MRI's, Lesions, & Symptoms

[Quixotic1]

MY QUICK AND DIRTY EXPLANATION OF HOW MRI'S SHOW LESIONS IN MS

The Life History of an MS Lesion

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 iswollen and 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.  The body attempt to repair the damage that is being done and sometimes these areas re-myelinate.  They may disappear from the next MRI.  They aren't perfect in their function, but the area may return to a normal appearance.

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 become more dense  - more dense than the normal brain around them.  These are the classic MS plaques and are considered old lesions. They show up as the bright areas most of us have seen in pictures and on our films.

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 body tries to reabsorb the dead area.  It becomes "less dense" then the surrounding normal nerve tissue.  After a longer time - probably years - the scar can reabsorb completely and the area becomes "empty."  It's called a black hole.

How the MRI Shows These Different Stages of MS Lesions

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 MRI 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, scarred, mature MS lesion is a little bit oval, will have well-defined borders and will be in the white matter.  Characteristic places (but not the only 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 image 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.  In brain atrophy there will be an increased space between the skull and the brain.  Also the deep folds in the brain will appear widened.  

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.   Anywhere the blood vessels are more dilated than usual,  bringing more blood to the area, as in inflammation, 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 a new attack right around them (also called reactivation) 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  (these say the same thing).  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

[Quixotic1]

WHAT IS THE DIFFERENCE BETWEEN T1, T2, AND T2 FLAIR IMAGES?

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 EM 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 combinations of pulse techniques.   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-gray 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 T2 technique is the best for showing the mature, scarred lesions, where the oval lesions look brighter than the surrounding brain.  The T1 is best for showing the old, reabsorbed "black holes" where the lesions once were.

The FLAIR is a little easier for me, but still involves a miracle happening.  It stands for FLuid Attenuated Inversion Recovery.  It is part of the T2 imaging, with a twist. It is another miracle of pulses and signals.  It's purpose is to distinguish things that border on areas of fluid (mostly for our purpose - CSF in the ventricles).  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

There are other techniques like fast-spin. spinm echo and such, but they are techniques used to clarify tiny differences in the tissue and to make lesions stand out better.

Quix

[Quixotic1]

WHAT IS THE DIFFERENCE BETWEEN THE OLD MRI's AND THE NEW 3T MRI?

I came across a good back-to-back comparision of the 1.5T MRI versus the 3T MRI on MS patients with known multiple brain lesions without enhancement.  They did an MRI using the MS protocol of  thin slices.  The neuroradiologists reading the films were not told which machine they werE done on.  The 3T machine consistently picked up more lesions - on average 25% more.  

Now if you already have 8 lesions, and we know most brain lesions are not "eloquent", that is, they don't cause recognizable symPToms, who cares if  there are 8 or 10?  In the vast majority of cases the increased number of lesions picked up does not affect the diagnosis, the treatment, or the prognosis.  So there isn't a huge rush to convert to the newer and more expensive machines.

However, I make a big deal of the issue here for the reason that several of us, including me, have languished without a diagnosis because of having "no" or "not enough" lesions on the MRI.  If you are in diagnostic limbo and everyting you are suffering from screams "Multiple Sclerosis", but the MRI is not diagnostic, you need every bit of increased sensitivity you can get.  Even several of our neuros have told us regretfully, "You might have lesions that are just too small to be seen."  WELL??

I again tell the same, old story  about this spring.  I had ZERO spinal lesions on a 1.5T machine in March. In April I developed a fairly severe L'Hermitte's sign (lighting zaps down my left leg when I fllexed my neck)  This is a common in MS, but non-specific sign of  cervical spine nerve lesions.  My neuro ordered a repeat MRI ofr the spine on the 3T MRI.  Suddenly there were SIX old (non-enhancing) lesions.

T-Lynn had no lesions, but classic disease for years.  Suddenly she had "brain atrophy".  Her first MRI sign was the accumulation of so many old, reabsorbed (and invisible) lesions, called "black holes", that when the brain tissue contracted around them the MRI showed loss of brain volume!  After this diagnosis they did an MRI on a 3T machine and she showed lesions thoughout the brain.

Granted it's only two cases, but it is two cases where the diagnosis was delayed and we were dismissed by the neuro's as being crocks.  In the faced of the "undiagnosed" that small increase in resolution becomes very important.  When someone looks at the pictures, like a tech, they may not look that much clearer.  What the tech does not see is the comparison back to back on old and on new machines, and what the appearance of just a few more lesions can mean clinically.  There's no way they could see this.

It is more than the art of interpretation, though that clearly makes a difference in the overall picture.

