual evoked potential waveforms was delayed. Again this by itself does not signify that you have MS. The diagnosis of MS is clinical, though at times we need supporting evidence from MRI, spinal puncture/tap studies and evoked potential studies.
I would suggest you follow with your doctor and if needed he can refer you to a MS specialist.
Personal Regards,
Nitin Sethi, MD
thanks for getting back to me my nero stated in the letter no ms at this stage am having touble seeing out of my rite eye and my left leg burns and keeps going numb can u tell me what the nero mean by not at this stage thank again
Dr. Sethi,
May I first thank you for taking the time to help people with questions. It seems so many doctors are unwilling to do that.
Mine is a long story of two years of “mystery illness”. I won’t bother getting into the details but we are now looking into sarcoidosis. I have had numerous transcient facial paralysis, wound healing problems in surgical incision, unexplained feeling of ice pick in ear, high urine calcium, kidney stones, and the list goes on. CSF showed elevated protein and red blood cells. My question is from my brain MRI. It states 7 mm ovoid focus of increased T2/FLAIR signal present within the subcortical white matter posterior left frontal lobe. Since I don’t have a clue what this means, could it in any way be consistent with neurosarcoidosis?
With much appreciation for your help,
Tammy
Dear Tammy,
thank you for writing in and for the words of appreciation. Well lets see what your MRI means in simple lay man terms. It seems they found a 7 mm lesion (now 7 mm is really small) which had increased T2/FLAIR signal (appeared more brighter than the surrounding brain) and which is situated in the white matter in the posterior left frontal lobe.
As I stated in my post, there can be numerous causes of increased signal white matter lesions in the brain. They are most commonly seen in patients who have diseases like hypertension and diabetes which makes them more prone to have ischemia (lack of blood flow) in the small vessels of the brain (we call this as microvascular ischemic small vessel disease). White matter lesions though also have been reported in patients with migraine and multiple sclerosis (here the lesions have a characteristic distribution in the brain and line the ventricles).
You can see them in other diseases which involve the blood vessels of the brain (causing vasculitis that is inflammation of the blood vessels) and this list includes neurosarcoidosis.
The way to go about ruling out or ruling in neurosarcoidosis would be to look for evidence of sarcoidosis else where in the body such as the lungs and with the aid of other tests like determination of ACE levels. A spinal tap would at times be helpful in this regard. Neurosarcoidosis (when sarcoidosis just involves the brain and not the rest of the body) is not very common and other diagnosis should be considered.
Continue to follow with your doctor and I am sure that they would be able to figure this out for you.
Personal Regards,
Nitin Sethi, MD
Thank you so much for your help!
Dear Tammy,
you are always welcome.
Personal Regards,
Nitin Sethi, MD
Dear Dr.
In june I experienced some very unusual headaches that felt think electrical shocks throughout my head. One night I experienced the worst headache of my life in my forehead only. It lasted all night and in the morning it was better; however I experienced dizziness and if I bent over a swell of pain would radiate through my head. A week later I experienced an eye problem and was told that it was uveitis. Because uveitis can be caused by a virus or autoimmune problem, I immediately began testing for an autoimmune problem. During this testing I continued to experiece overall nerve pain in by head (forehead, temple, back of head) as well as neck pain, should nerve pain through fingers, neck, ankels), joint & chest pain. The only positive test result showed a high ANA test of 1:640 but all other blood tests(c-reactive protein, RF, Sed Rad, SM etc..) were normal. I also had an MRI and the radiologist noted several tiny foci white matter in the frontal lobe area. He indicated that it is may or may not be of clinical significane but could be small vessel ischemia disease or possible dymlienation. I wonder if there is a correlation to the several headache I had in my forehead with the MRI results. My neurologist initially said I had occpital headaches and is normally caused by a pinched nerve; but after receiving this MRI, I don’t think he has it right. I feel the headaches and vision problems along with the other symtoms correlate together. Should I be concerned about this MRI. I don’t feel that this is MS because I’m not having muscular/walking issues; but greatly concerned that if these headaches continue, cognitive problems could occur. Your opinion would be greatly appreciated.
Hello Dr,
I am a 28 asian/indian female. I was brought up in India for large part of my file.
I had symptoms of blind spots in my vision sometime back. The condition persisted for 2 days before I scheduled an appointment with my opthamalogist. He suspected that I have optic nueritis and advised me for a MRI. Now the lab technician says that I have a few lesions in my brain and asked me to consult a nuerologist. I have a pending appointment. My eye became completely normal in about 10 days from onset. By googling I found that it might be a case of MS.
Is it always the case optic nueritis + MRI lesions = MS? Is there anything else I should be looking at? I’ve had problems of vitamin deficiencies in the past. I have had some tongue rashes, gastro problems. Nothing serious but minor issues though.
Thanks,
Riddler
You had indicated vitamin deficiencies. Can you tell me which vitamins were found deficient.? b12 can cause tongue swelling/redness/inflamation. What gastro issues have you been diagnosed with? As you know, b12 malabsorption issues could cause a deficiency. There are documented cases of optic neuritis from b12 deficiencies. Prior to supplementation you should have serum b12, MMA and homocysteine tests performed to rule this out.
Dear Dave,
thank you for writing in again. I have posted your query and I hope you hear back from the reader of my blog.
Personal Regards,
Nitin Sethi, MD
I have recently been having headaches and my right arm curls up from the hand the the fore arm. I thight the the arm might have been a pinched nerve. I was told to get the results of an MRI I had done in 2005. I was diagnosed with a small left cerebellar CVA and lesions of the white matter I never followed up at the time, but I had no more symptoms. Now I am havig fatigue and minor memory problems as well. Could all of this be related or could it be just stress? Thanks, Susan
Dear Susan,
the curling of the right arm may not be due to a pinched nerve, it may be on account of your past left cerebellar stroke (sometimes wierd movement disorders arise if there is damage to the cerebellum or the basal ganglia as these help in motor planning).
The fatigue and memory problems may not be related. Follow up with your doctor, he may consider repeating your MRI scan and comparing it with your scan from 2005. The answer lies not in the scan, it lies in a good history and physical examination. The scan can only then be interpreted in the right context.
Personal Regards,
Nitin Sethi, MD
i just recvd my daughter mri results. she is 9 yrs old. it showed . THERE ARE MULTIPLE PUNCTUATE INCREASED T2 SIGNAL LESIONS THROUGHOUT THE PERIVENTRICULAR WHITE MATTER .SUCH FINDINGS CAN BE SEEN IN VASCULITIS, MULTIPLE SCLEROSIS, LUPUS , OR LYME DISEASE.
THE DOCTOR IS SENDING US TO A NEUROLOGIST. HE REALLY DIDNT EXPLAIN MUCH.
Dear Bree,
thank you for writing in. The MRI by itself does not tell me much, white matter lesions can be seen in many conditions. It has to be taken in context with the age of the patient (pediatric versus adult), history and clinical examination. Please follow up with the neurologist.
Personal Regards,
Nitin Sethi, MD
My name is Laura, I’m 29 years old and I’m from Burlington, Vermont. I lost half the eyesight in my left eye about 10 days ago (very scary!) and went to see an opthamologist. He told be he suspected optic neuritis and sent me for an MRI within 5 days of his diagnosis. I was not sure what cause they were looking for but, after some research, I discovered that optic neurtis is often the first sign of MS. I had a CAT Scan (which showed no bleeding in the brain) and an MRI, which showed some very small white matter lesions in my brain. I will be going to see a neurologist next week.
I have had numbness in my toes and feet in the past, but nothing serious or bothersome. My question is: Do white matter lesions always indicate something as serious as MS? Should I be very worried by my symptoms and test results? The doctors seem worried that there are lesions in the brain of someone my age. I am not looking for a diagnosis, just some hope. Thank you sincerely.
Dear Laura,
No, white matter lesions do not always indicate a demyelinating disease such as multiple sclerosis. As I stated in my post, there can be many other causes for white matter lesions in the brain.
The findings on the scan have to be interpreted taking the history, clinical presentation and examination into context. The diagnosis of MS is clinical, supported by findings on tests like MRI brain and spinal cord, spinal tap findings and other tests like visual evoked potentials.
You can read more about how a diagnosis of MS is made on my website (http://braindiseases.info).
See the neurologist, he/ she shall be the best person to guide your diagnostic workup.
Personal Regards,
Nitin Sethi, MD
I am the same Laura as above and am writing with an update. I had a lumbar puncture on 11-12-08 (after getting extremelly ill with what they thought might be menegitis!). My oligoclonal bands showed at 12, when I was told normal is under 4. My question is: Is this a high number? What is a normal range for this test? I know that 4 would be a low number, but what is the high range for this test? The way I understand this is that it shows the beginning phases of MS.
It sounds like a slam dunk case of MS to me when you take into account the Optic Neuritis and the lesions on my MRI. I just want to know basically what a result of 12 means in the grand scheme of things. How bad does this sound? I can’t find anything about this test online. Seeing the neurologist on 12-8-08, but I am just looking for some insight. Thank you sincerely!
