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MRIs and MS
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MRIs and MS

I'm going to cause some controversy.

When it comes to MRIs and MS, it would be great if every doctor and insurance company would agree to a 3T MS Protocol MRI (that includes Gadolinium contrast and post contrast T1 sequences as part of the MS Protocol) of the brain and cervical spine.  

With the way most hospitals and imaging centers bill for studies (by the body part,) I think they are forcing the insurance companies to question the need for certain studies.  Should a doctor order a c-spine MRI if you are not having Lhermitte's Sign or symmetric defects of the extremities?  Is Gadolinium needed if there are no T2 lesions to start with?  

Consider that in many metro areas, hospital MRIs are booked 24 hours a day 7 days a week.  I went for my last MRI  at 7:30 PM.  If you don't have symmetric extremity signs with or without Lhermitte's sign, what is the incidence of C-spine lesions?  (Might be a good idea for a multi center study.)  If you don't have T2 hyperintensities, then Gadolimium is a drug that there is no indication to administer.  (yes, it is a diagnostic drug regulated by the FDA and requires a prescription.)  It can only show enhancement on T1 of a lesion less than about 40 days old.  Well, that lesion also shows on a T2 sequence, so if you have T2 lesions, then GAD makes sense.

There is an MS protocol, but it might be the "most ideal" and not balanced with "most practical."  When someone says "I need an SUV."  there is a big difference in cost between a Range Rover and Ford Explorer.  Both get you down the road, and I'm not sure the Range Rover will do it any better or faster, but I can tell you it will cost you more!

Part of the expertise in being a doctor is picking the right diagnostic tests, not ordering the most expensive battery of tests.  It is up to the doctor to figure out what they need to get to a diagnosis with the lest expenditure of resources.  That include the time the patient spends in the MRI machine delaying others from getting their tests done.  

There are a limited number of MRI machines.  There are even less 3T machines.  I think that the 3t machines should e used for those studies that require their higher resolution, but I'm not sure that imaging and medical physics community have determined what those are yet.  There are a limited number of Rad Techs to do the studies. There are a limited number of radiologists and even less neuroradiologists.  I really think MRIs of the brain need to be read by a neuroradiologist, not a neurologist.  Most Neurologists go lesion counting.  They don't read the whole study in the absence of clinical bias.  Neuroradiologists are much better at reading a study rather than trying to "support or disprove" a clinical impression.      

Just something to talk about. By the way, my first MRI was not MS protocol Brain & C-spine but 5mm slices without/with GAD on a 1.5T and my second was 3mm slice Brain only with and without GAD on a 1.5T.  I never had a GAD enhancing lesion.  My presenting problem was ON (3/2010) and I was diagnosed (11/2010) with RRMS at the Rocky Mountain MS Center.

Bob
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1394601_tn?1328035908
Bob?  It has been my understanding that having a 1.5T would not have (and in fact did not) show the lesions on my spine.  It wasn't until I had a 3T that those lesions showed.  In the mean time, while waiting, a hell of a lot of damage has been done to my body.  Would have it happened with or without being diagnosed?  I don't know.  I will probably never know but I will say this, I would have scrimped and saved my own money (forget insurance) to have been given a 3T and a chance to use DMD's.  Maybe, just maybe, I wouldn't be faced with the condition  I am in today.
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1453990_tn?1329235026
And in your case, your doctor may have ordered it based on your case.  I agree.  I;m not sure every case needs a 3T.  I'm not sure every patient should get GAD.  In your case I agree that you needed the resolution.  In my case, after 6 months of "watch and wait" the doctor didn't.  I'm getting a bit concerned about people recommending to case that they get a 3T MS protocol MRI of the Brain and C-Spine.  That may be a "misapplication of a limited resource."

I'm only opening it up for discussion.  If my 1.5T was negative, given my symptoms, I'd have pushed for a 3T MRI.  I'm not sure that limited resource should be expended on every R/O MS case.  

I'm bringing up this discussion because a Radiation Oncologist I know was telling me that they were waiting excessively longs times (a couple of weeks) to get Neuro Oncology patients to the 3T.  Oncology seems to need the higher resolution for some of the IMRT therapy planning.  It just got me thinking about what is the best way to cut down on the wait for a limited resource and who really has the highest medical need.