I think a lot of doctors do not want to admit that they have been missing diagnoses, even if the reason is beyond their control.  They don't want to admit they don't have access to better equipment, so they deny it is better.  Yes, I have sat in the doc's lounge and heard discussions and rationalizations for more than twenty years.  Doctors in general, and neurologists in particular, can have huge egos and need to "save face."

We also must remember that the vast majority of the some 400,000 people in the UK and US with MS were diagnosed using the older equipment.  For them the new one wasn't needed.  We here, who are just lacking sufficient MRI evidence are the one's most likely to benefit from use of the higher resolution machines.  

Final word (really??) If the signs and symptoms are suggestive and the MRI bafflingly negative - why not go for an image with a better resolution.  Quix

[Quixotic1]

SHOULD THERE BE A LESION SEEN ON MRI FOR ALL OF MY DIFFERENT SYMPTOMS?

NO!

Right now it seems that one of the most difficult questions on the forum is whether the lesions seen on the MRI's are supposed to be directly related to the problems that people have, their symptoms and their signs.   The answer is THEY ARE NOT PERFECTLY RELATED.   Too many doctors, neurologists, and people try to draw conclusions about this.  It is probably the greatest pitfall in understanding the disease of Multiple Sclerosis.

THE BRAIN

First, lets talk about the BRAIN.  Remember that about 90% or so of our brains are "unused."  That means that we don't know what those areas do or might do if they are damaged.  ALL of the scientific articles are clear that the majority of MS lesions in the brain are not "eloquent", that is, they don't "speak up" with specific symptoms.  No good MS Specialist is going to try to map the lesions with the symptoms that are showing up in the patient.  It is almost impossible and it is a waste of time.  It is well documented that some people with many, and severe symptoms may have few visible lesions.  And some people who are diagnosed when they have just one symptom may have a whole brain full of lesions which had never before "spoken up."

Now, some lesions can be big enough and in known active areas and we can recognize that they cause a specific symptom.  But this is the exception, not the rule.  MS "tends" to cause lesions within a characteristic pattern, but knowing this just means that when you look at a HUGE number of people with MS and plot all their lesions, the majority of lesions will fall into this pattern.  ANY ONE person or any person with just a few lesions may have them occur in any white matter location.  .  Even people with a "characteristic pattern of lesions" will have some that don't fall into the perfect "zone."   Please reread those last two sentences.

The more the lesions follow the common pattern, the easier the diagnosis and the easier the job of the neurologist.  It's those people with suggestive symptoms and suggestive abnormalities on physical exam but WHO HAVE NO LESIONS, VERY FEW LESIONS, OR LESIONS IN LESS USUAL PLACES that will have a tougher time with the diagnosis (if they have MS).  

Secondly, all good MS doc's will tell you that they believe that many brain lesions are still invisible to the MRI.  So we know that there are some lesions that can't be seen which can still cause symptoms.  So that makes drawing conclusions IMPOSSIBLE between where the lesions in the brain sit and what the symptoms are.  But, sometimes they can form generalities.   Some researchers have found a statistical relationship betwee frontal lobe lesions (which is not one of the commonest places) to the very debilitating fatigue. Lesions in the brainstem are often associated with balance problems or spatial orientation problems.

The point to take home:  Most lesions seen in the MRI of the brain do not correlate well with the problems the patient has.  A good doctor will not try to tell you different.  And you shouldn't spin your wheels trying to look up mapping of the brain - unless that is something you would do anyway for giggles.

THE BRAINSTEM AND SPINE

The nerves in the brainstem and spine are all "eloquent."  They drive the functions and the movement of the body and they relay information from the body back to the brain.  A small area of damaged myelin in the spine is "more likely" to cause a direct symptom or problem.  Spinal lesions are a little less common than brain lesions, but more directly connected (in an obvious way) to our disease.  But, also many spinal lesions are still invisible.  They are also harder to get good clear MRI images on.  This is one area in which the newer T3 machines seem to excell.

[Quixotic1]

I was up late last night, so I consolidated all the MRI/Lesion stuff into this thread.  It will be easier to point people toward answers.  What do you think? Q

[Quixotic1]

Focus - a spot

Foci - more than one spot

Increased signal - abnormality, usually referring to a lesion

enhancement - area of increased blood flow, inflammation, (in MS) new and active lesion

UBO - Unidentified Bright Object - a bright area, lesion, not specified.

lesion - abnormality, area where the tissue shows change (may be scarring, missing, more dense)

T1, T2, FLAIR - different imaging techniques

peri-ventricular - something aligned along/near the edges of the ventricles (which are the CSF fluid filled spaces in the brain)

perpendicular to the ventricles - a lesion which is usually oval and has the longer axis pointing AT the edge of the ventricle.

gray matter - The thinking cells around the outside of the brain - the cortex

White matter - the communication network joining the thinking cells.  The white matter are the long nerve fibers and the white is the fatty, myelin sheath of the brain and spinal cord.