Dear Laura,
thank you for writing in. You ask some very specific questions and that is what I shall attempt to answer. One of my other readers asked me the same question and hence I am reproducing my comments below:
“Oligoclonal bands are frequently present in the CSF of MS patients. Here I have to add that oligoclonal bands can be seen in many other conditions other than MS hence one has to make sure that they are present only in the CSF and not in the blood (In MS these bands are produced intrathecally meaning present only in CSF but not in blood). One study suggested that low or absent number of oligoclonal bands in the cerebrospinal fluid at the time of diagnosis predicts a better prognosis. However quantification of oligoclonal bands in the CSF remains an insensitive prognostic indicator and hence should not be used to influence decisions regarding treatment.”
I hope you find that helpful. You are indeed passing through a very difficult time. My thoughts, prayers and best wishes are there with you.
Personal Regards,
Nitin Sethi, MD
Very impressed with your site and then responses to questions asked. So I’d like to try.
I’m 46 now and in early menopause (confirmed by blood test). Some history is my grand mother suffered from migranes, my mother mentioned lights in her eyes and I suffered migranes in my early 30’s for around 2 years. My mother had TIA’s, my grandfather died of a stroke as did an uncle. I was a Type A workaholic during my 20’s and 30’s – always stressed and under pressure.
Almost 4 years ago I was having problems catching my breath, exhaustion and blackouts. After an attempted suicide I went off work. Two months after being off work I went to a clinic for difficulty breathing and chest pains – bp was 192/145, the doctor sent me in for some rush tests, the next day I went back because I couldn’t breath at all and was sent to emergency. Test after test and they said that it was trauma around the heart…. long and short My GP and everyone else felt that it was to do with stress and anxiety, but I still have high BP – increases fast when I don’t take medication.
I began having more episodes of minor dizziness and blackouts and then 2 years ago I had a grand mal seizure. A month later I had an eye exam and they asked me to come in to do one test with a specialist, I just found out a few months ago that they said ’something was really wrong in my brain back then but improved now’. (I believe this was a reaction test) Over the next 8 months I suffered from more blackouts, total exhaustion, numbness of the face, elbows to hands and knees to feet, memory and concentration problems….. I began to notice improvement after about 12 and after 24 months I feel good some days and really off others. My Doctor assured me it wasn’t a stroke.
I still have dizziness, and the feeling of exhaustion, tingling all over my body (like in my blood) and numbness feet hands and face. I have some cognitive problems – concentration and get mixed up – and short term memory is gone.
I have had my third MRI in just over 2 years. I do have lesions, but I believe they said there hasn’t been significant change.
My questions are – Do my symptoms sound like the results of stress? Turning 40? or are all these symptoms from depression? Could early menopause cause this stuff? or did something happen in my brain that caused early menopause?
I am sorry about sounding scattered, but I am trying not to miss anything. I will appreciate any information or incite you can give me.. thank you in advance, deb
Dear Deb,
thank you for writing in. Your history is complicated. I am sorry to hear that you have been through so much and still do not have a clear explanation for your symptoms. Stress can be a big mimicker and can mimic signs and symptoms of various neurological and systemic diseases. Depression too falls in this category. But these remain diagnoses of exclusion. My advise to you would be to follow up with a doctor you trust, someone who can sit down with you and go over your case history with a fresh pair of eyes.
If you go about this in a systematic manner, I am certain you shall have an answer to what ails you. Please do not hesitate to get in touch with me again. I wish you my very best.
Personal Regards,
Nitin Sethi, MD
Hello DR Sethi,
I had a bout of Optical Neuritis around nine years ago. A firm diagnosis could not be made nine years ago (no MRI scan)and within a week it was gone.
This year (very early Jan) it came back I had an MRI scan the surgeons found a few lesions
But, they couldn’t confirm MS as I have not had any other symptoms (touch wood and the first episode was written off as it had been so long ago). My blood test results were fine but I’m just a bit worried I’m a 30 year old female and lead a healthy lifestyle. I know that you dont have the answers but could my lesions just be silent ones and as I have had Neuritie twice could it be MS???
I look forward to hearing from you.
Kulbinder
Dear Kulbinder,
thank you for writing in. Your history does raise a question of possible MS. What I would advise you would be to get a neurologist’s opinion. He or she after taking a detailed history and examination might like to get a MRI scan of the brain and cervical spine. Other tests like examination of the spinal fluid, visual evoked potentials (VEP) and somatosensory evoked potentials (SSEP) can aid in ruling in or ruling out multiple sclerosis.
Personal Regards,
Nitin Sethi, MD
Dear Dr. Sethi,
I have recently been diagnosed with what doctors thought was bell’s palsy and a month later i had an incident of double vision, this resolved and became partial double vision (with fast mouvements everytime i rapidely turn my head, which resolves when the eyes focus) I also started developing a hearing loss, blocked ear problem four weeks after double vision. After MRI, the doctor told me that i have lesions in the brain stem area which he thinks mean MS, I had an LP done results of which I am still waiting for. I might have hypertension however because I do feel an unusually fast flow of blood circulation every time I am tested by doctors for blood pressure and other things. I am a female, 27 years old, living in Canada and my blood tests were normal. Perhaps all of these factors made the doctor come to MS conclusion too. I was just wondering whether the bell’s palsey, face paralysis somehow spread in other nerve areas in CNS thus causing these symptoms. So I was wondering what could be another diagnosis of what I have if not MS? It seems all of my problems have to do with nerves around the brain stem area.
Thank you!
Dear Sol,
thank you for writing in. Bell’s palsy by defination is an idiopathic lower motor neuron type facial palsy (meaning the facial nerve gets inflammed somewhere along its course from its nucleus which lies in the brainstem to its terminal branches supplying the muscles of the face). The whole one side of the face gets paralysed. In Bells palsy, this inflammation is idiopathic (no definite cause for inflammation is found) though inflammation by the herpes group of viruses has been implicated in its etiology. Some patients have developed Bells palsy after been exposed to cold air (this has never been proved though). Bells palsy is not life threatening but can be quite socially disabling especially if severe (you can imagine how socially disruptive it might be to have one half of your face paralysed and be unable to smile or emote with your face).
Usually when you scan these patients, the MRI comes back normal though at times one can visualize high signal in the facial nerve indicating inflammation. Multiple sclerois usually presents with optic neuritis (inflammation of the optic nerve) and not facial nerve palsy. There can be other causes of facial palsy, diseases like sarcoidosis and other vasculitis need to be ruled out. I think the spinal fluid results shall prove to be helpful.
Please feel free to write in again.
Personal Regards,
Nitin Sethi, MD
Thank you Dr. Sethi! Your reply makes a lot of sense. I am still waiting for results of spinal tap. I have recently come across other information on the web which hints that patients may develop double vision after occurance of Ramsey’s Hunt, which I think I might have had instead of bell’s palsey because of symptoms of hearing loss at the same time as facial paralysis, although no shingles. It would be strange if MS presented itself with facial paralysis first, right? Should I be taking or asking my doctor for any anti viral medicin to help with decrease of these symptoms (loss of hearing, partial double vision)?
Dear Sol,
you are very welcome. You should get in touch with your doctor and ask him whether he/she would advise steroids with or without anti-viral therapy. Since he has examined you, he shall be the best person to make that decision for you. You should not be taking them on your own without consulting your doctor first.
I can tell you though, that in Bells palsy, steroids and anti-viral medications are effective only if started within the first 4 days of symptom onset. Also one study showed that it is the steroids which are the most effective, anti-viral medications have little or no effect on the symptomatology of Bells palsy.
Personal Regards,
Nitin Sethi, MD
Hello Dr Sethi,
Thank you for your response. I had an MRI scan which showed demylination early last year in a few areas but my symtpons have been silent. Bar the Optic Neuritis (one 9 years ago and one a year ago this month.)
As there has been quite a lot of time between the two symptons the neurologist is not worried and has said its possible MS – but I should wait and see if I have another episode – if I have nothing in this year then I have nothing to worry about – is that correct does it get written off?
I know that MS is different from people to people so could mine be just one that has slight symptons – benign MS??? I feel fine in myself but am just a little worried and don’t really want to have lots of tests done as I know that the neurologists won’t be able to tell me what’s round the corner with it being such a hit and miss disease… I’m 31 so if it was to show up would I be in a bad way now and would more symptons be present if it was a bad case?
I look forward to hearing from you.
Kulbinder
Dear Kulbinder,
it is always good to hear from you again. Unfortunately it is extremely difficult to predict when the next attack would occur, if it indeed does occur. Not all patients who have optic neuritis go on to develop multiple sclerosis. If a patient presents just with optic neuritis and we as doctors find no other evidence of multiple sclerosis lesions (plaques) in the brain or spinal cord, we refer to it as clinically isolated syndrome or CSI.
Many patients who have CSI do not go on to develop MS but some do and at times many years after the first attack of optic neuritis. So my advise to you would be to remain in close follow up with your doctor. You have had two attacks of optic neuritis and that makes me a little wary of ruling out MS just yet.
Read my interview on healthnet, there is a link from my blog here, it shall give you more information about CSI. Keep in touch.
