White matter lesions, migraine and memory problems: a question and an answer

One of the readers of my blog wrote in with a question about white matter lesions on brain MRI. Her question and my response to it follows.

Question:

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.

Answer

Thank you for writing in to me M.  White matter lesions are commonly documented on brain MRI done for various reasons (in your case as a work up of migraines). The differential diagnosis of white matter lesions is broad and varies based on the age of the patient. In “most” adult patients especially those with risk factors for microvascular disease such as diabetes mellitus, essential hypertension (high blood pressure), dyslipidemia (high cholesterol), current or past heavy smokers these white matter lesions respresent small vessel disease (also referred to as microvascular ischemic small vessel disease). Meaning that the small blood vessels in the brain are showing signs of ischemia (lack of blood flow). So when I see extensive microvascular (small vessel) disease on a patient’s MRI scan of the brain what I worry about is the possibility of a stroke in the future. As a neurologist, I then try to identify his stroke risk factors and attempt to modify them. If he has high blood pressure and is not an on anti-hypertensive medication–start an appropriate anti-hypertensive, if he is already taking a blood pressure medication but the blood pressure is still not well controlled then I may need to increase the dose of his medication and/or change it. As per the new Joint National Commission guidelines broadly speaking the lower the blood pressure the better it is (earlier a blood pressure of 140/80 mm Hg was accepted as ” normal”, now we aim for level of 120/70 mm Hg). If the patient’s blood sugar is high (fasting blood sugar greater than 107mg/dl), I would investigate him for diabetes mellitus. For this blood sugar is tested in a fasting state and after meal (post prandial). There are normal values and if the patient’s blood sugar exceeds these normal values, then he has diabetes mellitus. Diabetes mellitus can be controlled by a combination of dietary modification, exercise, oral hypoglycemic medications (pills) and/or insulin injections. If the lipid profile is deranged (high total cholesterol, high low density lipoprotein, high triglycerides and low high density lipoprotein), then again dietary modifications, exercise and lipid lowering medications (statin group of medications such as Lipitor are one example) are recommended.

Now what do white matter lesions represent when they are seen in a young person (like for example in a  young lady 25 years of age)?  The main differential and what concerns most patients and physicians alike is whether this could represent multiple sclerosis. I have written about this before and again want to emphasize that the diagnosis of multiple sclerosis is a clinical one and not based solely on the MRI scan of the brain. The MRI scan always has to be interpreted after taking the history and examination findings into consideration. Also the white matter lesions of ischemic small vessel disease are different from the white matter lesions (plaques) of multiple sclerosis. In multiple sclerosis the lesions have a characteristic appearance and distribution in the brain.

White matter lesions can also be seen in many other infectious (Lyme disease is a good example) and inflammatory conditions (sarcoidosis, connective tissue diseases which cause vasculitis in the brain). Most of these diseases can be identified with the help of a good history and some basic tests.

White matter lesions are also commonly seen in people who suffer from migraines (more commonly seen in women migraine sufferers). Why do white matter lesions occur in migraine patients. While there are many theories of migraine pathophysiology, migraine is a vascular headache and hence the blood vessels are again involved.

Do white matter lesions cause memory problems. Now that is a tough question to answer. When I see extensive white matter disease in a brain MRI, it tells me about the health of the brain and the blood vessels. If a person has extensive white matter disease, the same pathology shall be seen in the blood vessels of the heart. So they are prone to both heart disease and brain disease (stroke, transient ischemic attacks). While Alzhemier’s disease is the most common primary dementia, vascular dementia is exceedingly common too. What is vascular dementia? As the name suggests, it is dementia (memory impairment, problems in multiple cognitive domains) caused due to multiple small strokes in the brain or rather strokes in a strategic location. These strokes occur over a period of time and may be clinically silent (meaning that the patient may not even realise that he has suffered a stroke). The small strokes over a period of time though add up and cause vascular dementia.

I hope this helps in answering some of your questions M. My advise to you is to follow up with your primary care physician and the neurologist. They shall help guide your work-up further.

Personal Regards,

Nitin Sethi, MD

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49 thoughts on “White matter lesions, migraine and memory problems: a question and an answer

  1. I have many little damage in the left and right brain MR image showing small lesions in 2007 but showed no contrast imaging and LP was ok Although they suspected MS. Then waited until March 2008 MRI showed undersökninig sama plaque neither new plaques were added or lost and the spinal cord was plackfri and another MRI revealed no further damage in 2010 and the LP was ok no signs of MS. EEC examination was normal. I got ischmiske stroke diagnosis but I do not believe in my doctor in Sweden because I have very few symptoms, but the dizziness and talrubbring and weak in kroppenn problems are outrageous and my symptoms vary per timber and munuter. My Dr. seems to think that might be why I have the microvascular damage. Moreover, it is very difficult or impossible to see the difference between the demyelinating lesions and small vessel infarcts on an MRI? I take the 1:01 aspirin and 2 pp Antin and a simvavastin and 10mg amlodipinom because I have högblodtryck a day days. I wonder why I can not live a day without symptoms and often return many symptoms for me I live in Sweden in stockholm.Jag think of MS forever. kortison taking steroid tablets and taking high-dose I purchasing the netet despite mi doctor refuses to take it, then I become refreshed 2 day ago,

    • Dear Hiwa,
      thank you for writing in. I have not examined you, so shall not attempt to diagnose what plagues you over the Internet. I do have a word of advise. I would not recommend taking steroids without the approval of your doctor. Steroids can at times have serious side-effects-such as gastric bleeding, weight gain, muscle weakness, immune suppression making you prone to infectious diseases and so forth. So please do follow up with your doctor.