Do it yourself MRI report interpretation.

Quix

[Momzilla]

Wow.  You should write a book.  I know how hard that is for you, with the vertigo and diplopia and fatigue.  That was so great of you to do.  I'm at work.  Shouldn't be reading it.  And rereading it.  

The definitions put eveything into context, thanks.  Still don't really get the gray/white matter fully.  Is the gray matter just cells?  Are they sort of electric or just organic, whatever that may mean?  I get the white myelin more.  But does that include the long fiber inside the sheath?  Is that white matter?  That's got the sort of electric charge or exchange, right?  

Do tell.

Zilla*

[floridamom2]

Thanks sooo much for all the work you put into this!!  It really helped me understand that I do need to eventually have the repeat MRI of Brain w/ contrast.  I am going to see my 2nd neuro tomorrow and was planning on asking for repeat MRI of Brain w/ contrast.

My question is this:  Since my initial attack ended at around end of June I have only had milder sx with "baby attacks" that focus around my menses.  These milder attacks include weakness, numbness, blurry vision, and tremors.  They have lasted around 2 weeks for the last two going on 3 periods now.   Should I wait until I have another full blown attack to have the repeat MRI done as there may be no activity now since initial attack is over?   My first MRI was done mid June without contrast only.

Thanks again for your help and knowledge!!  I am sorry you have been having trouble with your doctors again!  I get a bit discouraged when I read that even you a "rocket science" pediatrician who more than dabbles in neurology are having trouble getting them to take you seriously!!  Thanks for all your support and help!!

Take care and Hi to Momzilla and all the Gang!!!!!!!

Kristin

[Siddy1]

Well done, Quix!  You have really put this in a way that we all can understand and I know everyone on this forum appreciates the time and effort you have put into it.  I like this DIY approach.  I also want to bump it up to the top again.
Cheers
Marcie

[metabolicwreck]

Wow, I am impressed!  That took a lot of work.

I guess years of peds helped you figure out how to get it to a basic, understandable level. (helpful for those of us with congnitive issues).

Thanks for re-posting it!

[vera from Hong Kong]

It would be a live dictionary and guide to me. Some of the points which I ask my doctor with no answer. And now, I do have a basic knowledge of MS. You are really the nicest person in the world.

[Jazzyfizzle]

Quix this is fantastic, thank you so much. I have a couple questions, please forgive me if you have already answered it. I tend to get foggy and confused after reading more than one small paragraph at a time.

What originally causes the attack on the myelin in the beginning? Or do they know?

I have (right now) 2 doctors saying two different things. My personal doctor believes I have had/am having mini strokes and they are damaging the brain. Another doctor feels I have MS.
Does the damage from both diseases look 'alike' on the MRI? Or how does it look different if it does?


All the best
Jazzy

[grannyhotwheels]

Wow,  Thank you so much for all the hard work and time that this took.  You are the jack of all trades.  We are so fortunate to have you here and I think that because we have someone like you who is a MD and a MSer, well, that's why people come here and stay.  

So many forums have people like me who does'nt know a thing, and that's all they have.  After a while it gets boring talking to me.  You know what I mean.
I hate it when I can't type what I'm trying to say.  But, I hope you know.

We truely love you Quix.  Not just because your a doctor but more so because you are one of the kindest and most understanding person, that will go that extra mile to find out answers to our questions, I know.

We salute you and thank you!
Carol

[Quixotic1]

CAN YOU HAVE A NEGATIVE MRI AND STILL HAVE MS?

know we have covered this before, and I really should spend more time on the National MS Society site, but this is a quote from the NMSS Sourcebook on MRI's.  It says everything so much more succinctly than I do when I'm "winging it."

"Diagnosis
Because MRI is particularly useful in detecting central nervous system demyelination, it is a powerful tool in helping to establish the diagnosis of MS. It should be remembered, however, that approximately 5% of patients with clinically definite MS do not show lesions on MRI, and the absence of demyelination on MRI does not rule out MS. Also, since many lesions seen on MRI may be in so-called "silent" areas of the brain, it is not always possible to make a specific correlation between what is seen on the MRI scan and the patient's clinical signs and symptoms. In addition, with advancing age (probably over age 50), there are often small areas seen on MRI in healthy people that resemble MS but are actually related to the aging process, and are of no clinical significance."

http://www.nationalmssociety.org/site/PageServer?pagename=HOM_LIB_sourcebook_mri

Guys, not to restate the obvious but this is 1 out of every 20!!!  I'll keep looking, but even my MS Neuro, whom I consider very smart, felt that MS was ruled out by normal MRI's.  I need to understand whether the 5% got diagnosed because they presented so classically - maybe with Optic Neuritis, more than one clear attack, a very positive LP, and a tatoo on their forehead that says, "I have MS!" LOL

Quix

[T-lynn]

My initial DX came with brain atrophy ,LP results, past ON and transverse myelititis.abnormal evoked potentials.No tatoo's.