Personal Regards,
Nitin Sethi, MD
Dear Dr. Sethi,
I am hoping you might be of some help. I’m 31 years old, and have been having a variety of what I have learned to be MS symptoms for the past 7 years. These symptoms include dizziness/vertigo, a strange buzzing sound or clicking when I move my head, numbness and tingling in my upper and lower extremities, occasional bouts of one sided muscle weakness, muscle spasms, a face pain that is stabbing like, impaired coordination and dexterity, fatigue, bladder incontinence, a strange tightness in my chest that comes and goes, no tolerance to heat, and I have mixed up (reversed) words and syllables in sentences, have had poor word recall, and other general attention problems. These symptoms have come and gone over the past 7 years, sometimes they are gone for months at a time, and they don’t all happen at the same time. I’ve had two MRIs done already, with the third being done tomorrow. My first MRI showed “unspecified white matter of no clinical significance” The second MRI I was told was “normal.” I am currently battling my first ever case of optic neuritis. I’m extremely frustrated. I’ve been told I don’t have lupus, lyme disease, and many other diseases/conditions that can be diagnosed with a blood test. I’ve seen a resident in neurology, and he told me I might have fibromyalgia. I’ve done the research on that, and it seems to be predominantly characterized by widespread pain, nothing about the other symptoms as part of fibromyalgia.
I’m not sure what to do, who to talk to, or where to go at this point. I feel as though the Dr. isn’t listening to my concerns, and even went so far as suggesting this is “all in my head.” MANY of my friends have seen these various symptoms I have had.
Can you offer any suggestions? Please?
Dear Kristen,
thank you for writing in. Multiple sclerosis can present with various symptoms, many of them are non-specific. The fact you say that you are currently battling optic neuritis though worries me. Optic neuritis is a hard clinical sign.
My advise to you would be to see your primary medical doctor and ask him or her to refer you to a neurologist for a second opinion. That would help in figuring out what plagues you.
Personal Regards,
Nitin Sethi, MD
Dr. Sethi, I received a copy of a friend’s MRI report. He is a young male who does not use elicit drugs, is healthy, bright, and hard-working. He had a sudden onset of weakness to his left arm, then later, his left leg with some numbness to his arm, leg, and left side of his face. His strength of his left side was obviously weaker. He looked normal when he smiled, was swallowing without problems. He did not have a headache, or history of headaches. He is a runner and exercises regularly.
His MRI report states “no MR evidence of acute or subacute cerebral ischemia. No abnormal brain edema or mass or swelling. The ventricles and sulci are normal in size with incidental note of a prominent cisterna magna. On the FLAIR sequence, there is some question of a 5 mm focus of T2 signal in the subcortical white matter of the inferior right frontal brain adjacent to the medial sylvian fissure and insular cortex measuring again 5 mm in size.”
The CT scan was performed the previous day with ” with questionable or subtle CT findings right posterior temporal and inferior parietal brain. Could you make this more understandable. Thank you
Dear Sue,
thank you for writing in. Let me try to make the MRI and CT scan reports a little simple. From what you tell me your friend who is young (you do not tell me his age) and in good health suffered an acute neurological event which led to weakness in his left arm and leg (motor deficit). He also has numbness in the same distribution (sensory deficit).
As you know the brain is wired in such a way that the left half of the brain controls the right side of the body and the right half of the brain (right hemisphere) controls the motor and sensory function of the left side of the body. Your friend has motor and sensory deficits on the left and his MRI and CT scan is showing a small area of signal change in the white matter of the right side of the brain (namely in the right frontal area adjacent to the median sylvian fissure).
So his examination findings as described by you and the MRI scan are compatible.
As I see it, it is highly likely that he has suffered a stroke like episode. Strokes in the young can have multiple causes. He warrants a thorough neurological work-up to identify risk factors for stroke and to rule out any other disease which may be mimicking as stroke.
His doctor shall be the best person to guide his work-up further and to initiate appropiate treatment so that he does not have similar episodes in the future.
Personal Regards,
Nitin Sethi, MD
Dr. Sethi, I am very happy to have found this site! I will try to make this short. I have had Optic Neuritis 4 times in the last 5 years, fatigue on and off lasting as long as 9 months, bladder problems on and off and now numbness on the left side of my body including my left cheek, front of my left arm, front of my left leg and top of my left foot. I have burning pain on and off ( mostly on now) from my upper back to my shoulders and it has gone down both arms, around my ribs and down my legs at times. I am always stiff especially first thing in the morning and at night. I have had 2 severe incidences of vertigo which resulted in falling in the shower and breaking 2 ribs and falling down the stairs and requiring 6 staples in my head. I have had 2 MRI’s, one 5 years ago and the last was a month ago. Both were normal. Actually, the neuro said that for my age, I’m 48 now, it was incredible to have not a single mark show up. She is a very thorough neuro and admits that she is stumped! What else could all this be? Also, can a MRI with contrast show anything that did not show up before? She would like me to have a LP which I am seriously considering.
I eagerly await your reply because right now I just feel like I am nuts!
Thank you so much for your time,
Connie
Dear Connie,
thank you for writing in. Your case history intrigues me and while I would not try to make a “guess” about what plagues you, I do have some suggestions. Was an MRI of the spine done? Was the MRI of the brain done with contrast? The answer I feel lies in a good history and examination findings. Multiple sclerosis has been called the great mimicker and can mimic the presentation of many other diseases. Vice versa there are other conditions which can superfically resemble MS. You can read about them in the interview I did for MS health portal. There is a link to their website from my blog.
The decision to do a spinal tap is something which only a neurologist who has examined you can decide. It may or may not yield additional useful information. Sometimes when the diagnosis of MS is suspected but not proven, we do additional tests like spinal tap (LP), visual and somatosensory evoked potentials to either rule in or rule out the diagnosis.
Personal Regards,
Nitin Sethi, MD
Thank you so much for your swift and interesting reply Dr. Sethi. To answer your questions, both MRI’s included my cervical spine and brain but both were without contrast. My neuro is attempting to book me for a complete spinal and brain MRI with contrast but is worried that her request will be denied by the specialist at the hospital. It is usually a 3 month wait here in BC Canada and I still have not heard from booking. She had suggested an LP and asked me to call her if I decided to have one. I understand that an LP is not very reliable so we shall see. She has not suggested any of the evoked potential tests.
Thank you again for your time,
Connie
You are very welcome Connie. Please feel free to write in again and let me know how it works out. I wish you my very best.
Personal Regards,
Nitin Sethi, MD
Hi Dr. Sethi, I have finally been scheduled for an MRI with contrast but not until June. So I have just one question. Is it possible for active lesions not to show up on normal MRI but then show up with contrast? All of this has become very confusing for me.
Thank you for providing great information,
Connie
Dear Connie,
good to hear from you again. Yes it is possible for “active MS lesions” not to show up on MRI. Infact there is much work being done as we speak to improve MRI correlates of MS disease activity. The diagnosis of MS is secured in these cases by a combination of MRI findings and other tests such as lumbar puncture and evoked potentials.
Personal Regards,
Nitin Sethi, MD
Hello my husband was in Iraq about one year ago and he was constantly out on missions that had IED blowing up all the time and hitting his vehicle. Although he didn’t have any external issues he is suffering internally. He has since had major headaches, his blood pressure is high and his attention span and tolerance level are extremely low. He has PTSD and he also just had an MRI done because of the headaches. His results are as follows (his has the results now but due to no availability can’t see the doctor for them to read it to him until the end of the month):
Ventricles, cisterns, and sulci are normal in size and configuration. There are a few tiny foci of increased FLAIR signal in subcortical and deep white matter of both frontal lobes, nonspecific findings. No abnormal fluid collection, mass, hemorrhage, or enhancement. Central vascular signal voids and bone and soft tissues are unremarkable. IMPRESSION: Nonspecific bifrontal white matter signal changes.
Is there anyway that you can briefly give me your take on this finding?
Hi Mr. Sethi,
I do like the way you help people on the net from all around the world.So I thought maybe at least you can comment on our case too.
We live in Turkey, and my wife is 35 years old.Our story begun about 2 months ago with a terrible headache.We went to a neurologist, and after we have told her the story, she requested a brain MRI.We got the results almost 15 days later, and the radiologists have only indicated an ependimal 1cmx1cm cyst in left hypocampus, which was most probably morphed during the birth process.The brain MRI stated no other thing such as white matters or something else.During this time we had an Xray of the neck, which showed a Cervical lordosis.Then after this Xray, our doctor requested a Cervical MRI to see what is happening.Also there was no white matter in this Cervical MRI, but there was almost a full Cervical Lordosis.During this period, my wife was experiencing headaches which were mostly felt in the left top of the head.She was also having some pain mostly on left shoulder.She was having some kind of anxiety problems also, which we have thought was because of Cervical Lordosis .She went to a psyciatrist for these anxiety and the psyciatrist gave her an antidepresant.After 1 week , this numbness with consciousness begun to catch more severely,especially at evenings.And almost for a week, my wife can barely speak, can speak very slowly, and can speak normal very rarely.We have seen almost 3 neurologs in Emergency centers of several hospitals in 1 week.She shows the symptoms of MS and Miyasthenia Gravis.Her right eye is slightly narrowed.But there is no loss of vision in the eye.And her chin has fatigue while eating something.She also has difficulty swallowing sometime, but the worst of all is her speaking slowly, as if she cant move her tongue.And she always tells me there is something on the upper left of her head above her eye, waiting for to come.And when it comes (she calls it something like a fog but her consciousness is always full, no blockouts), she can only speak very slowly and she has fatigue, she can breath hardly, she can walk very slowly, and so on.