      Personal Regards,

      Nitin Sethi, MD

  2. Dear Jeanne,
    thank you for writing in to me. It is possible that in your daughter’s case the white matter lesions may represent sequelae of traumatic brain injury. Post traumatic headaches have to be differentiated from other primary headache disorders such as migraines and tension type headaches. At times they can be disabling and hard to “cure”.
    My advise to you would be to have her maintain follow up with her doctor. I wish her my very best.

    Personal Regards,

    Nitin Sethi, MD

  3. You are very welcome Mary. A second opinion never hurts but a word of advise. Do not fall into the trap of doctor shopping. Hopefully you shall have the answers soon. I send you my very best and feel free to write in again.

    Personal Regards,

    Nitin Sethi, MD

  4. Dear doc Sethi
    I had mri today with and without die ,,I have been having memory loss ,,,but the loss is not what scares me i cant remember at all . I have to look up what i have forgot and when i find the answer it is hard to believe . I feel confused a lot cant focus ,and while im looking at a clock i get lost on time , have a hard time on time span,, I noticed some symptoms about A year ago but thought it was just life ,,but lately almost every day ,, im female 39 can you tell me what might be wrong the doctor keeps asking me about depression but i think I would know if i was depressed wouldn’t i ,,, im scared im going to forget something very important that will hurt somebody PLEASE HELP

    • Dear Mollie,
      thank you for writing in to me. I am sorry to hear that you are passing through such difficult times. I do have one valuable piece of advise. In my experience a formal neuropsychological evaluation is extremely helpful in patients like you. The neuropsychological testing is able to be establish objectively in what different domains are you experiencing difficulties such as attention, concentration, verbal and non verbal memory, executive planning and so forth. Your doctor shall then be in a better position to help you.

      Personal Regards,

      Nitin Sethi, MD

  5. Dr. Sethi,

    My mother just recently had MR imaging of her brain performed and received the results yesterday. It revealed about 30 lesions in the small vessels. She is 55 and has no history of hypertension nor diabetes. She was a smoker for a number of years but quit 20 years ago. She has been having “events” for about 13 years which had lessened during the middle 10 years of that span. They came on suddenly and with intensity. She had about 6-7 of them early on and then we began aggressively pursuing lifestyle changes to attempt to find answers. Western medicine had no answers other than anaphylaxis. During these events, she would pass out, seize and lose control of her bodily functions. For the past 13 years she has seen innumerable alternative care providers that resulted in great improvements in her health. However, she has recently began having these events again. She recently (two years ago) left a horrible marriage which I had hoped would improve her health. However, the toll of the divorce and subsequent changes to her economic status have taxed her greatly and after 30 years of sobriety, she began drinking again. Her health is complicated and I am not looking for a pat answer. I am more curious about the MRI findings and what light you may be able to shed on those reports. Thank you so much for your time.

    • Dear Moriah,
      thank you for writing in to me about your mother. You want me to make some sense of the MRI scan and so that is what I shall attempt to do. As I have stated in my post, there can be multiple causes of white matter lesions on the brain MRI scan. The most common cause of these white matter lesions is what is called ischemic/ microvascular small vessel disease. These lesions are more commonly seen in patients who have microvascular risk factors such as essential hypertension, diabetes mellitus, dyslipidemia (bad cholesterol) and who smoke.
      With respect to your mother’s clinical presentation, they may or may not have anything to do with it. The lesions always have to be interpreted taking the patient’s clinical presentation, history and physical and neurological exam findings into consideration.

      Personal Regards,

      Nitin Sethi, MD

  6. Dear Doctor,
    Thank you very much for this wonderful forum. I was wondering if you could possibly give me your opinion. I am a 36 year old mother of three, I have been suffering with migraines for over 20 years. My migraines are less frequent but treated well with maxalt. In a brain MRI from 18 months ago, it showed i had a focus of abnormal T2 signal in the right frontal subcortical white matter. I had second MRI done 7 months later which was unchanged. I am due for my 3rd next week, this time with contrast. The other symptoms i am having is muscle spasms/twitches, restless legs and parastesia of hand and feet (comes and goes) as well as mild vertigo that can last upwards of two weeks. This “episode” that i am having this time included starting with daily headaches, ,on came the vertigo and then the RLS. The muscle spasms have never really dissapated nor has the parastesia (but the parastesia does seem to ween away at times). i am afreaid i am “relapsing”. I know i should not get ahead of myself and the fact that the MRI has not changed is great! but, i cant help but think that something is here… what is it and why is it being overlooked.??? Any information,feedback you can offere me woulod be greatly appreciated.
    SIgned…frustrated and scared in NY

    • Dear Kim,
      thank you for writing in to me. I shall not try to diagnose you here over the Internet since I ave not examined you nor taken a detailed history. That said I am not sure why you are having follow up MRIs and just exactly what your doctor is trying to rule out. Is he considering multiple sclerosis? You used the word “relapsing”. Please give me some more information and I shall be able to advice you better.