The info is awesome.

Thanks it will help many to understand the DX process and the MRI's

T

[floridamom2]

Kicking this back up - extremely informative - Another great job by our resident expert and Den mother - Quix!!

Glad you are feeling a bit better Quix - please don't over do it!  We will all still be here and are still going to help with the newbies!

Take care all!
Kristin

[grannyhotwheels]

I wondered what that MS on my forehead stood for.  Thanks!! lol hahahehe

We need to keep this bumped up to the top.  Not only do I need it but it's perfect for the new people needing info. on all of this.

Carol

[kline]

WOW! This was wonderful for me to find. I was just advised that I have lesions on my thoracic area between T4-T7. I am waiting on a bone scan to rule out a metastic something and to determine if it is MS.I have been searching the web for all kinds of info, and the explainations I found above were very helpful.
The only question I have is: did any of you have severe pain at the lesion site and if so was it part of the MS?

[nurse1973]

I had an MRI that stated nonspecific subcortical white matter changes are identified in the right and left parietal and frontoparietal regions. Lesions extend into the white matter in the occipital lobes and approach periventricular position. Best seen on T2,flair and proton density sequences,without evidence to indicate acute infarct and without enhancement. Findings are nonspecific and are not typical of MS. However,MS can have this appearance. What are your thoughts on these findings?

Took months to get into a Neuro and he didn't even glance at my films but instead asked me if I had migraines? I said,"Yes." He said well that's pretty typical of migraines. Sent me out the door. 2 yrs later,symptoms are worse than ever and I had an MRI of chest spine,lumbar spine,neck spine, all without dye performed today. Will go back in one month to follow up on those findings with this new doctor. Do my former results sound indicative of MS?

[Momzilla]

Hi, Nurse!  

That is outrageous!  Insulting!  And, welcome!

I want to welcome you to our forum here, but I can't get over your doctor's preposterous behavior.  I am sorry that happened.  I do want to tell you, though that this thread is not the best way to get your question answered.  

Is there any way I could coax you into repeating your question in a new post?  I promise that others will be as appalled as I am, and we will get to the bottom of whether your lesions are indicative of MS.  

OY!  What a dufus doctor!   List your symptoms, as well, if you want.  Or don't.  Everyone will ask you what they are, anyway.  We'll be all over this one!

I really don't know the answer, or I'd tell you.  But no one is going to find you here.  All the regulars have seen this!  I hope to see you on the "New Question,"  Nurse!  You deserve some good attention!

Be well,

Momzilla*

[kitten o]

THIS IS GREAT THE WAY YOU EXPLANED IT. I WANT TO PRINT THIS BUT I CAN'T.
CAN YOU SOME HOW SEND IT TO MY E-MAIL AND MAYBE I CAN PRINT IT
FROM THERE, OR CAN YOU TELL ME WHERE YOU GOT THIS FROM?
THANKS AGAIN KITTEN

[Quixotic1]

I'D BE GLAD TO EMAIL IT TO YOU.  I WROTE IT MYSELF SO I WOULD HAVE TO COPY IT AND EMAIL IT THAT WAY.  THIS FORUM WON'T LET YOU POST AN EMAIL ADDRESS SO I HAVE TO GIVE YOU MY EMAIL ADDRESS IN PIECES. YOU CAN CONTACT ME AT MY NICKNAME neuroquix AND USE THE EMAIL SERVICE OF gmail dot com.  I HOPE THAT MAKES SENSE.  IF YOU CONTACT ME WITH YOUR EMAIL ADDRESS I'LL TRY TO GET IT TO YOU.  DO YOU WANT JUST THE INFO OR THE QUESTIONS AND ANSWERS ALSO?

QUIX

[Quixotic1]

LOL, "Recommended Reading"  to save my poor fingers.  Q

[Johnny Utah]

Nice work Quix!

[Millerman]

Thank you for shining a light on such a murky topic!   :)

Chris

[Sam888]

In the absence of many lesions, can MS start slowly, say, with the presence of one small lesion but the person could have other symptoms like muscle soreness, tingly sensations, loss of concentration, memory loss, and anxiety?

[Eliza3]

I found out a lot about MRI's. So the past MRI's I had done in the 90's and 2002 may have not been strong enough to catch the lesions? This last MRI caught a big lesion and other stuff.