Notice, I never said "not needed" or  anything of the type.  I said: "...expertise in being a doctor is picking the right diagnostic tests, not ordering the most expensive battery of tests.  It is up to the doctor to figure out what they need to get to a diagnosis with the lest expenditure of resources.  That include the time the patient spends in the MRI machine delaying others from getting their tests done."

Don't read this as "Never."  I just think that folks on the forum telling everyone "they should get a 3T MS Protocol MRI of the Brain and C-Spine without and with contrast (which is redundant)"  may not be the advice we should be providing.  The Protocol left the MRI power out, because they know 3.0T is better, but there are just not enough of them for every case.

Like I said: This is for discussion and will create some controversy.

Bob
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338416_tn?1260996698
There are many neuros out there who won't diagnose you without a lesion count.  Personally I believe that we rely too much on MRI for diagnosis.  However, if you're going to get it done at all, which the neurological community seems to insist upon, then it should be done on a machine that's going to show as much information as possible.
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1394601_tn?1328035908
Bob, I think this is an excellent topic and probably something that should be addressed...especially by someone that understands the darn machines and what they are capable of doing.

I do think my case was an usual one.  Looking back, I believe my neuro could only see one thing.  A devoted and protective husband.  A "little" woman playing him (my husband)for sympathy and getting it.  So, he played the "game" with us.  He medicated me enough that it suited my husband.  He was more than willing to discuss my medical care in detail with him and did convince both of us that it was a nerve in my neck...of course, not operable.  Things went along fine until the "little" woman loss the use of her dominate hand.  Then.....

All hell broke loose.  That "little" woman went on the war path with husband following BEHIND her...lol...

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1466984_tn?1310564208
Your point :

expertise in being a doctor is picking the right diagnostic tests, not ordering the most expensive battery of tests.  It is up to the doctor to figure out what they need to get to a diagnosis with the lest expenditure of resources.  That include the time the patient spends in the MRI machine delaying others from getting their tests done."  

is well stated, and I agree.  I think there is a lot of waste of time and resources in medicine.

could be due to a doc's problem with dx, or a patient being very pushy and the worry about lawsuits -   whatever the case may be - I think we all need to be smart consumers of medicine and ask our docs some very pointed questions any time they order tests.

My lesions in my brain showed up very nicely on a 1.5 - but a 2nd opinion neuro has recommended doing a follow up study on a 3T - now that I think about it, I'm not sure why I would need to do that.  I am on DMD - staying on until someone proves I have something other than MS.  This neuro also ordered an MRA looking for SSS- even he admitted this to be a "longshot" after I told him I wasn't going to do it.

Every person needs to do what they feel is right for their care in cooperation with their doc....but I think it's good to ask lots of questions.

I highly recommend the book- How Doctors Think  - by Jerome Groopman, MD.  It's an easy and interesting read, and it really helps to understand ways docs come up with their dx, etc.  The author gives a lot of very interesting anecdotes of real patients stories - shared by the docs  that he interviewed for the book.

As far as people recommending a 3T MRI to others on this site - I think people are just wanting someone who may have MS to have the knowledge - and not to just assume all is fine if they have had a 1.5 and not found any lesions.


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1312898_tn?1314571733
Do you ever wonder what life was like before the MRI became a tool that surpassed everything?  It’s unfortunate that physicians are not confident with their own clinical skills.  A good neurologist can even pinpoint where each lesion is in the brain or spinal cord.  It’s a waste of education.  Doctors order test in a defensive manner instead of using their own expertise.  

If physicians believed their patients were good historians, this diagnosis could be given faster.  Men are diagnosed sooner than women because women are viewed as poor historians and hysterical.  Perhaps they present in a more dramatic yet objective manner.

It’s the patients that suffer either way.

Even the 3T MRI doesn’t pick up all the lesions or hyperintensities.  Some day people will laugh at our medical equipment and think it useless.  