3 neurologs made some 10 minute physical diagnosis at the emergency clinic, and they said al sysmptoms show psychiatric case.Also after a brain and a cervical MRI, 3 days ago we had a CT in Emergency to check for the cyst in left hypocampus and doc said everything was clear, nothing to worry.I also asked him whether it could be MS or MG(miyasthenia Gravis) but he said no.
So finally we went to see a psychiatrist, and he told us to give up the antidepressant we use, and he gave some other thing called Diazem, he told us to use it for 5 days and go and see him again.We will go to see him next Monday, so here are my questions if you can comment.
1) There are no MS Plaques neither in Brain MRI nor in Cervical MRI.Do I need to make a further diagnosis for this MS issue?
2) Can it be MG ? Why do you think they insistingly tell it is psychitaric?
3) What other thing can it be? Can it really be because of stress? (Until this slow talking issue, I was also thinking it may be psychiatric but this slow speaking really makes me afraid)
Please comment on this subject, because here in Turkey, it is really hard to get good health service if you dont have much money.I am eager to let you know about any further info you could need to know to comment.
Very best regards…
Cengiz.
Dear Cengiz,
thank you for writing in and for your kind words of encouragement. While I shall not attempt a diagnosis in your wife’s case since I have not personally seen her, I can answer your questions.
1. Nearly all patients with clinically definite MS, shall show plaques in the brain and/or the spinal cord. It is only patients who have a clinically isolated syndrome in whom the MRI scans may not show any evidence of plaques but who still may go on to develop MS in the future. But these patients usually present with an acute loss of vision in one eye (we call this optic neuritis). The way your wife’s symptoms started and have progressed makes me think MS is unlikely (PLEASE NOTE I HAVE NOT SEEN YOUR WIFE, SO TAKE THIS INFORMATION WITH A GRAIN OF SALT).
2. Patients who have myasthenia gravis usually present with weakness. Classically there is a history of fatigue and the weakness becomes more prominent as the day goes on. You make them rest for a few minutes and they again feel strong. MG may also involve the eye. Patient’s usually have drooping of the eyelids (again improves with rest) and may complain of double vision. They do not have difficulty in speaking per-se, but when they talk for a long period of time their voice may became weaker (less loud). Patients with MG may also complain of difficulty in swallowing especially foods like meat which need to be chewed well (this is because their muscles of mastication become fatigued).
3. While I am not sure what plagues your wife, stress can cause a variety of symptoms (both conversion and somatoform disorders have been reported).
Personal Regards,
Nitin Sethi, MD
Dear Sethi,
Really thanks for your very fast response, I am really happy and satisfied with most of what you have said.I will ask some other little things for some of the comment you have made, and appreciate again if you can reply.
1)My wife does not have an acute loose of vision in the eye (optic neuritis), and as for what she tells me she has never lived such a thing before.But there is slightly drop of right eyelid.For the isolated MS or active MS lesions, is it neccessory that we take contrast MRI for both cervical and brain? Or do you suggest any other way to rule out MS totally? (I also ruled out MS on my mind but I want to be surer, I know that you know the feeling).
2) As for Myasthenia Gravis, I especially want to ask about the difficulty of talking here.When she has that fog (I mentioned above) in her left side above the left eye, when she speaks, I observed her muscles to her shoulder yesterday, and you can see when you observe that she is making so much effort and taking strength from her muscles on her shoulder through the neck.I see a stiffness and a movement of these neck to shoulder muscles while she tries to speak.And rarely during the day her speech is ok you can say.And when speech is ok, there is no extraordinary stiffness or movement of these mentioned muscles.Also when she speaks slowly, the tone of her voice is almost transposed down a few tones like a slow tape(I am sure you get that too).
3) One more important thing I want to mention is, when this attack comes (the fog), one of the most important thing observed is the abnormal activity of the veins (blood vessels on the neck especially on her left neck).And afterwards she can hardly breath, and after that a hot spot falls into her chest, then comes a situation of crying for a few minutes, then it goes.I want to ask if MG may cause this situation, have you ever seen sych a scenario? I know that every patient is different and could be considered seperately but, what I want to know is, can MG cause this or can these symptoms lead to a situation pretending as MG? Your comment is very valuable before seeing neurologists and psyciatrists on Monday.
4) What disorder should we concerned about this speech disorder considering all mentioned above? Is there a typical illness other than MG?
Like all the others who have been grateful, I am grateful for your help and the time you spared for all of us.(Also you can ask me any computer hardware problems, I am a computer hardware specialist)
Best Regards.
Cengiz
Dear Cengiz,
thank you for writing in again. Let me answer some of your questions.
1. The diagnosis of MS is clinical and is made on the basis of history of repeated attacks suggestive of demyelination and examination findings suggestive of multiple lesions in the brain or the spinal cord. When the diagnosis is in doubt, tests like MRI of the brain and the spinal cord, spinal fluid examination, evoked potentials (especially visual evoked potentials) are done. We like to give contrast because it tells us about the disease activity (is the lesion new or old etc).
2. You talk about Myasthenia Gravis. Its presentation can be varied but mostly commonly patients have drooping of the eyelids, voice which gets fatigued, weakness which comes on at the end of the day or after exertion. Some times patient may have weakness of the respiratory muscles and may need to be intubated and artificially ventilated.
I shall not attempt a diagnosis on what plagues your wife as I have not examined her. That shall be the privilege of her doctors. Thank you very much for your offer of helping me out with computer hardware issues. I may very well call on your expertize at some point in time.
Personal Regards,
Nitin Sethi, MD
This is Cengiz again,
And please escuse me I forgot, what do you mean by conversion and somatoform diseases, I will be happy if you can explain shortly.Thanks again.
Sure I shall be happy to explain. Somatoform disorder is characterized by physical symptoms that mimic disease for which there is no identifiable organic cause . In somatoform disorder the symptoms are usually related to psychological factors. In conversion disorder the patient usually presents with symptoms referable to the nervous system (such as weakness in a arm or leg, unable to speak etc), again for which no organic cause is found inspite of a battery of tests.
Nitin Sethi, MD
Dear Nitin Sethi,
Your explanations have been more than helpful for me.I really appreciate your sincere concern and comments.
We have been to a good neurologist yesterday.In the earlier three neurologists, I had always forwarded the doctors about some disorders, but this time I asked the doctor to make a diagnoses by what she observes really.There was normally a very good history of my wife, which I had prepared very detailed for all the doctors I went to visit.She made her physical diagnose after listening to my wife, and afterwards she was totally convinced that, it was totally psyciatric.But she also expressed that, it was not something like depression but something deeper than that, which should be properly cured by teraphy of some kind also for there are some traumas in my wifes past.
In this point, I like to thank you, for you also gave me a relief earlier than the neurologist we visited yesterday.We have already started our treatment and we will see a psyciatrist regularly.We will also try to understand the nature of somatoform and conversion disorders by reading a lot.
Hope the best of the days for you, for your patients and everybody.I am really willing to help, you have my mail address already, about any technical computer problems.
Very best regards,
Cengiz.
Dear Mr. Dr. Sethi
I’m writing in order to get some answers about my mri examination. I am 26 years old. It was about 10 months ago. I do really appreciate your work too.
I had a psychological problem (still have it but not that much). I feel that I am sick. I had many kinds of medical examinations (blood tests, blood pressure tests, urine tests, thyroid tests, ultrasound in heart) all of them were totally clear. Once, I heard from my mother that her friend’s son was diagnosed with ms. I read about its symptoms and, as a result, in a few days later, I felt a smooth numbness in my leg and I went immediately at a neuro. He examined me, started to laugh and told me that I’m totally healthy and there’s nothing to worry about, but I couldn’t be calm and persuaded him to have an mri. I know it’s funny but anyway.
Unfortunately, the results were not so good. The report said “A pathological signal lesion is recognized in the sub cortical white matter of the right frontal lobe. It has ellipsoid shape and its max diameter is 5mm, is characterized by high intension of T2 and flair images without showing any kind of intense to getting larger and without any kind of enhancement after the injury of gadolinium. Similar signal abnormalities
are recognized also in periventricular white matter at the occipital area. These pathological findings cannot diagnose a specific brain illness. However, taking into account the clinical appearance and the age of the examinant, in order to rule out any kind of demyelinating disease, is recommended clinical laboratory examination and re-examination.” This machinery was constructed in 2006 and its magnetic field was 1.5 tesla. The mri at spinal cord was ok.
This examination was in June of 2008. Generally my neuro told me that might be ms but there was no point in doing other examinations to prove it because I would get in depression. It would be clear in a few months, years; unknown when it would be.
As a result, I got mad and went to another neuro. Unexpectedly, she paid no attention in this lesion and the other abnormalities, she examined me and I was fine but she recommended another mri scan in brain as well as in spinal cord too 3 months later to check dissemination in time. So I did and the mri showed just the one lesion without the other abnormalities and my neuro told me that there’s nothing to worry about.
Generally I don’t have any symptoms except some smooth symptoms like headaches, numbness in my back or up side of head which lasts up to 30 seconds, dribbling only after emptying the bladder as far as I saw, some unintentionally movements of my fingers, urination many times per day, but all of them are very smooth and most of them I had many years ago. Besides, I’m very stressful. Also I have never had a stroke (clinical episode).
I don’t seek for a diagnosis. I’m not a doctor but I can understand your point of view.
My question is just what to do? What are the possibilities to have ms? Is there something that you want to point out? Something that I missed write?
