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How MRI's Show MS Lesions
by Quixotic1, Aug 01, 2007 07:08PM
, Aug 01, 2007 07:08PMMY QUICK AND DIRTY EXPLANATION OF HOW MRI'S SHOW LESIONS IN MS
I am going to overexplain the MRI with contrast / without contrast thing again, so that you and your husband can have it as clear as possible in your minds.
MS does it's damage by causing the nerves in localized areas in the brain and spinal cord to lose their protective sheaths, called myelin. At first, when the myelin is being attacked, the body brings a higher blood supply to the area to fight the attack and the area becomes inflamed. These areas, now become lesions. At this point they are called "active lesions." At first the nerves haven't changed much and they appear (and have the same density) as the healthy areas around them. At this point after some time, probably months, the body CAN repair the damage and remyelinate the nerve. This repaired nerve still won't be as good as new, but the lesion "looks" like normal brain. Sometimes later an old scarred lesion will "reactivate" and the adjacent areas will inflame and have increased blood flow.
If the attack on the myelin sheath is too strong for the immune system to repair, more and more myelin disappears and the area of nerves eventually dies. Then it contracts and scars. The blood flow is decreased to that area and the area becomes "less dense" then the surrounding normal nerve tissue. After a longer time - probably years - the scar can reabsorb and the area becomes "empty." It's called a black hole.
When you image these lesions with an MRI you can see different things, depending on the technique,the age (stage) of the lesion, the power of the MRI, and whether contrast is used.
The first image is done without contrast. This technique will show old lesions that are big enough to be seen by the power of that MRI machine. WE KNOW that many lesions in MS are too small to be seen. If the newer, more powerful MRI with a 3 Tesla magnet is used many more lesions will be seen (by at least 25%) than on the older 1.5 Tesla machines. The classic old, mature MS lesion is a little bit oval, will have well-defined borders and will be in the white matter. Characteristic places are subcortical, peri-ventricular and in the corpus callosum. The classic MS lesion will also have it's long axis perpendicular to the ventricles of the brain. Also, important and very symptomatic lesions are found in the brainstem, the cervical and the thoracic spine. The spinal cord ends at the bottom of the thoracic spine, so there is no such thing as a lumbar spinal cord lesion in the normal spine.
These scarred lesions will show up as light, bright areas. These are the classic, MS lesions or "plaques."
Now the very old, scarred ones that have been reabsorbed will show up as a black (empty) space or black hole. If there are many of these empty areas the brain will contract around them eventually and show up as a loss of brain volume. This is also know as brain atrophy. This is particularly seen in the progressive types of MS.
However, a newly active MS lesion may not show up on a regular MRI because the area of nerves, though inflamed, is still pretty much intact and has normal brain density. On the MRI it will look like normal brain. Without contrast it won't show up and will be missed.
When the next phase of MRI is done the contrast is in the blood vessels. So the large blood vessels show up, too. Anywhere the tiny blood blood vessels are more dilated than usual, as in inlfammation, the areas will "highlight" or "enhance." They show up as even brighter. So new lesions will show up as enhancing, or active. Also, older lesions, that have undergone new attack right around them will show an enhancing rim or ring. When you compare the regular MRI to the Contrast MRI you can see this reactivated, old lesion.
That's how some reports can call active lesions or some report no newly enhancing lesions. Also since some new ones heal they can be compared to old films and show they disappeared. In addition, between different sets of MRI done after a time has passed, the radiologist can see an increase in old and in new activity.
Please ask question where I haven't been clear.
Quix
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MY QUICK AND DIRTY EXPLANATION OF HOW MRI'S SHOW LESIONS IN MS
MS does it's damage by causing the nerves in localized areas in the brain and spinal cord to lose their protective sheaths, called myelin. At first, when the myelin is being attacked, the body brings a higher blood supply to the area to fight the attack and the area becomes inflamed. These areas now become "lesions." At this point, when they are inflamed and blood engorged, they are called "active lesions." At first the nerves, themselves, haven't changed much and they appear (and have the same density) as the healthy areas around them. After some time, probably weeks to months, the body CAN repair the damage and remyelinate the nerve. This repaired nerve still won't be as good as new, but the lesion "looks" like normal brain. Sometimes later an old scarred lesion will "reactivate" and the adjacent areas will inflame and have increased blood flow as the renewed demyelination takes place.