MRI’s are ordered on a whim.  The MRI is read and report completed before the patient is leaving the clinic.  Words and phrases are on ‘buttons’ or ‘clip-boards’ within the program that are inserted as you would with Microsoft Word.   Once it prints it is sent out.  Not a second thought.  I had a neuro-radiologist that didn’t pick up on my Chiari Malformation.  I called him and tipped him off and he sent a revised report.

A few months before I began having symptoms I was going to the gym 3-4 times per week.  When my symptoms began I ignored them.  After 9 months I began using a walker.  I can only walk 30 feet or so before I become too weak.    The pain at times feels unlivable.   Sometimes I sit myself hunched over holding a footstool just amazed, amazed that our bodies can contain such a pervasive and such great a pain.  

It has been about 16 months since the onset of symptoms; soon I will most likely be in a wheelchair.  Doctors have gone back and forth with “Chronic” or “Primary Progressive” MS to “you don’t have enough lesions” and back and forth with different doctors.  The one thing that every one of them agrees on is that I have Progressive something.   There isn’t a treatment anyway so I don’t want any MRI’s.  I just wonder if I am dying.

The MRI was never intended to be worshipped like it is.  It was supposed to be a tool, not something that surpasses the clinical exam.  That's my opinion.  

I enjoy debate and discourse, yet this particular topic will inevitably be come with emotion for some of us.

Red
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1453990_tn?1329235026
Yes, i will be very emotional.  I can bet almost everyone thinks we should have more 3T and 7T MRIs, but the don't realize the capital costs involved.  A 1.5T closed bore MRI is about $1.5 Million US Dollars.  A 3.0T is about 3.0 Million US Dollars And the 7.0T Research units are costing about $10 Million US dollars.  I can buy TWO 1.5T MRI and double my billings for the cost of a 3.0T MRI.  

The insurance companies will not pay TWICE as much for a 3.0T MRI study. Health care is a business.  If you have a teaching hospital in your area that is getting research grants, that is where you will find the cutting edge of medicine.  Your local hospital can't afford to play.  Many hospital have nuclear imaging, but the only place I have ever seen SPECT or PET is teaching hospitals with active clinical research programs.  

When I started having neurological problems, I was being seen by a neuro-ophthalmologist who has a private neurology practice.  He was good, but had to farm everything out to various hospitals and imaging center.  After my second appointment I moved my care to the Health Science Center at the University of Colorado.  They have a couple of 1.5Ts and a couple of 3.0Ts.  They have SPECT, PET, etc. They still had to farm out the spinal fluid isoelectric focusing for OCBs.  They sent it to the reference lab at the University of Utah.  I was told that they send them to Utah beacuse that lab has some of the most reproducible results in the US.  Sounds good to me.

I'm pretty sorry that they look at females as being hysterical or unreliable.  
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1312898_tn?1314571733
I was trying to say that we shouldn't need this many MRI's.  That doctors depend on them instead of their clinical skills.  So much has become so specialized that our care ends up somewhat fragmented.

I know medicine is business, it became big business when Kaiser raised it's ugly head in the late 60's.  Later, Nixon was the first to see that big money was going to be made from managed care/profit companies.  The HMO's made it 'big business'.



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I agree that Neruologists should be able to dx with history and clinical exam too.

My neuro did just that, and at my first appointment, after my neuro exam, he told me he was very sure that it was MS.
Now, I had brought with me my MRI from 6 weeks prior (on a 1.5T) it showed no lesions at all......but that did not sway his thoughts. He ordered a new MRI, evoked potentials, and sent me to an opthalmologist.
My second MRI was done on a 3T machine, and it showed 10 lesions consistent with MS, including one on the corpus callosum. I failed my SSEP. The opthalmologist dx optic neuritis. I was dx RRMS at my next visit.

My thinking is if the first MRI was done on a 3T machine, I wouldn't have need a second and the cost would have been less to me and the insurance company. If doctors need an MRI to dx MS for the insurance companies, then I think they should initially be done on the best machine available.....it will save time and money in the long run, by not having so many repeat MRI when the first one doesn't show anything or not enough.
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338416_tn?1260996698
Very good point!  Get it right the first time, and then we wouldn't have all this repeat testing.
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1511858_tn?1290481059
Hi Redflame,
  I know this convo isnt really my business or my expertise. I do know I go for my tspine and c spine next tuesday. After a failed lp.