Thanks again for your consultancy and your attention to us.
P.S. I am really sorry for my bad English but I am not a native speaker. I am originally Greek. I was as clear as I could.
Yours sincerely,
Johnnie Bouras
Dear Johnie,
thank you for writing in. I shall not give an opinion based on a MRI report. My advise to you would be to follow up with your doctors. If the opinion of two neurologists is that this is not MS, then likely you do not have this condition.
Personal Regards,
Nitin Sethi, MD
Dear Sethi,
I am 33 year old female. I am having problems with right side body numbness, and tingling since September 2007. I had severe headaches, my physician order MRI of my brain but came out normal. Few months later, one night I suddenly experienced numbness on my right side of my body from feet to all the way to my face. It felt too numb and very heavy and I was dizzy. I rushed to ER and they did CT scan on my brain and found calcification on my brain. They sent me to neurologist. He suspected pinched nerve and ordered MRI of my head, neck and lumber spine. And found herniated disc C5&C6 and percribed me with some pain medications to ease the pain. But the pain or numbness never went away since then. And now I have developed constant pain in my shoulder. MRI of my shoulder showed bone calcification, stiffness, and some fuild in my shoulder. Now am going for EMG to find out pinch nerve/damage.
Last summer while I was driving I suddenly had extreme dizziness. I stoped the car everything was spinning around me. I could not sit, stand or open my eyes and it lasted for about an hour or so then the dizziness was mild I was able to get up and walk. Then few weeks later I started to have the similar systems, but this time I had strange pressure like pain on top of my head. The pressure was so strong it felt like my head is being lifted upwards. and numbness on my right side got worse. I saw my physician and he ordered MRI of my brain, and found White matter leisons on of the brain. To rule out MS my doctor ordered blood test to rule out Lyme disease, but that came out negative. Then I saw the neurologist and he suspects I have MS and now I am going for MRI of my brain with contrast study. He does not want to do Spinal Tap study though.
The numbness gone worse. I feel so much weekness in my right side. Everytime I want to lift or grab something with my right hand it is like I have to tell my brain to do it. I find it very hard to write or perform small tasks with my right hand. I feel so much fatigue. Just within the last two months my energy has dropped so much. I used to walk alot, and lift weights few times a week, now after 15-20 min of walk I get tired and lifting small weights is too much. I feel dizzy when I get up or suddenly turn my head and sometimes lose my balance.
I am worried what is going on. I fell from stairs and hit my head on the wall and all of these symptoms (numbness, weakenss, tingling, white matter on brain, C5, C6 herniated disc, and shoulder pain) showed up few months later after my fall.
My question is it possible to get MS after minor brain injury?
Could increasing numbness lead to complete disablity?
Dear Sidhu,
thank you for writing in. Minor brain injury does not cause MS. Multiple sclerosis is an autoimmune disease caused by the intermix of yet unidentified environmental and genetic factors. My advise would be to take a second opinion from a neurologist. A thorough work-up shall help identify what plagues you.
Personal Regards,
Nitin Sethi, MD
I’ve had ongoing problems with migraines and headaches for approximately 4 yrs now. I’ve seen 3 different neurologists and have had a cat scan, 3 mri’s, multiple eye exams including eye pressure tests, field of vision tests and so on. I’ve had complete numbness down the left side of my body on more than one occasion. I was told by the last neurologist something about complicated migraines but now she’s also ordering a lumbar puncture. what would be the purpose of that? I’m on like 4 different medications now to try and control them but still have headaches daily. I still have numbness and tingling down my left arm and shoulder. I’ve been told I do have white matter lesions but not where or how many. Can they affect short term memory? I’ve noticed memory changes in the last year or so. I’ve also within the last month have started to get blurred vision and seeing flashes of light, and traces of images if I move my head too quick. When the migraines get real bad I have a spot on the back, right side of my head that’s very sensitive to touch and the skin turns kinda reddish around the spot. I’m just more curious about the memory loss, reason for the lumbar puncture, and if there’s any other questions I should be asking my doctor? and also why now the blurred vision and flashes of light. thank you very much
Dear Jon,
migraines have a vascular basis (meaning that it is usually the blood vessels in the brain which go into a spasm and then dilate). Patients who have migraines frequently have other symptomatology. Some get an aura (usually a visual aura of flashing lights and blind spot in the eye) prior to the onset of the headaches. We refer to this as classical migraine or migraine with aura. Some patients during the migraine attack may develop other neurological deficits–vertigo, numbness or tingling in the face, weakness in the arm or leg. All these attacks are broadly included under the umbrella of complicated migraine (examples include basilar artery migraine, opthalmoplegic migraine, hemiplegic migraine). Frequently during the migraine attack, patients develop what is called central sensitization–the hair on the scalp or the skin of the face, forehead or eyes is painful to touch. Example combing the hair may be painful.
I cannot answer the question why your doctor is ordering the spinal tap since I have not examined you or seen your scans. I hope you find the information useful.
Personal Regards,
Nitin Sethi, MD
Dear Dr. Sethi, I recently had an MRI (with contrast) to rule out an acoustic neuroma. The report came back negative for that, but my audiologist called, saying he was going to make a referral to a neurologist because my brain “looks like (I’m) a 75 year old hypertensive heavy smoker.” I’m a 40 year old female with low blood pressure, who smoked ever so briefly in my early twenties. The audiologist seemed convinced that I have MS or some other degenerative condition. Unfortunately, my neurology appointment isn’t for another five months, and I am now left to wonder what might be going on.
I believe myself to be generally healthy, although had cancer as a teenager. I have had migraines, although not very often (compared to my siblings) and have not had one in quite a few years. (I never experienced auras or really any other neurological issues with the migraines; just pain and sometimes nausea). For the last several months the right side of my face has been rather numb (which I have been attributing to clenching my jaw), I have constant tinnitus, and often get dizzy and am easily fatigued, but these are the only other symptoms that stick out to me, and they are easy to ignore.
My question is whether MS really is a possibility, or might migraines– even though they’ve been infrequent and not recent- be the underlying reason for my MRI to look the way it does? Or are there other possibilities?
Dear Kay,
thank you for writing in. Hmm I can understand your concern and anxiety. The way I see it though is different. It seems your MRI brain done to rule out an acoustic neuroma incidentally showed white matter lesions. You are 40 and as per your admission really do not have any signs or symptoms to suggest that you indeed do have multiple sclerosis. MS usually starts a little earlier (usually in the later teens, early 20s or early 30s).
As I have stated in my post and my comments repeatedly not all white matter lesions in the brain represent MS. People who suffer from migraines or have other microvascular conditions such as hypertension, diabetes or those who smoke too can have multiple white matter lesions in the brain scan.
There are certain features on the MRI scan (not just the number of lesions but rather the type and size of the lesions and their location in the brain) which make us doctors think that a patient indeed has MS. My advise to you would be to relax, see your neurologist. He/ she shall be the best person to decide if you indeed do need further work-up to rule out or rule in MS.
Feel free to write in again.
Personal Regards,
Nitin Sethi, MD
I have had optic neuritis in 2000. At that time I had an MRI of brain with and without contrast. There were no spots. Seven years later, I had a tear in my Rt. Retina and I have had Chronic Uveitis since then. On April 1st this year, I had a hemmoraghe in my left eye and now Chronic Uveitis. In Feb of this year, I woke up in excruciating pain in my joints, arms,wrists,fingers,elbows,shoulders,neck. Throbbing and tingling in my arms. That lasted 3 weeks. I was okay for one month, then woke up with numbness and tingling all over extremities and torso. That lasted 2 and a half weeks. 3 weeks later I woke up with joint pain and numbness and tingling all over body. I had about 24 hours with a feeling of a vice on the top of my head. The numbness and tingling is still there 4 weeks later. I have tripped several times. I have problems with balance upon rising or turning fast. I did go to a neurologist. He examined me. Said I look pretty good, but has no idea why my feet and calfs are numb. Did an MRI of brain with and without contrast. Spotty signal change on T2 of white brain matter. I am not looking for a diagnosis, because I will see my doctor again next week. Just looking for possibilities of what it could be. Oh yes, I forgot to mention I have bouts of where it is all I can do to work M-F and I am exhausted. When I have these bouts. I sleep all day saturdays.
Good Morning Dr. Sethi,
I was diagnosed by my Dr. with Trigeminal Neuralgia. My Dr. I go to when I go south in the winter diagnosed a Neuroma. I had an MRI of the head last week without contrast, and the report says small vessel degenerative change in the cerebral hemisphere white matter bilaterally. I have a sharpe stabing pain in my left ear right above my ear lobe. I had a mole removed from that area about 15 years ago. I am 67 years old, take no medications and take a lot of vitamins. I exercise daily doing a tread mill or water areobics for at least an hour. Most of the time my blood pressure systolic readings in the 120-130 zone and diastolic readings in the 70-80 zone. I have found I have to exercise or my BP will rise to 150/90 zone. Should I be concerned about this MRI report, and is there anything I can do to alter this degenerative process? I will be looking forward to your reply. Thank you so much, and you have a great day. Rena
Dear Rena,
thank you for writing in. The changes you describe in your MRI report are rather non-specific and may be indicative of small vessel ischemic disease (likely due to your history of hypertension). Please note I have not seen your MRI myself. I would advise you to follow up with your doctor. Continue to exercise and keep that blood pressure under control. Many patients after the age of 60 manifest similar changes in their brain MRI. Some of them may be age related degenerative changes. I would not worry about it too much.
