MRI white matter lesions: does it represent MS?

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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270 thoughts on “MRI white matter lesions: does it represent MS?

  1. 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

  2. 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

  3. 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?

  4. 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

    • Hi – I could have written that! EXACTLY as I have experienced but getting fobbed off with migraine and as far as I know discharged from Neurologist list as I had no brain at appointment and couldn’t remember any of my relevant problems. I try not to visit GP as they only prescribe meds to try and I wont take them until I know why I have all these problems! Now diagnosed wihttp://braindiseases.wordpress.com/wp-admin/edit-comments.php?comment_status=moderated#comments-formth CFS :( White matter hasn’t changed a year between my scans!!

  5. 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.

    • @Robin , hello your story / symptoms sound so much like myself . My mri resulted from severe pain in the right side of my brain and waking up to the entire left side of my face sagging and incredible weakness on the left side of my body . Yes there were white LIL spots that showed on the mri . Shortly after this I began to experience bouts of paralysis from my neck down.
      I began treatment for M.S but had stopped because 9 months later another neurologist performed a lumbar puncture and ruled out M.S.
      The attacks continue daily and I have several other symptoms such as complete numbness throughout my entire body and head neck ect .. Loss of control with bladder and even bowels at times. I am 47 yrs old and after a yr of this I am incredibly afraid . I hope that you do not have to suffer this long because you are just too young and have yrs of life left . Good luck and god bless you and best regards to you from …
      No diagnosis in Missouri

      • I have similar issues, my Vit B12 is 230 normal but 10 percent of people have symptoms with this low normal, in Japan they use the cutoff 550 here in the US 190, that may be why less alzheimers in japan. check yourself closely for vit b12 deficiency, mimiks MS toatally, including mro lesions, but vit b12 shots are a simple fix, I take sublingual methylcobalamine spray in addition, many folks with MS also have vit b12 defieciency, many are misdiagnosed.

  6. 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.

  7. Dear S,
    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

  8. 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)

  9. Dear R,
    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

  10. 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…

  11. I would say get the MRI done R. 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

  12. 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.

    • I am not a doctor…31 year old female…I personally have had many health related issues lately, and an MRI scan that indicated flare hyperintensitity in four areas in my brain within the white matter. Doctors are running many tests to find out what the issue is as I have experienced dizziness and numbness…tingly sensations. I recently stopped taking the medication Singulair due to side effects…you may want to look up all your medications and check drug side effects as well. I had to stop taking that medication because I was having so many of the side effects. I wish you well.

    • I am intrigued by your post. I am 34 and share a lot of the symptoms that you describe I have dealt with for many years. I just recently got an MRI done both with and without contrast. They found about 5 white areas in my brain. It was explained to me that there are a ton of things what this could signify. It could be nothing or it could be sign that something is amiss. The next step if I choose to take it would be a spinal tap to help clarify the results better. I share many of the same symptoms dizziness/unbalance, tremor in my right hand, massive headaches, fatigue, I get the tingling and numbness along with stiffness and just overall pain in majority of my joints, mental fog, I struggle with regulating my thyroid if I don’t take my supplements and I have pain in my left eye that started after a bout of sickness that’s going on 4 years now. Now I’m not complaining it’s just frustrating not understanding what’s happening to your body of course depression and anxiety accompany this and I struggle with IBS which I have had for years. I do believe that stress has been a heavy contributor to whatever is ailing me…sometimes mentally we can’t cope with certain things in our life so it manifests in our body attacking itself. I don’t know what the answer in how to solve this is…One thing is changing the way I live my life…I have a decision to make whether to continue to try to fight to find out what’s wrong or just accept what cards I have been dealt and move on. You get tired of not feeling well but I refuse to be a victim of these symptoms and try not to let define me as hard as it is at times to work through it. I hope everyone struggling with similar things will be able to care for themselves as best as you can and good luck in your journeys. “C” I would like to hear back from you if you continue on with your testing if you are able to find anything conclusive to the symptoms you have had. Good luck to all!

  13. Dear C,

    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

  14. 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.
    R

  15. Dear R,
    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

  16. 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

      • hi Dr Sethi,

        Yes I was diagnosed w/ severe b12 deficiency and know of the symptoms first hand. The neuro issues take a long time to recover from. I am into around 4 months of recovery and still run into issues. My issues were severe all body wide twitching, internal tremors and lightening shocks in my hips down my legs. I was also diagnosed w/ restless leg syndrome. We found out afterwards, that this was due to the b12 deficiency.

      • I am still having issues with twitching as well as a tremor in my left lower and upper eyelid (this issue is the most stubborn, it is in its 6th month now). I am on very high doses of both sublingual and IM injection therapy with methylcobalamin and sublingual adeno. The neuro issues seem to take a very long time to heal. I am always concerned that it could be some other neuro issue since I do still have neuro issues. However, they have improved signficantly during the last 2.5 months of intensive treatment (supplementation). In your experience, how long do the neuro symtoms take to heal? I suppose it varies from individual to indivdual. I also encounter balance issues as well, sporadically.

      • In my experience, at times you have to supplement Vitamin B12 for life. The usual dose is 1000 micrograms intramuscularly once a month (but please check with your treating physician regarding the exact dose for you).

        Personal Regards,
        Nitin Sethi, MD

  17. Dear L,
    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

  18. 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

  19. 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

  20. 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

  21. 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,
    T

  22. 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

  23. 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.

  24. 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.

      • Thanks. The tongue inflammataion/rash is very specific to b12. I hope that the patient has found out what the problem was and if not, that we can somehow contact the patient to find out if b12 has been ruled out.

      • Thanks Dr. Sethi.

        Quick question. I did have thoracic, cervical and brain MRIs done. There were no white matter lesions. There was a partially empty sella, but subsequent hormone blood level testing looks fine (I am hypothyroid, but that runs in our family). The other finding was :

        MILD PROMINENCE OF THE EXTRAAXIAL CSF SPACE IN THE VERTEX MAY REPRESENT EITHER NORMAL VARIATION OR MILD ATROPHY. NO DEMYELINATING/INFLAMMATORY WHITE MATTER CHANGES ARE EVIDENT

        I did read your paper on
        Deficiency of vitamin B12 causes cerebral atrophy

        http://braindiseases.info/vitamin_b12_for_dementia

        My neurologist is not concerned as I do not exhibit any dementia. My question is, if the atrophy is mild, is it possible that it can be reversed over time with the therapeutic mega dosing of methylcobalmain that I am on (both injections and subcutaneous oral therapies).?

        I also recommend the active form of b12 be used in all therapies, oral, subligual or injection. The research on methylcobalamin’s benefits over cyano or hydroxo, in healing the neuro damage done by extended b12 deficiencies (and even as a therapeutic agent for other neuro disorders) is there. In particular with the Japanese research.

  25. 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, S

  26. 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

  27. 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.

  28. 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

  29. 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.

  30. 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

  31. 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!

  32. 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

  33. 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

      • Dear Sue,
        thank you for writing in. CADASIL is a not so common cause of white matter lesions in the brain. It is a leukoencephalopathy which involves the blood vessels of the brain. You are right when you say that patients usually give history of migraines, strokes and cognitive (memory) problems. There is a genetic test which can be carried out (NOTCH 3 gene) and helps to differentiate CADASIL from other leukoencephalopathies and diseases such as amyloidosis.

        Nitin K Sethi, MD

  34. 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.

    K

  35. 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

  36. 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

  37. 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)?

  38. 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

  39. 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.

    • 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

  40. 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?

  41. 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

  42. 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

  43. 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

  44. 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,
    C

    • 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

  45. 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,
    C

  46. 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

  47. 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,
    C

  48. 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

  49. 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?

  50. 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

  51. 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.
    C

    • 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

  52. 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

  53. 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,
    C

  54. 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,

    • 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

  55. 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

  56. 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

  57. 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

  58. 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.

  59. 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

  60. 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…

  61. 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.

    • 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

  62. 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,

    • 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.

      • 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

  63. 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,

    • 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

  64. 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,

    • 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. :)

      • 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

  65. 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.

    • 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,

  66. 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

    • 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

  67. 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

  68. 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

  69. 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,

    J

    • 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 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

  70. 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.
    H

    • 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

  71. 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,

  72. Dear Dr. Sethi, This question is about my daughter who was 14 at the time. My daughter has always been a good student until the 7th grade when she began having problems with drugs and her school work suffered. She was having dizzy spells when she got up quickly etc. She snuck out of the house one night, drank alcohol and passed out in the xxx.
    The long and short of it is that she had an MRI done and was examined by a nurologist who said that she was ok although he was worried about her falling grades. After drug rehab I was talking to the scool principal and he asked if she had a CAT scan. The head of the nurology dept reviewed the MRI and said further examination should be done.She saw a pediactric nurologist who said the CAT scan was ok but that she had multipal brain lesion and that this was very rare. Another MRI was done with no change. The doctor sent her to Mayo Clinic The whole situation was very upsting and we found out what it wasn’t. It could have been an injury, they knew it was not MS or anything that they could test for. Tey tested for everthing which they could test for. I’ve always thought it could have been drugs or huffing.
    My question is should I continue to try to find out what these lesions are. Are they affecting her school work and can they be treated. Mayo recommended yearly MRI but the upset to my daughter and wife have made that very difficult. Other than the poor grades and antisocial behavor she has no problems. Currantly she is on anti depresants.
    thank you for your respose. xxx (if possiable I would not want this published on the internet)

    • Dear XXX,
      I have removed all possible identification from your email to me. Thank you for writing in. I am not sure what plagues your daughter and what these lesions on the MRI scan represent. We shall have to rule infectious, inflammatory, toxic (could drugs be the culprit here?) and autoimmune pathologies. Did she have a spinal tap done to look at the spinal fluid?

      Personal Regards,
      Nitin Sethi, MD

  73. Hmmm, where do I begin? Bottom line, i would like to know if optic nerves and chiasm are supposed to be dimunitive. Also, I wouls like to know of any significance to ” two small abnormal foci of white matter disease and left frontal lobe, which may represent a microangiopathic process or small foci of demylination”.
    I have been seeing neuro- opthamologists for a year now for central vision loss bilaterally. They have been unable to give me a definitive diagnosis, but have been suspecting a mitochondrial disease. Any info you can give me is very appreciated. Thank you.

  74. Hi i’m wondering if you can shed some light on this for me, my partener finally went to our GP after i nagged him for a long time, for years he’s had dizziness when looking up, his hearing is awful in one ear after a silly prank when he was younger, he was on the hood of a car whilst it was moving and came off of it, his ear bled at the time and no he never went to get it looked at and for 10+ yrs his memory is terrible, silly things like a conversation he’ll forget and you have to remind him. After a long long time nagging at him he finally went to a GP and she arranged an appointment with ENT. Ent in turn sent him for an MRI, as far a s he knew all was well and he was discharged, yesterday we got a letter from Neurology with an apppoitment, i contacted our Doctor and she gave us a copy of the hospital letter, it says “There were hyper-intense non specific plaques detected in both frontal lobes” and that a referal to Neurology had been arranged. His apppointment is 3 wks away so he’s desperate to know what this means. Any help is greatly appreciated

  75. Hi i’m wondering if you can shed some light on my husbands situation, for yrs he has been having dizzy spells especailly when he looks up and some hearing loss in one ear. Many yrs ago (10+) on a drunken night out was on the bonnet of a moving car he fell off hitting his head and one ear bled, stupidly he never went to a GP to have himself checked, his memory is awful and can forget parts of a converation with moments you have to remind him. His blood pressure has been high (no meds) and he mentioned these problems to our GP after yrs of me nagging him! She sent him to the ENT department and they in turn sent him for an MRI, when he went for his appointment the specialist discharged him saying all was well. This wk we’ve had an appointment with Neurology with an appointment to see a neurologist. We contacted our GP and the receptionist has sent us the hospital letter. On it is that there was no space occupying lesions in his internal auditory meatus. Which is good. However it also says “There were hyper-sensitive non specific plaques detected in both frontal lobes” He has an appointment for 3 wks away but obviously is concerned it’s serious, is this something to be overly concerned about?.
    Kind regards,

  76. Dear Dr. Sethi,

    Your blog is very helpful and reading back on the posts it is refreshing to see someone so willing to give their time to answer peoples questions. I would like to ask you, in not too much detail, about symptoms and tests my mother(aged 50) has experienced. About a year ago she had a severe case of what was then diagnosed as Vertigo. It took about 3 weeks before she was fully recovered from this and she had 2 MRI scans at the time, both of which came up clear. Whether at the time this was poorly diagnosed or not I am not sure. In the last year she was experiencing other symptoms. These include not being able to sleep at night (She thinks she gets about 2-3 hours a night if she’s lucky) and weakness down one arm. This weakness effects her when lifting even small object or opening items. Another symptom is fatigue but I presume this is down to the simple lack of sleep?

    In the past month she has had another MRI done and this showed up white matter lesions. I don’t know if this helps but one of the areas where these lesions existed would effect her balance, bringing on the vertigo effect according to the neurologist. They said it was most likely due to poor blood supply to the area. Last week she underwent an ultra-sound around her neck to check the blood flow to the brain and this came out clear so the problem has yet to be found. Obviously she is getting worried about this, although trying not to show it. I apologies for my lack of technical detail as I’m not sure of the terms used for the tests she has had.

    I would greatly appreciate it if you could give me your input on this. For one thing, if the ultra-sound came up clear is the blockage or poor blood flow likely to be found in the brain itself? Is there any conditions that you could associate with the symptoms described above? With these symptoms should this matter be taken care of as soon as possible, presuming poor blood flow could result in something like a stroke?

    I thank you once again for taking the time to read this and hopefully responding. I know you can’t diagnose anything without seeing test results but I would be happy with any input you can provide.

    Thanks for your help,

    • Dear Anthony,
      thank you for your kind words. While I cannot diagnose what plagues your mother, there are a few points of singular interest. Determining the etiology of vertigo/ dizziness is always hard. The first thing one has to attempt is to determine whether the vertigo is central (coming from the brain/brainstem) in origin Vs whether it is peripheral (coming from the ear) in origin.
      While vascular disease can cause vertigo in the elderly–we call this vertibrobasilar insufficiency, this is a diagnosis made based on clinical features, vascular studies such as carotid and vertebral artery doppler and MRI.
      Please feel free to write in if you need any further help.

      Personal Regards,
      Nitin Sethi, MD

      • Dear Dr. Sethi,

        Thank you so much for taking the time to reply. Once I find out more detail I will reply. As with most of the people in here I think the waiting is the difficult part. If people knew exactly what they had then they could begin to deal with the problem, whatever it may be. Hopefully it’s nothing too serious, I will keep you updated. Thanks again for the help,

        Kind Regards,

      • Dear Anthony,
        thank you for the feedback. Atrial septal defect, patent foramen ovale (PFO) and atrial septal aneurysm can at times lead to paradoxical embolism and resulting stroke. These congenital heart defects are usually detected by either a transthoracic ECHO (TTE) or a transesophageal ECHO (TEE) usually done along with a bubble study.
        I am glad they were able to determine the cause of your mother’s cryptogenic stroke. Once the defect in the heart is repaired, further strokes may be prevented.

        Personal Regards,
        Nitin Sethi, MD

  77. Just found this and there is great info.

    My situation began three years ago. (54 years old) I was always active, Type A, worked full-time and additional part-time. I fell forward on a tile floor, fractured patella. Since that time, I have had severe chronic pain in neck, arms, back, buttocks, both legs. It feels like a burning pain. I have become greatly weakened with extreme balance problems. I have frequent bouts of “brain fog” and I still have not been able to return to work. I had MS workup, negative a year ago. EMG normal. Was diagnosed with FMS, CPS, severe. I had brain MRI 3 months ago, Numerous foci of signal hyperintensityin the periventricular and subcortical white matter. Several of which have appearance to suggest possibilityof demyleiniation disease in the appropriate clinical circumstances.

    Now recommending LP, but still have not had good explanation for what this means. I just want my life back, I feel like I am missing so much with my family and feeling pretty desperate for some relief. Have taken Lyrica (450mg per day), only made me stoned, did not relieve pain, neurontin did nothing, Cymbalta-severely allergic, Amitryptiline-severe reaction, Welbutrin-severe reaction, Darvocet, severe reaction, Lortab-did nothing at all. Recently tried Savella, the worst reaction of all meds so far. Right now only Flexeril 10 mg 3 x day.

    Can FMS/CPS mimic MS and what does MRI mean?

    Thank you for your site and time to read this.