Thanks again
Eliza

[Sam888]

*bump*

Quixotic1. In the absence of many lesions, can MS start slowly, say, with the presence of one small lesion but the person could have other symptoms like muscle soreness, tingly sensations, loss of concentration, memory loss, and anxiety?

[Happy christmas]

You really seem to know what you are talking about.  Could you help me.  I have a lot of the invisible MS symptoms but no disability.  I had an MRI taken of head and spine with/without, which my Neuro ruled out MS as there were no lesions new or old, but i had enlarged ventricles for my age, 37.  Do you think it is possible to have progressive ms, no lesions, but enlarged ventricles? Thankyou

[Quixotic1]

Recommended reading for newcomers to the site.  Q

[Heather3418]

up, up and away...with our newcomers and as fast as this board moves...(thank goodness, it shows we have a GREAT FORUM) it's hard to keep this posting near the top for all the newbies to read...

[steveo007]

Sorry if you've already answered a similar question in this thread, but here goes. Am I right in thinking that the result of my brain MRI w/o contrast, which
states that there are no cerabral abnomalities, leaves me with a 5% or 1 in
20 chance of still having MS.
I appreciate that there can be confusion in reading MRI results, where other
non specific things show up on a scan, but would this usually be the case where the scan is apparently completely clear

Thanks

Steve
  

[Roxie0818]

I was looking for this post for Melinda and never found it!!  It was buried.  Ok maybe I just didnt see it!  Thanks for finding it Heather or whoever.

[pneeb419]

I'm just bumping this back to the top.  I don't say a lot but I read almost everything here, and this is a must read for anyone who wants to know more about this crappy disease we have

[needanswers54]