      Personal Regards,

      Nitin Sethi, MD

      • Dear Dr.
        its been a while and ive been trying to just “ignore” some of my symptoms but its hard when they are now getting in the way of daily living. I have been suffering for about two months with “chest pain and tightness.” I have gone through a gammet of testing incuding RUQ sono, CT of pelvis and abdomen, upper GI, HIDA scana and blood work. All normal. the tightening radiates to my arms and hand and is fleeting although it happens many times a day, My Dr. ordered a brain MRI and MRI of thoracic spine. He also ordered a echo and carotid sono. I am trying not to worry and just wish i had some answers,,,Any suggestions? i cant help but think of MS. Trying not to jump ahead of myself but he did say that he was looking for lesions in spinal cord.
        please help! i know you cannot diagnose my over the computer but i would love to know your opinion

    • I suffer from idiopathic intracranial hypertension and my symptoms mimic your almost identically including the updates you added. I only had on white lesion that was pretty much considered insignificant on MRI. I showed slightly elevated ventrical size. The neurologist was certain it was only migraine disorder until a follow-up spinal tap showed highly elevated cerebrial spinal fluid volume. If you have not already found a solution you might inquire about this disorder. I am much improved (although not perfect) with treatment reliant on acetazolamide. I have been undergoing treatment since 2010.

  7. Hi Dr.

    I have been experiencing Migraines from the age of 16. However it only occurred twice a year at most and then began increasing. I am now 25 Years of age and in the last month, I have experience minor headaches atleast every second day and three severe migraines. I do wear spectacles and had my last eye test in February 2010,could this be the problem? Also I am currently studying and thought it was due to stress or maybe my diet is incorrect although I have not changed my diet and eat normally. I also suffer from sinus and my GP said that they are not migraines, just sinus headaches, however, I experience all the symptoms of a migraine, nausea, vomiting, cannot focus and have to be left alone in a quiet, dark room to be able to sleep. Can you please help me find out what the problems is.

  8. I have been having migraines all my life but 100x more since my open heart surgery in 11/10. I am on coumadin now and since the day before I left the hospital I was actually having aura type migraines 3x a day. I just had an MRI last week so I do not know any results. I have tried migraine meds but they do not like me.
    This is so similar, I have serious memory issues. I need to know wht is wrong. The memory issues were bad before but much worse now. And they are NOT from my heart meds.
    Just very curious to read others………………..

  9. Hi Dr. Sethi

    I am so glad to have found your blog and I hope you can help.

    I am hypertensive and an on medication for it and it is under control.
    I have had an severe epistaxis attack about 10 years ago and things have never been the same. I have migraines and also slight co ordination problems , especially my writing ability. There is also the problem of bright shiny floaters around the periphery of my vision , occasionally.

    Recently I had an excruciating headache and my wife then arranged for me to have a full physical and also an MRI. The physicals went ok , pressure under control and coordination checked , then referred to neuro for further tests. The MRI was done and I do have the report which says :

    Findings ( these are translated into english from afrikaans , south africa )

    There is bilateral isolated frontal, subcortical and deep white matter T2/Flair noncontrast foci in asymmetrical distribution which is consistent with microvasculopathy.
    The rest of the supra/infratentorial peripheral SSV spaces , ventricular and lobe profile is normal. There is no diffuse destruction or abnormal mineralisation. The major intracranial blood sinuses show normal flow patterns on all sides. The KSA cerebello corners , pituatary fossa , orbital and paranasal sinuses are normal.

    Opinion

    Isolated age related and risk factor associated microvascular lesions exist.
    The rest of the diagnosis is normal.

    Dr Sethi , should I be concerned or careful after reading this ?

    Thanks once again for a brilliant blog.

  10. Dr. Sethi,

    I have a question in regards to my son in law. He is 32 years old and was diagnosed with sarcoidosis and then neurosarcoidos due to lung nodules and eventually a pituitary growth within the last 5 years.

    He was having some very noticeable memory issues and his family doctor ordered an MRI of the brain. The results stated that the pituitary infundibulum is now normal and only .3cm and that the group of enhancing subcentimeter foci of FLAIR and T2 hyperintensiry in the left hypothalamus and basal ganglia has improved also.

    The worrisome part……..Nonenhancing confluent FLAIR and T2 hyperintensities are noted again within the periventricular white matter bilaterally without change, however, there are new subcentimeter foci of nonenhancing FLAIR and T2 hyperintensity within the frontal subcortical white matter bilaterally. While these findings most likely reflect areas of microvascular ischemia; however, demyelination and gliosis cannot be excluded.

    Obviously I’m concerned about MS, although the only symptoms that he would be having are the memory loss and alot of fatigue. It would be important to mention that he also was hospitalized with high blood sugar about 6 months ago and was given poor IV care, which ended up with him having 3 blood clots in his arm and put on blood thinners until recently.

    Could these changes on the MRI be associated to the sarcoidosis? Or if they are ischemia related could they be the result of the blood clots in the arm a few months back that caused the lack of blood flow?

    Just hoping that he doesn’t have something new to deal with since the neuro sarcoidosis has been tough on him and my daughter……..leaving him unable to conceive a child due to the pituitary involvement. On a happier note they were able thru the wonders of fertility to use a sperm donor and now have a beautiful 3 month old baby girl that is the light of their lives!! Thanks so much for you time and opinion!