    • Dear Sally,
      thank you for writing in. I am uncertain what plagues you. In reply to your question, yes fibromyalgia and complex regional pain syndrome can mimic MS or rather I should say MS can mimic many other diseases in its clinical presentation. Usually though MS is not a “painful” disease–it may be characterized by fatigue and tiredness but patients usually do not complain of pain rather they complain of paraesthesias—numbness, tingling and other abnormal sensations. Please feel free to write in again.

      Personal Regards,
      Nitin Sethi, MD

      • Dear Brielle,
        Thank you for writing in to me. I agree with you the paresthesias in MS can be problematic and tough to treat since we have drugs available to tackle this symptom. Would you mind elaborating on your symptoms? I think it shall be very useful to other readers.
        Personal Regards,
        Nitin Sethi,MD

  78. hi..

    I am a 33 year old male, i had twitching in my eyes 9 -10 months back which did not go for 3 months, so my doc recommended a brain MRI. Later on twitching spread out to other parts of the body aswell. My Vitamin B 12 level too was low 150pg / ml.

    my lipids to were bad.
    LIPID Profile
    ® CHOLESTEROL 250.00 mg/dL 130 – 220
    TRIGLYCERIDES 351.00 mg/dL 50 – 150
    H.D.L. CHOLESTEROL 41.00 mg/dL 30 – 75
    L.D.L. CHOLESTEROL(DIRECT) 143.00 mg/dL 30 – 100
    SERUM VLDL CHOLESTEROL 70.20 mg/dL 10 – 30
    SERUM CHOLESTEROL-HDL RATIO 6.10 : 1
    SERUM CHOLESTEROL – TRIGLYCERIDE 0.71 : 1
    RATIO

    Here are the MRI findings

    MR imaging of the brain was performed and high resolution T 1 and T2 weighted serial sections obtained in the sagittal and axial planes. Contiguous fast flair images were also obtained in the coronal plane on a 1.5 Tesa scanner using a dedicated 8 channel phased – array surface coil. Intracranial MR angiography was performed using 3 D Time of Flight technique with MOTSA and the angiogram viewed in multiple projections . T 1 weighted serial sections were also obtained in the sagittal, axial and coronal planes after injections of intravenous (gadodiamide) .
    The patient has complaints of pares thesis and fasiculations
    The study reveals multiple small T2/ Fast Flair hyper intense focal lesions in subcortical and periventricular white matter of supratentorial brain parenchyma showing corresponding mild hypointense signal on T1 images. None of the lesion is showing any post contrast enhancement .
    No restriction is seen on diffusion weighted images . No focal area of signal alteration is seen on the corpus callosum. Remaining brain parenchyma is unremarkable . Bilateral basal ganglia . thalami and internal capsules are normal. No abnormal meningeal enhancement is seen.
    The cerebellum , pituitary and brainstream are un remarkable.
    The lateral, third. Fourth ventricles are normal in size, shape and position. The basal cisterns, fissures and sulci are normal.

    Intracranial Mr angiography reveal normal caliber and flow signal of bilateral intracranial internal carotid arteries. Bilateral anterior, middle abd posterior cerebal arteries are normal in course , branching and flow signal. Right vertebral artery is hypoplastic representing a normal variation. The visualized vertebrobasilar system is unremarkable. No evident AVM/aneurysm/flow limitation is seen.
    Opinion: Mr findings are suggestive of multiple focal non enhancing T2/ fast flait hyperintense focal lesions in supratentorial white matter. These are non specific in appearance and may representing demyleniating/ chronic ischemic foci. On comparison with previous MRI(done 4 months before this mRI) No significant interval change is seen .

    Now the situation is that Neurologists says that clinically i don’t have MS , but these lesions may be because of MS, which has really disturbed me.

    Can these lesions specify MS ?
    Can they be harmless througout ?
    Can these lesions be caused because of my Vitamin B 12 deficiency ?
    Can they be by birth ?

    Please give me your opinion on this?

    • hi, I am sure that Dr. Sethi will also reply. I also experienced a severe b12 deficiency and had twitching and tremors throughout my body prior to diagnosis and quite a time after that. The left eylid twitch is now in its 7th month. It subsides for long periods of time with the methyl b12 injection protocol that i am under. Lesions can be caused by b12 deficiency, and from what I have read, they can be reversed. I will let the Dr confirm this, or I can point you to the medical documentation that indicates this. I hope this helps a bit.

    • Dear Gautam,
      thank you for writing in. Well let me try to make some sense of your medical history. Your lipid profile is slightly deranged and your Vitamin B12 level was low. Your MRI shows multiple small white matter lesions, though the MRA shows normal blood vessels and hence no evidence to suggest vasculitis. First and foremost your MRI findings may be incidental (meaning that the white matter lesions may not be related to what made you seek medical attention in the first place namely the twitching in your eyes). That said and done, you are 33 and it is unusual to see white matter lesions at this young age.
      So this is what I advise. You need to follow up with your doctor and request him for a neurological opinion. You shall need a few additional tests to determine the etiology of these white matter lesions. Not all white matter lesions signify MS. As regarding Vitamin B12, yes low B12 level can cause white matter lesions.
      But you need further work-up to get to the bottom of what plagues you.

      Personal Regards,
      Nitin Sethi, MD

      • Dear Dr. Sethi,
        Thank you very much for your response. What kind of tests should i go through to determine etiology of these white matter lesions ? I have been told to repeat mri after 6 months. Few neurologists say that if it is due to MS, lesions will be seen growing in next mri, few say lesions may not increase. Still i am in limbo land.

  79. I am so glad I found this site. My husband (HE JUST TURNED 39) had an MRI on Dec.14th and we just recieved the results in the mail. He had symtoms of excruciatoing head pain during and following an orgasm, one time he litterally passed out. The pain was unbearable and he is unable to function for hours after. Also, he gets dizzy, numbness in hands, and when the doctor asked him to stand with his arms out and touch his nose he was extremely off on the left side. Theses are the results we recieved in the mail today 12/23…
    MRI/Brain without contrast
    Pulse Sequence: Sagittal T1 flash 2D, axial T2 turbo spin echo, T2 axial FLAIR, and axial diffusion-weighted images were obtained without contrast

    IMPRESSION: SMALL POLYP OR RETENTION CYST IN THE RIGHT MAXILLARY SINUS

    SEVERAL PUNCTATE HYPERTENSITIES WITHIN THE DEEP WHITE MATTER AND PERIVENTRICULAR WHITE MATTER, WHICH ARE NON-SPECIFIC. MAY BE DUE TO MIGRAINE HEADACHE OR VASCULITIS. DEMYELINATING DISEASE CANNOT BE EXCLUDED. CLINICAL CORRELATION RECOMMENDED.

    Please help me understand and make sense of this information. We have not recieved any calls from our doctor about this.

    Thank you so much

    • Dear Lisa,
      thank you for writing in. As I have stated in my post, not all white matter lesions on the MRI scan indicate multiple sclerosis. In the case of your husband, they may signify small vessel ischemic disease (we also refer to this as white matter disease–basically the small vessels in the brain are showing signs of ischemia). Small vessel ischemic disease is more commonly seen as we age and in those who have vascular risk factors such as hypertension, diabetes, high cholesterol and those who are active smokers. They have also been commonly documented in patients who have migraines.
      Please remember the MRI scan just yields the picture and suggests certain disease possibilities. I am not sure what plagues your husband. That only his doctor can help answer, for it requires correlating the MRI findings with that of his presenting history and neurological examination.

      Personal Regards,
      Nitin Sethi, MD

      • Thank you so much for taking the time to answer on this site. It is amazing to find that there are still people who take the time to help people by answering these questions and getting nothing in return. I am in awe of your kindness. Thank you so much.
        Lisa

  80. Dear Lisa,
    thank you for writing in. You are right, the thought of neuroborreliosis (Lyme disease affecting the brain) should be borne in mind when investigating a patient with mysterious white matter lesions.

    Personal Regards,
    Nitin Sethi, MD

  81. hi im 33 years i have been with my husband 11 years nearly and we have a 3 year old daughter whom we waited a long time for and is our world ! last christmas i was amitted to hosptial as my doc thought i had a TIA my symptoms started with numbness in my hands ,numbness tingling in the right side of my face and my hearing went for a very brief time in my right ear ,my periphial vision in both eyes went very blurred i had ct scan bloods done lumber puncture and mri and eeg done which all came back normal but the mri showed 5 white spots in the right side of brain .since i have been under a very good neruo whom is suspicous of ms i have had further symptoms of my speech going slurred and muscle weakness in my right leg i aslo have found numb spots on my right leg and foot and toes i have just had my 3rd mri done of the brain and spine i havent seen my neruo as of yet but read the report and i now have several small scattered foci of increased signal intensity on t2 weighting are preasent in the deep white matter in the right frontal lobe it dose say that early changes associated with deep white matter ischemia cannot be excluded
    ?? i havnt heard opf this and was woundering if you could tell me or give info as to what it is . thankyou heaps bellinda xo

    • Dear Bellinda,
      thank you for writing in. My advise to you would be to follow up with your neurologist. He/ she shall be the best to determine whether you have MS or are these lesions more suggestive of small vessel ischemic disease of the brain. He/ she shall then advise you further: do you need further work up for MS? Do you warrant to be on medications such as aspirin for stroke prophylaxis and so forth.

      Personal Regards,
      Nitin Sethi, MD

  82. Dear Dr Sethi,
    I am a 56 year old female in excellent health (good weight, exercise daily, cholesterol: HDL 81, LDL 146, Triglycerides: 55 and C-reactive protein .31
    About 2 months ago I began having dull headaches, unrelenting, not responsive to advil, aspirin, naproxyn…The headaches are not severe but constant (about a 2-3 on a 1-10 scale). They are located on the right side of my face from below my eye up to my forehead. I had an eye exam which was normal, I then went to my primary care MD who ordered a MRI with and without contrast. The results of the MRI showed no mass or tumor but diffuse small white matter changes. My MD said that these changes were not clinically significant (I have no other symptoms except anxiety about all this! but the headaches continue).
    I asked about acupuncture for dealing with the headaches and he agreed it is worth a try.
    Do you think this is the right approach or should I see a neurologist (I have a PPO so I can make the appointment without a referral). Thank-you in advance.

    • Dear Susan,
      since I have not examined you, I shall be quite tempered in my advise to you. If the headaches are unrelenting, it may be worth your while to get a second opinion. I would though do this in consultation with your primary care physician. There are many causes of headache and some which a neurologist may consider more readily such as arteritis and neuralgias.

      Personal Regards,
      Nitin Sethi, MD

  83. I have had severe migraines and cluster headaches for over 15 years. I used to treat them with Fiorocet but have now been on Topamax (now up to 300mg/day to prevent them for about 2 years. Recently my neurologist ordered a brain MRI to check if everything was “ok”. Well….it came back “nonspecific abnormal” findings…and now I am going in for follow up blood work and he is checking things like B12 levels etc…. Should I assume he is looking to rule out MS?

    • Dear Nancie,
      you did not mention your age and whether you had risk factors for stroke such as hypertension and diabetes. Likely your doctor is casting a wide net and ruling out various causes such as deficiencies of vitamins and so forth. I would not get unduly worried about MS but would certainly follow up with him.

      Personal Regards,
      Nitin Sethi, MD

  84. I have recently had a MRI scan and it shows that i have SUB-CORTICAL HIGH SIGNAL INTENSITY LESIONS IN THE WHITE MATTER. As i already suffer with cystic fibrosis since birth and diabetes type 1 for 21yrs. I am confused and getting no straight answers of my doctor, im very curious in what may have caused it and what it actually is, as im suffer with costant dizziness 24/7, headaches and feeling really sick. Is there any information you could give me regarding this i would be very gratefull, as sometimes i find it hard to sleep at night with worry about it.

    • Dear Nicki,
      thank you for writing in. As I explained in my post not all white matter lesions represt MS. Subcortical white matter lesions are frequently seen in patients who have risk factors for microvascular disease wich as diabetes, hypertension, high cholesterol and those who smoke.
      They indicate small vessel ischemic disease of the brain. Your doctor shall be the best person to guide your work-up forward. They may or may be the cause of your symptoms. Your doctor shall determine your stroke risk and whether you need to be on any stroke prophylaxis.
      Personal Regards,
      Nitin Sethi, MD

  85. Dear Maria,
    thank you for writing in to me. Patients with fibromyalgia and chronic fatigue syndrome do not usually manifest with white matter lesions in their brain MRI. That said and done as I stated in my post, women with migraine frequently have these non-specific white matter abnormalities seen on their brain scan.
    Atypical MS (multiple sclerosis) is not really a scientific term. Doctors use it loosely to describe patients in whom they suspect MS but who present with atypical features or atypical neuroimaging findings. It may also be used to describe a MS patient whose disease behaves atypically (meaning does not follow the normal disease course).

    Personal Regards,
    Nitin Sethi, MD

  86. Patience is long gone. Perhaps you could shed light… bottom line: 51 yr old female w/ too numerous to count lesions on brain MRI – but not all are consistent w/MS, plus multitude of MS symptoms.

    1994-1996 had MS like symptoms. No clinical evidence found; MRIs and spinal tap normal. Leading MS expert in USA said it was job stress. So when legs, arms, etc. would act up, I considered as stress barometers. Jump to Aug 2008. Sight suddenly changed while driving. Painted white lines were also appearing about three feet above pavement. Been to 17 doctors in 19 months and no clinical Dx (yet).

    Brain MRI impression Nov 2008: Mild nonspecific deep and periventrical white matter disease and increased T2 weighted signal intensity in pons. Differential Dx includes small vessel ischemic disease, demylenating disease such as MS, and migraines.

    Cervical/Thoracic MRIs, spinal tap, VEP – all normal. I have monocular and binocular diplopia. Had ptosis until Dx with Myasthenia April 2009. Mestinon helps. Left eye aches constantly. Noticing sharp increase in migraines. Have flexor and expansor spasms plus intention and postural tremors. Cognitive issues increasing, can’t drive at night, sometimes in daylight too. Feet have constant buzz. Feel electric surges in armpits and groin areas – similar to cell phone on vibrate but it’s not on me. See TV static, from nearly translucent to regular TV static. Frustration with process is understatement.

    McDonald’s criteria: have two attacks with time and space. No lesions in 1994-1996 but Nov 2008 “scattered lesions” and Nov 2009 “too numerous to count lesions”. Why is it so hard to get a clinically definite Dx for whatever this is, be it MS or something else?

    • Dear JM S,
      thank you for writing in to me. Your history is complicated and you have been under the care of multiple physicians, not to mention the multitude of tests you have endured. So I shall not attempt to make a diagnosis over the Internet. Apart from multiple sclerosis, there are other diseases which can cause demyelination of the central and at times of the peripheral nervous system. These diseases are rare but an attempt should be made to rule out or rule them in. Any physician would hate to miss a treatable condition in his or her patient. Unfortunately as one goes “fishing” for a diagnosis, what I fear is that you risk causing iatrogenic injury (an invasive test such as a biopsy of the brain tissue or of a blood vessel or muscle or peripheral nerve might cause more harm than good to the patient).
      So any advise? Yes, find a physician who is willing to look this over with a fresh pair of eyes. One who goes about it systematically. I send you my very best.

      Personal Regards,
      Nitin Sethi, MD

  87. hi there just quick question l have no idea whats going on lm 28 year old and a year old things where getting worst like l lose my balance and me knees just go on me even walking with my he had to hold me up then my speech went and had left side weakness down my body my face droopled it was very scary now l have spastic parestis there other day my left eye theres was a flashing light but l always had blurred version since my left side went they said l was to young to have a stroke 5 people in my family had stroke and loads little mini ones l do have a c1 c2 fracture in my with pins in and rods as had accient three year ago they did a mri without dye last year and its showed it lost signal in spinal cord but nothing on brain a year later they did a brain one and found two lesion on me brain not sure what is and doctor said they found shadows on there l seen neurogists in hospital he said he reckoned l be using canes for the rest of me life cause me left side thing s just getting worst what is it l have really bad spasms in my legs l sleep a lot l dont have miragines as never had on l did have leck of bladder controls for 6 months thanks

  88. I did ask these questions yesterday, but I don’t know where they went. I am 60 yrs. old. I have had balance problems for a long time, but when I was 57 I started falling. Besides the balance problem I have some cognitive problems. I had an MRI of the brain then. The interpretation was white matter lesions most likely due to demyelinating disease ( due to location ) something like that. I had an abnormal VER, seizure activity in right temporal lobe and normall visual fields. I also had neuropsychological testinginterepreted as moderate cognitive deficits. I had another MRI recently by another radiology group. I brought the first one with me so it could be compared. Interpretation….No changes from previous MRI though lesions are probably from micro-vascular… due to the location of the lesions and my age.