Personal Regards,
Nitin Sethi, MD
Hi Dr. Sethi
Excuse me in advance for the english, it’s not my mother tongue (i’m Italian).
I’m 23. My unknown-illness starts about 3 years ago, a morning, with light dizziness that started almost suddenly. Vestibular testing was ok. Meanwhile, this dizziness and other symptoms i’ll describe, made me an extreme hypochondriac. I’ll write down every and each thing I’ve experienced (I wrote them on notes)
Dizziness evolved to the point where I have to have near visual cues to know where I am heading and where my arms are, or else I’ll feel like I am without the sense of self-percpetion in space. I also always feel like every part of me is oscillating at the same exact rate of my heartbeat, esp. when I close the eyes. If I look at a wall closely, based on what my foot tell me, after a bit it will seem like the floor is moving. I also have a kind of visual fatigue when I’m in malls with all those lights and people moving around, I feel my thought slows down.
Speaking of eyes, I see visual noise in the peripheral field always when looking at the sky, of a sparkling-white-dots type, much like falling stars. I sometimes have a flickering vision too. I also noticed that if I exert sustained force on my neck (ie when looking at my armpit), after a bit I can distinctly see and focus bright dots, slowly moving and coming in my central field of view, lasting about 10 seconds.
Speaking of ears, on 2 occasions I had a slight temporary lowerment of hearing in my right ear, lasting a week. More frequently and in both ears, I have bouts of tinnitus that suddenly start and end in 10 seconds or so.
Anyway in May 2008 I had myself examined by a neurologist and the outcome was all clear. She prescribed an EEG (all clear) and a MRI.
In July 2008 I had a very high fever (max 105°F) with strong neck pain and twice a scotoma in the eyes (i think) with flashing light, but without any cognitive impairment or tiredness. I report here bcause it may be linked, who knows.
That summer, tremors started in most of my muscles. My finger motion was clunky, and fine finger control weared off. Trunk shivers vigorously when I try holding it halfway up while laying flat. These tremors are still there maybe got a little softer, and I got used to them.
In October 2008 I underwent the MRI and the outcome reads: “various small hyper-sensitive areas in long-TR sequences, different in sizes, found bilaterally in frontal regions – some are aligned to vascular structures. can not exclude a demyelinating form or a vasculitic pathology (immune-mediated?)”.
Fast-forward to now, and starting a week ago, my legs are feeling tired and always in need of a stretch, like when you wake up in the morning, and my arms are exhausted very quickly, and I find them very tired right after just getting up and washing my face. I don’t think they are weaker – I can still jump and touch the rooftop on my room with ease – but this makes me very depressed and willing to go to bed again and do nothing for the rest of the day.
Now I’m going back to the neurologist on july 13 – a long pause, but I couldn’t find energies for confronting her again, after the MRI. I fear being sick of a progressive illness that’ll constrict me on a wheelchair in 10 years or so, be it MS or whatever. For now I still think I have a life to live and hope to do the same after july 13.
Many many thanks again and sorry for the longest comment of the post, I never met a blogger who is aware of his readers and commenters for more than a few days!
Dear Enrico,
thank you for writing in. Your history is long and complicated. It seems you are having a combination of vestibular, visual and motor symptoms. I shall not attempt to diagnose you here as I have neither taken a history myself or have had the privilege of examining you. The MRI report though does raise a red flag (taking your young age into consideration). I shall advise keeping your appointment with the neurologist on July 13. You may or may not warrant further testing to determine the exact etiology of your symptom complex.
Do not get depressed. Follow with your doctor and take it one step at a time. My best wishes remain with you.
Personal Regards,
Nitin Sethi, MD
Thank you so much for answering.
If you have some time to spare I can send you in (at your email) my MRI images in a digital format, when I’ll be back at home.
I certainly don’t want a diagnosis from you, who shall be a very busy person, but would like only to know if you can find those spots. I tried hard, but I couldn’t find any white spot in any scan.
Thank you another time…
Dr. Sethi,
A couple months ago i had optic neuritis so the neurologist set me up to get a mri. The results came back and she said i had multiple white matter lesions and that i most probably have ms. Could the white matter lesions represent anything else other tan ms? I’ve had causes of migraines for a long time.
Tammy
Dear Tammy,
as I have stated in my posts, white matter lesions on MRI can have many causes and have to considered in the context of the patient’s history and examination findings. There are also specific MRI criteria for diagnosing multiple sclerosis (based on the number of lesions, the size and location of lesions in the brain and spinal cord).
Personal Regards,
Nitin Sethi, MD
Dear Dr. Sethi, It’s been awhile since we last corresponded but I wanted to update you on my journey. In a nutshell, over a course of about 5 years, I have had the following symptoms- ON 4 times, bladder incontinence which comes and goes, fatigue especially when stressed or hot, left sided numbness which has never completely resolved, vertigo which comes and goes, nerve pain in back which spreads down back, arms and legs, eye/headache pain which comes and goes. After 4 MRI’s, last one with contrast, I have no signs of demyelinating disease, again not a spot even for my age which is 49. I visited my neuro again the beginning of July and she is 99.9% certain that it is MS. Perhaps I am one of the 5% who have no signs of lesions for years. We spoke about an LP which she is hesitant to do because I recently tested positive for a genetic blood clotting disorder and thinks at this time it is too invasive and I agree. We also talked about DMD’s and both agreed that we shall put those on hold for now and perhaps see how the oral meds do once on the market.
I am not happy about the outcome, of course, who would be!! But like my Dr. said, it’s nice to know that I am not crazy. Both my GP and Neuro have been very supportive through this and have let me know that I am to contact them should things not feel right or I if I just have a question. I feel blessed to have them and wish that everyone could be so lucky.
Thank you for your time, and thank you for helping so many who are still looking for answers.
Very Sincerely,
Connie B
BC Cananda
Dear Connie,
it is a pleasure to hear from you again. Thank you for updating me on your history. It seems you are indeed passing through a rough patch but I am happy to know that you have some people you can lean and depend upon. MRI negative MS is not so common and most people should show evidence of demyelinating lesions on the brain MRI (especially if they have had multiple clinical attacks suggestive of MS).
A few pointers which you may consider discussing with your doctors on your next visit. Did you have a VEP test and did it actually show evidence suggestive of optic neuritis. Do you have optic neuritis in both or just one eye? Did they image your spine and lastly was testing for neuromyelitis optica / Devic’s disease carried out?
Again my thoughts and good wishes remain with you.
Personal Regards,
Nitin Sethi, MD
Hi Dr. Sethi,
In response to your questions.
“Did you have a VEP test and did it actually show evidence suggestive of optic neuritis.”
My doctor is scheduling me for a VEP. I have no idea when this will occur.
” Do you have optic neuritis in both or just one eye?”
I have only had ON in my left eye however I do have days when both eyes are extremely painful when I move them and very sensitive to light.
“Did they image your spine and lastly was testing for neuromyelitis optica / Devic’s disease carried out?”
My last MRI was of my brain and spine with contrast. My doctor said that they have tested me for anything else it could be so I a presuming that would include a test for neuromyletisis opitica.
I will be discussing the neuromyletisis optica at my next neuro appt.
Once again, thank you so much for your input and swift response. I shall keep you updated.
Sincerely,
Connie B
Dear Dr. Sethi,
I have been reading through these posts with great interest. I have had two MRI’s with contrast for possible MS, one in 02′ and one in Nov. 08′. Both were interpreted by the same neuro, whom I have also been sent to twice for possible RSD diagnoses, including Nerve conduction studies. All have been negative. The exam before the MRI was even negative for MS in Nov. 08′, but he gave me the MRI any way, as a foot surgeon was insistent I have it before surgery. My scan came back with lesions that the neuro explained orally (haven’t seen the report) showed evidence of migraine (which I really don’t have). I have been diagnosed with an IGg deficiency, but am in the process of being tested further, as I developed a bad cryptosporidium infection that lasted for several months while recovering from foot surgery. During this infection, I developed severe pain in my right shoulder and neck, but my pain doctor couldn’t help because I was too weak. I have been experiencing hand tremors for two years, and have been experiencing facial twitches for the past year. I have problems writing, sometimes speaking (I say the wrong words), extreme fatigue, and balance.
Please tell me if I need to see another neurologist. I am going to see a new DO next month as he won’t send me to a different neurologist and has misdiagnosed me for years. My pain doctor feels I have some sort of muscle problem, related to the immune system.
Any help is appreciated, as I have seen too many doctors, and yet my symptoms are slowly growing worse, and the cryposporidium infection was very dangerous.
Thank you very sincerely,
Krys P, Iowa
Dear Krys,
thank you for writing in. I shall not attempt to diagnose you over the Internet since I have neither examined you nor have had the privilege of taking your history. Your history sounds complicated and my advise is that you follow up with your doctor and request him to send you for a second opinion. In that way, communication between your various health care providers shall be maintained.