  11. Dear Dr. Sethi,

    I can’t tell you how much I admire your writting here. I am sure this is really very appreciated.

    I would also have a question fro you. I am having strange pain in my had since several years. I think they started more than 10 year ago in my right ear (sometimes behind my ear or above my ear) – shooting, sharp pain like an electronic impulse. But it was not so severe and it lasted for a day or two. THe paing has always been triggered by some wind. SO I ignored it since I thought it was just an ear.
    THan 4 year ago after being on a very strong wind I experienced the sma but extremely severe pain – it started in my right eear and went up to top of my haed. It lasted 2 days. Since than I am having this pain 1 to 2 times per year (this year already twice). SOmetimes just on the top of my head, somtimes just in my ear sometimes both. IT really bothers me. Oftenly I have an experience that my top head and right ear are very sensitive and I can feel very strange but not bothering feeling there – I mean even when I do not have pains.
    So I went to neurologist, who sent me to MRI, which results were the following:
    – some minor hipersenstive lesions in white matter, which show demielization which correlates to MS
    – after application of contrast in the above mentioned lesions there is no increased signal
    – but there is signal increased deeply in the white matter on the left side, where in FLAIR there is no clear demielization
    – if the patient has the symptoms of MS, thsi could be the active lesion

    I went back to my neurologist, who said that my pain can be the only symptom of MS and that I can have MS.

    Then I went to MS specialist who said that I do not have any symtoms of MS and that maybe my neurologist thought about trigeminal neuralgia, which I do not have. He told me that my lesions are not specific and that they can be due to migrains -but I am not sure if I have them. I have just normal headaches around my period (I am 40) but not severe and not just on one side and without visual disturbances. so this specialst just told me to forget about anything.

    But I can’t. I am afraid ot this teribble pain, I hate this occasional strange feeling in my ear and top head (it would not bother me If I would knew what is it). Why my neurologist was so sure that I had MS – she sid because of the active lesion. And than MS specialist so sure that I do not have it.
    Can the active lesion be present even if I do not have a migraine attack at the moment? Can it be linked to my strange pains – which are really like some neuralgia? I have to stress that I did never have any pains in my face.

    THank you very much in advance. I appologize for my bad English.

    I wish you all the best and kind regards,

    Lona

    • Dear Lona,
      thank you for writing in to me and thank you for your kind words of encouragement. Your history is quite intriguing. As I have already stated in numerous other replies, I shall not attempt to make a diagnosis over the Internet without having examined you. That would be fool hardy. That said there are a few thoughts I can share with you. Your pain history sounds like a neuralgia (nerve pain) and Trigeminal Neuralgia remains as one of the differential diagnosis. Please read my recent post on Trigeminal Neuralgia. It shall help you better understand the topic. The MRI findings though are intriguing. Just want does this increased signal in the white matter on the left side represent? My advise yo you would be to maintain follow up with your doctor and neurologist. It may be worthwhile to investigate you further for MS. You may warrant additional tests such as visual evoked potential and examination of the cerebrospinal fluid. See my post on how to make a diagnosis of MS at http://braindiseases.info.

      Personal Regards,

      Nitin Sethi, MD

  12. Dear Dr. Sethi,

    Thank you for writting back. Would it be possible that this would be some other kind on neuralgia, because I read everything about it and I can not recognise myself in any description. I never had any pain in my face or mouth neither had any glosofaringeal problems. My face is not sensitive, but only my outer ear and scalp on the top of my head (not allways). MS specialist also thinks that this is not trigeminal neuralgia. He even thinks that I just have headaches but this is what I can not beleive and I still think is some sort of neuralgia.
    Accoridng to the MS specialist the lesions are not on the specifica places for MS, they are just minor, this is why he did not recomed any additional diagnostic procedure at this time but only one more MRI in 1 year time. What do you think? Should I go for furher diagnosing immediately. I am already 40 this is why I am worried that if this would end with MS it could be very progressive due to my age – what do you think?
    And again I do not have any other syptoms, the neurological eclinical xamination was without any abnormalities.

    Once again thank you. You ara making our lives easier.

    My best regards,

    Lona

  13. I’m a 41 yr black woman with MS. How long I have had this I don’t know. Around April of 2009 things started getting worse, the slurd speech, dizziness got really bad,memory loss, the headaches were to much to take. The pain in my right leg was bad I wanted to have it cut off( no lie). My eye sight started to fall me, I could not see far away signs. Things right in my face was a total blurr. I have never wore glasses or had eye problems. I’ been with my husband since he was 16 and I 17 still inlove how ever It hurt to have sex! I lost my physical lust for him all I could do is cry in he arms! Then came the seizures… my world was turned upside down. The pain on the left side of my body is waiste up. the pain on the right side is my lower back down. The pain is much too much to take. We left TX. due to the heat worsing the seizures and went to GA. were I have family but find myself being stressed out!!! I still have never had the chickenpoxs, no cavitiesNot a smoker nor have i ever been, yes I am over weight but I’ve lost 35lbs. A healthy person how could this be happening to me?

  14. Dear Sunil,
    in simple terms the brain is divided into the cortex (surface of the brain where the grey matter is. Grey matter consists of the cell bodies of the neurons) and the subcortical area (this is referred to as white matter and consists mostly of the myelinated axons which carry information to and from the brain).