  But I just want to say your story made me cry and I hope they find out whats going on with you and able to stop your attack. I will be praying for you, I hope that doesnt upset you I know everybody has there own religion preference.

  Peace to you and god bless
Barbara
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572651_tn?1333939396
What a good conversation.  I think the concensus here in giving advice is a 3T will show so much more than  a 1.5 T, so why waste the effort and resources with the lesser machine?  For difficult to call cases, a 3T can mean the difference between dx and not.  Just ask Quix, who went through numerous doctors and tests before a 3T was used and her spinal lesions spotted.

My own personal experience was I was dx'd on a 1.5T w/wo gad and the lesions popped on the film.  Enhancing and otherwise.  I also know how fortunate I am that they showed up like they did.  Otherwise I would have been patted on the head, told to deal with the PN and get on with living.  Looking for MS was not in my differential diagnosis at the time.

The cost differencel in the purchase of the machines is significant.  The cost difference paid by the insurance company (I have Blue Cross) is minimal.  

As for neuroradiologists - not a single one of my reports said much - a few sentences and that was it.  It has been up to my doctors , particularly my neurologist, to inspect my MRI closely and construct a thorough report and not a simple gloss-over.  I have confidence that my  msologist knows exactly what he is looking at and for on my MRI's.

I would love to see the MRI scrapped entirely for dx and require doctors to use their brains and skills instead.  But alas, that ain't happening.

Thanks again Bob for giving our brains a work out to think through the complexity of our health  care and the diagnostic path.

best, Lulu
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1312898_tn?1314571733
Hi Barbara,

Thank you for you kind words, and yes I need your prayers!  Everyone can put there opinion or experience here.  Sometimes I get sidetracked while writing and respond out of my pain when it's not the topic. I have redhair and it gets twisted into a knot sometimes!  Thank you for noticing.  

Bob knew he was starting a controversial thread and it just developed.  Good discussion.

I see you live in Huntington Beach, I was born in L.A. county and we lived in Anaheim until I was 10.  You're so lucky to be there, I miss those Christmas's in 72 degree weather.    

Hugs
Red
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Personally I think radiologists s u c k as much as neuros (no offence Bob). I have had two different MRIs reported on by two different radiologists and both contradicted each other:

ONe says demyelination, one says not. One says supependymal nodularity, the other fails to notice it. One says no lesion on cerebellum, the other notices it - even I noticed it!  One says Migraine, the other says MS.

Combine that with 5 neurologists who cannot agree and quite frankly i think they're all f****ng mental.

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987762_tn?1331031553
I did write a post but its gone to cyber space, so i'll try again.

In Australia, we have the same dx problems, Insurance has absolutely nothing to do with if a person gets dx or not, most people are not under private insurance, it is government funded health system. New machines at hospitals are partially funded by the gov and the rest is raised by hard working supported people, selling raffle tickets etc. Yes thats a lot of tickets but charity raises 10's of millions every year, people power lol.

There are very few 3T MRI's in the country, only 1 that i'm aware of in my state and thats at the children's hospital, so no good to  me. As Quix pointed out earlier this year, 1.5T using old software is not as good as a 1.5T using the latest, a 3T would be ideal but a 1.5T using new software is almost as good as a 3T using old software, or something along those lines.

In my other post i found stats relating to neurological conditions in oz, off the top of my head there are 18-20,000 MSers in OZ campaired to the 400,000 epilepcy, 200,000 dementia, 80,000 Parkinson's etc. From my perspective the problem lies at the expertice of the neurologist, unless they specialise in MS the chance that they do ever see and dx MS in there life time would be slim due to the population of over 22 million.

I had no choice in strength machine, 1.5T and i havent a clue about the type of software used, after having the MRI the technitians asked "how long have you had MS?", the neurologist said "i had a normal MRI, a good brain" and "only a few irrelevant bleeds" then explained away my cognitive sx with probably senile dimentia (dementia) (45) and my physical sx as probably psychological. It took me a year before i'd see another neuro, he was even worse than the first and my sx have progressed, he didn't see the MRI either, just read the report and all the clinical sx he found, he dismissed because I shouldn't have them with SVD. He even asked my DH how he was doing, wtf!