    After my neurologist saw the first MRI she said that I was too well to have these lesions. She also put words in my mouth and kept asking me if i wanted to stop working…No I don’t eant to stop working.. I said yes to the words she put in my mouth although the answer was no. i am intimidated by her. She did give me a diagnosis of mini-strokes because I was postive for factor 5 leiden. I think she is very smart and I probably had mini-strokes and am still having them occasionally.

    The only question i have is: How can the same MRI have 2 interpretations?

    Thanks,

    terri

    • Dear Terri,
      thank you for writing in to me. I did get both your questions and I apologize for the delay in replying back to you. So lets us get to your first question. Not all white matter lesions on a brain MRI represent multiple sclerosis. You must understand that the MRI is ordered by a neurologist but read by a radiologist. The radiologist does not have a detailed history of your presenting complaints, let alone your examination findings and results of other tests such as VEP when he or she interprets your MRI scan. So at times neuroradiology reports are ambiguous. It may read somewhat like this ” white matter lesions compatible with microvascular small vessel disease” or “white matter lesions compatible with CNS demyelinating lesions”.
      It is the location of the lesions, their size and orientation which help the radiologist in suggestive microvascular disease Vs MS. The diagnosis of multiple sclerosis can be purely clinical without the need to resort to additional testing such as MRIs of the brain and spinal cord, lumbar puncture and VEPs (you can read more about the same on my website http://braindiseases.info).
      It is your neurologist who shall make sense of the MRI report/images and putting the history, examination findings and other tests into the mix determine what plagues you.

      Personal Regards,
      Nitin Sethi, MD

  89. I hope someone can help me…I have been diagnosed by my primary care physician with probable MS. He then proceeded to refer me to a neurologist. The neourologist ordered a MRI of my brain. The MRI had shown “one” area of plaque on the brain. The neurologist considers this one area of plaque to be normal – and highly unlikely to be MS. My symptoms continue (extreme muscular weakness, and muscle tightness – stairs make me want to cry – shortness of breath – dizziness – changes in vision – urinary stress incontinence – tingling sensations – banded feeling on the back of my head – and it feels like i have been beaten on the left side of my rib cage at times) all of the symptoms come and go. My first initial visit to the neurologist had shown that I was extemely deficient in vitamin “D”. I have taken vitamin D as prescribed, and 5 months later, I continue with MS symptoms. Took a return trip to the neurologist – still have no answers. She wants me to continue with the Vitamin D, and she will Pray for me…Lucky Me! I guess my question is – is it possible to have MS with only one brain lesion…A MRI scan of the spinal column was never done at the time of the head MRI, and other autoimmune disorders have been ruled out. I feel like I need a second opinion… Any comments?

  90. I am looking for a little help here…I was diagnosed earlier this spring with probable MS by my primary care provider. I have several of the MS symptoms with my main complaint being the extreme muscle weakness, and vertigo. My primary care provider refered me to a neruologist to rule out the MS diagnosis. An MRI was done of just my head (No images of spinal cord). The MRI had shown “ONE” area of white matter (plaque). She feels that this is a normal MRI. Earlier this spring the neurologist had ruled out other autoimmune diseases which mimic MS. My blood work did show that I was really deficient in Vitamin “D” – which can mimic MS…I have been on a Vitamin D prescription strength replacement regimine as ordered by the neurologist…and continue with extreme muscle weakness, muscle tightness (which is painful at times), changes in vision, tingling, banded feeling which goes around my head… My question is…Is it possible to have a positive MS diagnosis with only ONE brain lesion? I dont feel like the neurologist is going to do much more for me…should I get a second opinion from another doctor/neurogist? This neurologist wants to order exercise which is hard to do when I cant even climb a flight of stairs without wanting to die…and dietary supplements (Coenzyme Q10, high performance multivitamin, & Omega fatty acids) Help!

  91. Dear Dr.,
    The past 4 weeks have been filled with many questions. I am hoping that you could help me. I appreciate you giving your time and skill to answer our endless questions.

    My MRI shows extensive white matter disease. The only symptoms that I noticed about 2 years ago are difficulty finding words (expressive aphasia), losing thought while talking and ocassional stutter. The stutter seems to have resolved. I had a second MRI that shows non enhancing lesions. The nurse practioner at the neurology office who I have been seeing for this issue said I didn’t pass the Mc Donald’s critieria for the diagnosis of MS. My question is , is it possible that this WMD occurred when I was an infant or in the womb? If so, why did I only notice the symptoms 2-3 yeras ago? Should I go for a spinal tap? If this is not MS then what is it?

    Thank you for your time.

  92. I am 45 now when I was 25 I was diagnosed as have a pituitary adenoma that caused no active symptoms. Over the years my PCP would follow up with MRI’s and visual field tests. An MRI performed in 03 showed some non specific periventricular high signal white matter changes on the left. Recently in Oct 2010 another MRI was repeated for follow up purposes only. This time it showed several tiny areas of subcortical white matter high signal changes are identified in the right parietal region as well. Pituitary was normal. I am 125 lbs, caucasian femal and I have no neurological symptoms, high blood pressure or diabetes an occasional headache that I get is so mild and I usually pass if off for being tired. My question is what can I do (if anything) to stop these changes from occurring. Does calcium have an effect on this, alcohol consumption (8 to 10 per week) or can cognitive games, etc? Thank you for any input. Best Regards Dianne

    • Dear Dianne,
      thank you for writing in. You ask a very good question. Like I explained in my post not all white matter lesions represent MS plaques. The majority of these white matter lesions are what we refer to as ischemic small vessel disease. As the name suggests the pathology lies in the small vessels in the brain. Ischemic white matter disease is more commonly seen as we age. Also patients who have vascular risk factors are more likely to show white matter disease. The common modifiable risk factors are: essential hypertension, diabetes mellitus, dyslipidemia (increased total cholesterol, increased low density lipoprotein and triglycerides and decreased high density lipoprotein), smoking, excessive alcohol intake, obesity and sedentary lifestyle. Some people are hypercoagulable and thus are more prone to strokes and heart disease. Patients who suffer from chronic migraines (especially women) also frequently have “excessive” white matter disease.
      Now the million dollar question is whether this white matter disease is harmful to the brain. Does it affect the patient cognitively? There are indeed studies that show that excessive white matter disease may make the person prone to cognitive problems later on in life. This is called vascular dementia. My advise to you would be this:
      If you have any of the above vascular risk factors, I would attempt to modify them. Good control of blood pressure is paramount. Earlier a blood pressure of 130/80 or 140/80 was considered acceptable. Nowdays the teaching is “lower the better”. Hence the new guidelines recommend lowering the blood pressure down to 120/70 mm Hg. In the same vein the guidelines with respect to acceptable cholesterol, triglycerides (TG) and low density lipoprotein (LDL) have become more stringent and again the teaching nowdays is “the lower the better”. If you smoke, quit completely as no amount of smoking is good for your heart or the brain. I would advise you to eat a healthy diet rich in vegetables, fruits and nuts. Exercise on a regular basis (cardiovascular exercise such as jogging or brisk walking has been found to be the most beneficial). I usually recommend my patients to take 1-2 tablets of a good multivitamin per day (one that has all the B group of vitamins). Studies have shown that vitamin B12 plays an important role in cognition and so I usually recommend it to most of my elderly patients especially those who are vegetarians and have a marginal diet. I find my patients frequently deficient in Vitamin D (vitamin D is made in the skin from sunlight and so caucasians living in the temperate areas are frequently vitamin D deficient) and so I supplement it. The amount of vitamin D needed on a daily basis varies according to your sex and age and you should consult your primary care physician to determine how much you should take. I usually give my patients around 400 international units of vitamin D per day.
      I am a big believer in cognitive games (the fancy word for this now is Neurobics). You can read more about these in my neurobic post here or on my website http://braindiseases.info.
      I hope I have addressed your concerns adequately.

      Personal Regards,
      Nitin Sethi, MD

  93. I have had many neurological symptoms for several years now, with no luck on determining what process might be causing my symptoms. I am nearing 40, female and have had the following symtpoms:
    — parasthesias, all four extremities
    — leg sensations ranging from vibration, to muscle spasms, numbness, tingling
    — recently I have some increase focal sensation loss in my dominant hand as well as a loss of strength
    — poor balance
    — dizziness
    — fatigue
    — the last few weeks my legs have been painful, increasing as the day goes on, in the late afternoon my pain is 4-5/10 deep aching in all of both of my legs
    — in the last few weeks I have noticed difficulty swallowing

    A few years ago I had an MRI which showed UBO’s in both frontal lobes (one each)
    In May I had a repeat MRI of my brain and one of my c-spine (nothing new)
    I test negative for tick borne illness, HIV, hepatitis, thyriod issues, etc, etc
    I recently had a modified barium swallow which showed a delay in my swallowing with mild aspiration, decreased motility of the back of my tongue
    Today, I had nerve conduction tests which revealed normal sensory and motor responses in my left (affected) hand, but with some issue with the F-Wave test. My understanding was the numbers were okay but the waveform was atypical.

    When seeking medical attention I am treated as though I am fabricating my symproms or something, but I am a PT so if I wanted to fabricate, I could make it closer to some disease. I am hoping since some tests which I have no control over are abnormal I can get some answers soon. Use of my hands is critical to my job. I do not want to wait until I am disabled to figure this out, I want to address it now.

    All thoughts will be appreciated.

    • Dear B,
      thank you for writing in to me and I am sorry you are passing through such difficult times. My advise to patients like you is not to get frustrated. At times inspite of many investigations the etiology remains a mystery. Find a doctor who is willing to look at your case with a fresh pair of eyes and continue to maintain a good relationship with your current physician. Sometimes it is a matter of time and things become more clear. In the meantime your physician can treat your symptoms so that your quality of life is maintained.

      Personal Regards,
      Nitin Sethi, MD

  94. Dear Tom,
    thank you for writing in. You do not mention your age. There are many disease processes other than MS that cause demyelinating lesions in the brain. These include other infectious, inflammatory and vasculitic processes. My advise to you would be to follow with your physician and he/ she shall guide further work-up.

    Personal Regards,
    Nitin Sethi, MD

  95. Dear Julie,
    it is indeed difficult for me to advise you since I have neither examined you nor taken a history. There can be many causes of dizziness/ vertigo. Broady speaking the various causes can be divided into 2 main groups:
    Central causes of vertigo: meaning the vertigo comes from the brain (usually at the level of the brainstem and cerebellum)
    Perpheral causes of vertigo: the vertigo comes from pathology in the inner ear.
    Your doctor and/or a neurologist should be able to differentiate between central and peripheral vertigo based on the history and examination findings.
    Personal Regards,
    Nitin Sethi, MD

  96. Thank you for writing in again Julie. It is possible that your primary care physician feels that the yield of a biopsy shall be higher as compared to that of a CT scan. With a biopsy one can get a tissue sample and a histopathological diagnosis is invaluable at times. Again my advise shall be to talk to your primary care physician. I am sure he/she shall be happy to explain to you why a biopsy of the lymph nodes is warranted.

    Personal Regards,
    Nitin Sethi, MD

  97. Dear Adam,
    thank you for writing in to me. While multiple sclerosis remains in the differential, there are many other disease processes which can resemble MS radiologically and in their clinical presentation. I am sure there is a reason why your neurologist has requested an EEG and NCV study. My advise would be to follow up with him.

    Personal Regards,
    Nitin Sethi, MD

  98. Dear Lyssna,
    thank you for writing in. Let me begin my answering your questions. Usually by the time a diagnosis of clinically definite MS is made the brain or the cervical spine MRI shall show evidence of dissemination of disease in space (meaning that one should see multiple lesions scattered in the brain and the cervical spine). Abnormalities in the spinal fluid at times may be subtle and all one may find is increased number of inflammatory cells. Also when the spinal tap is done is important.
    As I have stated in my posts on multiple occasions there are many disease processes that can mimic MS radiologically and in their clinical manifestations. In difficult cases ancillary tests such as visual evoked potential, somatosensory and brainstem auditory evoked potentials are very helpful in ruling out or ruling in MS.

    Personal Regards,
    Nitin Sethi, MD

  99. Dear Rose,
    thank you for writing in to me. As I stated in my post, not all white matter lesions in the brain MRI represent multiple sclerosis plaques. White matter lesions have been noted in patients who suffer from migraines. My advise to you would be to make a follow up appointment with your current neurologist. I am sure he/ she shall be happy to explain the test results and advise you about the future plan of care.

    Personal Regards,
    Nitin Sethi, MD

  100. First I’d like to say that you have a wonderfully informative blog here and I’m incredibly impressed regarding the time and effort you put into your communications with your readers!

    I’m a 47 year old who last year began having symptoms of; numbness/tingling, wrap sensation around foot, let and upper back, intermittent muscle weakness and tremors (much worse after hot shower), bladder problems, swallowing difficulties and more recently, dizziness, balance issues, cognitive/memory problems, pain behind eyes and intermittent sharp pains in side of face. I have a visible r. hand tremor and very brisk lower reflexes and just this past week, shock-like pains down the front side of my neck when I look over my shoulder.

    An MRI I had in Oct./10 shows approx. 15 small T2 White matter lesions in the supraentorial brain. I saw a neuro who after insisting that my problem was ‘muscular’ and doing an EMG that ruled that out, says that my symptoms are not neurological and that the lesions are merely due to aging. she said that despite the 15 lesions, my MRI results are ‘essentially normal’ for a woman of my age. I Have always been physically fit, non-smoking, never had high blood pressure.

    A recent ANA test was negative (last year was low positive), an ENA was positive, but the subtests were all negative.

    I’m baffled and frustrated that this neurologist has completely dismissed not only the lesions in my MRI but also all of my symptoms.

    IN Canada all referrals to specialists must go through a GP. Since my GP has received this neurologists report, I fear that he likely won’t make any future referrals to a neurologist for me….he’s told me that I must simply accept my symptoms and learn to live with them. Needless to say, I’m finding this pretty distressing.

    While I do understand that it’s possible that the lesions are not related to my symptoms, I’m having a hard time believing that such an absolute diagnosis could be given regarding the benign nature of these lesions based upon one cursory examination.

    The MRI I had was of head and cervical spine, w/o contrast. I’m considering a patient paid MRI with contrast. I’m wondering what your opinion is regarding the wisdom of this….would it likely be a waste of money only 3 months after my last MRI w/o contrast…or is it possible that I may gain some valid answers?

    Thanks so much for any light you can shed on my situation.

  101. Hi, I have a question regarding WML. I have had MS symptoms since 2006. They include extreme fatigue, numbness and tingling, nerve pain, balance problems, muscle spasticity, muscle weakness, slurred speech, paresthesia, cognitive problems (memory and problems concentrating), tremors, vision problems, etc. Over the years, I’ve had several bad flare up of symptoms, and usually have residual symptoms after each flare up.

    The last flare up I had was this past October. During that time I had new symptoms of constantly smelling wood smoke for about two weeks, and then started having “mini-seizures” which would occur as I was drifting off to sleep. My whole body would stiffen, and my right hand, arm, and leg would start shaking and my eyelids would flutter. The first two times it happened, I also saw vibrant colored swirls of light when my eyes were closed. I was aware during these episodes, but could do nothing to stop them.

    I’ve had numerous tests to rule out just about everything that might cause these problems, but the only thing that has been abnormal was an SSER on my left leg which showed a delayed signal. I also have had a present Babinski reflex in my left foot, hyperactive knee reflexes on the left side, and absent ankle reflexes.

    I had an MRI with contrast in October right after the flare up of symptoms, and it showed four subcortical T2 hyperintensities located in the frontal and temporal lobes, but no enhancing or peri-ventricular lesions. The radiologist who read the report noted that two of the WML were on my MRI in April 2009, though they weren’t mentioned on the report at that time. I recently looked at my first MRI from 2006 and found them there too. Again, they were never mentioned on any of the MRIs I’ve had over the years until now.

    The nurse practitioner at my neurologist’s office looked at the MRI and said the WML are from hypertension and aging. (I”m now 48.) However, I didn’t have hypertension back in 2006 when two of the areas first showed up, though I do now, but my blood pressure has always been well-controlled with medication. She said she doesn’t feel that they are connected to my symptoms at all.