    Personal Regards,
    Nitin Sethi, MD

  15. Dr. Sethi,

    My 22 year old daughter recently had an MRI and the report states the following under impression:

    Numerous periventricular white matter and subcortical white matter lesions. This have typical features of multiple sclerosis, but can be seen with a variety of inflammatory, infectious, and ischemic processes.

    The findings say:

    Several small scattered white matter lesions are noted. These are concentrated in the periventricular white matter, where they have somewhat perpendicular configuration to the axis of the bilateral leteral ventricles. There are smaller number of such tiny lesions within the subcortical white matter, particularly of the bilateral frontal lobes. These measure up to 1.2 cm in diameter.

    The mri does not show diffusion restriction nor intracranial hemorrhage.

    I having had a rare autoimmune disease (lymphocytic Hypoficitis) which affected my pituitary gland where it swelled out of function kind of understand what this means. My question is; who is the best neurologist in the south which can diagnose my daughter and treat her.

    Thanks in advance for your help

    Rene

  16. About six months ago I had a two-minute “vision” of pastel-colored balls in an array across my eyesight, but my ophthalmalogist said it was either my brain or my heart sending the display, not my vision. So I ended up with an MRI. Here is the radiologist’s report:

    FINDINGS: There is moderate bilateral temporal lobe volume loss with cortical and deep as well as mild cortical volume loss elsewhere in the moderate central volume. There is some fluid and abnormal signal intensity in the subcortical periventricular white matter of centrum semiovale corona radiata. In addition there are multiple confluence areas of abnormal signal intensity within the central and lower pons. Bodies findings are nonspecific but most likely due to chronic severe microvascular disease. There is no restricted diffusion. No intracranial hemorrhage. There is no abnormal enhancement of the brain. The internal auditory canals are normal bilaterally. No abnormality of the cerebella pontine angles is seen. The inner ear is unremarkable. There is no abnormal enhancement.

    CONCLUSION: 1. Prominent temporal lobe and central volume loss. 2. Severe white matter disease most likely due to chronic microvascular ischemia. 3. Severe microvascular ischemic change of the pons. 4. No abnormality of the internal auditory canals or CP angles.

    I’m 70 years old. At first my doctor was sure I had atheresclerosis due to lifestyle, but when I told him I’d had intensive cobalt radition therapy to my pituitary gland when I was 24, he changed his mind and is now sure that I am suffering long-term effects of radiation burns. The purpose of the therapy was to try to control my blood pressure, which had soared to 220/120 and wouldn’t come down no matter what they did. The doctors said they were going to “calm down” my pituitary.

    I have some unsteadiness but can get along okay. My doctor ordered a four-wheeled walker for me, and I also bought a cane. My memory isn’t as strong as it once was, but I’m 70 years old. I can still read, write, think.

    My doctor (internal medicine) put me on just about every kind of B vitamin there is and urged me to avoid cholesterol and minimize use of sodium and sugar. He says my biggest risk is a stroke.

    I tell people I have a terminal disease, but I honestly don’t know if I do or not. What should I be doing about it? I am sleepy much of the time, have incontinence about half the time, lost most of my hearing in my right ear, and have irregular blood pressure from 90/65 to 165/95 but nothing to to worry me. I do fall now and then and recently sustained a bad concussion when I landed on a concrete sidewalk at a neighbor’s place. That was four months ago, and I still have a lump on my forehead.

    Any advice at all?

  17. i want to know about the reason for the flair hyperintense foci noted
    in bilateral frontoparietal subcortical white matter suggestive of
    lacunar infarcts
    Is it alzhiemers..i have small headaque and i loss memmory shortly(cant remember the events just before 6 months) .is it possible to overcome from this disease through medical treatment??can i regain my lossed memmory?
    i hope a positive reply to my Email as earlier

  18. I was diagnosed with a hole in my heart. I suffer from daily vestibular headaches that affect my balance. My headaches get much worse in the winter. If I don’t have a headache I don’t have dizziness and I feel fine. I had an MRI 9 years ago and then again 2 years ago. They say almost the exact same thing with no changes. It says non specific white matter possibly from small ischemic vessel change, or migraine. Not likely to be demyelating disease. However my cardiologist wants me to be checked for MS again just to rule it out before he repairs the PFO. I had a spinal tap 14 years ago and it was negative for MS. My body is very sensitive to meds, testing, etc. do you think I really need another lp? I don’t not have any other physical symptoms of MS.

  19. I was taking Diovan 160mg for stage I hypertension..Went for check up w/PA and still had stage I hypertension and he put me on Diovan 325mg..I started the higher dose.On the eight day I was extremely confused, felt very faint, blurry vision..checked my b/p at home 3 times it was 60/40..there was a horrible pain across my shoulder blades and around my neck..being in this state of mind I didnot get to the hosp. this was 4 yrs. ago. I have been told that I had small strokes.vasculapathy periventricular leukopathy.my last mri I have a question..T2 hyperintense lesions in periventricular deep & subcortical white matter . approx 35 lesions.Several of the lesions are oriented along the long axis of the expected of the deep medullary veins in a pattern suggesting demyelinating process. a few of the white-matter T2 signal lesions have T1 hypointensity associated with them
    thank you for your time….helping me understand my mri

  20. Dear Dr. Sethi,

    For two years, I have been plagued by some sort of paresthesia or peripheral nerve disorder, perhaps simply Benign Fasciculation Syndrome or anxiety/stress — random weird sensations like daily muscles twitching or gently spasming, vibrations, brief burning/numb spots, and frequent fatigue. I have tried many interventions (vitamin supplements, caffeine reduction, counseling, change in employment, exercise, etc.), all to no avail. In addition, I am hypertensive, usually controlled with medicine (runs in my family). I am 10-20% overweight (it changes) but I’m active and exercise regularly.

