MRI Decision Dilemma - 2 Quick Questions

[Sarahsmom46]

The neurosurgeon I saw yesterday wants to do another set of MRIs of head, cervical and thoracic spine as a follow-up from my initial illness nearly 3 months ago.  I have a tentative dx from that illness of acute transverse myelitis.  My questions are:

1.  Is there any possibility that anything new will show up in less than 3 months especially since he said we don't need to use contrast this time?

and

2.  Is it true that if we are going through something acute that an MRI can't detect lesions through inflammation?  

You guys are so smart and I've learned so very much from you.  I hope soon I will be able to help someone too!  Thanks.

Julie  - aka Sarahsmom46

[Sarahsmom46]

That will most certainly work.  I must look like a total coward, but I'm really not.  I believe you commented on my journal entry from a couple weeks ago about my last visit with the neurologist where I went in with a plan, 4 questions for what I need, and accomplished each and every goal.  I don't know why this neurosurgeon made me so nervous, but he did.  I guess I've read so much about negative experiences others have had that I am wondering when the other shoe will drop in my case and I end up with a total jerk.  I'll let you know how it turns out.  I am making a mountain out of a molehill.  OK enough said about it.  I can do this.  

Danke Schon!

Julie

[Quixotic1]

Okay, we're going to pretend that you were talking to your family fiend, who is a doctor with MS.  She told you that:

"
The easiest way to convey this to him is to write it up and say:

Dear Doctor XXX,

"As you know my Primary Doctor feels that my problem is very possibly MS."

A family friend, who is also a doctor and who has MS, spoke to me on the phone just now.  She wanted me to tell you that (and these are her words. She made me write them down exactly)  "since MS was even being considered, that it was important to use contrast to see if there were any new and enhancing lesions.  An enhancing lesion now would be a strong indicator of MS.  She wanted me to be sure that the MRI was being run "per MS Protocol"

I promised her I would tell you this.  Please don't think I am telling you how to do your job.  This woman has been a good friend and just wants the MRI to show everything it can to help clarify my diagnosis.

I appreciate everything that you are doing for me.  Thank you.

Julie XXX

Then you can fax this to his office.  Once you have done that call his office assistant and ask that he/she make sure he sees it.  That's all you can do.  And this way, you don't have to do it to his face.

Quix

[Sarahsmom46]

Oh boy, I'm going to ask this NS with his wonderful typical ego to redo the script to show that we are going to us contrast and now I have to request "MS Protocol"?  Please help me with how to do this?  What if he says "Why?"  I'm cringing right now because I'm not sure if I have the guts to do it.  I need some encouraging words to help me be brave and not look like a demanding pain in the behind patient.  

Thank you so much because I don't really have a clue what I'm doing.  

Julie

[Quixotic1]

Ooops, I misspook above.  You need to request that the MRI be done per "MS Protocol."

Sorry

Q  :))

[Sarahsmom46]

Another excellent suggestion and I am just that type of person who will kick myself again and again for not going for it.  Now it is up to the doctor to add the contrast.  Hopefully he won't think I am questioning his judgment, just merely looking out for myself.  

Thanks again to all of you for your valuable advice.  

:)Julie

[shoshin]

You can have new lesions, including enhancing ones, if they're "silent" lesions that don't cause any symptoms.

Also, if you look at the McDonald Criteria in the health pages, you can see that enhancing lesions are counted differently so one could possibly make a difference to your diagnosis.

So I agree with everybody above that if you don't get the contrast and nothing shows up, you may be left wondering what if?

sho

[Sarahsmom46]

Fabulous advice.  I never even thought of that.  I'll take care of this first thing Monday. My appointment is a week later, but you know how long it takes these neuros to get back with you.  My gut was telling me that I might regret it if I didn't ask you guys.  This MRI and testing stuff is new for me and I just don't know the ins and out of it all.  Thanks again so very much.  Have a great weekend.

Julie

[happyname]

I know you guys have covered this but my neuro always ordered contrast even for those types of symptoms.  I will give this one suggestion since it has happened to me.  He once had a loaner nurse who left off the contrast when ordering the test and I had to reschedule because they could not get the insurance auth changed in time.  If that is something that would be an issue for your it might be a good idea to call ahead with your concerns if you don't have another visit before then.  

Joy

[lala47]

Hey, Please listen to this advice and do what you can to make sure it's done right the first time.  I recently had a second MRI, the first showed lesions on a closed MRI machine. I think 1.5 and for some strange reason the second was done on a open MRI machine  with a strenght of .3 a much weaker machine.  This MRI showed NOTHING.
Completely normal.  Now I have gone backwards in my dx.  A NS should know about different strenghts of machines.  Keep fighting and Good Luck.

Lori

[Sarahsmom46]

I think I finally got it!!!!  

Yes, I am still having problems since my "exacerbation", not quite as acute thankfully.

Your suggestions on how to approach the NS will work.  He does have an ego for sure, but seems to be reasonable.  I don't think he will have a problem with my request for the contrast now that I have a way to explain why I'm asking for it, thanks to you guys.

Oh and for the record, my family likes you and the rest of the gang from the forum very much.  My kids are so happy that I found this group and I feel so grateful to be here.  

Thanks for being so patient with my questions.  