    To me, logic says that if it looks like a duck and quacks like a duck, it must be a duck. I have neurological symptoms of MS. I have four WMLs. So is it possible the WML are indicative of MS in this case? And even if they aren’t, could they be causing any of my symptoms? (I’m just so frustrated at having gone for so long without any answers!)

    Thanks!

    Lisa

  102. Hi Dr,

    My 7 year old year old sun has recently been diagnosed with epilepsy. We had an MRI done and it showed a “Bright Spots on his cerebellum. We have now had another MRI with contrast. But I am a worried mother and no one seems to be able to tell me what we may be dealing with here. The neurologist did say that this spot did not have anything to do with the epilepsy and that this is just something they found during the MRI. Any advice that you could give would be so appreciated.

    Thank You!

  103. I have been having sever vertigo for several years. I went to ENT and they diagnosed me with Mine ares syndrome. Symptions: Major loss of hearing in left ear (with ringing, blocked sounds and distorted sounds) during the day. At night the ear although still has loss of hearing the ringing, etc. goes away. Vertigo with headache that takes up to 4+ hours to stop. Than it seems that i have positional Vertigo w/o headaches (movement when laying on pillow, looking up or down to long). Both also have a hot flash at the beginning of the episode. Since the medicine for this did not work I went to a neurologist and he said i have migraine syndrome. I am now on other medicines that keep me from having these episodes as often but i still have them. Some time it’s with a headache and sometimes without (when i have looked up to long). My mri said: Minor deep white matter ischemic change. I really don’t understand what this means for me. I feel as if i have 2 conditions going on: 1) Migraine syndrome (where i get a total brain headache (in other words my whole brain is hurting) 2) Positional where the vertigo and accompanying nausea don’t last as long. In both situations my eyes are majorly affected. I also have times when i lay on that left side and have numbness all around my ear and left side of face. I really would like to know what to do and who to go see. Could you help? Neurologist would not discuss anything else with me but Migraine Syndrome.

  104. Dear Helena,
    thank you for writing in to me. There can be many causes of “white matter disease” (leukoencephalopathy)in a newborn/infant. Infectious, inflammatory and metabolic causes need to be ruled out. Another differential that needs to be ruled out is hypoxic ischemic encephalopathy (lack of oxygen to the brain at or near the time of childbirth).
    My advise would be to follow up with his pediatrician.

    Personal Regards,

    Nitin Sethi, MD

  105. Dear Sherin,
    idiopathic Trigeminal neuralgia usually occurs in person above the age of 60. So when Trigeminal neuralgia occurs in young people (especially in a young woman like yourself) one differential that needs to be borne in mind and ruled out is multiple sclerosis (MS). Usually there is a MS plaque which is irritating the root entry zone of the Trigeminal nerve and is the cause of the pain.

    So my advise to you would be to follow up with your neurologist. Based on his examination, he may order additional tests such as MRI of the brain and cervical spine, visual evoked potential (VEP), brainstem auditory evoked potential (BAEP), somatosensory evoked potential (SSEP) and lumbar puncture to rule out or rule in MS.

    I wish you my very best.

    Personal Regards,

    Nitin Sethi, MD

  106. I was recently referred to a neurologist by my primary care physician for treatment of my migraines. While migraines have a been a part of my life, they have been occuring with greater frequency of late (10+ per month). To rule out any other cause of my migraines, the doctor ordered an MRI. The MRI revealed 20+ white matter lesions throughout my brain (various locations, various sizes). The neuro was at a loss as to why I had so many. I did inform him that approx 15 years ago I had unilateral ect, and asked if perhaps this had caused it? I also let him know that I was experiencing significant memory issues (forgetting short term and long term memories, and even blanking on spelling my own last name for a minute or two). I asked him if ect could be responsible? The neuro has since followed up with me and has stated that ect could NOT be responsible for the lesions, and was not likely to be responsible for my recent, memory issues. I have been tested for MS, lyme, infection, etc. – all negative. I do not suffer from depression or take any other medications which would cause memory issues. Any thoughts? What else could cause these lesions? Is these any research at all into lesions and ect? I am trying to get into Neuropsych testing to determine the extent of my memory loss. The migraines are now currently being sufficiently controlled with Imitrex.

  107. I will ask you to please forgive my lengthy post. I had to type it out in notepad first and I know it’s not worded correctly to my liking but its the best I can do at this time.

    I’m a 47 year old female with a PMH of:
    PTX (bilateral) 1999
    Bilateral VATS secondary to PTX (cogenital blebs) 1999
    PTX w/ R Thoracotomy with bled resection 2006
    Post Thoracic Pain Syndrome 2006 (resolved 6 months later)
    Trigeminal Neuralgia x 2 (years apart after tooth extractions) 2006/2011
    SA Node ablation x 2 (supraventricular tachycardia) 2001
    PVCs
    Nephrolithiasis

    +smoker (I did quit for two years after surgery)

    110 lbs 5’5

    In 2006 when I found myself a bit off balance, uncoordinated. During my annual physical exam with primary MD, she had me perform standing with feet together and

    arms straight out with my eyes closed. I couldn’t stand for a nanosecond without falling. She said, “Hmmm you have a positive rhomberg”. I should follow up with a

    neurologist. ( I didn’t at the time).

    Other symptoms were vibration of my feet (which I thought it was the floor that I was standing on that was vibrating with Xerox machines, computers, etc.) and my right

    groin. My toes would cramp and hyperextend for hours, and it was painful. Hard to recall words that I want to use in a sentence to explain what I was saying. Urinary

    frequency, uncoordinated swallowing during drinking water, paresthesia in the back of my throat or tongue. Essential tremors. Ptosis. Thinking I saw a rat run across

    the floors at times.

    After my second surgery of my right lung, I ended up having what they called this PTPS (Post thoracic pain syndrome). It was the most painful thing I’ve ever

    experienced. 24/7 pain. I was on 32 mg of Dilaudid and 300mg of lyrica a day. Eventually as time went on, the pain began to subside and I tapered myself off of the

    medication and left myself on Lyrica for a bit longer. This is when I had seen a Neurologist.

    Now, I had memory issues (blamed it on the narcotics), incontinence, weird neurosensory (cant think of the word I want to use). I had a MRI done of the brain, cspine,

    thoracic and lumbar in 2007. The findings:

    Small nodular areas of abnormal hypertinse signal are seen bliaterally in the frontal, and parietal white matter on Floar and T2 weighted imaging. These areas of

    abnormal signal measure 3-5mm in size. Small lesions are seen bilaterally in the high frontal region. There is a small abnormality within the anterior aspect of the left

    centrum semiovale and a simliar small abnormality in the white matter at the posterio margin of the posterior body of the right lateral ventricle. No discrete lesions within

    the corpus collosum or extending perpendiccular to the superior aspect of the lateral ventricles seen.

    The Cspine and Thoracic came out clean at that time.

    Occassionally I would return to the neurologist because sometimes I would get the pain back from the surgery or weird sensory deficits on the right side and also to

    complain about minor symptoms that really didn’t hurt just annoyed me. Another repeat of a MRI was done in 2008.

    Several small nodular areas of hyperintense signal are seen scattered in the subcortical frontal and parietal white matter of both cerebral hemisheres on FLAIR and T2

    imagin. These areas are 4 – 5mm in size. No significant change since the prior MRI. The Cspine and Thoracic also came out fine with nothing.

    In 2010, I had EBV for 2 months. No sore throat but myalgia, fatigue (extreme, extreme, debilitating), no fever, diarrhea, 12 lb weight loss in 10 days. Recuperated went

    back to work. (still had occasional nausea) Later in August of 2010, I was fatigued again (like I was when the EBV was active), nausea (no vomiting), night sweats,

    myalgia, back pain no my spine hurt the entire spine, paresthesia bilaterally in lower legs (feet), hip pain like it was dislocated, bilateral knee pain. Finally I went to the

    ER and asked them to do a lyme titer ELISA. They sent me home after giving me zofran. Went to GI doctor had moderate gastritis after colonoscopy and EGD. I went

    to follow up with primary MD. She did every blood test imaginable: Lyme was negative, Copper, RPR, CBC, BMP, Celiac, VitD 25 hyrdoxy Homocysteine, serum

    calcium, Vit b12 and folate Celiac disease comprehensive, ANA w/ reflex, RA, Parvovirus, EBV again (was active again) Lipid panel, Thyroid, UA C+S. Everything was

    normal. Even though my Vit b12 was normal I went for the shots anyways 7 straight days in a row because I could not perform at work with the fatigue. (didnt work)

    Finally she said I had to stop blaming Mono and wanted to do a MRI. I told her I had one done years ago but insisted I go.

    MRI of Nov 2011:

    Scattered punctate foci of abnormal signal in the periventricular white matter. These are nonspecific.

    Im out on leave of absence from work because I can’t function as a Registered Nurse with the cognitive issues and debilitating fatigue. I continue to have those annoying

    symptoms on and off with paresthesia, ptosis, swellign of one extremity (yadda).

    I can’t see a neurologist until I can get myself health insurance. I’m waiting for approval.

    My question is now that I see there are new lesions in comparison to the one prior on the MRI — when I go see the Neuro, do you think I would sincerely need a LP? I

    rather not — for my history shows Im not good with surgical procedures or any stress done to my body, it tends to go the neuro route and I end up suffering more.

    Would you also think that this is possibly MS?

  108. Oh I forgot the CSpine:

    Findings:
    anterior column marrow signal is heterogenous (I dont know what that means)
    c5-c6 tiny focal left paracentral disc osteophye compmlect with minimal left anterolateral subarachnoid space encroachment.

    Thoracic spine:
    Mid thoracic vertebral body foci of hypersensitivity may reflect hemangiomas

  109. Dear Nev,
    thank you for writing in to me. As I have stated in the post itself and the comments that follow there can be multiple causes of small white matter lesions on the brain MRI. The etiology of these lesions varies based on the patient’s age, sex, presence of microvascular risk factors (such as hypertension, diabetes, smoking, increased cholesterol) and most importantly the clinical presentation.
    Your doctor shall be the best person to advice you further on this.

    Personal Regards,

    Nitin Sethi, MD

  110. I had a CT scan and the radiologist noted a 5mm spot in my subcoritcal white matter. Had the scan done because I was feeling woozy/vague perceptual change/brain fog (along with vague bodily symptoms – IBS, dry eyes & mouth, a bit of tingling in my fingers, fatigue – and just generally feeling peculiar with no cause I could think of). Also did a lot of blood tests and everything came back normal, including tests for rhuematoid/autoimmune stuff (which really seemed to fit a lot of my symtoms). My doctor has no more ideas. Maybe what’s left now after these exclusions is Chronic Fatigue Syndrome? I’m 35 years old.

    But I’m wondering, would there be anything to be gleaned from an MRI? How much does MRI reveal that CT doesn’t? My doc said it’s an option but I declined due to the cost.

  111. Hi Just thought since you have been so helpful to others I would ask some questions for myself. I had a severe case of EBV approx 6 years ago with liver and spleen involvement and high fevers, since then my cholesterol tests come back med to borderline high for bad fats but ok for other tests. Prior to the diagnosis of EBV I had recurring bouts of central chest pain for a few weeks which then resolved. During my bout with EBV I developed severe muscle cramps/spasms mainly involvin my abdo and chest muscles, spasms would often work up my trunk to my chest and throat and would make it difficult to breathe. I always remained conscious during these attacks but felt spaced out after for a while could hear people talking to me but couldn’t answer them. I als o get a warning before attackes a smell at times or suddenly constantly swallowing before my throat seizes and spasms start. They initially were only at night but then escalated to day time and gradually lasted longer each time, as in one after another without much break between them. Drs did not know what was wrong and suggested either I was attention seeking or it was stress. No tests were done at the time. My GP at the time gave me IMI Lioresal when they became severe which worked then they just disappeared. It took me prob 2 to 3 years before I could say I was functioning at a near normal level both in strength and cognitive ability again. I was studying at the time and had to put my studies on hold. Since then I have had periods of depression, muscle pain, headaches, tiredness and fatigued in the mornings to the point where I prefer to work nights as I feel I can cope better that way. Recently I have been feeling more unwell and having more cognitive problems again, STML forgetting what I was saying in the middle of a sentence, peoples names that are familiar to me etc. More pain and stiffness in the mornings and severe chest/rib muscle pain that consistently wakes me every 2 – 3 hours at night. I also get severe spasms down my spine when bending head forward or back or when deep breathing (as in when Drs checking lungs etc) I have been checked by a rheumatologist who says I have 13/18 tender points for fibromyalgia and because I had 2 aunts die from MS sent me for a brain MRI (non contrast) 12/4/11. Showed white matter changes periventricular, deep corticol and sub corticol and pontine areas with T2 hypersensitivities and flair , diff included possible Vasculitis or possible MS. Suggest repeat scan in 3 months. I have over the past two weeks or so had spasms back again similar to the previous ones also increasing in frequency and strength to the point I presented at my local hosp A&E who gave me valium 5 TDS which made me sleepy but didn’t stop the spasms I went back and he switched to Quinine 600mgs TDS which dulled them a little but did not stop them, them my legs felt they wouldn’t hold me up so I stopped the quinine. 2 days ago I went to my GP feeling shaky weak and worsening spasms again. He gave me IMI tramal which eased the muscle pain from the spasms but didn’t stop them he sent me too a larger base hosp who gave me morphine and valium did blood tests vasculitis screen and ? other what ones. overnight spasms increased to non stop with sl elevated temp increased heart rate greatly increased BP and became diaphoretic. Madazalam and morphine was the only thing that stopped them and that took a couple of doses they the went back to less frequently. I noticed my eyes were stinging when I looked at lights and prefered a darkened room shining lights in my eyes triggered spasms as did sudden noises. Nero specialist feels it is vasculitis caused by stresses of life will possibly do repeat scan but is not keen. No LP or other tests done discharged on aspirin. I am also on thyroxine (for underactive thyroid have been for almost 30 yrs) I am now 55 yrs young. Is this vasculitis, should I get other tests done I feel like because it is not typical and has Drs a little confused they are playing it down as stress, I do not normally have hypertension and I am not diabetic what is the prognosis if this is vasculitis of developing more seizure type muscle spasms. They are truly debilitating and scary and I do have to be able to work and drive. Sorry this is long winded I wanted to give as much info as poss. Thankyou appreciate your response and opinion.

    • Dear Katie,
      thank you for writing in to me and I apologize for my delayed response. Your history is intriguing and complicated and from what you tell me, I am uncertain what plagues you. While this maye be little advice sometimes going to have a second opinion and having a fresh pair of eyes examine you and review all your previous test results may be the the best way forward.

      Personal Regards,

      Nitin Sethi, MD

  112. Hello,

    A few weeks ago my husband was seen by his doctor for numbness/tingling at the tip of his left thumb and forefinger. The doctor told him he thought it was a pinched nerve at C-5, C-6 and ordered an MRI. The MRI confirmed the pinched nerve but also caught a glimpse of something suspicious in the C-1, C-2 area.

    A second MRI was ordered which has discovered plaques that are consistent with MS. My husband has no other symptoms and has been ordered to see a neurologist for further testing.

    His father has MS and I am concerned that they are jumping to this conclusion based on his family history. Are there any other medical conditions I should be aware of that could cause similar findings on an MRI that should be considered.

    Needless to say, we are beside ourselves as we have a front row seat to the devistation this disease can cause.

    Any insight or advice you can give would be greatly appreciated.

    Thanks!

    • Dear Shawnna,
      thank you for writing in to me. My advice is simple actually. Follow up with a neurologist. Based on history, a good neurological examination and some non-invasive tests such as MRI of the brain (does it too show plaques? or is it clean?), visual evoked potentials (VEP), somatosensory evoked potentials (SSEP) and spinal tap, he shall be able to rule in or rule out multiple sclerosis. Again not all these tests may be warranted (they have different sensitivity and specificity when it comes to diagnosing multiple sclerosis) and hence the simple thing would be to follow up with the neurologist and let him make sense of the current data. Is the plaque at C1-C2 actually a white matter lesion? Does it represent MS or is it just an incidental finding?

      Personal Regards,

      Nitin Sethi, MD

  113. Dr. Sethi:

    In 2006, I was leisurely walking and something inside my head felt as if it had exploded and there was massive intense pressure. After several Cat Scans, MRIs, MRAs, Spinal Taps, Lab Tests (Blood & Urinalysis) MRI in 2006 showed lesions on white matter of the brain, possibly related to Microvascular Ischemia, small vessel disease or demyelination. A repeat MRI in 2008 and in 2011 showed pretty much the same thing. SInce all that, I have had intense pain in my left abdomen, pelvic region which radiates to my hip and back. The Spinal Tap showed something in my serum, and my doctor sent me for an IgG Blood and Urine test that also came back negative. Blood tests show elevated ACE Levels and Sed Rate levels and a high CRP level. However, these tests seem to flucutate from month to month. Sometimes my CRP may be at an 11, then a 15, then a 13, then back to an 11. Or my Sed Rate may be at a 38, 48, then a 41.