    I’ve had multiple blood tests, several thyroid tests, a nerve conduction test, and most recently a neurological workup including MRI. I received a letter in the mail on Thursday confirming the presence of “a few nonspecific abnormal white matter lesions on the frontal lobes bilaterally,” and my doctor added the note that the lesions could be the result of high blood pressure.

    I could not reach my doctor on Friday to ask questions. Of course, my blood pressure shot up this weekend, ranging from 135/88 all the way up to 160/110. (I upped my dose by 50% and took some xanax.)

    My main question is whether the high blood pressure lesions could be causing all my muscle sensations. My brother recently passed away from ALS, and my team of health care providers seem to have ruled this out, but our familial weakness in neurological issues also includes my father who had either alcohol or high blood pressure-induced Parkinson’s symptoms.

    I hope you can understand my concerns. Your thoughts?

  21. Finally after 15 Yrs. of trying to figure out exactly what my Nerolologist was trying to explain to me I got it. This really helps me as I have been a Migraine Sufferer all my life. And, believe me when I tell you I have tried “EVERYTHING” out there. As a teenage, I started drinking alcohol thinking this would help- Boy was I wrong. Then I tried smoking Pot,(Marigana) I was wrong again. I tried every over the counter pain meds I could get my hands on- Wrong! I seriously was having to go into the E.R. Hospital at least 3-4 times a week to get shots of Toradol. This would help a little but would knock me out for days. Finally, at the age of 30 Yrs. Old. I went in for a serious MRI because the Migraine were taking a toll on me and my brother was in the ICU for an Anerlysum. Forgive for my misspelling of some of these words. In my case, I was told that I have what they call, ‘Restricted Blood Vessels thus causing the Migraines. So, it was at this point that I finally found the best medication that has worked for me and ever since the day I had that MRI done in August, 2005. I was started on Forional w/ Codeine. (You have to use the medication correctly as it is a narcotic drug and if a person is not careful you can get addicted0 You do not want this to happen because then you will have two medical problems instead of just one. Best thing in the World!!! It is a highly addictive medication but I will tell you everything else, even the Imatax just about killed me so with this medication I have not had to return to the E.R. and no way, no how am I ever going to use any other medication as this one does work for me. Sad, it took me so long to find. I suffered greatly! I must also add the fact that at a very young age I had to have a complete Hsytrorimany. I had had a tumor for a very long time and did not know it. But my homones were a mess. I was only 29 yrs. old when I had to do this. Plus having a History of Migraine Sufferers in my family and Anyrusms does not help me at all. All I can say is I too have suffered from the long-short term memory loss and there is not much I can do about that. But for the moment this medication works the best for me! It’s been a long, hard, life living with so much pain but at less now I can function a little better and I have learned things like breathing, eating the right foods, stress factors. You name it and I have done it. My grandmother was a Medicine Woman and she too would try different thing when she was alive. They never worked for me. “It does feel good to finally understand what is going on in my brain!” Probably the most important thing that has worked for me personally is having a strong, spiritual relationship with God!” I wish you all the the best as I know it is not easy. You make due, You never give up. You can’t. My prayers and thoughts go out to all of you that suffer with disabiliting migraines.

  22. I am a 73-year-old non smoker, not diabetic, blood rpessure 130/75, exerciser, eat right, not overweight. Compared to am MRI w/o contrast four years ago, this MRI shows “signal abnormality in a patch distribution in subcortical and periventricular white matter. Nonspecifc pattern but suggests white matter change from low-grade ischemia due to small vessel disease. No sign of infarct. “Now I am panicking that I will develop dementia despite my healthy lifestyle. Doctor wants me to take .75 mg. Plavix, which I hate to do but don’t want to be stupid. How scared should I be about progression? Is it inevitable? There are no lifestyle changes I can make.

    • Dear Sandy,
      thank you for writing in. There is a lot which has been written about microvascular small vessel disease and cognition. The questions you ask me shall be best answered by your doctor/neurologist. Based on what he feels is the cause of your white matter disease, he may advice anti-platelet drug therapy. Is the microvascular disease progressive, are there any other life style changes that you can make, should you be taking a statin or another cholesterol lowering drug such as omega 3 fatty acids–are all good questions that only he can answer best since he has examined you.

      Personal Regards,
      Nitin Sethi, MD

      • Great question and the answer to which we still do not know. There are many patients who have extensive white matter disease in the brain and never develop cognitive difficulties in their lifetime. There are others who do. At times the vascular pathology/dementia coexists with Alzheimer’s pathology (neuritic plaques and neurofibrillary tangles).

        Personal Regards,

        Nitin K Sethi, MD

  23. Mary: Are you a OIF veteran? I ask because if so, you could be suffering from a neurological condition similar to MS but not and due to toxic exposure. If not, then I encourage you to keep getting MRIs as frequently as possibly and demanding further investigation if the lesions keep increasing in number and/or size.