If the nerves do not remyelinate and the damage continues, for a long time the lesions sit as scars. These scarred areas have damaged and dying cells in them, the blood supply shrinks, and the areas are not very dense - not as dense as the normal brain around them. These are the classic MS plaques and are considered old lesions.
If the attack on the myelin sheath is too strong for the immune system to repair, more and more myelin disappears and the area of nerves eventually dies. Then it contracts and scars. The blood flow is decreased to that area and the area becomes "less dense" then the surrounding normal nerve tissue. After a longer time - probably years - the scar can reabsorb and the area becomes "empty." It's called a black hole.
When you image these lesions with an MRI you can see different things, depending on the technique, the age (stage) of the lesion, the power of the MRI, and whether contrast is used.
The first image is done without contrast. This technique will show old lesions that are big enough to be seen by the power of that MRI machine. WE KNOW that many lesions in MS are too small to be seen. If the newer, more powerful MRI with a 3 Tesla magnet is used many more lesions will be seen (by at least 25%) than on the older 1.5 Tesla machines. The classic old, mature MS lesion is a little bit oval, will have well-defined borders and will be in the white matter. Characteristic places are subcortical, peri-ventricular and in the corpus callosum. The classic MS lesion will also have it's long axis perpendicular to the ventricles of the brain. Also, important and very symptomatic lesions are found in the brainstem, the cervical and the thoracic spine. The spinal cord ends at the bottom of the thoracic spine, so there is no such thing as a lumbar spinal cord lesion in the normal spine.
The scarred lesions will show up as light, bright areas. These are the classic, MS lesions or "plaques." But, with just the regular MRI one can NOT say if it is old and dormant or if it has active inflammation in it.
Now the very old, scarred ones that have been reabsorbed will show up as a black (empty) space or black hole. If there are many of these empty areas the brain will contract around them eventually and show up as a loss of brain volume. This is also know as brain atrophy. This is particularly seen in the progressive types of MS.
However, a newly active MS lesion may not show up on a regular MRI because the area of nerves, though inflamed, is still pretty much intact and has normal brain density. On the MRI it will look like normal brain. Without contrast it won't show up and will be missed.
When the next phase of MRI is done the contrast is in the blood vessels. So the large blood vessels show up, too. Anywhere the blood vessels are more dilated than usual, bringing more blood to the area, as in inlfammation, the areas will "highlight" or "enhance." They show up as even brighter than the brain around them and brighter than an old, scarred lesion. So new lesions will show up as enhancing, or active. Also, older lesions, that have undergone new attack right around them will show an enhancing rim or ring. When you compare the regular MRI to the Contrast MRI you can see this reactivated, old lesion.
That's how some reports can call active lesions or some report no newly enhancing lesions. Also since some new ones heal they can be compared to old films and show they disappeared. In addition, between different sets of MRI done after a time has passed, the radiologist can see an increase in old and in new activity.
Please ask question where I haven't been clear.
Quix
Being here helps me feel useful. It's both a selfish thing and a way to keep my years of education from going to waste. My story is on the thread on this page called "What I Went Through to Get a Diagnosis of MS."
Quix
The radiologist says my MRI shows demylenation. The neurologist says the spots are from blood pressure, which has been controlled for years with medication. She said the spots are not the right shape or in the right spot.
They are in the right posterior frontal subcortical white matter. Oh, and my MRI was done on a Telsa 1. Sorry if I have asked this before....can't remember! Who do I trust?
LATW
One more question please, A test of the paraneoplastic autoantibody screen showed elevated ganglionic acetylcholine receptor antibodies. The level was 0.05 with the normal being 0.02 or below. What does this mean and how would it effect me? I don't know if it even has anything to do with the MRI's or not but it was written underneath my MRI report.
Thank you for everything,
Carol
A question for you ~ what is the difference between T1, T2 and FLAIR? My neuro said the FLAIR images were best to look at when we were viewing my films.
Have a great evening! Pat :)
I just had one more question. I have small white circular dots all over my MRI films/pictures, not sure what to call them. Do you know what those could be? I know I'm going to the doctor soon, and will find out, but it kind of bugs me to see on the film. And I"m just curious by nature.
Jenn
Iv got my scan on the 14th of August and i am so worried they will miss something im already getting worked up that this will not show something and im on a long journey to find out whats wrong!!