Personal Regards,
Nitin Sethi, MD
10 years ago upon waking I discovered I had double vision. I saw my dr who advised me to rest. After 10 days my vision cleared and I was sent to see a neurologist. He sent me for evoked potentials all of which i passed. My MRI was loaded with white matter lesions (neurologist said he was frightened for the number and size of of them) and I was diagnosed with probable MS. Further testing was requested to verify definite MS. After redoing the MRI with contrast, the lesions were seen again and so was a pituitary tumor. This tumor was ignored. In terms of size the tumor was 7 mm and slightly overlapped the pituitary.
I have had two additional bouts with double vision. Each time it was oblique double vision and vanished when I looked in a different direction. Each lasted less than two days.
At year number 5 , it was discovered I had hyperactive thyroid illness. This has by far caused me the most grief. I was also told my blood clumped too fast. Not sure what they meant by that?
I have yearly MRI’s for doctors are monitoring the tumor. With each MRI more and more lesions are seen yet I have no symptoms of MS at this point. At what point can I safely relax and not worry about MS? This will be year #11. I have no problems walking and still have no symptoms of it.
Can depression cause white matter lesions? I know I have been depressed for a number of years. Not taking anything for it.
Thank you for your time,
Grace
Dear Grace,
thank you for writing in. Your history intrigues me and I wish I had the benefit of looking at your MRI scans by myself. I am also not certain what to make of your transient symptoms of double vision as many disease including thyroid opthalmopathy can present with visual symptoms. Pituitary tumors too at times can present with visual problems (field cuts).
–I would do the simple things first–make sure your thyroid status is normal (meaning that you are euthyroid). Was a MRI of the spine done? Was a spinal tap carried out? All these shall help to rule in or rule out MS.
Personal Regards,
Nitin Sethi, MD
No Dr. Sethi an MRI of my spine was never done — I would welcome it as I have a herniated disc. Spinal tap never done.
I have been asked several times if I was on blood thinners.
Dark shadows consistently are seen on my MRI films. What does that mean?
Of what importance is Rouleaux? I consistently have Rouleaux reported on blood draws?
You are a very kind doctor for helping people.
Grace
06/08/2009
Dear Dr. N.SETHI,
On 6th July’2009, my son was found playing computer games with his left hand. Generally, he uses both his hand for playing games. On being asked for reason, his answer was- not getting enough strength in right hand & feeling the same for the last one month. In school also, writing speed got slow. His age is 15 Years & studying in class 10. There is no case of abnormality before the said period. Consulted neurologist on 7th July’ 2009. Doctor advised for MRI.
MRI REPORT OF BRAIN
SEQUENCES: SE T1-Axial, Sagittal
FSE T2-Axial, Sagittal, Coronal
Axial-GRE, FLAIR, DWI
Findings:
Hyperintense signal on T2 WI is seen in white matter of left motor cortex, posterior part of left corona radiata, posterior limb of left internal capsule, left crus cerebri, left sided descending pontine fibres and in left pyramid.
Hyperintense signal on T2 WI is also seen in posterior part of right corona radiata, small part of right sided posterior internal capsule & right sided descending pontine fibres.
Posterior temporal white matter shows linear Hyperintense signal on FLAIR lateral to lateral ventricles.
Coronal T2 WI shows Champagne glass sign.
Cerebellum is normal;
Pituitary gland, sella & parasellar structures are normal;
Orbits appear normal;
Paranasal sinuses appear normal;
Skull vault & scalp appear normal.
IMPRESSION:
Imaging feature suggests the possibility of Amytrophic Lateral Sclerosis with bilateral pyramidal tract involvement; more on left side.
Advice: Clinical Correlation
After going through the MRI report, Neurologist diagnosed the disease as ALS / MND. Also requested us to take second opinion.
Second Opinion:
Consulted another Neurologist on 23rd July’ 2009, who ruled out the possibility of ALS / MND, but suspected “Juvenile Krabbe”, & only be confirmed after getting the blood report. Blood report expected on 27th August’2009. The MRI report of “Second Neurologist” is- White matter signal changes in bilateral posterior limb of internal capsule, subcortical & pontine region. If blood tests comes negative, then other types of blood tests neds to be carried out.
Getting Confused.
Would request for your valuable advise.
With Highest Regards,
Yours Truely,
Pranab Chakraborty
Dear Mr. Chakraborty,
thank you for writing in. I shall not attempt to diagnose your son’s case over the Internet since I have not examined him nor seen the scans myself. There are a few points of singular interst though–
1. He was developmentally normal and then starts regressing around the age of 15.
2. MRI scans shows white matter changes–are they symmetrical or asymmetrical. Are the subcortical U fibers involved?
ALS/ MND is not a disease of childhood. It rather starts off in the late 40’s or 50s. Moreover it presents clinically in a different way. I would tend to lean towards the second neurologist’s opion and aggressively search for a leukodystophy such as Krabbe’s disease (white matter disease).
Luckly we now have biomarkers for most of these diseases (blood and gene markers). I hope this helps you out.
Personal Regards,
Nitin Sethi, MD
Dear Dr. Nitin Sethi,
Many many thanks for your reply & valuable advice. Just I am waiting for the “Blood Report”. The text of blood report is produced below-
A) Assay for leukocytes galactocerebrosidase enzyme (Krabbe Disease)
= 16.3 nmol / 17 hr./ mg.
(Range in normal subject(n=46): 18~84 nmol/17 hr./mg.
Mean : 33.24 nmol/17 hr./mg.
Patient Range : 0~6.0 nmol/17 hr./mg.)
Comments: The value of Galactocerebrosidase Enzyme is towards lower side of the normal range but not in defficient range.
B) Report of “Plasma Total Lipid Very Long Chain & Branched Chain Fatty Acids”-
All unit is in ug/ml.
C26:0 Hexacosanoic- 0.290; C26:1- 0.160 ; Phytanic Acid- 0.500 ; Pristanic Acid-0.050 ; C22:0- 15.16 ; C24:0- 12.55 ; C22:1 (n-9)- 1.430 ; C24/C22-0.828 ; C26/C22-0.019;
Interpretation- Normal Results.
Above is the 02 nos. blood report which I have received on 12 th. September’2009.
Would request for your valuable advise.
With Regards,
Yours Truely,
Pranab Chakraborty
Hi Dr Sethi,
always interesting to find a site where lots of people have similar problems and are wondering where to look next for the answers.
Me, well I am a 39 year old female. History:
PCOS – 2 children post lap ovarian diarthermy
ANA 1:1280 in 1999 no other diagnosis given other than fibromyalgia
reactive lymph node removed 1999
2003 autoimmune thyroiditis,
various ‘flare ups’ of aches and pains over the years,
2009 April, vertigo, dizziness, neuropathies, pressure type headache, fatigue, altered mental capacity ( unable to concentrate and focus on work. (Imaging technologist) ) very irritable, sleepy and exercise capacity diminished.
normal CT scan,
sent to Neuro, MRI with and without. Multiple foci in deep white matter frontal lobes non ehancing suggestive of demylenation, vasculitis, migraines etc
blood work, all normal except ANA 1:360 and ACE elevated,
Neuro said to go to Rheumatologist, possibly sarcoidosis.. does not look like MS.. except I have to wait till next year to get into the rheumatologist… worried about neurosarc, can’t imagine any of the other causes of elevated ACE, i.e Hiv, leprosy, TB, lymphoma, gauchers, wegeners.
I know more tests will be required, just don’t believe I should have to wait so long. If this is vasculitis, is there a risk of stroke? My mother died at 66 after a stroke and severe lung problems, she also had autoimmune diseases.
Thanks for all your thoughtful insights
Regards
Tracy
Dear Tracy,
thank you for writing in. As I have stated in my post and in previous questions I have answered not all white matter lesions in the brain represent multiple sclerosis. The differential diagnosis is broad and other inflammatory, autoimmune and connective tissue diseases need to be ruled out. These include vasculitic conditions such as neurosarcoidosis. Sarcoidosis is usually a multi-systemic inflammatory condition–the lungs are commonly involved. That said and done sometimes the inflammatory response may be limited to the central nervous system. When sarcoidosis involves the central nervous system, it is referred to as neurosarcoidosis.
Neurosarcoidosis is not a common condition though. The symptoms which plague you are quite non-specific and do not localize to any particular part of the central or peripheral nervous system. It should be easy to rule out or rule in sarcoidosis as the diagnosis in your case. Sometimes we need to resort to biopsy of a regional lymph node or the lung.
You are right when you worry about vasculitis causing stroke. Usually though the presentation is quite different from that of a typical stroke. Patients who have active vasculitis are quite sick. They may have other systemic signs such as fever.
My advise remains to follow up with your doctor. Hopefully you can be seen earlier. I send you my very best.
Personal Regards,
Nitin Sethi, MD
Greetings,
I had an MRI done because I had a glomus tumor in my ear.
The report came back: White matter lesions noted with one focus possibly in the corpus callosum strongly raising the possibility of a demyelinating process. My ENT didn’t bring up the subject. Other than the ear symptoms, I feel healthy. Should I be concerned? Thank you.
Dear James,
thank you for writing in. While I doubt you have MS, the best advise I can offer is to bring this report to the attention of your PMD. He may or may think it is necessary to seek a neurologist’s opinion for the same.
I wish you the best.