    I do suffer from Ulcerative Colitis, but I am not currently in flare up mode. I have excrutiating abdominal pain on and off and it seems like it just got worse within the past two months. Cat Scan in abdomen reavealed modestly enlarged retroperitoneal and mesentric lymph nodes, but say they too have remained stable over the past Cat scan or two.

    My CBC is normal, but I do have spleen pain on occasion and in the past had a modestly enlarged spleen, but that was three Cat Scans ago. This past Cat Scan showed all organs to be unremarkable.

    Do you think this sounds similiar to a Lymphoma type of Cancer and if so, would that have anything to do with the reason my Brain MRI reads micrcovascular or demyelination changes?

    I have visted doctor after doctor and they all do not believe it is related to Cancer. I have seen an OB/GYN, my gastroenterologist, my primary care physician and a general surgeon.

    I am scared and totally confused and mentally exhausted.

  114. CADASIL is an acronym for Cerebral Autosomal Dominant Arteriopathy Subcortical Infarcts Leukoencephalopathy. This means that it is a hereditary disease that affects small and mid-sized arteries, which creates oxygen deficiency. It is caused by a mutation in the Notch3 gene. Though rare, it is a degenerative disease, with no known cure or treatment. Symptoms vary by patient but may include migraines with aura, mood swings, and memory loss.
    Many of the symptoms on your site are thing same as Cadasil.

  115. Dear Bani,
    interpreting an MRI report without having any history on hand is liking sailing a boat on uncharted seas. Hence I shall not do this. Please follow up with your doctor. He shall be the best person to interpret the MRI scan after taking your history and examination findings into consideration.

    Personal Regards,

    Nitin Sethi, MD

  116. Dr. Sethi, my husband is 60 yrs old, strokes run in his family and caused his father’s death. Husband is also type 2 diabetic on insulin, Hep-C, COPD, POTS, RLS – those are primary problems. He has been having memory problems for awhile and much worse over the last yr. Neuro dr did labs (good) and neuro brain tracking (normal). He also ordered MRI w/o contrast which showed several white spots, one fairly large. He said number and placement were of concern and said the cause is either MS (no symptoms) or mini strokes. He said spots can cause husband’s memory problems. I shared w/dr that for the last several yrs my husband has become irritable, mood changes, road rage, etc, unusual for him. Dr ordered sono or echo of heart and cartoid arteries which start next week, and a lumbar puncture (awaiting appointment info). I have 2 questions:
    - Could something else be the cause of these white spots?
    - Can these spots cause my husband’s mood changes?
    Thank you, Phyllis

  117. Hello I am a 27 year old female who recently had an mri of my brain with no contrast I insisted on the mri because Ive had headaches and alot of anxiety and my dr thought getting the mri Would reassure me all was ok. My results read several white matter foci, one has a perivenular type distribution concern for clinical corilation with ms does this mean I have ms? I have had 1 day where I had blurred vision only in the bright light and went to opthamologist but nothing abnormal was found since it went away they said it was pbly just a new medicine. I have also fainted 2 times in the last year and they said most likely due to stress and anxiety. Is it more likely to have ms? I also did have nystagmus in my right eye for 1 week 6 years ago I have an appt with a nuerologist in 3 weeks and the questions are driving me crazy any response would much be appreciated I have 3 small children and im trying to not let my fears consume me.

  118. Sir,
    my 60 year old mother mother was asked to do brain MRI scan by her physician, when she went to him with a complaint of discomfort from elbow of right arm, and was unable to eat as she used to with her right hand since not able to move fingers freely. She was unable to comb with right hand.
    The brain mri scan report has following content:
    1. Few tiny focal areas of bright signal in the bilateral frontal and temporal sub cortical white matter, may represent old lacunar infarct.
    2. No acute infarct on DW images seen.
    3. No other significant abnormality is detected.

    Please note that she is being treated for hypertension.
    I would like to know of what is the problem with her, and is it severe.

    Thank You very much,

    Vijaya

  119. wow! after reading all this, i wonder was i diagnosed properly?
    last oct i got an MRI done, found 1 white spot consitent with MS. 6 months later got a new MRI found a new spot…the “old” one remained unchanged, i was then diagnosed.

    could it be that easy? can i have something other than MS? i do have an appt with a Neoro next month. BTW, do have other symptoms like headaches sensitivity to light, some tiggling on my arm, legs, tied…

  120. Hello Doctor, looking forward to your opinion.

    History: 1996, left side of face pins and needles, top of head numbness, dizziness. Neurologic workup, found nothing. Dizziness went away, face and head pins & needles still have it to this day, it’s constant. Aprox. 3 yrs. later, left thigh pins and needles, shocks in feet & toes (both feet). Still have these symptoms to this day. Over the years these were symptoms i carried with me, always. I didn’t think of the possible MS of 1996 because I do have a history of L spine disc problems, so that is what I blamed it on, oh and of course, I’m over weight. All blood work normal, and normal BP. One day in 2008 my entire back got pins and needles that lasted aprox. 30 seconds. This would happen everyday for one week, then twice a week, then a couple of times a month. This is when I thought I wonder if the question of MS is back. Still I didn’t go to the doc. This Feb. 2011, I got really tired and stayed tired to present day. I wake up tired. Seven hours of sleep, 8, or 10, it doesn’t matter….soooo blasted tired, dragging my butt. Doc. did blood work. Vitamin D low, thyriod ok. Six months later, another thyriod test, normal…D is better but not normal. I decide to go to neuro. I tell him what Im telling you, only now I add in left arm slight numbing, left leg pain with bad thigh cramps, jabbing pain, jumpy. Now I’m walking funny. I have trouble finding my words, and slured them twice in two days- full sentences. The only test in the office I failed at (I think) was when i closed my eyes and walked heel to toe i was wobbly. He orders an Brain MRI without contrast. Results: Scattered High T2 signal intensity abnormalities in the white matter, question MS versus small vessel ischemia. I am now 51 years old. Otherwise normal MRI of the brain. He also orders, MRI, thoracic spine with and without contrast, MRI of cervical spine with and without contrast-Impressions of both: At the c6-7 level there is small central disc protrusion with tear of the snnulus only slightly indenting on the ventral thecal sac midline. Mild disc bulging at c4-5 and c5-6 level w/o evidence of spinal or foraminal stenosis. the MRI of the cervical spine with and w/o contrast is otherwise unremarkable. there are no cord abnormalities that would suggest demyelination disease. T10-t11, t11-t12, t12-L1 disc protrusion with ventral thecal sac mild compression and no cord compression. Multi- level disc mild degenerative change. Left renal cysts. No spinal cord abnormal enhancing or non enhancing pathology or ms plaque noted. He also ordered Cerebrospinal fluid thin prep. Results: Everything normal except Myelin Basic Protein is high, 1.51 units/ng/ml [0.00-1.10] He is sending me to a specialist in MS, my appt. is Nov. 1st, 2011. Also I had a scan of my left kidney and seeing a specialist recommended by my GP, apparently there is many cysts engulfing the whole kidney.
    Looking forward to your reply,
    N in NJ

  121. A MRI was done on 9/9/2011 with and without contrast due to vision problem, headache and night sweats. In addition my brother has MS for over 15 years.
    The impression result read as followed: Multiple scattered bilater al hemispheric white matter foci which are nonenhancing. Differential considerations include small vessel ischemia, gliosis and vasculitis amongst other causes. A demyelinating process inluding multiple sclerosis could not be excluded.
    My question is: What does the impression results really means? I’m worried because the doctor didn’t really explain in detail the results. He requested to repeat another MRI in a few months. Should I seek for a second opinion? Please advise.

  122. Dear Dr Sethi,

    About 3 months ago I moved back to Australia to live with my family. I was extremely stressed and one morning I woke up with the left hand and feel feeling weaker compared to the right. I went to my GP, he thought it was a stroke and sent me to the hospital. They did an MRI in the hospital and the neurologists sent me home after recommeding that I consult a psychologist. This was strange considering that all the tests they did indicated that my left side was weaker. When I went to give my GP to give him the good news that it wasn’t a stroke he noticed that the MRI had detected 3 tiny lesions. I went back to my neurologist and he says anyone could have those lesions and they they are non-specific. He says the spots of the lesions don’t correlate with parts of the body where I feel I am experiencing MS symptoms, e.g, weakness and pain on the left side. I have consulted him twice now and he just doesn’t seem to take me seriously. He says anyone could google my symptoms I have and diagnose themselves with MS. BUT what about the lesions the MRI detected? I just don’t understand. My symptoms keep changing, but generally they are as follows:

    - fatigue (which is getting better now)
    - join pain
    - twiching in my eyes, legs and back sometimes
    - numbness and pain in my left two fingers
    - severe migrains
    - inability to write and speak as fluently
    - I get better and then as soon as I exercise the symptoms come back
    - used to get itchy when I exercised in the gym, but that has also stopped recently
    - headaches
    - pain in my eyes sometimes
    - dry eyes (for a short period of time)
    - delayed response to questions
    - cracking bones – all over and it is seriously alarming.

    If it’s not MS, what is it? I am so frustrated. My neurologists says I am depressed and anxious. I am on medication now for anxiety, but the symtoms are there. I hope you can help.

    Regards,

  123. Dr sethi

    Do hope that you can shed some light.. My daughter age 28 had tingling in her legs and slight numbness. This came on after a viral infection. She has had mri scans of her back and brain and 2 very small patches of inflammation were found on her spine but several patches were found in her brain. Which is very scary. Blood tests all normal, nerve conductivity test normal, chest xray normal. The want to do another scan in 3 months to check. Neurologist didnt want to do a LP. He says there is a fair chance it could be MS. Is it possible that she could have had this for some time ? Other than the tingling ( which is slowly decreasing) she has had no other symptoms.

    I know it is difficult to comment without seeing results but in your experience can these incidents sometimes be just a one off viral inflammation or do they always lead to MS one form or another.Maybe I am expecting too much but our GP has said there are often cases where it is just a one off bout. Does the amount of patches make a difference or is it their position?

    The Neurologist said that her age was in her favour . Do hope you can give some advice as I am in a permanent state of anxiety and need to keep strong for my daughter

    Awaiting your reply thank you.

  124. hello,
    I am 21, I recently had an mri done due to vision changes, many white dots were found located on the front of my brain as well as what they think might be a cyst on my pituitary gland, i have been told i have fibromyalgia and was curious if these symptoms could infact be something different due to the new evidence that has occured. I do plan on having follow up test done but my curiosity is getting the best of me
    thank you

  125. Dear Dr,
    I had an MRI scan about 5 months ago, as I was experience numbness in my toes constantly and sometimes in my hands, they said my sinus was enlarged and I had some White spotting, no further tests were done. Last week I experienced vomiting and the a violent headache, I thought my head was going to explode, I went to a and e and they did a cat scan and lumber puncture and said both were clear and put it down to a migraine, which I have never experienced before, I am still feeling not right, my head hurts and toes still numb!
    Can u give me advice!
    Thank you

  126. Hello. I am a 35 year old femaile. About a year ago, I started having face and arm numbness. I had a MRI of the Brain with contrast and it was negative. A few weeks ago, I had a visual disturbance that sent me to the ER. I was told for follow up with neuro who I see at the end of this month. I am a MRI technologist. Yesterday, our machine was acting up so I had a coworker run a Brain scan on me to see if the machine issue was resolved. Multiple UBO’s showed up that were not there a year ago. Do you feel that this is something I should be concerned about? Is it normal for multiple UBOs to show up in a years time? Thank you for your opinion.

    • Dear Michele,
      thank you for writing in to me. I can understand your anxiety.My advice would be to follow up with the neurologist. Based on your history (presenting complaints and symptoms), neurological examination and MRI scan, he shall be able to figure out what is the significance of these unidentified bright objects seen on the scan. A word of advice, carry both the scans with you (the recent one and the one from a year ago) when you go to consult the neurologist. Feel free to write in again.

      Personal Regards,

      Nitin Sethi, MD

  127. I had a MRI of the brain and the results are confusing, here is what they read: No mass effect or midline shift. No intracranial hemorrhage or extraaxial fluid collections. The ventricles and sulci are symmetric and normal in size for patients age. Post contrast images demonstrate no abnormal intraparenchymal or extraaxial enhancement. Diffusion weighted images demonstrate no areas of restricted diffusion. The visualized mastiod air cells, paranasal sinuses and orbits are normal.

    What is confusing is this, what does this mean?: Normal MRI of brain except a few tiny punctate areas of subcortical T2/FLAIR white matter signal (abnormality) hyperintensities in the high frontal lobe.These are very nonspecific in appearance.

    I am 31 years old, female, 5’1″ and 165 lbs. I have a history of headaches, mostly tension types, but also occipital neuralgia, as well as some migraine symptoms, but not the usual migraine symptoms.

  128. Oh, I should also mention that there is vascular things in my family history…My 13 year old had HSP which is a type of autoammuine vasculitis, my 3 year old has a vascular thing on his shoulder and I have recently had the below:

    I had a CT of my abdomen and it showed liver lesions, so my GI doctor ordered a MRI of abdomen specifically of the liver. The results are in and I am confused. It states that: There are several similar appearing T2 hyperintense, T1 hypointense lesions in multi left and right hepatic lobes would show a similar enhancement pattern of peripheral nodular discontiguous enhancement with gradual centripedal fill-in. Then it goes on to list 7 different segments for examples. The largest is seen to measure 11mm. No concerning web lesion is evident. Impression: Liver lesions as described above, correlate with the patients prior CT scan and are mostlye consistent with benign hemangiomas. No additional follow up or workup is recommended. Liver lesions appear benign on MRI. So my doctors are dismissing it. I have a sometimes sharp pain in the upper right quadrant of my abdomen, sometimes it hurts when I breath in deep and sometimes the pain radiates into my right shoulder blade. It is very uncomfortable and scary at times. I did have a CT of my chest to check for PE and it came back fine. What should my next steps be? I have consulted University of Michigan Liver Tumor Clinic and am trying to get an appt. for a second opinion there.

  129. Dr. Sethi,
    I apologize ahead of time for the lengthly history.
    I am a 31 year old female who went to the doctor about 4 months ago related to pain in my legs. I have no joint swelling or inflammation, just pain that seems to radiate away from my joints. My primary care doc ran some test and my ANA came back positive, so he sent me to a rhematologist. Rhematologist said in his opinion he did not feel my symptoms or test results indicated RA or Lupus. I have also had bouts of abnormal vision, double vision that lasted a entire day but by time I had gone to the opthamologist it had resolved.
    I have progressively gotten worse with pain all over: upper back, shoulders, clavical area, neck and head, hips, and lower back. Two months ago I suddenly began having numbness and tingling in my left arm and hand that comes and goes close to 60 times a day. I am having problems with cognition and being able to form intellegent sentences and memory. I have fatigue and just don’t feel normal. My mom had stated to me that it sound like I am have multiple migraines all day and that I should call my doc. My mom has advanced white brain matter disease r/t what the doctors say is ASD and migraines. I called my primary care doc and saw him again. He wanted to rule out Hypothyroidism and MS. So I set an appointment with a neurologist and a cardiologist(to rule out the ASD). The cardiologist was able to get me in right away, I am still waiting for my neurology appointment.
    Cardiologist ran multiple tests, one of which being an MRI. The MRI says,”Nurmerous unspecific scattered tiny punctate cerebral (frontal lobe predominant) white matter foci of T2/FLAIR signal hyperintensity are demonstrated – without associated mass effect, volume loss or enhancement.” The impression: “The number of cerebral white matter foci identified is significantly abnormal for a patient of this age. Dx considerations may include the sequela of advanced chronic microvascular ischemic or embolic disease, post inflammatory, infectious or traumatic gliotic scarring and the potential contribution of underlying migraine headaches, diabetes or hypertension – in the appropriate clinical setting.” I also had 5+ ratings on the doppler bubble test and was difinitively diagnosed with a large shunt ASD. My cardiologist suggested the MRI results were related to strokes from my ASD. I questioned him on the theory my Primary care doctor had regarding MS and he said he (obviously) didn’t know for sure. He said the numbness and tingling could be a result from a stroke and that may never go away.
    I have been trying to research what the results of my MRI could mean and I guess I want it to say somewhere that yes it is result of multiple strokes, but it doesn’t. The only information I get is regarding MS.
    I had my ASD closed last week and I still have all my same symptoms. Pain is unbareable at times and I feel lost as to what I should expect from my neurologist. Can I have MS definitively excuded from a possible diagnosis with a LP? Is that a test I should ask my neurologist to perform?
    Please help. Sorry about the long forum.

