Asking your Neuroradiologist

[Sidesteps]

Hi all!

I've been really thinking about my MRI lately. I realize I am not a radiologist and do not have the expertise needed to review my MRI BUT.... there are some things on my MRI's that are highly suspicious. The largest issue I see is a spot in my cerebella that he placed as an artifact (some sort of vein mirror image) on my brain MRI.

I'm fine with artifacts. I understand the concept and get that these things happen.  Except, it shows up in several different slides AND is VERY clear in my cervical MRI as well (which is a totally different MRI a month earlier.) This "artifact" also explains a large portion of my symptoms. There also appears to be a periventricular lesion on the right side that isn't mentioned at all. I also can see multiple punctate lesions that are not mentioned. These show on ALL my scans as well.

I'm not sure I understand how these were missed since they were all at the same location.  It's almost as if my MRI's were ran through a software program for a specific issue and wasn't really reviewed by a person against the other scans I had there. My CT scan shows lower density areas (that match my periventricular lesion) that were mentioned, the cervical MRI shows something odd in the very center of my cerebella, this was named an artifact in my brain MRI.  I think that is suspcious considering all these were done about 30 days apart from another, over the course of three months.

My Neuro has a lot of respect for the Neuro-radiologist that read my MRI's and I don't mean to be disrespectful but I have questions. I also didn't have much time with my Neuro to explain this to her. She did question something on my Optic Nerve so she ordered an enhanced orbit MRI. She has explained he is one of the best (if not the best in our County)... so she's sending me back there.

My question: Is it reasonable to go directly to Neuro-radiologist and ask questions about these specific issues? I am willing to listen to the arguments both ways but I'll be honest, I'm pretty sure I'm going to call him because I am not very good at not being assertive with these health issues I am having. I sort of "fear" that if they missed something and I don't ask... I'm risking my liveihood or worse. If I do this, then how do I go about it...and has anyone else done this?

[Sidesteps]

I have looked at the atlas. They do appear to be very subtle and just like the lesions I'm in a dither about. The are like hazy spots in a lot of cases...

This orbit MRI should be at very small intervals. She told me it will be very thin slices. I think my concern is that my issue isn't in my optic tract. My issues with my vision are so difficult to describe at the moment. I would venture to guess it is multiple issues from different areas. Back when I was flared it was very clear that I had ON symtpoms then the darn VEP showed up negative. We are redoing that which is good.  I'm hoping SOMEthing shows. I want to move on to fixing it, if it can be fixed.

I know I'm not losing my mind which is partly my frustration. :) My Neuro is trying to treat my symptoms. She prescribed a medicine for my tremor's, I haven't noticed a huge improvement but I am taking them to give her solid feedback. She tells me what she sees (for the most part) and she is willing to try to get to the bottom of my vision issues.

I'm trying not to dwell so much on the MRI but they seem to rely so heavily on it or it seems that way. So far, whatever is going on with me... isn't worse than it was a few months ago... so my thinking morbid is probably unreasonable, eh? LOL I just need to be patient. I'm trying. It's hard. :)

[COBOB]

Anything is possible.  Things get missed.  I had one lesion on my first MRI and 5 on my second.  The doc said they may have missed 4 on the first one becase they were doing 5mm "slices", not 3mm.  I asked him if it mattered since I had ON and then 4 months later TN.  

For my third MRI, they said good news, no new lesions and the doc called the next da to remind me that I had another round of Optic Neuritis, so I needed to make sure I stayed on my meds (including Copaxone.)  He said no new MRI lesions is great.  Having optic neuritis a second time in the same eye was not a good thing.

Not sure what you can do about getting a second opinion.  Have you looked at the MRI Atlas of MS images, or some of the MS images at USUHS like:
http://rad.usuhs.edu/medpix/kiosk_image.html?mode=quiz&imid=370&fname=tachy_pics/synpic370.jpg&quiz=yes&table=card&hx=0#pic
MS lesions are usually not something that jumps out at you.  They can be very subtle.  

I guess I'd give you the advise most of us wish the doctors would follow:  Don't concentrate so much on the MRI.  It is one test.  It has to be taken into account with the Clinical Exam, VEP, Lumbar puncture and other tests.  At the minimum, they could be treating your symptoms.  

Bob

[Sidesteps]

The ones I've encounted seem to respect the Neuro-radiologists report so much they just don't look at the actual films?  I KNOW the MS specialist didn't look at it. 7 minutes wasn't long enough. I think my new Neuro flipped through it.

Maybe I should just let this go... and I'm grasping. I just don't want them to miss anything and at the same time, she said, I see something on your optic track that wasn't in a report so I'm ordering a more detailed MRI.  

My doctor's are all linked together as well. They have access to all my tests, reports, etc.  My latest Neuro had my scans and the report on the computer. I didn't even have to give them to her despite asking me to bring them. It was unsettling.

Second opinions? Seem like they are going to be much harder to find and that is concerning to me. Maybe I’m a bit of a skeptic at the moment. I accept that we all aren't perfect. We need someone to double check things. These doctor’s also seem to be on such a time crunch they run out of time. I felt while my last Neuro was good, that I didn't get a chance to go over my concerns fully. My next appointment in a month.

Okay, moving forward --- so, the questionable area on the right side of my brain that shows on both the FLAIR, T2 AND CT scan... that would be worthy of question. No? It wasn’t mentioned at all in any of the reports. Actually none of the spots on my brain were.

I'll have to check that artifact and what sequences it was taken on.

If the artifact shows on the same sequence (I understand that) how is possible for the same artifact to show on two different MRI's? Different views? One being Cervical and another Brain T2.  (I did not post my brain MRI reflecting the artifact because it was stated to be an artifact.)  I’ll post it later. Is it a legitimate question?

Another question: If the Flair and the T2 are different slices though? Where say the imagine was taken (at H14.7 on Flair and H15.8 on T2). Isn't it possible to miss a lesion between?

LOL – I am repeating myself. I'm sorry. :)

[COBOB]

The bigger issue is not what the Neuroradiologist said, but that your neurologist is not looking at the studies himself.  Neuroradiologists are usually very good at what they do.  There are some strange artifacts that pop up on MRI.  One is an "end on view" of a vessel artifact that shows up as a slightly white round smudge on T2/FLAIR.

These images are not slices like a CT scan.  They do One Scout, One T1 without contrast sequence, One T2 Sequence, One Flair Sequence and One T2 with contrast sequence.  The data is "captured in the computer as x,y,z, and voxel value.  So if the if the artifact is in the T2 Coronal, it will also be in the Sagittal and the axial since they all come from the same single T2 data set.  What they radiologists look for is if it is in the T2, is it also in the FLAIR?  If not, it is then most likely an artifact in the T2 data set and will show up in all the T2 views.  MRI artifact effect all views constructed out of the same data set.  Each view is not a new scan.  

MRI has many nuances that take a lot of time to understand.  Even the term "slice"  is a bit different since it is a a slice through the 3-D data set, noth says it has to be axial, coronal or sagittal.  Those are just common views.

A bit confusing, I know.  It is all magic that happens inside the computer.  By the way, most software the reads MRI images picks up way too much that is not there.  It takes bore time for the doctors to remove the garbage from the reports than it does to read them.  It is getting better, but most medical software (xray, MRI, ECG, etc.) over-diagnoses to cover the vendor's butt.

.Bob