Iv cut and pasted the info as off to spend some time with my husbands parnets as finding it hard to look after kids as feeling rough so will read it in more detail when i get back.
I went to the ER because I was very dizzy. I have high blood pressure and suspected it was up (I had not been taking my meds for a long time - bad, I know). Blood pressure was up - 184/126. They did a CT to see if I had a stroke. No stroke, but the CT showed "brain atrophy." My primary physician ordered an MRI.
My MRI report says, "In the periventricular deep white matter are multiple abnormal bright T2 and FLAIR weighted foci, which do not appear to contrast enhance. Their location and appearance is suspicious for demylenating disorder, such as multiple sclerosis. The rest of the brain appeared unremarkable. There are no contrast enhancing lesions. Posterior fossa appeared unremarkable. Brain stem appeared normal. Seventh adn eighth cranial nerves appeared unremarkable. The parasellar region appeared normal."
I have an appointment to see a neurologist on 8/20. In the meantime, I can't help but wonder if there's any chance what they're seeing could be indicative of ALS, since my mother died from ALS. I guess what confuses me about what the MRI report says is where it says "there are no contrast enhancing lesions." I thought with MS they were supposed to see lesions on the MRI - or is the report saying there are lesions, but they do not contrast enhance?
Anyway, any thoughts you have are appreciated, and you are doing such a wonderful thing here - definitely using your education for good. Many thanks.
Quick answer because I know you're worried. No NOTHING in what you posted sounds like ALS. And no, you CANNOT rebuild weakened muscle in ALS.
Talk to you more after you post on the main forum page. If you are reading this, then right at the bottom of the page is a blue button "Back to Forum." Click on that and then at the top of the page click on "Post a Question." The paste in your two posts and we will flock to your side.
Quix
LATW - You definitely need a tiebreaker - or two. If you look at my post above you'll see that I had a radiologist and my neurologist misread two of My brain MRI's. One went to great lengths to say that he would mention my 1cm, well-defined, oval bright spot (Called a UBO- Unidentified Bright Object) ONLY for the sake of completeness and that it was normal for age. My "evil" neuro looked at it and emphasized that they didn't know what caused UBO's but that they were insignificant. They were both wrong. In the face of neurological symptoms NO lesion can be dismissed. Yes, typical lesions in MS have a characteristic pattern and shape. Yours don't. This lessens the likelihood of MS, but does NOT RULE IT OUT! Get thee to a good second opinion.
One place to get the names of Doc's that see a lot of MS patients is to attend a local support group (though often they don't meet in the summer because of the heat) but they will tell you who is compassionate, who is smart and who they've dumped. We are a vocal crowd, lol
You need another evaluation, including a thorough neuro exam (Momzilla can now tell you what a thorough exam looks like) and a new opinion. A 1Tesla machine won't show nearly the true number or shape of MS lesions. Make sure you are not mixing up the MRI report which talks about T1-weighted images. This is not talking about the strength of the MRI magnet, but of an imaging technique. If, indeed, your images were on that old a machine, discuss with the new MS specialist repeating the images on a newer, more powerful machine.
If you go this route I again highly recommend a concise timeline!!
CAROL! - I hope you see this. What your doctors told you is correct. Your lesions were old, scarred and some were becoming black holes, I think. No, Once they get to the bright stage seen without enhancement, I do not think that they can heal, because by then they are scars. I do not think they think you have relapsing-remitting. That is the category that can see some healing and resolution of lesions.
Lesions that heal - These are seen only in Relapsing-Remitting MS - RRMS. They correspond to the relapses which can be so dramatic as to involve blindness or paralysis, but then over time the symptoms may completely disappear. This is due to a lesion who had damaged myelin, but that the body was fairly successful at remyelinating. Again, studies show that the "remyelinated" nerves are not as good as new. Their nerve signal conduction remains a little slower and they are more fragile. But those lesions which caused that relapse may disappear within a few months.
Carol - I don't know much about the paraneoplastic syndromes. On my next foray into looking things up I'll check out that antibody. Sorry. You need to tell us how you are doing on the new treatment? How ARE you doing?
Pat - Boy! I was really hoping you would not ask that PARTICULAR question! Arggghh... Okay, I was looking up for a good description and didn't readily come across an easy one. I did find a thorough discussion of the T1 - T2 topic. It is a deeply scientific matter of mathematics and physics and trying to read it made my brain hurt! :( So, I will describe what I understood. Where the stuff is really technical (ie. I don't understand it) I will just refer to the "miracle.