Julie

[Quixotic1]

I can see his point that you are not having any new, acute symptoms, but you are still having problems, right?  Since he is looking for plaques (which indicates MS to me) then he should do the test that will best look for very new lesions.  You can always tell hime that a friend of the family is a physician with MS. That would be me.  Your family likes me okay don't they?  Tell him that this friend that if MS is being considered, contrast should be used as it can provide key evidence for the diagnosis.  Put it all on my shoulders.  NS's can have huge egos, but he might accept this.  (You can always use me to request something of a doctor)  What you can do is jot this down on a scrap of paper as if it is something I told you on the phone and then refer to it.  Yes, we be sneaky when we need to be.

Myelitis = disease of the spinal cord.  If you had/have lesions there you have myelitis by definition.

Atrophy = He's looking for any sign that the cord has shrunk.

Stroke = probably using it as a catch all to make sure insurance approves it.

Jen - is mostly right, except that new lesions may well show up without the contrast.  The trouble is you won't know "how new" they are.  If they show up all you know is that they developed some time after the last MRI.  If they enhance you know they are at max 6 weeks old (some would say 4 weeks).  Without the contrast a new lesion looks pretty much like an old lesion.

Tonya is correct.  You need to ask if the NS is going to request that the MRI be done using "MRI Protocol."

Hoever, it probably needs to be done on the same intensity as the first one.  The reason for this is you are using it for direct comparison to the old one.  If you step up to a higher MRI and see more lesions, you don't know whether these were there in the first place, but missed by a lower power machine, or if they are really new lesions.  I realize that this seems to be a departure from what I have always said, but if you think about it, it makes sense.  the difference is that we already know you have lesions.  that is not is question.  What we want to know is whether you have "new" lesions since the last MRI.

Did I make things worse?  :))

Quix

[Sarahsmom46]

I am still a little confused...Sorry, this is still not sinking in.

Firstly, the doctor wrote on the script for the brain MRI that he was looking for plaques / stroke.  The cervical/thoracic script stated "myelitis and atrophy".

He said he didn't think we needed to use contrast this time because I wasn't in an acute phase or state or something like that.  

I am usually a good advocate for myself, but maybe I'm tired of all the testing or what, but even if I ask for contrast what do I say to justify it?


Thanks again and again :)

Julie

[tonyad]

Just wanted to throw in a thought. Please make sure that ....

1. You are using a closed MRI

2. That it is at the very least a 1.5T MRI machine

Otherwise, it is pretty much a waist of time and money. Is that  accurate Quix?
There are so many of us that get an MRI and have used either an open machine or a
1T or less (strength)
Quix, please correct me if I am wrong, but should she request that the MRI be done using the MS protocol?  (contrast and 3mm slices?)  I am such a good student, I learned that from the "great Teachings of Quix!"  :)
Good luck Julie,
~Tonya

[jensequitur]

If he's going to send you for an MRI anyway, I'd say go ahead and push for the contrast.  If your neuro wants to eliminate MS conclusively, it would be the best way.  Just my 2¢...

[Sarahsmom46]

I don't know what is wrong with me because I still don't quite get this.  I am not having a flare up, least don't think so, but should I still ask for contrast and if so, how do I do I ask?  I don't want to waste my time with not doing things right.  That is what I've learned from you all.  So, I wholeheartedly welcome your input.  :) Thanks a bunch.

Julie

[jensequitur]

1.  Is there any possibility that anything new will show up in less than 3 months especially since he said we don't need to use contrast this time?

For anything recent, you'll need gadolinium to enhance new lesions (if you're trying to rule out MS.)  Old lesions will show up, but your neurologist isn't looking for anything old.  So the answer is no, if the MRI is done without contrast, then it probably won't show anything new.  Does that make any sense?

I recommend doing it with and without contrast, personally.  You're going to be in the tube anyway - might as well juice you up and take the MRI with contrast, just to be sure.

2.  Is it true that if we are going through something acute that an MRI can't detect lesions through inflammation?  

Mmmm, hmm... not sure what you're asking here.  If you're going through an acute flare, then your brain should show new lesion formation.  (Which will only show up if you use gadolinium contrast.)

[Sarahsmom46]

I am still a little confused...Sorry.

Firstly, the doctor wrote on the script for the brain MRI that he was looking for plaques / stroke.  The cervical/thoracic script stated "myelitis and atrophy".

He said he didn't think we needed to use contrast this time because I wasn't in an acute phase or state or something like that.  

This was my first consultation with this guy, but he did say he read over my hospital and rehab notes and viewed my MRIs. I'm not sure whether he is thinking MS or something else, but the other neurologists who have been on my case for last 3 months have mentioned that they are trying to rule it out.  

What would you suggest?

Thanks:)

Julie

[Quixotic1]

I'll try to answer what I think you're asking.

1)  Absolutely a new lesion can show - even within a one month period.  There is no doubt about this.

2)  The MRI can certainly detect something acute.  Even an enhancing lesion may well show up.  You just won't know that it has acute inflammation going on.  It may look just like an older lesion.  So, the contrast will tell you that it is very new (6 weeks or less). I honestly question the neruosurgeon's decision not to use contrast.  If MS is in the consideration, then an enhancing lesion might make your diagnosis.  Any MS Specialist would say that THIS is the time to definitely use contrast.  Can you request it?

Whether something shows up depends on the size of the lesion and the resolution of the MRI machine.

New, inflammatory lesions will typically enhance for 3 to 6 weeks.  Some sources say only up to 4 weeks or so.

At the very, very beginning of a lesion's development (first hours/days), there may not be enough change in it's structure and density to "see" it except by using contrast.  But, the vast majority will show up.  For kids with ADEM, they often get their MRIs within a day of the beginning of symptoms and already they have large lesions seen on T2 imaging.

Do any of these statements answer your questions?

Quix