  130. Hello,
    I have to say, I think you are remarkable for what you are doing here Dr Sethi, helping people who are facing uncertainty around very difficult health concerns all around the world, is rare and extremely comforting of human good will.

    I am a 41 year old female and over the past 3 years have been experiencing sensory and slight motor symptoms, including numbness and weakness in the front of my lower legs, left arm, left hand, and now recently in the left side of my face (around my left temporal lobe down to my chin). I have severe cramping in lower legs and feet, tingling down my legs, crawling sensations in legs and abdomen (muscle twitching), burning heals at night time, stabbing pains in legs, and involuntary movements of toes, all of which have been intermittent (usually happening for a couple of weeks every few months or so). Lately I’ve experience severe fatigue and problems with concentration. I have on occasion word finding difficulty when speaking and forgetting how to spell easy words when writing.

    I had an MRI of brain and spinal cord about 2 years ago which came up clear. I have also come up clear in a clinical assessment (no optic neuritis) My identical twin sister and mother has MS, so I have been quite concerned about these symptoms. My twin sister was diagnosed in her early 20′s, about 17 years ago.

    I am due for another MRI in two days time, but am also aware that lesions can show up from smoking and age (I’ve been a light smoker for the past 4 years). Naturally with my genetics corresponding with these symptoms has me concerned, particularly now with my face going numb on one side.

    I guess I’m asking you if these type of symptoms at my age is something I should be concerned about as perhaps early onset of MS? It’s hard for me to by into some other health problem given my genetics and symptoms. Probably impossible for you to answer medically, but it’s worth a shot :)

    Sincerely,
    Karen

    • Dear Karen,
      thank you for writing in to me and thank you also for your kind words. While it would be foolhardy of me to attempt to diagnose you over the Internet, I can answer a few questions. It seems you are worried that you may have multiple sclerosis(MS). Multiple sclerosis does at times present with non-specific symptoms such as numbness/ sensory symptoms on one side of the body or face, weakness on one side of the body, problems with balance, incoordination and bladder/bowel dysfunction. If the spinal cord is involved by the disease process patients may present with more symmetrical signs depending on the level of cord involvement (such as bilateral lower limb weakness due to transverse myelitis. See my post on transverse myelitis to learn more). So the symptoms are indeed very non-specific but usually the neurological examination helps to shorten the differential diagnosis. In a patient with MS, the neurological examination indicates multifocal central nervous system involvement. Please refer to my post on http://braindiseases.info on making the diagnosis of MS. MRI of the brain and cervical spine level show the lesions of MS-we call them plaques and neuroimaging shows that the plaques are scattered in different parts of the brain and spinal cord and this explains the non-specific signs which do not localize to any one area of the brain.Further testing such as lumbar puncture to look at the spinal fluid, visual and somatosensory evoked potentials may be carried out if the diagnosis remains in doubt.

      Multiple sclerosis usually starts off in the second to their decade of life though later and earlier onsets have certainly been reported.

      A pure seizure disorder (epilepsy) does not explain all your reported symptoms. Seizures have been reported in MS patients but in my personal experience are not the presenting symptoms.

      So Karen my advice to you is this: do not self diagnose yourself. Follow up with your doctor. My best wishes remain with you.

      Nitin Sethi, MD

  131. Wow! This site is a blessing. My son in law had an MRI and it showed 3 white spots. 2 on one side of the brain and one on the other. They also have discovered he has thyroid issues which they have started hgh. He is getting an EMG next week. he Dr. saaid worse case scenario would be MS. I am just sick. Any advice or lessons to share would be most helpful.

  132. Hi Dr Sethi,
    I am a 52 year old white female. I do have hypothyroidism that was controlled with Armour Thyroid.
    In Jan 2009 I had optic neuritis in one eye.(out of the blue)(49 years old)
    Two MRI’s were performed during this time, optic neuritis was confirmed with no white matter lesions.
    Since then I have had approximately 3 bouts of memory loss, lasting about 6-8 hours, about 6-7 months apart. The first in June 2010.
    The Dr I work for ordered an MRI at this time , but I did not have it done because I was fine the next day. I did not think it would happen again..But on New Years day this year I had another spell.
    The spell I’m referring to… example: I can see in my minds eye a couch but I could not think of the word “couch”. This was very frustrating because when I tried to carry on a conversation I would have to stop because I could not think of what I wanted to say. This lasted about 6 hrs.
    With the pushing of my Dr. I decided to have the MRI. This time it showed a white matter lesion. Although I do not fit the criteria in the age group of MS, or have other symptoms.Should I be concern or could this be an age thing?
    I contribute all this to menopause as I have been going thru this the past 6 months.
    The meds I was taking during this time were: (1)Armour Thyroid 3gr.
    (2)Pristiq 50mg. (3)xyzal for allergies,(4)Lunesta 3mg for sleep..

    Since this time I have changed my meds to: synthroid and cytomel for thyroid, cymbalta 30mg and xyzal for allergies. nothing for sleep although i really need it..I just do not know what these meds could be doing to my brain.

    My brain just doesnt feel as sharp as it did in my 20,30 40′s. I cant remember or learn things near as fast. I can not focus on anything.

    I do NOT have diabetes, hyperlipidemia or hypertension.
    I was diagnosed with hypothyroidism when I was 17 yrs old.

    I am an MA in a very fast paced medical facility, I have to be able to mentally keep up with the everyday changing of computers, meds and most importantly our patients.

    Thanks for your time

  133. I am a 49 year old woman. I had some type of attack while out walking. My blood pressure dropped very low and I became very confused. Since then I have been weak, have balance difficulties and some other symptoms. I had an MRI of the brain. Here is the report text:

    Findings: No mass lesions are seen. No intracranial hemorrage is identified. The ventricles and subarachnoid spaces are within normal limits. Normal flow voids are identified in the proximal vessels of the Circle of Willis. The visualized sinuses and mastoid air cells are clear. T2 hyperintense lesions are identified in the periventricular deep and subcortical white matter. There are approximately 35 lesions. The largest is in the left posterior frontal white matter measuring approximately 11 mm in maximum diameter. Several of the lesions are oriented along the long axis of the expected of the deep medullary veins in a pattern suggesting demyelinating process. Diffuse weighted imaging is negative. No regions of abnormal contrast-enhancement are seen. A few of the white-matter T2 signal lesions have T1 hypointensity associated with them.

    Impression:
    1. White-matter T2 signal abnormalities as described above which are nonspecific but suggestive of demyelinating process. No abnormal contrast-enhancement is identified to suggest active demyelinating plaque.
    2. No mass lesions, no intracranial hemorrage and no evidence of acute cerebral vascular accident seen.

    Can you tell me what this means in layman’s terms?

  134. Hi i hope you can give me some answers if you can please in 2009 i had mri due to feeling dizzy & sensations in my hands i had white spots in the brain i was tested for ms there were no signs as yet. last week had mri & now found 3 more i still get dizzy on & off, if this is less blood flow or smaller vessall dieing in the brain. is there something i can take 2 help with the blood flow.if the spots persist how much can the brain take till you loose all function. im 40yr i have young children i want to be there for them growing up. i hope you can give me some answer please
    KE

  135. hello
    i was hope you could shed some light on what is going on with my head
    i had a MRI monday they found non specific white matter lesion my tongue devates to the left i have alot of headaches and i forget alot of things and also haveing some muscle twitches i am 32yrs old female could you give me a idea what this is and some questions i should ask my doctor

    thank you
    angela

  136. I had a MRI done in 2006 for a concussion that they ended up diagnosing me with post concussion disorder or whatever its called. I went to Vanderbilt for cognative therapy for a bit. Report said “There is a slightly complex fluid within the left petrous apex which has high signal intensity on T2-weighted images and intermediate signal intesnsity on T1-weighted images. This is felt to be incidental finding and not related to the patient’s trauma.”
    They said it wasn’t a big deal but I’ve been having a lot of trouble lately with headaches, confusion/fog, finding the right words/mixing up words, unrelenting sinus infections, and my blood pressure has been getting very low to the point where I feel weak and feel like I’m going to pass-out. When my blood pressure gets this low, my legs and feet swell and feel heavy. This is every day now.

    I don’t have a bunch of money to throw around; If I had to pick a specialist to see, what kind of specialist would you suggest I look into first?

    Should I be worried about an MRI from 2006 or would that fluid have dissolved by now?

    Any suggestions?

  137. A CT Scan and a subsequent MRI with and without contrast both showed two lesions in my brain. In is about 1.2cm and the other is about 5.5cm. my symptoms started out as dizzy spells, which slowly turned into focal seizure type episodes. Firstly involving tightening of my left leg, and more recently spasm/jerking of my left arm. I am scheduled for a followup MRI to see if the lesions have grown, stayed the same, or possibly shrunk. Word from the Neurosurgeon is that the lesions do not have the characteristics of an agressive tumor, and may have been there for “decades”. I have no headaches (other than tension related) and feel otherwise totally healthy.

    Any thoughts.

  138. Thanks for this site. My husband is 67 years of age and for many years he has had many nuerologically related problems. At first he was treated by an ENT who said it was Meneries and BPVP. But his symptoms continued to progress and his legs got weak, he has fallen down many times, he has lost his hearing in the left ear, he has balance problems, double vision, slurred speech and walks stiff legged at times. He has had 5 mri’s over the years with numerous blood work and eeg’s. The never gave any MS or other diagnosis. On this last mri taken just last week the findings came back mostly negative except there are a “couple nonspecific foci of white matter signal change adjacent to the anterior horn of the left ventricle” and also “again noted suggestion of vermian hypoplasia”. There are now sending him to UPMC because they think his brain stem has atrophy. Can you make sense of this for us? After over 5 years with no definite diagnosis you can imagine the frustration. He had been on Keppra and they are now weaning him off of it.

  139. Dear Dr.,
    My Neurologist is attempting to determine the cause of numbness of my tongue (left side) and dizziness. WML’ s (3) apparently appear to be from possibly a vascular issue or MS. I have had the symptoms for over a month and now am experiencing numbness on my right side including arm back and mouth as well as weakness in my legs. Could this still be a vascular problem ’cause it seems to me that this is covering a large area of my body for a smaller vascular problem. Any input would be greatly appreciated. Thanks, D.

  140. Thank You for saying “CSF (spinal fluid) examination and MRI, not just on the basis of the MRI alone”
    It is scary to have a bought of optic neuritis, and a then have an mri come up with some white spots in general (even if they are small). But since I’ve been examined by my doctor, I have recently found that there are viruses and other autoimmune disorders that can “mimic” are “act like” m.s. So It is very important, to get a spinal tap, and follow up FULL mri exam’s, and listen carefully to what you your doctor is saying, and how to proceed next. It is sometimes hard to hear when you are worried, but there are a lot of other factors for your doctor to look into for each and every case. best of luck to all on the forum.

    • Dear Katie,
      thank you for your comment. Yes you are right in saying that not all white matter lesions on MRI represent multiple sclerosis. There is a vast differential diagnosis which needs to be considered and ruled out in a systematic fashion.

      Personal Regards,

      Nitin Sethi, MD

  141. I have a question I had an mri (without contrast) nuerologist called me and said I had small vessel damage caused by mini strokes we made an apt and when I went in he said oops soory all I had was the films and not the report its just old age Im 47 being treated for essentail tremor mom had mini strokes I have an ataxic gait (according to ent and nuerologist) tingly numbness in extremities and memory and concentration problems the reason I was sent to neurologist was because i stumble and feel like im walking (being pulled to the side) ent said its not an ent problem but he called the nureologist while I was there and told neurologist that his opion is that its ms and asked him to do an mri because of the ataxicgait he said I failed the rhomberg test and had the eye movement thing (sorry dont know the name think it begins with an N) my neroloist has not done any type of exam on me except holding my knee down andd has never watched me walk am wondering what your opinion is the mri says foci of T2 and flair hyperintentisy in periventricular and subcortical white matter bilaterally. These are likely foci of microvascular disease but a demyelinating process cannot be excluded.there are also 2 tiny remote cortical infractions in the cerebellar cortex. his solution is a cane any insight would be greatly appreciated (tryed to make my question as short as possible :)

  142. Dear sir
    My 5 year old daughter got left eye blinking tic 3 months before. We refered to neurologist who asked us to go for her MRI.last week we got the report which shows “few punctate areas of increased signal within the subcortical white matter at the centrum semiovale and at the right frontal lobe. After the intravenous administration of contrast there are no enhancing lesions or abnormal vascular structures.”
    Now the doctor has asked us to go for another MRI after 6 monthys. Apart from this he didnt tell us anything. Can u please suggest me whether this matter can be by birth or in what conditions they occur? There is no past history of any kind of problem, no vision problem or any other thing. Only because of one eye blinking we went to neurologist. Please suggest what to do or how to proceed further.
    Eagerly waiting for your reply. Please help.

    • Dear Nisha,
      thank you from writing to me. I shall and cannot make a diagnosis of what plagues your loved one over the Internet. You use the word left eye blinking and then tic in the same sentence. So was the left eye blinking diagnosed as a tic? Why was the MRI ordered. The result of the MRI scan has to be interpreted taking the history and neurological examination into consideration. Your daughter’s physician shall be the best person to comment on the MRI findings and whether further work-up and if yes what is warranted.

      Personal Regards,

      Nitin Sethi, MD

  143. Dear Dr. Sethi, Many Thank You for providing such well written and pertinent information about an area of medical expertise that is not only difficult to understand, but that also seems to be riddled with Dr.’s who do not generally communicate well with patients.

    I can’t help but notice how many queries you receive from patients like myself, who are seeing a neurologist, but who are for one reason or another not receiving adequate answers to the questions they are asking.

    I’ve been having escalating MS-like symptoms for 3 years now. Numbness and tingling in extremities has now moved into spasms and spasticity, weakness, episodic vertigo, seeing flashing lights, vibrating vision, cognitive/memory problems, etc. Symptoms worsen with exercise and hot shower.

    My neurologist has noted; brisk reflexes, increasing tone, bilateral babinski sign, gait abnormality. My last MRI (Feb/11) showed 12 non-specific, white matter T2 lesions. A brain MRI 5 years previous (due to symptoms of vertigo, tinnitus and tingling) was clean. My spinal MRI is clean. My EMG was normal.

    He’s having me wait until June/12 to have my next brain/cervical spine MRI and has said that if a lesion shows up in another area of my brain or enhances, he’ll diagnose MS, but until that time, he cannot diagnose me.

    After my initial visit with him, He wrote a letter to my GP stating possible diagnoses of MS, primary lateral sclerosis or systemic sclerosis. The latter two simply don’t seem to fit from my perspective. (no signs of scleroderma and too many sensory symptoms for PLS)…but my Dr. refuses to discuss particulars with me.

    On my last visit,( I went back a few months ago because I was having increased stiffness in legs and hands) I asked him if he’s still thinking MS. He simply replied that what I have is very uncommon and he believes it is also untreatable and there’s really nothing I can do to make things better, thus he sees no point in using labels to discuss it until we know for sure. He also says that as it’s likely untreatable, there is no benefit to diagnosing sooner rather later. What he fails to consider though, is my psychological health.

    It seems to me that according to the MacDonald criteria, my symptoms and clinical findings DO indicate MS…likely more of a progressive form than relapsing/remitting, but I get the sense there’s something about my case that is causing him to doubt that….not sure..and I’m also not sure why he wouldn’t order a spinal tap, as from what I’ve read this is often used in MS diag.

    I’ve been in this place of limbo now for almost three years and the worst part is the feeling that I’m being left out of the loop regarding my own health.

    I think my greatest fear is not of any diagnosis in particular, because at this point, simply ‘knowing’ would be a relief, but that the MRI will show no change, and thus, I’ll remain in this position of experiencing worsening symptoms while having no explanation as to why, indefinitely.

    In your estimation, is 15 months between brain MRI’s standard protocol under such circumstances? And if there are no changes, would that rule out MS? Thank you so much for any clarity you can help provide.