  24. Greetings Dr.

    I am a 45 year old woman, I have been seeing my family doctor regularily for the past several months (6 plus). I have had a series of sudden onset symptoms which slid in and out lasting anywhere from a a week to two weeks at a time. generally they come on quite quickly and are as follows;
    – headache (scale of 1-10 …6-7ish) – feels like my brain is pushing against the skull … mainly situated in the back of the head.
    – I have lost my vision momentarily once, although I get double vision in general with it
    – confusion
    – loss of memory, total blank on peoples names, my passwords, pin numbers, names of reports, and sometimes loss of thought in mid-sentence … I have a fairly detailed oriented job and am often depended on to lead the management team…as you can imagine this is beginning to affect my ability to do so.
    – I have had facial numbness on the left side
    – loss of balance
    – dizziness/vertigo
    – my left arm and hand sometimes has difficulty working (such as droping my keys randomly and repetitively)
    – extereme exhaustion all the time – no matter how much sleep I get
    – I have always been good at keep my emotions to myself and yet I seem to cry at the drop of a hat and not because there is a reason to be sad.
    – I do not suffer from depression
    – I have had an MRI to rule out MS… which came back with; a small number of white matter hypertensities in the subcortical brain of both cerebral hemispheres and a 3 mm hypertensity is present in the centrum semiovale of the right cerebral hemisphere. The report states that they are more in commonly seeing in ischemic demyelination than typical demyelinating plaques (not sure exactly what that means)
    – my blood pressure (accept for during an eppisode) is generally around 102/68 – will go up to 138/80, likely due to the pain or fear of the episode – thus not an issue
    – my cholesterol is 2.6 – thus not an issue
    – my heart, arteries and veins (accept for in my brain…lol) are in great shape
    – I was realtively active before this began
    – I eat relatively healthy.

    I am awaiting a referal to a Nerologist … however in the meantime should I be concerned and is there anything I can be doing now?

  25. Thank you for the information. I have posted your comment Ingo though I personally have not used this product and hence cannot comment on it or endorse it.

    Nitin K Sethi, MD

  26. Hi,
    Just wondering if you can give me some information? A year ago, in one day, I developed slurring speech with mix up of words, 50% loss in right arm strength, loss of sensation in right fingers. I had an MRI which stated “Non-specific small foci of increased signal intensity in the deep white matter of the frontal lobes bilaterally. These are most likely due to small vessel disease”
    At the time the doctor told me I had carpel tunnel … I am about to commence seeing a new GP
    Could you tell me what this means? I dont seem to be getting any answers.
    Thanks

    • Dear Twoody,
      your symptoms raise concern for what we neurologists refer to as transient ischemic attack or TIA. As the name suggests there is transient decrease in blood flow to a part of the brain which results in neurological deficits on one side of the body. Usually this occurs because a small clot goes up to the brain and transiently blocks one of the blood vessels. You should bring this to the attention of your GP in a timely fashion. Even though the symptoms occurred more than an year ago, it shall be prudent to do a stroke work up and attempt to identify any stroke predisposing factors.

      Personal Regards,

      Nitin K Sethi, MD

  27. Dear Dr. Sethi
    you cant believe how grateful i am to read your item on white matter, if you have time i would be grateful for your opinion, not diagnoses obviously, i had a stroke, CT scan showed hypodensities in left frontal lobe (small vessel disease) neuro has me on aspirin, ramipril and statin (high cholestral ) im 51 been ill for 3 yrs also have pernious anemia, fibromyalgia and vit d deficency. just had a MRI which showed multiple high signal foci in subcortical white matter more particulary in the frontal lobes.
    after reading your article i am fairy conviced it is small vessel disease if i am understanding correctly would you agree with this? and i would just like to ask you a question or two, from this finding only does it look like MS will be ruled out, also could the ‘foci’ represent silent strokes and just out of curiosity do these strokes slowly damage you as appose to having a major stroke and being damaged all at once, many thanks for taking the time to read this, and your article is so easy to understand and i am very grateful for that, kind regards

    • Dear Teresa,
      thank you for writing in to me and I am glad that you have found my site useful. So let me answer your question about white matter disease. The current thinking about white matter disease also called as microvascular small vessel disease is that it is likely due to vascular causes such as uncontrolled hypertension, diabetes mellitus, high cholesterol, smoking and so forth. There is intense interest in white matter disease of the brain especially with respect to cognition meaning does white matter disease contribute or lead to vascular dementia later in life and whether white matter disease adds to the disease burden in a patient who develops a primary dementia such as Alzheimer’s disease (meaning that white matter disease and vascular dementia may coexist with Alzheimer’s dementia and add to the disease burden).
      So while I shall not say that white matter disease represents silent strokes in the brain, it is thought to be due to vascular causes and how aggressively it needs to be controlled remains to be decided.