Yeah, kinda know what you mean.  Just became diagnosed with MS this week.  Have been trying to get someone to listen to me concerning my Migraines and my other neuro problems for years.  Went to a John Hopkins graduate and neuro-opthalmologist who keep insisting it is just daily classical and ocular-migraines and depression.  I do not disagree that I have that.  But, I kept telling them about all the other weird symptoms and they will not believe me...even with the tremors, falling, temporary foot-dragging and temporary infrequent paralysis, weakness, dropping things, palinopsia, being accused of being drunk (when I do not drink), etc. and numbness for over a year at varied places to the point I received second degree burns and did not even know that I had them (until someone pointed them out to me).  Went to ER and they would not do an MRI, just CT.  No time.  But, they had time to do a LP and throw the fluids out without running a lupus, MS, India ink, etc. or do a pressure test on me (even after I pleaded with them).  And I am allergic to local anesthetics.  I guess the ER doc just needed LP practice.  Anyway, I even showed a spot on my spine to the docs in 2001 and they said it was just an artifact;  Showed them the same spot on 2005 MRI and still no concern.  Decided to have cervical fusion against neuro's advice as I was having so many problems.  Every medical person in surgeons office gave me a different reason for the spot.  The surgeon said he thought his surgery would alleviate 85-90% of my symptoms.  I told the surgeon I would agree to the surgery, but only after he first diagnosed the seriousness of that spot pre-surgery.  He then asked me if I thought I had MS.  I told him that he was the doctor; that he should tell me.  He decided I was too high risk for being able to "cure my problems".  He never advised me that there were really any other problems or suggested any other tests.  The medical community finally had my family and me ready to accept that I was either a nut-job or to just give up trying.  Finally, got my primary to sent me to another neuro who appeased me with another C-spine MRI.  I was almost resigned to the fact that it was all in my head (literally); but, I just knew that something would show-up and a nice size lesion did further down my spine.  She still did not believe MS.  She moved.  I was sent to another top doctor who said it could be a combination of all the other problems, osteoarthritis, migraines, bilateral carpal tunnel, bulging/herniated disks, probably fibromyalgia, depression, etc.  Okay, enough already.  So, I get my old rheumatologist to order a MRI of C-spine, reluctantly.  I said maybe this was all from stenosis or something.  No prominent hyper-reflexivity yet.  Just mostly numbness, weakness, polyopia, varying reflexes, and increasing tremors to the point I could barely utilize utensils for a few days.  Had a truly tossed salad and pasta at the holiday get-together that landed on the couch and have had fingernail polish that flew across the room.  Like I really needed that attention.
Called the MRI tech at the hospital to see if they could get the rheumatologist to allow contrast if indicated on the films.  Said that they would do it.  Then, they did not administer contrast.  I asked them to, again, while on the table and even told them where spots had been and I thought still were on the films.  They said the radiologist said the spine was normal.  I sent the tech back again asking for contrast and pointing the spots out.  Still, no luck.  Requested a neuro-radiologist read the films.  Days later, after I said I would pick the results-up myself and take to doctor, they hurriedly contacted him asking for a new MRI to be done with contrast.  He did not want to handle it and sent me to a new neurologist.  They thought I had focal demylination of the upper spine and a C6-C7 syrinx.  Took films to another top neuro who said it was all bogus that I just was not straight on the scanning table (on all MRIs). Sent to another neuro who simply stated that spots in your spine do not matter.  No hyperreflexivity and a normal brain scan means no MS or other disorder.  He finally agreed that perhaps it could have been a bit of myelitis--not a big deal that I have recovered from.  He did not believe the tremors or even do a finger to nose test and told me I was a hypochondriac and go see a shrink.  He even gave me a letter of recommendation for one.  Oh, goody!  Went to ER in winter for severe migraine and pain and ongoing problems.  They refused to run tests or check my prior MRI results.  Gave me an imitrex pill ( usually get benadryl and/or antiemetic, toradol, dilaudid) and decided I was nuts and did not need any other testing.  Pain so bad I was ready to give up.  Finally, got into this new neuro who diagnosed MS on second visit after reordering the head and C-spine with and without contrast.  Told me to go to MS clinic.  I asked a neuro-radiologist check films.  She explained over the phone that the reading radiologist did not note the "many, many" WMLs (probably as I was fifty) [and of course I am a migraneuer] and simply called it normal; but they were never mentioned in the report.  I do not know if other two prior MRIs (at least one before I was fifty y.o.) had spots or not (as the same radiologist read at least one of them, too)..  I am curious to see.  She was concerned and said MS with TM, ADEM, or possibly more serious.  She said do not wait until next year.  She said to get seen right away.  I cannot get in.  Trying to get new primary to order more tests including T-spine with contrast this week.  Also, exposed to many toxins at work and employer will not release info even to hospital ER where I was sent.  He never told OSHA, and refuses all subpoenas.  OSHA cannot help as employer laid me off after I complained of problems (some of which are documented by their medical personnel).  And now that it has been at least three years all records were allowed to be destroyed.  Cannot help but wonder if something triggered this as symptoms started after the exposure.  I am now on disability.  At least a little validation that I am not totally (perhaps just partially) a nut-job from this neuro problem is better than nothing.  Last few days I keep mixing up my words and am having to really concentrate to start speaking...quite a change for the talker that I am and the dextrous noted lab and nuclear tech, chemist, and researcher that I used to be.  A medical doctor/researcher from a noted institution and a well-known neurologist have both written letters to the judge and court to try and obtain information to help me without avail.  
And yet, few people would believe this true saga...I am so sorry for you and all the many others out there who go through so much more than even this.  My family became so weary of it...They basically appear to be in denial and tell me my life is wasted.  Perhaps, I embarrass them or bore them because I cannot do things as I used to do them.  I have been pretty much ex-communicated except by one child.  I cannot even imagine what it must have been like for all the orphans out there who grew up without a family and not even a family medical history.  I have no medical history for auto-immune disorders on either side that I am aware of.  But, it certainly helps sometimes to know one's family history.  I have always tried to be an independent, self-sufficient, charitable adult and pretty much a single Mom that has survived many traumas.  But, without family and loved ones life can be so different.  So, let's all be strong and helpful for each other.  I am new to this forum and very grateful for it.  Thanks to all of you!!!!

[Quixotic1]

OMG!!!!  UN believable, yet totally too believable, given our collective experience here.  You are match made in heaven, and in the h***you've been through, for this forum.  I thank you for the time and frustration is took to write this.  Many of us have had similar dismissal of our symptoms and lesions by physicians who who  were too stupid or too lazy to put some simple things together.  I am glad you got the diagnosis you knew you had.

But, I am going to ask you to post this same post back on the main page.  Just copy it and hit the "Back to Forum" button at the bottom.  Then hit  "Post a Question" at the top.  And paste it as is.  Many of our member who are still going through similar rat-mazes need to read what you have to tell.

But, here, most of them won't see your post here, buried in this one, and you certainly deserve your own thread.  We also will point you toward our thread of stories to diagnosis, and others.  Welcome to our forum.  You bleong here and we have about the best group of people this side of the ionosphere.

I am a physician, but not a neurologist, and am no longer in practice.  I write some of the informative threads, like this one.  I had my own experiences of having abnormal MRIs dismissed as "normal for age" and was even accused of making up my symptoms, before finally getting my diagnosis last spring.

See you on the front page!

Quix, MD

[Quixotic1]

Please read this if you have any questions about MRI and how they fit with MS lesions and symptoms!!