That was before cognitive testing showed a loss of approx 45 IQ points, psych testing showed I had NO psychological condition and before sight testing showed I had Nystagmus, pale optic disc etc. He didn't even look at the MRI, just read the report that said small vessel disease was inconsistent with my age group but still concluded "chronic ischaemic small vessel disease". I have clonus and hyperactive reflexes in my left side only, dx intercostal muscle spasms (MS hug) I could go on but the evidence is there, my ducks are quacking load and clear lol.

I see the issue as being the neurologist not the strength of MRI, I have more than one clinical sign of spinal lesions but nothing showed on the 1.5T now would they have showed up on a 3T is the question and I do think they probably would have. I have more to say but have to run (wobble lol) to the tax man, as they say in hollywood i'll be back!

Cheers......JJ


  

  
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559187_tn?1330786456
I just had to add my 2-cents based simply my own experience.  

I was dx with MS in May 2009, 2 years after I experienced my first major relapse.  

The initial MRI was on te hospital's 1.5T  for brain, cerrvical and thoracic spine and so was the second follow-up MRI brain only.  About 6 months after that initial relapse I got into a clinical trial and had my first 3T MRI with MS protocol of brain/cervical/throacic and it showed several more lesions that were not picked up by the 1.5T hospital MRI.  Subsequent clinical trial MRIs showed that a few of the lesions actually disappeared which the doctor said was characteristic of what they might see in MS.  

My bottom line thought here is that had I not been admitted into the clinical trial, then the doctor's may still be diagnosing me with "small vessel ischemia" and not MS - the more appropriate diagnosis. I may not have known about the more powerful 3T if the non-clinical trrial doctors didn't want to push for it. The 3T made a difference in my case.

I've used up my 2 cents now. Thanks for bringing up a good discussion.

Julie
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I've had 3 MRIs in total. Two on 1.5s. One on a 3T.

The two I mention above were both on a 1.5T. Both of those showed masses of lesions - too many to bother counting. And both have been viewed by different radiologists and neuros with difffering views, as I stated.

The MRI done on the 3T I have no copy of- just the report. The radiologist report for that was undecided as well. He compared it to the 1st 1.5T scans and declared there to be more lesions but could not say if they were technique related or not...............And it had 4 neuros looking at it, 2 saying MS and two saying migraine.

I can't say anything else without being rude about the medical profession.
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338416_tn?1260996698
I do think the neurologists are to blame for our current problem with diagnosis.  I'm not sure why that is.  

Perhaps it's that many people are graduating directly from college and becoming specialists, rather than spending time as a general practitioner.  I hear that it takes less time to pay off your student loans if you're a specialist rather than a GP.  
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1394601_tn?1328035908
I think Cobob has a valid point.  We are advising people that join the board to immediately run to an MS specialist or to demand a 3T MRI based on our own experiences.  Many of us still carry our ax because the neuro we put trust in were not doing their job.  Some of us did gave them years to figure out our problems and while waiting damage was done to our bodies.  We have to step back and try to see with new eyes.  Some of our new posters are just getting started with their neuro's.  We truly are not even giving these doctors a chance without pounding on them...lol...

Thank you Bob for a reminder,.   We need to let the neuro's have a chance to figure things out.  MS has so many mimics, it isn't exactly the easiest thing to diagnose.  
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1453990_tn?1329235026
I don't take offense at anyone bad mouthing radiologists.  I'm not a radiologist.  I used to be a biomedical engineer, and I can tell you that a 3.0T shows about 20% more lesions than a 1.5T based on the studies.  So instead of 5 lesions you get 6.  Lesion count means much less than LOCATION.  It makes questionable lesions less questionable. Oh yeah and that is at twice the capital cost.  Are you willing to pay $3000 for a 3T that shows nothing?  Or $1500 for a 1.5T that shows nothing.  You might have one lesion on a 1.5T and hit that magic 2nd lesion on the 3.0T, but will it matter to the Neurologist (at twice the cost?)  Will you insurance even approve?

