White matter lesions in the brain: a question and an answer

One of the readers of my blog asked a very interesting question. I am reproducing her question here. My response to it follows. I hope you shall find it helpful.

Personal Regards,

Nitin Sethi, MD

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 D

 
 
braindiseases Dear D,
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

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6 thoughts on “White matter lesions in the brain: a question and an answer

  1. Dear Terri,
    thank you for writing in. Yes Factor V leiden deficiency causes an inherited resistance to activated protein C. This makes patients hypercoagulable and thus more prone to strokes and I assume ischemic white matter disease. An aspirin a day may be advisable but consult your doctor first.

    Personal Regards,
    Nitin Sethi, MD

  2. Dear Joanne,
    thank you for writing in to me. Chiari I malformation should not be the cause of the white matter lesions in your brain. Likely this is ischemic small vessel disease (microvascular disease) related to your smoking. My advise to you would be to quit smoking (not cut down but quit if possible) and follow up with your physician.

    Personal Regards,

    Nitin Sethi, MD

  3. Hello, I have had a diagnosis of Lacunar Infarct in the lower right side of my brain in the white matter. I also have been told by several doctors I had MS due to drop foot an numbness in feet along with emotional problems with personality changes when I had a bleed from this old stroke. I am 60 now but I think I had my stroke at 17 but did not seek medical attention. Years later in 2000 I experienced a stroke like feeling, called my doctor who told me to go to the emergency room. where they then could refer me to him I did not have a primary doctor at the time or insurance. Finally I had insurance and got or had to beg for an Mri of my brain and there were some lesions on both sides along with the finding of the stroke which was explained to me it was an old stroke with a fresh bleed coming from that area. Nothing was done for me . I was told that all OLD PEOPLE get lesions, & I had peripifal neuropathy of my feet. I get spasms in mostly my left leg foot ankle where it reminds me of labor pains the way our tummy gets hard during the contraction then relaxes until the next one. It feels like a railroad tie is being pounded on the top of my feet. You can see the muscle coming from the ankle up the side in full definition. I get spasms in my hands so bad I can’t hold onto a pen or say lift a cup of coffee. I was diagnosed with bilateral optical neuritis. If I am outside and it is hot I get these horrid attacks and sleep away the day .. I am on opiate therapy and take Valium for the spasms. However the drug itself is robbing me of oxygen getting to my brain. so I am suppose to use the oxygen at night. I must admit I do not use it as directed. I get lost and very mixed up when I have these attacks. Today I have double vision so bad I can’t see the tv. Even writing this is hard. I am up rather late due to having severe numbness and pain in my right arm and hand, the pointer finger the finger next to my thumb is so numb I can’t hardly use the mouse to click or typing as well. I have had so many different contradictory diagnosis that I just went plum crazy. I ended up on SSI and with the trouble in congress I worry a lot about what will happen to me if they take my check away.. I get no treatment for doctors are or hate us on SSI. I was even told it was all in my head and I am just getting old. I am healthy in all other respects but for the neurological things. I have ruined relationships due to outbursts that I use to have, I have learned to control them now after all these years. I am sitting here crying for I am stuck in a state where I am not from and have no funds to get out. I have no family and my daughter lives in Portland ORE and haven’t seen her for over 10 years. we just can’t afford the trips.. The MRI’s I get are very low or quickly diagnosed as if they don’t have the time to explain to me what is going on with me. They say there has been very little change in my MRI results I Asked so what is little mean? that is when I found out I wasn’t getting oxygen fullyu to my brain, he mentioned 2% I didn’t understand. MDs do not have the training for these kinds of matters, they send us to neurological doctors but in KS the doctors are not taking SSI medicaid patients because they are full up. I tested them an a few weeks later I called in and lied saying I had insurance & needed an appointment, they had room for me then. I just hung up and knew then it was politics.
    All I want is a diagnosis that is true and correct so I can prepare to either die or plan on being an old lady rocking her great grandchild on my porch. Because I prefer opiate therapy and was lucky to find a doctor risk the DEA on his or her back.. I get looked down upon at the drug store and other doctors. I also have COPD due to a chemical spill in AZ while working around them and one of the containers broke open and I was out side in the middle of it while it bubbled the concrete patio around me. I was sand blasting lead paint off of air conditioner grates without mask or any protection. I got the heck out of there and told the owner what happened and he ran to shut down the huge metal doors and sent me home.. soon he fired me within that week.. I think he knew I was going to have some lung issues due to the spill which I did, 25% irreversable and now it is 50% when tested after I was complaining of breathing problems. the good news was it was damage caused by something all at once. and I did not have diseased lungs.
    my question is :
    do you know any doctor who could help me find the truth for me?
    I am not fat or ugly and this I guess plays against me for doctors think I wanted social security and dragged my case on for years. Unlike before we would get paid for waiting but since I was not working full time since 86 I did not have enough points to get SSDI and get medicare and not looked down on.
    I love life but I swear being alone house bound I think death is better
    with respect

  4. I had an MRI when I was 57…the results were: white matter lesions probably due to demyelinating disease. I also have peripheral neuropathy which the neurologist didn’t tell me… I looked up the the coding numbers she used and they were for peripheral neuropathy. At age 60 I went to a different radiology office (one the neurologist told me to go to ) I brought my MRI from age 57 for comparison. This time the the results were read as microvascular lesions due to my age and no change from MRI at 57.

  5. I have white matter leisons found when Neurologists were trying to determine why I just had a CRAO when I had little or no plaque in my system. Now they are wondering if I could have a PFO. I have never had migraines, ran every day for long distances, blood pressure averages 110/60, never had a health problem and I am 62. I look and act like a 30/40 year old but I am beginning to have memory problems, I think. Or maybe it is I have “too much on plate.” Doctors said I am a “zebra.” I think they just do not know enough about the brain or the heart to know what these things are cabable of producting. Can a PFO…IF I have one cause the white matter leisons? So what if I do have them? And can PFO cause another CRAO? Would you use TPA to try to stop them?

  6. Dr Sethi

    I am 42 y old, female, with a 6 month history of fatigue. A recent visit to a neurologist, followed by a MRI shows periventricular deep white matter lesions, probably small vessel disease. I do have a history of migraines, but no hypertension or abnormal lipid profile. Until October 2011, for 4 months, I was prescribed Stelazine (1mg), after which my symptoms started. Primary neurological symptoms were propioceptive dysfunction on left side (like my foot had fallen into a ditch). This waned within 2 months of stopping stelazine, but continued into a mild imbalance while walking. Now, since my lesions are more on the right than left, the doctor has prescribed Plavix. I would not like to take this, so would aspirin be ok? Also, could stelazine have triggered this syndrome? My fatigue still continues and I am unable to take on activities that I previously did with ease. Doctor has asked for blood tests for LE, VDRL, B12 and RA factor. Thanks for your reply and I enjoy reading your blogs. Very informative, level-headed and to the point.

    Kiran

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