[nette573]

Loved reading this.  Its hard for me to read after a while and understand.  I had mri of the brain because they thought I had a stroke.  
CLINICAQL HISTORY:  Weakness and hemiparesis with involvement of the right arm and leg.

PROCEDURE:  Sagittal and transaxial images are obtained employing selected pulse sequences.

FINDINGS:  The ventricular system is midline and normally configured.  The corical sulcal pattern is unremarkable. There are two tiny foci of increased signal intensity on FLAIR imagesdemonstrated within the subcortical white matter of the right parietal lobe.  The brain stem contours are normal.  The pituitary is not enlarged.  The normal signal flow void is confirmed within the basilar and both internal carotid arteries and superior sagittal sinus is patent.  Cerebellar hemisheres are unremarkable.  Seventh and eight nerve cranial complexes are grossly symmetrical.  No focus of restricted effusion is identified.

IMPRESSEON:
1.   NO EVIDENCE TO SUGGEST ACUTE INTRACRANIAL HEMORRHAGE.

2.   lacunar foci within the right paietal white matter may reflect remote foci of ischemia.

The neuro I was sent to said that it is on the wrong side.  and that he did not know what the two tiny foci of increased signal was.  I am still having problems and sometimes I cant remember words.  I will go back to my doctor and ask to go to another neuro and to have a mri on the brain with contrast!??????!!!

[Heather3418]

In the brain, the right brain controls the left side of your body and vice versa.  In the spinal cord, the opposite is true.  The right side of your spinal cord, controls the right side, etc.

I agree that you should see another neuro AND have another MRI of the brain and spine with and without contrast dye.

Please keep us up to date.

Heather

[spankyandrex]

bumpity bump - I just copied and pasted all of Quix's information, this is excellent! Thanks again Quix.

[dreamyeyes]

WOW!!! this forum has been very valuable information. Being a newbie to all this I am just starting to understand how difficult this journey to find answers and a diagnosis can be, and just how challenging!!! And the expense I'm sure is outragous, having to constantly seek answers from one neuro to another. I'm now asking myself "How does someone afford this with out insurance". Someone like myself!!! Its bad enough having to deal with the unknowns of this disease, what life will be like 5 years down the road, how it will affect myself and especially my family, my children!! But my goodness, I can't even imagine going down this road with out the support of my huge extended family, my daughters or my fiance`. I've been thinking alot about the need to double up on house payments, get it paid off early, and other financial concerns just incase someday I am incapable of continuing to work or on disability. But add in the concerns of the cost of health care as well and everything seems so overwhelming!!! ALOT to have to think about!!! And my diagnosis is still just a possibility!!!

[cherriepit]

Wow, this is all so confusing to me!

[sd324]

Great post, essdipity thanks for pointing me in this direction.  Found out more by reading this than I have in the 18 months I've been seeing GP and neurologist.  Many thanks.

[mooers777]

My god you have been through a lot! As I read your story it it brought tears to my eyes not only for the saddness of it but for the symptoms we have in commom and the fact that I cannot get a single doc to listen to me either. I feel at times that I am crazy and that it is all in my head. I have also been told to go to a shrink! Yeah right! I refuse to go to those nut jobs which are crazier then any of us at our worst!!!
I am so glad you now know what is wrong. And that you are not nuts.

Mooers777

[mooers777]

My last post in here was meant for you, sorry for the mix up!

[Jazzyfizzle]

Quix could you label the word 'infarct' and ischemic?  Thank ya

J.

[Quixotic1]

Ischemic - starved for blood, damage from restriction of blood flow, but may not be permanent.  For instance, if you put a tourniquet on too tightly (tighter than the arterial pressure and leave it, the arm will turn dusky and begin to ache.  It will be ischemic, but will recover if the blood flow is allowed to return.

Infarction (Infarct - for short) death of tissue from loss of blood flow to the area.

The two are often used somewhat interchangeably, but I learned that something can be ischemic and still recover.  An infarct is death of the area of tissue and this leads to scarring.  Another term used in place of these two is "microvascular disease."  I think this is a better description because it indicates very tiny areas of damage from occlusion of very tiny arteries.

HOWEVER - when it comes to MRIs of the brain "Ischemic White Matter Disease" seems to be the term they use for small, areas of scarring (which implies brain tissue death) from causes like sustained high blood pressure, migraine disease, vasculitis, or even very tiny strokes.  

These lesions, I THINK, but am not sure, occur most often in the area of the white matter just below the cortex (outer rim) of the brain.  It's often called the subcortical area.  The lesions tend to be "punctate" or pinpoint sized and more irregular than the typical MS plaque.