The T1-weighted images and the T2-weighted images refer to the different rates and strengths of the electromagnetic pulse that is sent through the body to the receiver. There are long-strong pulses, short-strong pulses and long and short weak pulses. In a miracle the machine and the programmers use these different pulse/spin sequences to make the different tissue structures in the body stand out from each other. In the 20+ years of studying the miracle they have discovered that different tissues (brain, bone, liver, blood, etc) all show up best using different pulse techniques. Many of these have to do with that tissue was compared to water, They have also discovered that certain combinations of techniques show abnormalities like tumors or scars or whatever. That's it, folks. I can't get any better than that. I do know that T1 images show the CSF to be white and the brain medium and the bone black. T2 (which I think are the most commonly displayed) show the bone to be white, the brain medium gray, and the CSF to be black. (they are flip-flops or positive/negative of one another) But the computer, during a miracle, compares these two and further delineates (distinguishes) things that weren't really apparent on either type image alone.
The FLAIR is a little easier for me, but still involves a miracle happening. It stands for FLuid Attenuated Inversion Recovery. It is another miracle of pulses and signals. It's purpose is to distinguish things that border on ares of fluid (mostly for our purpose - CSF). Apparently a lesion right up against the ventricles can blur out and be missed. The FLAIR technique recovers information and through a miracle makes the lesion show up. There! Here is the link that made my brain hurt:
http://spinwarp.ucsd.edu/neuroweb/Text/br-100.htm
Hi Corinne - I can't picture little white dots. So sorry, I will answer your question that you posted, though a little later. I have to bring up your old posts and reread them to see. I don't keep my opinions active (I don't remember them later) as I talk to people. I can't keep that much in my head and I've already, in three months here, learned how often I'm wrong (lots).
And finally:
LATW - No "enhancing" lesions means there are no "new" (6 weeks or less old) lesions that enhanced because of increase blow flow (inflammation) to them. It doesn't mean there were no lesions.
Quix - Out for the count!
I had to read it a few times, but I am getting the "picture." Thanks for painting it so well. I love the miracle metaphor. It's like magic, right? Some kind of holy smoke happens in there? Give me a few more weeks on my fish oil (supposed to help with cognitive function) and it just may click completely.
You da man, Girl!
Zilla*
Quix
I began to notice numbness and tingling, on my right side. When it was just my hand and arm to elbow, I attributed to carpal tunnel and cervical disk due to previous 2000 MVA. However, when it went to leg, foot to knee, same side/same time, I sought immediate medical treatment with my PCP. CT was WNL. MRI/MRA showed 3 lesions, done w/o contrast. Repeat 4 weeks later with contrast showed enhancing lesion in one area. Continued with tingling/numbness/spider on the face sensation, mostly on right side (lesions on the left). On 07/12 was hospitalized with acute loss of function on right side. Uncontrollable shaking in R leg and arm. Short term memory loss. Was hospitalized 6 days, high dose IV steroids, LP done, standard EEG and EP EEG (found to be inconclusive???) Was not able to track to the left. Regained function on right side after 2 days and gait resumed. Repeat MRI w/3 Tesla showed one new lesion (Doctors had all my previous records). Drs. suspicious for MS, but not convinced yet. LP fluid final studies showed I met the minimal requirements for MS based on Mayo Clinic standards. Since home, still with balance problems. Stand up and close eyes will tip, pivoting or quick movement makes me lose balance and fall into furniture, etc. Have acute jaw tightness. Hard to open enough to eat, yawn, speak. Put on Baclofan TID, and tapered as tolerated. However, after getting down to 2 Balofan per week, am now back up to BID to TID as the pain, tightness/spasm back. Also having leg spasms that wake me at night. I have been exercising on my stationary bicycle BID but don't see any improvement. When I go back in time, things make more sense, for whatever illness I have, as I was in very minor MVA in 12/06, and ended up in ICU with loss of function in right leg and put on high dose steroids with improvement and then home PT, regained function. Then in March 07 taken to ER for uncontrolled shaking on right side, but never followed up on. I am worried that I may have MS, but even more concerned for ALS, as I am doing all the things I feel are right, but not really getting better. Also, I find myself going into a room trying to remember why I am there. I failed to mention, I am only 42. Any insight from anyone would be appreciated. I have a great neurologist, and he is cautious and treating me symptomatically and watchful waiting - will repeat MRI in Sept. He has me home on disability at least through September 07, but I hate to bug him continuouly about my concerns. I called him 2 weeks ago when I woke up w/loss of vision and pain in my right eye, which returned in 48 hours, but that was scary and he and I did talk then.