      Personal Regards,

      Nitin K Sethi, MD

  28. Dear Dr. Sethi
    I am so grateful I have found your website. Reading though it made me feel better.
    I am 50yrs old, had bad migraines since I was10yrs old and has gotten worse as yrs went by. I ended up blanking out, and got confused, especially at the shopping centre, I just went dizzy and blank, couldnt remember where I was for a few seconds . As I sat down to calm down and try hard to remember where I was or where I parked my car or which end of the shopping centre I came from the car. This happened to me a few times. Then I started to get tinglings & numbness in my left arm and left upper thigh like someone tying a rope around my knee, this happened more when I was sleeping, it would wake me up.
    I also had tingling in my feet & toes. My face felt tingling and funny feeling that my eye sight was blurred. Sometimes I would awake, struggling for breath cant breathe. I went to my doctor, he took a scan of my brain and sent me to a neurologiist at the main hospital. I have been with the neuologist now for 3yrs, still having my epicsodes mostly when I am sleeping, feel so sick. they have done many MRI images and found I have alot of White matter/damage in my brain. To my good luck the MRI of my brain has not changed to the worse, stablised. My Neugolist is battled as to what it is and why I am having these epicsodes. Claims they are not TIA’s…my heart is okay too. He is now trying to make me go to another Neuologist and maybe he may find something…..Wished you could help I feel so bad, hoping he isnt thnking I am putting it on. Its so scarey when I have these epicsodes and not knowing what to do… I am at a lost now as he is not interested in helping me. I wont if anyone else has these epicsodes…???
    Look forward to hearing from you soon. thanks B (from Western Australia – Perth)

    • Dear Belinda,
      thank you for writing in to me from Perth, Australia. I am glad you found my post helpful. Afraid I do not have any pearls of wisdom to offer you. Are the white matter lesions the cause of your symptoms and if yes what is the cause of the white matter disease needs to be determined. I wish you good luck.

      Nitin K Sethi, MD

  29. Dear Dr Sethi, I have received my wife’s MRI report which suggested multiple tiny hyperintense lesions in bilateral frontoparietal subcortical white matter, possibly ischemic lessions,, please let me know is this dangerous and what is the best precaution to be taken. i am concerned since here being holidays the Dr who referred the test will be available only after one week.

    • Dear Mr. Pawan,
      without any history and why the MRI was carried out in the first place, I am afraid I cannot and should not interpret her MRI report as I may misguide you. Her doctor shall be the best person to do that.

      Personal Regards,

      Nitin K Sethi, MD

  30. Mary, my name is N, and I want to throw out one other option, that most dr’s do NOT think of: hashimoto’s encephalopathy. it is a condition where your immune system attacks your thyroid hormones and your nerves, but it is possible not to experience the thyroid symptoms. how do i know? i got it this year, and had to diagnose myself. please suggest that to your neuro and see what happens. you will only need a full thyroid panel blood test (ck for thyroid ANTIBODIES specifically) and an extra possible test is for alpha-enolase antibodies. it’s not that i think you have this, but trust me, if it IS H.E., you want to know sooner rather than later, and white matter lesions are common. fe

  31. Dear Dr. Sethi,
    My mom (age 73) had a CT scan done recently and had the following results
    ischemic lesions in frontal perventricular white matter and in post. parietal deep while matter bilaterally
    Ectatic vertbro-basilar system
    1cm size calcific density in the left high post. parietal parafalcin region

    Given her age is this normal degeneration of the brain tissue or are these early signs of Alzheimers. Her family history includes Bipolar and Alzheimer (siblings). She also is taking medication for hyertension.

    The reason for her MRI was my concern that she forgets things easily and repeats conversations. And due to her family history.

  32. I have had episodes of blurred vision, slurred speech, extreme fatigue and severe muscle spasms, sharp stabbing pain in my legs and confusion. My pcp ordered an MRI which showed changes. I saw a neurologist and she said I have migraines, but how can I have migraines when these issues are not associated with a headache of any kind? She said the balance issues and tripping were just a female thing. As well as blue finger and toenails. Should I get a second opinion?

  33. Hi i had my mri scan awhile ago got told i had a large amount of white matter on my left side of the front of my brain ithey have put me on tablets lyrica pregabalin im on 100mg a day iv noticed its for depression bit i dont suffer with it i have hepapleigic migraines and iv suffed without nowing for most of life they have just got worse as iv got older i have weekness on my left side very tied all the time burning feelings forget or my mond gos blank for awhile i mix up my words which is happenin more now and i get fustrated if anyone notices i do it both my mother and sister had m.s and my father had aletzimers disese im now concerned please advice me

  34. Dear Dr. Sethi,

    Thanks so much for this blog, which I found while researching this topic.

    My 12-year-old had an MRI after 3 tonic-clonic seizures (no prior history). The MRI occurred the day after the third seizure. It was expected to be normal, but there were a few lesions in the white matter. They want to wait 3 months for a follow-up MRI with contrast, but it seems that waiting a month is plenty. What do you think?

    I see some studies that suggest that the lesions may be transient and caused by the seizure the day before. If this is the case, an MRI a month later will show them lessened or gone. On the other hand, if they are still there and take up contrast, we want to get a 2nd opinion and deal with it ASAP.

    Thanks
    JP

    • Dear Jon,
      I hope your son is well now. A prolonged seizure or multiple seizures one after the other (status epilepticus) may lead to MRI signal changes which are usually transient. I agree with you and your son’s doctors that your son needs a follow up MRI scan and if the lesions are still there or have since evolved, a thorough evaluation for the same is warranted. My best wishes are with you.

      Nitin K Sethi, MD

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