Radiologists are the GPs of the imaging world.  Your really want a Neuroradiologist to read brain and spine images.  The reason is neurologists and MS specialists are sloppy.  All they do is look for lesions and there locations,  The Neuroradiologist told my neuro about the damage to my optic nerve and tract.  The risk of blindness is what drove the MS diagnosis and DMD (in my case.)  

I advised someone the other day that they should seek out a teaching hospital with a neuro-immunologist.  Your neurologist should know what specialist to send you to.  Same if you should be sent for a 3.0T or a 1.5T  Studies show that 3.0T only detects 20% more lesions (at twice the capital cost.)    Someone at GE told me there are less than 100 3.0 T machines in the US today.  Some states have none.  There are 1.5 T machines in trailers and used ones are about $800K.  I can by almost 4 of them for the cost of a new 3.0T.

I guess I'm trying to say is that I know what you want.  It might even be the right thing to do, but it will not happen quickly.  It you want "state of the art" in medicine, go to a teaching/research hospital.  Deal with the Med Students, Interns, Residents, Fellows, Professors, etc.  That is where the research money goes and that is where a majority of the 3.0 T machines in the US are located.

The amounts of money moved in medical health care  (spent-earned-wasted) is a huge part of the US GDP.  I know we don't want to see health care as a resource or as money, but the fact is that IT IS.  And it is rationed and allocated by these companies and institutions.  Most standalone centers will only install an MRI if there is a guarantee of insurance catchment.  Yep, they only build if they a guaranteed that the business will be sent their way.  Research grants fund most of the MRIs at teaching facilities. This has been my experience.  Folks that talk about Yale, Duke, Cleveland, CU HSC, etc. can attest to what you get from teaching and research hospitals. All of these teaching facilities have 3.0 T units.  The problem with a teaching hospital is you will have to wait.  The 7 year old kid with the Neuroblastoma is going to get imaged before the 47 year old MS patient.  We are not actively and rapidly dying like some of these other folks.  There are only so many time slots to get people into the bore.  And they do the triage.  The sickest ones most likely to benefit from the limited number of 3.0T timeslots are going to get the time in the machine.  For the most part, that is not most MS patients.  even less likely for someone in Limo Land that has not been imaged in a 1,5T machine.

Understand, that I'm not upset.  I get to listen to tea-party members who know nothing of the system. They know little about how health care is delivered or how it is funded.  They really think the insurance companies and private business know how to do this.  They don't.  By the way, I don't think most of the government has a clue either, but at least they have figured out it is broken.  

Bob
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Hmm thanks for that Bob. I just googled the radiologists who have done my reports and none are neuroradiologists.

The bit that has REALLY annoyed me is the mention of "bilateral subependymal nodularity"  that my neuro said, in a VERY offhand way, "Oh that's just aprt of your MS", but my MS nurse said "HUH?" and if you google that (and I know you have there is NO mention anywhere of it being related to MS, only to epilepsy and a disease called Tuberous Sclerosis.

GRRR.
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1453990_tn?1329235026
Most imaging centers get general radiologists (sometime the guys hospitals don;'t want on staff) to read their studies.  Most have little or no background in MRI physics or  neuroanatomy.   That is the first clue when you read the reports.  My report is in the my journal, and the anatomical references and and completeness of the report tip you off that a neuroradiologist read the the study (but then again, it was done at a reaching hospital with a neuroradiology fellowship program.)
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987762_tn?1331031553
I'm not doing too good with getting my posts online, lol so i'll be a tad blunt.

From my perspective I dont give a rats atsss what the machine cost, I need that dx so I stop loosing more of me! A medical condition that is left untreated so it can get worse enough for the likeing of any dr is a bad bugger of a dr! What about their hippocratic oath of "do no harm" they know these machines can help dx but its the clinical sx that dx, still they wait for the magic number of lesion on MRI or lesions in EVERY location, is this not against their oath?

I totally get what your saying from your perspective in the US but i'm confused why then once a person is dx, that MRI's are getting scheduled every 3, 6 or 12 months, is it really revenue raising or in the patients interest? I also dont understand why a person already dx and is refered to an MS specialist not for a confirmation of dx or second opinion but for continual care using 'best practice' and support of their MS. The new neurologist makes them go through the dx process all over again, more MRI's, repeat tests of all kinds, again are you saying its just revenue raising?