Thanks in advance to anyone who can respond. I am the mother of 2 boys, 8/10 y/o and the oldest has Asperger Syndrome. I need to try and understand what is happening to me, as being healthy for them is of great significance to me.
JoNoMom
This may help w/the Lesion Healing question you posted - it explains the demyl and remylenating process really well. . . .
alovingpoa
I wish you both less suffering,
Quix
Quix
I had my first symptoms about 4 months ago. It began with shaking of the right side, and a total loss of strenght. My left leg had no strenght and my right one, whenever i could get myself up (when i try to get up off a chair i feel like an 11 month pregnant elephant!) it starts wobbling around. I can't right, so i wanna kiss whoeven invented laptops. I also felt a terrible numbness in my feet and shins. One very hot day, after enjoying a music festival in Virginia, we went home with my boyfriend and i fell to the ground, not able to move. I asked him to "take whatever it was covering my feet" and he said "you're barefoot". The worst symptoms were not able to pronounce words ans sound like a drunk idiot, not remembering words, spasms, double vision and one time i got into my car and couldn't remember how to get to the gas station. But the fatigue is impossible to bear. I'm out of breath just sitting in my car. Typing is a nightmare. I have to go back over and over again and change the words i thought i meant and ended up typing something else, sorry for the typos. I was ok during a vacation, i could walk without my pink can (hey, i'm a girl in style!) and was better with the shakes and fatigue. After i came back, my parents insisted in me getting an MRI and it came out "clear" according to the MD they wanted me to see (who suggested a shrink since i have too many tattoos and that's the work of the devil.. Catholic Hospital) when i went to see my Neurologist, he looked at the MRIs and said, well, i see a couple of things, but this worries me a little. When i got the MRI they also took pictures of stuff that look more than a thunderstorm than a brain. Sorry, i can't remember which part of the brain they are, i guess it's the top? He said there was a vain that looked ok. It kinda twisted, came back and went "back", like a tail. The opposed one was supposed to do the same, but no "tail". All i have gotten is Xanax and Clobazam for the "shakes". But i haven't been able to get out of the bed for 3 days since i can't walk. My legs won't take my weight. I'm 5'7" and about 125lbs, so it's not like i'm too fat. I have spasms again and a weird feeling in my face. Tingling in my hands and of course, the pain, needles and pain came back to my legs and knees. I'm desperate. I'm (was) a student and i used to go to class at night, i also suffer from AS and imagine the pain. But i know how AS pain feels, and this is different.
What can i do to make my Neurologist take me seriously? it seems all they want to do is pat you in the back and send you home, but i know there's something wrong. Any help?
Thanks, guys.
Farrah
Could you repost your question as a new thread? Also, because many of us (including me!) have a hard time with reading big blocks of text, break up your post into several different paragraphs. (Just putting a return every five sentences or so really helps!)
I read in your text that there is a blood test that will exclude other things, but not necessarily show MS symptomology. I'm almost 55 years old! Isn't this rather late to find MS?
If you could add any comments to this I would greatly appreciate it. I do hope I rememebered your username and applied it correctly.
CHeers,
Udkas
Open to ideas?
As you know we can't diagnosis anything online - there just isn't enough info. But, I can talk about things in the context of MS and I will answer your question. IF the neuro (whom you don't like) was considering MS when he did the spinal tap, then he was wrong to tell you that MS was ruled out because the fluid was normal. A normal spinal tap (especially 2 years ago) does not mean that you don't have MS. There is NO requirement for the tap to be positive in order to diagnose MS. In fact, there is no requirement EVEN TO DO A TAP in order to diagnose MS. In Europe they do not use the spinal tap routinely at all.
Now the lesions could be many things. But you should have someone tell you what they likely mean before you can just dismiss them. I would encourage you to seek out a new neurologist. Why was the MRI done? What problems and symptoms have you had?
But, we would like to know more about you. From your profile I see that you must have a very complicated medical past and see that you are on oxygen. If you would start a new thread - just go to the top of this page and click on "Post a Question." Your post will be lost here and people won't see you.
Welcome again, quix