Personal Regards,
Nitin Sethi, MD
Dear Dr. Sethi,
I had twitching in my eyes since jan 09 which did not go away till april , so i was advised an MRI . Mri showed lesions on white matter later twitching spread to other body parts too, clinically no neurolgical disease was found . I had low levels of vitamin B 12 which was 150 and high triglyciede levels 363 . Now viatmin b 12 is back to 650 as i took vitamin b 12 supplements but triglycide levels are still high. Now it is september my eye twitching was reduced alot by vitamin b12 supplements but still some twitching is left in body which keeps on increasing or decreasing , dont know why it happens off lately i sometimes feel needle sensation or buzzing kind of sensation in feet or hands. Can lesions be because of high triglycide or low levels of vitamin b 12 as i had. What could be causeing twitching or needle type feeling or buzzing ??
Dear Gautam,
thank you for writing in. Low levels of Vitamin B12 can cause a myeloneuropathy (now what does that mean?). Well low vitamin B12 can involve those tracts in your spinal cord that carry the sensation of vibration, position sense, light touch and joint sense. Low vitamin B12 can also cause a neuropathy–this may present with numbness and tingling in the feet.
One needs to determine what is the cause of Vitamin B12 deficiency and then rectify it. High triglyceride level on the other hand can increase your risks for strokes and heart attacks..
Personal Regards,
Nitin Sethi, MD
Hi Nitin Sethi,
Your web-site is phenomenal. I am a 27 year old male presenting with what neurologists may term a CIS (Clinically Isolated Syndrome) for MS. MRI indicates multiple punctate lesions within the subcortical white matter. They are non specific but “too numerous” and abnormal for age.
My initial symptom that drew me to an MRI was a bought of dizziness approximately 2 years ago after consuming a large quantity of alcohol. I felt a slight jitter in my eyes that had resolved thru time.
Apparently this places me at high risk of conversion to MS. However, genetically, I am Indian, and the rate of conversion (at least in literature) seems to indicate approximately 80% conversion over 15+ years to MS.
My question is, are these research results outdated? Is it possible that white matter lesions are more common than what is currently presented in literature? If so, is it possible that this 80% conversion rate (published and very often cited in the New England Journal of Medicine) is actually much less?
I find research results on this topic very vague. Considering this may be considered as “pre-symptomatic” MS, I am questioning whether there are a lot more that actually may be in my boat than one may assume.
Many thanks,
Jagdeep
Dear Jagdeep,
thank you for writing in to me and thank you for appreciating the blog and website (http://braindiseases.info). You ask a very valid question. What is the rate of conversion of a CIS (clinically isolated syndrome) to CDMS (clinically definite MS).? Over what period is this conversion?
Well it is indeed hard to prognosticate patients who present with a CIS (usually by a CIS, I mean an attack of optic neuritis. Your presentation on the other hand was rather non-specific–dizziness after a bout of heavy drinking). If a patient presents with a CIS and his/her MRI shows multiple white matter lesions (plaques) suggestive of demyelination or the spinal fluid is positive for oligoclonal bands and myelin basic protein or the evoked potentials come back positive, well then indeed a majority of them shall progress to CDMS (some doctors may argue that they already have CDMS–as per Mc Donald’s criteria and warrant treatment).
On the other hand if the patient presents with a CIS, but the MRI of the brain and spinal cord shows no lesions, spinal fluid and evoked potentials show no evidence of demyelinating pathology–then it becomes hard to prognosticate. Some of these patients may never progress to CDMS while others may.
I hope that shed some light on your query.
Personal Regards,
Nitin Sethi, MD
Thank you for your response.
My spinal fluid is negative and evoked potentials are also negative. MBP negative.
Your response doesn’t seem to address my question. Perhaps I can ask differently. Given my genetic background, given the small sample set of all of the studies trying to predict MS, and given the situation I presented above, does it not seem logical that the published rate of conversion could be incredibly wrong?
Something doesn’t seem right here. Perhaps this publication can shed some light on my confusion: http://www3.interscience.wiley.com/journal/109680538/abstract .
This UBC publication mentions the rate of incidence in the South Asian community to be less than Caucasian, where Caucasian prevalance is 64.7/100,000, compared with South Asian at (15.7 from a population of 114,355).
Now, I have two close South Asian friends (one male, one female) that happen to show white matter lesions on MRI presenting with optic neuritis in this region.
Step back and think about this for a moment – Is it all a coincidence? Or are we all belonging to the 15.7 who may happen to have MS?
Dear Dr. Sethi,
I can’t tell you how much I appreciate your time and effort you dedicate to answering total strangers questions to help alleviate some of their concerns.
Sorry for the long message, but I am hoping you can help shed some light on my situation. About 2 years ago, I woke up with eye pain in RIGHT EYE, blurriness, and saw hundreds of small round shapes in my vision and a feeling like pressure behind my eye, and a constant feeling like some thing is always stuck in the eye. A retinal specialist said I had a vitreous detachment. Fast forward 2 years, and all my eye symptoms are still there.
3 months ago, I went to my internist complaining of MAJOR dizziness. This is the feeling of a lightness in the head, and is constant 24/7. It is very strong, but the room does not spin, and the dizziness is there regardless of whether I am moving, sitting, or lying down. The doctor said it was an inner ear infection and should go away in 4 weeks.
I have also been having extreme fatigue, where it is difficult to even do simple tasks. I work out at a gym so I am used to pushing my body hard during my work outs, but lately even simple chores are hard. I have insomnia which makes this more complex.
Finally went to neurologist and she diagnosed Nystagmus, and ordered a MRI w/wo contrast.
The tell tale Findings show : flair sequences show several ovoid abnormal foci of hyperintensity in white matter. abnormality noted in peritrigonal white matter extending into centrum semiovale on both sides. On left side, several ovoid lesions that are oriented somewhat perpendicular to ventricle. Right side shows a dominant large lesion in centrum semiovale. No other lesions are identified. No focal abnormality in occipital lobes or brainste. Cerebellum is unremarkable.
No evidence for abnormal enhancement following contrast administration.
IMPRESSION: there are several nonenhancing lesions in the periventricular white matter as described above. Although lesions are nonspecific the appearance could be consistent with demyelinating disease such as MS.
Whew! My questions are these, why are there no indications of sizes of lesions in this report, is this common or necessary? My neurologist wants to do another MRI of spine and more lab work. I am freaking out about another MRI, would an open MRI give sufficient results at this point? Is MS likely, after reading MRI results, or could this possibly be related to the vitreous detachment getting worse and fatigue is from lack of sleep?
Thanks so much for your time.
Helene
Dear Helene,
thank you for writing in to me and thank you for your kind words. Let me answer your questions. Your clinical presentation was with non-specific signs and symptoms. The MRI shows white matter lesions which are again non-specific. I have not seen your MRI scan myself. Only your doctor shall be the best person to determine if the MRI findings when correlated to your clinical history and presentation have significance or not.
An open MRI does not give the greatest quality images, so my advise would be that if you have to go through a MRI why not just take the better quality one so that the images are good and need not be repeated again. My advise would be to follow up with your neurologist. With the aid of some simple tests one would be able to determine if you indeed have MS or not.
I wish you my very best.
Personal Regards,
Nitin Sethi, MD
Dear Dr. Sethi,
Thank you for your reply. I do have one more question if you wouldn’t mind answering, since I have some updated lab results. My C-REATIVE PROTEIN, CARDIAC was 6.19 (standard for my lab is 0.00-3.00 mg/L), my ANTINUCLEAR ANTIBODIES DIRECT were positive, my ANTICARDIOLIPIN AB, IGM, QN was 37 (standard range 0-9MPL U/ml) my T4, FREE (DIRECT) was 1.73. All other lab work was within normal range. I read T4 can go up after contrast MRI’s.
If legions do show up on MRI spinal cord and neck films which I will get this week, then with the legions I have in brain (confirmed Dawson’s thumb by doctor) (please see previous posting describing MRI brain scan) is that information enough for a definitive diagnosis for MS. I was told I might also need a CSF, but I am TOO SCARED of what can go wrong during and after this procedure, even though I know that the odds are slight and DO NOT want to go through that.
I am scheduled for a VET in a few weeks too.
many thanks,
Helene
Dear Enrico,
you are very welcome. You can email me the MRI images at neurologistnyc@yahoo.com and I shall be happy to have a look at them.
Personal Regards,
Nitin Sethi, MD
Dear Connie,
thank you for replying back. Feel free to write in again and if you have any specific questions with respect to your case, I shall be happy to answer them.
Again my very best to you.
Personal Regards,
Nitin Sethi, MD
Dear Grace,
thank you very much for your kind words. Not sure what you mean by dark shadows on the MRI film. If you could be more specific, I might be able to shed some light on that.
Rouleaux is a term used in hematology. Basically refers to when red blood cells get stacked on top of each other. It may or may not have any significance to your case.
Personal Regards,
Nitin Sethi, MD
Dear Jagdeep,
thank you for writing in again. Let me answer your question in a different way. I trained and worked in India before I came to the US. For years neurologists in India thought that MS was a disease of the western world. That MS rarely occured in the Indian population. Why did we think that way? Well because we were not seeing MS patients in our practice. Rarely would a MS patient walk in through your door.
Now the situation in India is changing and we see more patients with MS. Why has this occured? Is MS becoming more common in India. If yes then what is the reason? Is it the changing lifestyles? Is it the dietary changes or is it that now with more sophisticated imaging available we are just identifying more cases which earlier went undiagnosed.
No one knows the answer.
Personal Regards,
Nitin Sethi, MD