I'm still trying to find a good source that will describe the various differences in the white matter lesions of ischemic disease versus demyelinating disease (locations, numbers, appearance, size, etc.)  I'm not totally clear on it all yet.  The different uses of the words by different radiologists keeps it all very confusing.

Quix

[SOONERMOM]

I recently found a website that discusses and shows the differences in white matter lesions. http://www.radiologyassistant.nl/en/4556dea65db62   Check it out when you get a chance!


Stacey

[grannyhotwheels]

I wish that all of you that had questions would start your own threads.  You each deserve your own responses but the way it is now some of the posts that need attention are buried in all of this.

Quix, what can I say?  You are one in a million.

I'll be praying,
Carol

[cherby]

is numerous non specific foci of high t2 signal within the white matter of both cerebreal hemispheres lesions???? or white spots?????

Thanks Quix you truly are a life saver!
Cheryl

[cjacks]

Cheryl,

I'm not sure , my report said the same thing . In Quix's definitions foci are spots. Did you post your report . if not , start your own thread and ask the questions you have . Not many will see you here . I read  your other post that said your report was fine , but maybe someone will have comments .

Take care        Jo

[Quixotic1]

Would you ask you question on the main page.  this is something we need to review periodically.  Thanks, Quix

[Sonaya]

Heather, thanx for finding this post and Quix bless you for typing it for all us newbies.  I was feeling very down tonight after my appt with the physician.  This is absolutely invaluable information put in laymans terms because lets face it, some doctors out they do not like giving too much away and we are just left to sit and take what they say or dont say as gospel.  For someone who has never really had a lot to do with medical terminology and suddenly being faced with so many different symptoms and possible dx, this helps immensley.

[mrwiggles]

I should have read this a long time ago! Amazing information.

[weezzE]

Hi new to all this. Have two foci in left perventricular neuro has request lumber puncture. Can anyone tell me please if the lp confirms only active lesions or also evidence of old ones? and how this will be worded? thank you

[sllowe]

Bump!

[TiredPT]

Wow, awesome explanation.  Thanks for all the time you put into that despite the Type C personality :)

Bumping up just because it is a must read for all us newbies!

[BloominHeather]

Wow thanks Quix! I learned a lot from that and my brain is now feeling quite full to capacity! lol
Very interesting. I wen't and looked at my copies and saw that mine that was just done in December was done with T1. Maybe that "small curvilinear area of enhancement along the left frontal convexity likely representing a venous angioma" isn't actually a venous angioma after all.  
Makes ya think anyways.
Thanks again. Very informative!
Dawn

[funmonkeytoes]

Thanks for defining most of the "MRI/MS Lingo" that we all have to face at one time or another.  Now, if only the MDs would answer my question about MRIs and MS that I posted a while ago.  Unfortunately your definitions didn't answer my question -- but it brought me to your post.....it is a "must" read -- especially for those in limbo.  Thanks again!

[vanhawk48]

Dear Quix
Thank you very  much  for  all you  do  for us .
You  are  just  fantastic .

Thank  you  
Vanda

[Heather3418]

bumping up for a member with questions...

[debj52]

hi quixotic, i have been a little worried ...i have asked several times but havnt been answered...i know that not every one can be but you seem to be the leading person on here that knows what your talking about.....
ok here goes..i have ddd multi level moderate to severe and i have hypothyroid...about 6 years ago i had hyperthyroid and graves and they did the iodine thing and told me eventually would probably go hypo.....well itdid....ok so now i have pain in the butt that goes all the way down the legs and i cant sneeze or cough without being in a lot of pain in my back....and when i turn my neck one way or the other it pops and a few times i have had like a zap or pop in my head. well my daughter was here today and i asked her to feel back of my head and shew went a little ballestic and told me to get in a doc tomorrow...it is swollen in the back of my head compared to hers.....and sometimes i forget what i wanted to say and its just really driving me crazy.....noise really bothers me to....i have a lot of muscle weakness in my arms and legs and i have experienced what i found out later might have been the ms hug ...oh my thats a hard thing to deal with and also my muscles willcramp up a lot and i get off balance a lot....well i have rattled on enough and if you or someone could have the patience with me and try to explain what all this means i would be soooo appreciative.......thanks for listening debj

[Irene5353]

Thanks from one living in limboland for it seems like forever.  I was recently undiagnosed after many years.  My neuro retired. I had a MRI completely free of lesions but had lesions (several) in the past especially in the caudate area.  Years from now they will figure it out.  I just want to continue with Copaxone because it keeps me from having so many attacks.  I was told to see a regular neuro.  I do not want to go through the diagnosis dance again so I am just laying low.  Oh they also suggest but do not diagnose somatoform disorder.  Is that why I have the lesions or those T2 really bright spots.

Do some people remyelinate better than others?