  144. Dear Dr. Sethi,
    I have left a question above and am just wondering if you think I should go any further with my diagnosis. Im basicaly just unsure what the mri “findings” mean.your opinion would be greatly appreciated. Thank you for your time

  145. First let me start out by saying, thank you for doing this weblog.
    My 11 yr old Daughter has headaches and migraines often. We had 2 MRI’s and they came back withlesions in the grey and white matter, 5 lesions in her T2 and then the Dr called about the second MRI and said he saw Dawson’s Fingers. We had and LP, to check for MS bands, Lyme Disease and checked for Porpheria because it runs in my family.
    The test all came back negative.
    My questions are:
    If you have Dawson’s Fingers do you have MS and the LP will test positive later?
    Can a spinal injury from falling straight down on your head compressing you spine also create Dawson’s Fingers?
    I just don’t understand the test results.

    Thank you for your time,
    JenJe

    • Dear Jenje,
      thank you for writing in to me. Dawson’s fingers is actually a pathological diagnosis–when the brain is looked at under the microscope lesions are seen in a characteristic distribution around the corpus callosum. It was described in patients with multiple sclerosis. That said the term nowadays is frequently used to describe lesions seen on the MRI scan of the brain distributed in a characteristic fashion around the corpus callosum. When we see this distribution of lesions on the MRI scan, a question of multiple sclerosis is raised. The diagnosis of MS though is made based on the history and examination findings at times supplemented with MRI (brain and cervical spine), lumbar puncture findings (oligoclonal bands, IgG index and myelin basic protein)and other tests such as visual and somatosensory evoked potentials.

      Personal Regards,

      Nitin K Sethi, MD

  146. Hi, Can you please help me as I am worried senseless!! I awoke six months ago with a loss of feeling n my right hand. After about 3 months I saw Doc who asked questions and said he didn’t think it a stroke or ms and that it could be a trapped nerve. I had no pain. Went to hospital for conductive tests, all ok. All blood tests 99%. Mri scan done, white lesions showing and inflammation in spine. The neurologist suggested he knew this becasue my right leg tingles when I bend my neck? Suggested another scan in six months. Feel well excepts for the stress of the mri scan, not tired in any shape or form, feel more reassured after reading the above, have you any thoughts?? Neurologist wants me to have 3 x 2 hour steroid transfusions in my arm next months..is this the right route to take or should I pay and get a second opnion first do you think??? APPRECIATE ANY HELP U CAN GIVE ME!

  147. Hello Dr

    Recently my 22 year old daughter began experiencing double vision which clears when she closes one eye. The Optamoligist conducted an MRI and it showed multiple white spots. He told my family that my daughter has MS. This was very disturbing to us, but i wanted to know how could he make that determination without further test? I ask that question after reading your post that more test should be conducted. I believe this information wod best be delivered by a Nuerosurgeon rather than an Optimologist. This same Dr initially told us that it was 6 cranial neuropalsy.

    Thanks
    Ty

  148. Hello Dr Sethi,
    Thanks a lot for the extremely informative blog.
    I am a 24 year old female from Hyderabad.I was diagnosed with MS in 2009 October after I complained of double vision, numbness and loss of balance. Actually I had complained of numbness in my right hand first in july 2009. later the symptoms reduced to a great extent. But the double vision set in around August. When I visited the neurologist, I mentioned the numbness in my hand and the double vision as two separate episodes. However I am not so sure that the earlier numbness had completely disappeared when I got the next symptom. My Mri in August showed multiple lesions. After taking steroids, all symtoms completely disappeared. A spinal tap was done and sent to Uk for confirmation. Unfortunately, that report was lost though we waited two months to get the results. The local result of the spinal tap showed no Oligoclonal bands. I have been on a weekly injection of Avonex now for two years, with no relapses occuring. Two follow up Mri s have shown one new lesion each, though the old lesions have healed considerably.
    I have been reading that two separate episodes are necessary to confirm a diagnosis of Ms. I would be grateful if you could kindly share your opinion on the same.Thanks alot for the immense service you are doing to a whole community of confused patients seeking some answers.

  149. Dear Dr.Sethi,
    great website and also have learned a lot. Thanks for keeping up with it and not letting it “die out”. I am 38 and was sent to do MRI of head after experiencing extreme pressure in head (behind my eyes, but no headache), some tingling and numbness in legs and hands, tired, dry eyes which I contributed to being in front of the computer for many hours in a day. The symptoms have since subsided, but were lasting for 2-3 weeks, and were somewhat scary. On the FLARE T2 SL10 sequence there is a row of 5 white dots (doctor described it as a cyst-like structural alterations, up to 5mm in size. What is really strange is that these dots are evenly spaced, in one line (as if someone had used a ruler underneath, or as if I was wearing a pearl necklace around my midhead), so that the doctor wrote that the artifact could not be excluded. But in conclusion he wrote that it looks like post-inflammatory changes, that do not correspond in shape and pattern to changes seen in MS.
    Otherwise I am healthy, no diabetis, no cholesterol, no high-blood pressure, recent blood work all normal. The radiologist recommended another MRI in a few months, but with the use of contrast. Can you shed any light on this finding? I have 3 small kids I need to attend to, a lot of stress and worrying, and this odd finding is not helping me. Many, many thanks.

    • Dear Tatjana,
      thank you for writing in to me. Since I have not seen the pictures myself my advice shall have to be tempered. I though am intrigued by what you describe. First of all you do not describe symptoms classically suggestive of demyelinating disease such as multiple sclerosis. I would discuss the scan findings with the doctor who recommended the MRI brain for you in the first place. He would be the best person to correlate the imaging findings with your history and examination findings. If he so feels he can send you to a neurologist for a second opinion. Whether the MRI brain should be repeated with contrast, whether additional neuroimaging such as MRA brain, CT scan head shed more light are all valid questions that would be best answered by him. I wish you good luck.

      Personal Regards,

      Nitin K Sethi, MD

      • Hi there Dr.Sethi, just wanted to tell you that I got a second reading of the MR images by the Head of Neuroradiology at the University Clinic, and he said that the image was an artifact, 5 spots, equally spaced one from another in one straight line, he said it was a “pulsation artifact” and they see it sometimes, and that I have nothing to worry about. I was so relieved. As far as my symptoms, I think it had to do something with my first post-partum period, as it started 2 weeks after the symptoms appeared. A bit unusual but given all the hormones, lack of sleep and stress, perhaps it was a cumulative effect. The symptoms then slowly subsided over the course of 3-4 weeks. Thank you for your help!

  150. Hi Dr. Sethi,
    About 2 years ago I started to get dizzy and had numbness in my face. I also had some minor balance issues but I think that was from the dizzy spells. I was sent to a neurologist and had an mri done with and without contrast. It came back with 3 lesions all non specific. I was then sent for a spinal tap which came back negative and then an ERT which also came back normal. The neurologist lists me as probable MS becuase of my symptoms even though the other tests came back negative. Is it still possible to have MS even when all test come back negative and the lesions are not in areas where MS normally presents?
    I also suffer from migrains which sometimes effects my visions which causes flashing lights. I take 1 advil it removes the vision problems and takes the edge off headache. I’m also kind of worried I got possible tape worm or roundworms. I worked as a vet tech for 5 years and got animal feces in my mouth several times while restraining different animals mostly cats and dogs, no pigs. I did see an infectious disease specialist around same time but he only did a stool sample and said it was negative.
    I also blacked out at work 1 day and someone said it looked like I had a minor seizor.

    I Plan on going back for a new MRI to see if i have any new lesions. Also can Lesions and cysts look similar or be mistaken for 1 another?

    Thanks for any help with all this,
    Robert

  151. Dr Sethi,

    Hi, I have somewhat of an interesting and perplexing case perhaps? I am hoping you can point me in a direction that I have not yet thought of where to go.

    About 3 years ago I was extermly healthy, all adventerous, surper active, triatholons, etc… Next thing you know I came down with Transverse Myelitis on right at C1-2 (worked myself back to normal – I do have nerves of steel). Due to this and the fact that I had about four months before this complined of tingling fingers when I ran on the treadmill to my GP (only when on treadmill – although they did get stuck one day – went to massuse for this). I was diagnosed with MS. Brain scans I was told showed what could develop into tiny, tiny white spots (I still don’t undestand the whole write up of that one) Sorry I am an auditor and I’ve been auditoring myself. So did everything I was supposed to do, went on the medicine for MS. (Side note: Found out down the road I had slipped discs at C5 and 6 and got spinal steriod epidural shot for that and was told that would have caused the tingling issue of my fingers – guess thats what crazy sports get you – been going that why whole life)

    Then the pain started back up again, felt like my head was going to explode again, so they just have stuffed pain pills down me, I did find Biaxin worked for me (think I was getting infection in my head at one time – unbearable). Pretty much this whole time has been unbearable – each day worse than the last. Seen about every speclist you can think of, ENT ordered a CT scan of my lungs and throat/face just to see if anything looked out of the ordinary – found I have a vascular structure growing from my heart up outside my rib cage to my head area they got it to the left stern musc and thats far as they traced it.

    Ended it going to see another ENT specilist head at teaching hospital due to my head pain (also my right ear/jaw, he though maybe my nerves were wrapped thought he had answer) so he reran a MRI. Now I do have white matter lesions it says, while before I didn’t, had one about 8 months prior where there were none present. The part I am getting to is now there is a 1.5 x 1.2 pineal gland cyst (or what they believe to believe a cyst they even write that in they are not sure) noted. I went through my old scans I can see it in all of them – but never noted.

    Could say a cyst (or a tumor? I have set up an appointment to see a neurosurgen to see what he thinks it is) cause lots of white spots? I know if you have pain like headaches you can get white spots. Mine have been pretty severe and have been increasing in severity. It feels like there is a cork in my head and that my head is bleeding. I have said since day 1 that it felt like a monster was trying to jump out of my head and literly now it feels like its bleeeding at times.

    I do get relief from traction from my physical theropist and wonder if this is the reason why. The “cyst” had never been brought to my attention. I guess I am just trying to sort myself out, since I never had any symtoms of MS but the doctors said I had it, so I did what I was told and took the meds. Thinking I’d get better, but all I did was get worse, I have no problem if I have MS but I think my head pain which feels like my head is being squeezed off isn’t due to my MS, espeically since it goes away when I lie die. I have not been able to find my symtoms of feeling like I’m being squeezed to death or bleeding in the brain and then doing away when I lie die anyway in MS (thats one reason why ENT was thinking nerves – but the nerves looked good – thats good news I guess).

    Sorry for the long questions but I guess my main thing is can say multiple years of head pain cause the white matter lesions that I have? One other thing to note is that the majority of them are on my right side – that is the side I had the TM on – and thats the only side that really feels pain like its bleeding and being squeezed (well until I lie down). Also, per your expertise can a pineal gland cyst cause TM and those type of pain symptoms I mention? Or can you think of anything that I should look into?

    Thank you so much,
    stardust

  152. Dr. Sethi,
    Just finished reading this message on MRI showing white matter and if it’s MS. First, I am a diabetic. One morning my right hand was numb and tingling and remain this was all day. I went to see my doctor and he ordered x-rays. All results were good. He then ordered a CT Scan of the head without contrast. The results of this MRI read: Reason for Order: recent lue dysesthesias, no headaches; Foci of white matter hypodensity are noted: left periventricular; superior to the right lateral ventricle, posterior horn (7mm); at the lateral aspect of the right putamen. No subdural or epidural hematoma is noted. Foci of dural calcification noted, particularly anterior superiority, calcified menignioma not excluded.
    IMPRESSION: Non-specific hypodense foci, some considerations include demyelinating disease (such as multiple sclerosis), inflammatory, infectious, neoplastic process.
    Lately my speech as become breaking up when talking, more forgetfull, and very fatigue wanting to sleep more.

    Any recommendations or suggestions. I did not accept that I have MS.

    • Dear EC,
      I too would not accept that you have MS. The white matter lesions may be non specific and related to ischemic white matter disease. My advice is to follow up with your doctor. He shall help to interpret the MRI findings taking your history and examination findings into consideration.

      Nitin K Sethi, MD

  153. Dear Dr.
    My situation is complicated, I have been on medication for anxiety for about a year because of pannick disorder. After about 6 months of the medication I started to feel tires all the time, dizzy, depression and muscle pain and tightness. I though it was the medication so I slowly weaned myself off, with a lot of withdrawal symptoms, I did have a lot of headaches during this process and possibly one or two migraines. my doctor send me for a ct scan that showed I small nonspecific lesions, so I then went for a MRI without contrast and this is the report…
    Multiple punctate foci of white matter hyper intensity of the axial T2 and flair sequence. the largest mesures6.5 mm, There are multiple tiny punctate scattered throughout the centrum semiovale and the corona radiate in order of 1-2mm. they are non specific.
    The Stella and suprastella are unremarkable, no abnormal colloidal abnormalities,

    My neurologist said that it is not typical of MS but will do another MRI in 6months, I asked if it might be small vessel disease and he also said it was not likely… I am 35 with anxiety disorder, no high blood pressure I tested negative for Lyme, HIV, Ana, and c reactive proteins

    Any suggestion would be greatly appreciated

    Thank you
    L

    • Dear Lili,
      as I have mentioned in my post many young women with migraine have white matter hyperintense lesions visible on their MRI brain. My advice would be to remain in follow up with your doctor.

      Personal Regards,

      Nitin K Sethi, MD

  154. Hi…I am looking for insight…I am a thirty year old male and physically fit…as of last December after a stressful flight and death of family member I came down with a one sided headache that persist for weeks…my MD said it could be occipital neuritis…lots of ear popping and mild numbness and tingling in right hand…finally as the symptoms didn’t improve, I got a MRI in feb of the brain and cervical spine..findings were 4.5mm focus within the white matter of the right cerebellum complex…and possible sinus infection…my dr seemed very fague on trying to explain the findings…as of today I have been seeing chiro and waiting on an ent and neurologist …some symptoms include that I still have right ear popping…right ear tingleness, eye twitching, right arm mild numbness and right calf numbness off and on…headaches have eased a bit but other systems persist…also back in march I developed a small rash on top of my right shoulder blades and my dr said it was shingles…went away fairly quick…also sensitive upper right teeth neck stiffness…
    I have seen an ent which checked out…accupunture, several chiros, and my one dr who is finally getting me set up for an neurologist and better ent…I have been worried about MS…from my MRI results should I be at ease? Or do these symptons seem only as a pinch nerve? my ear popping and discomfort seem to never go away as with most other symptons…I would appreciate your insight as I am trying to find a right direction to go…thanks Andy

  155. thanks Dr. I was a migraine sufferer until I change my diet. I did the MRI of the Brain because of the sinus headache, I wanted to make sure their was nothing else their and the headache was only because of the sinus, anyway the MRI found the white matter. I am not worried, I change my diet, stay away from all caffeine, etc and change my thinking by reading more books.. Now I don’t suffer with migraine anymore.

    • Dear Rodney,
      thank you for your comment. I am glad you made lifestyle changes and have controlled your migraines through non pharmacological means. Stay healthy.

      Nitin K Sethi, MD

  156. Dear Dr Sethi,

    I am a 46 yr old female. A few weeks ago, I experienced tremors in my left arm and hand. It started, then stopped after a few minutes, then started again. The neurologist ordered blood tests, an EEG, and an MRI. The EEG came back normal. The blood tests revealed a slight B12 deficiency. And the MRI revealed some “changes in white matter”. The doctor wants to see me again in 6 months for another MRI.

    Meanwhile, I learned that my 81 yr old father, who is still working full time and has a very keen mind, was diagnosed with white matter changes about 10 yrs ago.

    Given this history, should I worry about MS? What about Lymes? I had a bullseye rash about a month ago and was treated for Lyme even though I tested negative for Lyme.

    Thanks so much. And thank you for your wonderful blog.

    M

    • Dear Maya,
      thank you for the feedback. Like I stated in my post there are many causes for white matter changes in the brain MRI. Multiple sclerosis and Lyme’s disease of the brain are just a few of them and certainly not the most common. I would not worry about them too much at this juncture. Maintain follow up with your doctor. He shall order further tests if he feels he needs to rule out the diseases you mention. Supplement your B12. It is a water soluble vitamin and hence quite safe to take.

      Personal Regards,

      Nitin K Sethi, MD

  157. Dear Dr Sethi,
    I am a 56 year old woman, living in Canada,
    On the 8th of May this year I was the restrained passenger in an rear end collision. I was knocked out and cannot remember the accident or any thing before it for at least 30 minutes. In fact most of the weeks since the accident have been a plank. I woke in the ambulance on the way to the hospital. There I was told that my neck was x-rayed and found to be fine. I was discharged home with my husband, who was the driver and also knocked out. Two days later I was having terrible light sensitivity, headaches, loss of balance and nausea, my husband called and ambulance and I went back to the emergency room. I was given a head CT. The CT showed no bleed but did show a periventricular hypo attenuating area. An MRI was ordered. While I was waiting for that appointment I went to see my regular doctor as I was still having problems concentrating, headaches, dizziness and difficulty with memory. He diagnosed Post concussion syndrome and felt the area on the CT was the result of an old injury. At the age of four I was knocked out after a fall from a swing and had a grand mal seizure the next day.
    I had the MRI and went for the results yesterday.

    Impression: Bilateral periventricular and subcortical T2 and FLAIR hyperintense abnormalities. There may be few pericallosal T2 hyperintense tiny areas.
    These findings are nonspecific, however, demyelinationwill be one of the differential diagnosis, clinical correlation is advised.

    I have had migraines with sinusitis over the years. I avoid chocolate, and lentils that seem to cause them. All in all they have never prevented me from working. I have hypotention rather than hypertension. I have never complained or experienced any of the signs and symptoms of MS. My doctor thinks it is nothing to worry about. I have never told him about my migraines because I never needed his help with them. I am seeing a neurologist who I am consulting about my post concussion problems( which are making writing this very difficult), so my doctor told me to consult her about my MRI at the same time.
    Reading your article I do not think I have any worries but I would be interested in your input.
    Sincerely A

    • Dear Anne,
      thank you for writing in to me. After hearing your history I personally also feel that more than likely you are suffering from post concussion syndrome. The MRI findings are likely incidental (meaning they were picked up incidentally when the MRI was carried out for your current complaints). Post concussion symptoms should abate in due course of time and you should follow the instructions of your doctor. Regarding the white matter lesions, I would not worry about MS. More than likely this represents non-specific white matter disease. Again speak to your doctor about it though.

      Nitin K Sethi, MD

  158. Hi I am a 52 yr old female who has been gong through some unusal symptoms lately. This all started in April 2012. The symptoms are tingling in my arms and legs with pain in both legs, I feel like electricity going through my fingertips, I have severe vertigo at times, I have heaviness in my body and chest pain along with neck pain aching between my shoulder blades. I have been going thru numerous tests for MS thats ruled out, I have had my Vitamin D and Potassium levels checked they are ok. I have been taken by ambulance thinkin I am having a stroke, but all shows up that I have had a stroke within the last 6 months. I can work like crazy for 3 weeks at a time and then all of a sudden I have chest pain, or I can be doing housework and I suddenly feel like my brain is so tired I almost black out and no chest pain with this and I have to lay down and rest for awhile and try again. I have had a heart test done (stress test ) still waitin on results there. I feel really wierd in my head alot when this happens. I have had 3 doctors tell me that the white matter in my brain changes alot and they have no answers for me and I am almost to the end of my rope wondering whats wrong any suggestions?

    • Dear Linda,
      thank you for writing in. Your history is intriguing. Without reviewing your history, exam findings and results of the tests already carried out, it shall not be prudent of me to attempt to diagnose you over the Internet. My advice for what it counts is that you should remain in follow up with your doctor. Good luck.

      Personal Regards,

      Nitin K Sethi, MD

  159. Hello,

    I am a 39 year old female. I have been diagonesed with Neurocardiogenic syncope, I have had C3-C6 fusion and L5-S1 fusion.

    I have had lots of numbness and tingling in my hands and feet, I drop things all the time, vertigo and dizziness and numerous blackouts, memory loss and confusion. I was sent to a Neuerologist and meet with him in a few weeks. I have my Brain MRI and not sure what it means, would you be able to help me?

    Scattered areas of signal abnormality are noted in the subcortical white matter and left and right frontal lobes. There also appears to be some periventricular involvement.

    Impression: White matter changes suspicious for early demyelinating process.

    Thank you so much for helping me.

    • Dear Emily,
      keep your appointment with the neurologist. He shall be able to correlate the MRI findings to your history and examination findings. That shall determine whether further work up is needed or not.

      Nitin K Sethi, MD

  160. Hi I am a 38 year old female that had white matter changes on my mri.It was done by a neuro doctor. She then sent me for a spinal tap but it came back unconclusive. I was having problems with balance an muscle weekness. I also have chronic pain all over my body. Some days its hard to get around because i am too week.Do you have any sugestions for me what i should do next. They told me that it could be an onset of ms but never really gave me any more answers. Please I am a mother and have many kids an i just want answers. I am scared an unsure how I should proceed..ty

    • Dear Dana,
      as you may have read in my post, there are many causes for white matter lesions on MRI brain and as a physician even though I have not examined you nor have seen your MRI scan, multiple sclerosis is not the first differential diagnosis that crosses my mind. So follow up with your doctor and let him/her guide the workup further. Good luck.

      Personal Regards,

      Nitin K Sethi, MD

  161. I am a 55 year old male and three year’s ago diagnosed with ischaemic Cerebrovascular disease, Hydrotrophy at C3/4 with disc bulge and T2 Hypertensities in the subcortical and Periventricular White Matter in my Amygdala. I am feeling very unbalanced and extremely dizzy, have bouts of tingling in hands and feet (sometimes numb). I also have sore eye’s.I have also started to weep for no apparent reason. Whilst in hospital I was diagnosed with Hypertension and Grave’s Disease (Hyperthyriodism) , now Euthyroid after Radiotherapy.
    My doctor has now refered me for psychriatric assessment. After self diagnosisi I feel I my be feeling the early signs of MS. PS I am not a psychriatric case. My doctor I feel does not believe me, What should I do next? Thanking you in advance for your time and consideration in this matter Regards Paul

    • Dear Paul,
      thank you for writing in to me. You should follow up with your doctor or a neurologist. They shall be the best people to correlate the MRI findings with your history and examination. Not all white matter lesions represent multiple sclerosis. More commonly they represent ischemic white matter disease (microvascular small vessel disease of the brain).

      Personal Regards,
      Nitin K Sethi, MD

  162. Namaskar Dr,
    I am 37 year old. I was having gait problem since few time.Actually my left leg became stiff and heavy due to which my gait became like a drunken man. There was loss of balance also. I think this is a MS symptom and I got my Brain MRI done.
    Below is the report detail
    hyperintense oval shaped lesions their long axis perpendicular to the ventricles

    hyperintense in t2w1 and hypointense in t1w1
    open ring like enhancement seen of the lesion in photo medullary junction
    evidence of prominent cortial sulci, ventricular system and basal cistems
    cerebellar foci appears prominent
    posterior fossa shows evidence of prominent 4th ventricle except for hyperintense lesion in right half of photo medullary junction
    a small hyperintense lesion in left half of photo medullary region however can not be ruled out
    multiple oval shaped lesions in paraventriclular region / brain stem

    Please suggest what this report reveals. Is this a report which can suggest that I am having MS?
    Please help.

    Namaste

  163. Hello,
    I am a 34 year old woman and was recently told I had an unusually high number of white matter lesions in a recent MRI. The neurologist even remarked that my brain looked like that of a 60 year-old woman. Originally, I went to my GP because I was experiencing sudden tremors (lasting only a second, or less) in my hands and head. The tremors would usually occur in social settings, such as work meetings or social gatherings. So my GP initially suspected that anxiety was to blame and gave me a prescription for Ativan. But after the MRI results came back, she became more concerned and suggested I see a neurologist. The neurologist quickly ruled out MS and Parkinson’s. He agreed that the tremors may be anxiety induced, but he mentioned it could also be an essential tremor. He could not explain the white matter lesions though, and suggested I have another MRI in a year to see if my condition had progressed.

    Over the past few months, it seems my symptoms have worsened. I am still having the tremors, though infrequently. I have noticed that they are occurring when I am alone, not in a social setting. I have also been having terrible bouts of dizziness, which are debilitating and require complete rest. I have had the dizzy spells since I was a child, and several of my family members suffer from the affliction as well. Many times, my ears will ring during the dizzy spell and I will feel off balance. Most of these dizzy spells are followed by terrible headaches and nausea. My hands also frequently shake uncontrollably, to the point where it is difficult to write or hold a cup. The hand shaking is also MUCH worse when I am nervous…not so much a problem if I am calm.

    Any advice you can provide is greatly appreciated. I am very fearful for the tremors and shaking to occur in a social setting and it has greatly affected my ability to function normally.

    • Dear Christine,
      thank you for writing in to me. It seems your GP and neurologist have evaluated you thoroughly for the white matter lesions. At times waiting and watching and following the white matter lesions with serial MRIs is sound advice since further testing is frequently invasive and the yield is low. Not sure what to make of your dizzy spells accompanied by headache and nausea but I would like you to bring this to your neurologist’s attention. It is possible these are migraine attacks and that may explain your symptoms as well as the white matter lesions in your brain. Follow up with him.

      Nitin K Sethi, MD

  164. I had status asthmaticus with ventilator induced sepsis and prolonged paralysis(icu polyneuropathy). Last year I had a spinal tap and mri because the emg and nerve conduction tests came back mostly normal except for bilateral carpal tunnel and mononeuritis of the right peroneal nerve. The mri showed six lesions,4 periventricular adjacent to the tips of the horns(occipital and frontal horns)plus 2 juxtacortical lesions in the frontal lobe. Spinal tap came back mirror pattern oligoclonal bands which I heard was more systemic than ms. My problem is trying to figure out if it is ms or something left over from icu polyneuropathy/myopathy,sepsis and due to medical coma. How long do brain lesions last from hypoxima and would they be in this areas? also can mirror pattern bands stay for awhile after you’ve had sepsis?

  165. HI Dr. Nitin K Sethi,

    I am 41 years old male – about 2 years ago, i started suffering from dizziness, depression and anxiety and my physicians have been treating me for problems with inner ear – and when they ruled out the inner ear they put me on cipralex for anxiety and depression – dizziness did not go away, however depression and anxiety level did go down. Around 3 months ago, my right eyelid started twitching and it spread out to my right side of my lip, occasionally the twitch would move from right to left eye lid and then left side of lips – My family physicians wanted to rule out Mass and/or MS therefore she ordered MRI . I will share the MRI results as is with you for your review and comments:

    Technique: Axial T2-Weighted, flair, diffusion, and gradient echo images have ben obtained, as well as sagittal T1 weighted flair and coronal T2-weighted images.

    Magnetic Resonance Image Findings: On the axial T2 weighted and FLAIR images, 2 SMALL FOCI of increased signal intensities are noted in the white matter of the right frontal lobe. They LIKELY represent “small foci of non-specific gliosis” OR “early microangiopathic changes”. The differential diagnosis in this age group does include underlying vasculitis, post inflammatory causes, and demyelination, BUT are PROBABLY LESS LIKELY. . No focal Axial gradient echo images reveal no evidence of hemosiderin.

    Incidental note is made of slightly prominent right sided falx calcification, which is LIKELY of no clinical significance. Incidental note is also made of partially empty sella, which is of no clinical significance.

    A small mucous retention cyst is noted in the left maxillary antrum.

    Interpretation: The 2 small non-specific white matter foci in the right frontal lobe are of “doubtful clinical significance”, as described above. No focal intracranial lesion can be demonstrated. If clinical symptoms persist, possibly a follow-up MR Scan may be considered in a year’s time for further assessment.

    PLEASE, help me understand this better – Is this anything to worry about in terms of immediate danger, do you suggest any prevention and/or treatment and/or further assessment. Please I am very desperate and anxiously waiting for your feedback. God bless!

  166. I had status asthmaticus and respiratory failure..which led to icu psychosis,polyneuropathy and myopathy..almost three years later I am emg and nvc clean for polyneuropathy/myopathy but still have stiffness and tinnitus and occasional vertigo. I had a brain mri last year and I have 2 lesions near the tips of the occipital horns…10mm one is round and one is fairly round…2 3mm lesions near the tips of the lateral ventricles and (periventricular) and two 3mm frontal lobe juxtacortical lesions. I also had two lps within three months that showed 2 mirror pattern oligoclonal bands. It looks so much like ms but is it possible it could be something that had to do with the respiratory failure like the bilateral pneumonia(fungal from ventilator)and sepsis or the hypoxemia?

  167. Hello Dr.Sethi,

    My 4 year old son recently got diagnosed with Autism spectrum disorder(PDD NOS), he has improved a lot on his own in past 1 year, behaviour wise he is fine, delayed majorly in language whereas receptive is fine in both hindi and english. Looks like clumsy sometimes.Articulation is the main problem and he tends to forget things i believe so.He is perfect in relating things to context. Therapies are on going and changes are visible but he is still delayed.So looking at his delays and activities my doctor recommended an MRI with and without contrast ,Impression came was : Delayed terminal Zones of Myelination in peritrigonal white matter versus Leukomalacia. Myelination was appropriate.No areas of heteropia. No hydrocephalus.Increased signals in peritrigonal white matter bilaterally.

    I do not have any clues what does the report means and our doctor visit is due after 2 months, am restless and want to know how it relates to my sons development.He was pre-birth exposed to Sodium Valporate 1gm a day and 5 mg folic after i got to know about him, i feel guilty about what all he is going through is because of me and my lack of awareness when i conceived him. It would be great help if u reply to my question.Appreciate for reading this.

    Thanks Much!
    Neha

  168. i am a 40 year old female had my mri w/o contrast done due to headaches daily (24/7) white/gray matter show’s a small focal what appears to be an old farct in the posterior right cerebellar hemisphere inferiorly,a tiny small area of small vessel ischemic demyelination in the right parietal white matter is also seen and also in the periventricular frontal white matter the finding in the right cerebellar hemisphere is more subtantial but appears to be nonacute ( impression:) benign findings. probable small peripheral infarct in the inferior right cerebellar hemisphere nonacute.some minimal small vessel ischemic demylination in right parietal region and also adjacent to the anterior horn of the lateral ventricle i see a neurolagist in may.i was tested negative for lupus (my mother has lupus,the kind that effects the skin) an eye doctor suspected an autoimmune disease back about 6 years ago and thats why i was tested for lupus,i also have borderline diabetes and hypothyroidism i am yaking levothyroxine 75 mcg and estrace 1 mg ( surgical menopause due to precancer conditions) but any idea’s on what the mri means (doctor at emergentcy room said some thing about white matter disease yesterday.

    • Dear Rose,
      thank you for writing in to me. Let us try to make sense of your MRI report. In simple terms it reports an old/ chronic small stroke in the right cerebellar hemisphere. This stroke was likely silent since you never suffered any stroke like symptoms. There is also evidence of what we as neurologists refer to as white matter disease or microvascular/ small vessel disease. Meaning that the small vessels of the brain are showing signs of ischemia. My advice to you as to many of this blog is the same. Follow up with your doctor and your neurologist. They shall be the best people to determine what are your stroke risk factors and how you can modify them.

      Nitin K Sethi, MD

  169. Thank you. My husband had an MRI done on his brain and there was white matter found. He had the MRI done because of am on set of migraine and some hearing loss problem. But he would not discuss it further with me. The information you gave helped to put my mind at rest. Thank you.

  170. I have unexplained trigeminal numbness. And pain left side of face.Severe pain on occasion in my eye. Weird sensations going down my legs at times. MRI showed multiple lesions. MD States consistent with high cholesterol.HTN.

    which I dont have. . I have
    severe fatigue. Occasional
    Mild tremor in my left
    hand. Few weeks ago was
    unable to control my
    bladder and bowel was
    following. I was given
    steroids. Felt much better. I
    am trying hard not to
    Diagnose myself.. I have pain left leg pretty consistent it does not radiate down my buttocks although at times I feel some pain there. My whole leg is in evolved. MD is stating l5-s1 bulging. Per MRI..Myelogram. Is un remarkable. My Peers are all medical professionals and MS certified. Convinced I have MS. How do I confirm. I have been mis diagnosed so many times. “Lupus”. “Stills disease” Spondylosis” RA . Every time an MD tests to confirm a previous doctors diagnosis… it comes IP negative ? Please help

  171. I am a 40-year-old female. I had eyelid twitching last June (2012) and next month I was unable to walk due to feeling of weakness in my leg. Blood investigations at that time revealed that B12 was 182 and Vitamin D was 7. Rest of the blood investigations were normal.

    I underwent Gadolinium enhanced MRI of Brain and Spine on November 11, 2012, which revealed the following

    Multiple supratentorial white matter lesions of variable sized without enhancement.
    Focal dorsal spinal cord lesion without enhancement.
    Demyelinating process is likely – multiple sclerosis.

    I underwent this MRI at a time where I was B12 and vitamin D deficient. I would like to know whether these lesions represent MS.

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