Sure if your dx is questionable then go through the whole testing regime again to be sure but if its already a given, in who's interest is it, i'm sure the many patients who met the macdonald criteria before are not happy or thinking it was in their best interest when the neuro took their dx away, how? why? who's interest?

I'm thinking you cant have it both ways, 3T MRI's are expensive, limited resources, machine strength not as important, $$$$$ etc then once dx those same machines are scheduled regularly because what, now they're not that expensive, not that limited, 3T is now important, $$$$$ etc. Before dx they are too expensive to use on you but after dx then they know what they'll find but its easy money, insurance co's don't question, I just cant think in those terms, its ugly but it seriously sounds like thats what your saying is the reality of the health system.

Please correct me if i'm off base here!

Cheers.........JJ





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1453990_tn?1329235026
Pretty much correct.  Most PwMS are diagnosed on 1.5T machines.  If they don't see lesions, the doc should then be able to send you for a 3.0T scan.  There are very few 3.0T machines, so that would make sense.If a patient has indications of cervical or thoracic lesions at exam it might be reasonable to do C-spine and T-spine on 3.0T MRI.  

It is not reasonable to recommend to every Limbo Land case that comes along that they should go to a neurologist and request a  3.0T MRI of the Brain and C-Spine.  Go to a neurologist and let them figure out what imaging you need.  Most suspected MS patients with the typical asymmetric sensory and motor issues are going to have brain lesions and will show on a 1,5T.  If the patient has Lhermitte's sign and bilateral symptoms, a doc might want to order a 3,0T.

In  many areas that may not have access to a 3.0T, a 1.5T may be just as diagnostic.  I think that may be why the MRI strength was removed from the protocol.  Slice size and movement are the big issues with MRI.  More power just makes what is there shoe up clearer, Keep in mind, that MRI is a derived image.  It is not like x-ray or CT-scan that are real, primary images.  MRI is like mapping a town my listening to the signals produced the the microwave ovens in that town.

Clearly doctors (or the insurance companies) want a more accurate way to select those patients that are PwMS.  Today 1.5T MRI seems to be the tool they use.  Some insurance companies will not pay for GAD contrast today.  They could care less if the lesion is new (active) or old.  For those companies that will not pay for contrast, I expect that they would be even less likely to pay for a 3.0T scan.

I knew this would cause controversy.  I just want people to understand that not everyone can get a 3.0T MRI.  Most people DO NOT NEED a 3.0T MRI.  I had my 5 lesions in the correct areas,  They were oval shaped and perpendicular to the ventricles. Do I need a 3.0T - NO.  I thought they would do one, but they did not.
They have not even talked about annual scans for me.  They said major shift in the course of the disease would signal the need for more scans.  

My suggestion is that we stop suggesting that every neuro issue requires a 3.0T MS Protocol MRI.  More than half of the people coming to this forum with "Does this sound like MS?" get told "Not really, nut it sounds Neuro and you should be seen by a Neurologist."  Most docs are going to send people for 1,5T of the brain and c-spine.  The docs will use the tools they have.  In Denver, I don't know of a 3.0T scanner outside the research hospital.  So if you want a 3.0T scan here, you better be a outpatient at the hospital's neuro clinic.  

Bob
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Frankly I don't care what strength I have, as long as I get diagnosed.

When I first joined this forum, I had no idea there was a difference in MRI machines. One of my neuros kept sending me to an open MRI that was only.7T strength. This MRI place wasn't at a hospital..but was at it's own center. Every doctor that I saw after I dropped this guy said that the images from this MRI place was horrible. Images that I had to partly pay for until my deductible was met. They of course wasn't done to protocol..wrong recommended strength, wrong slices, etc..

Since then I've had your standard brain MRI & c & t spine MRI done on the 1.5 T. They have still not been done to protocol..wrong slices, some had movement so should have been redone..and still I had to partly pay for these images as well.

I don't care what strength they do it on..as long as it's done according to protocol and as long as my doctor is doing everything they can do to find out what is going on with me.I also think a doctor should think for themselves and quit relying on the MRI machine to show the whole picture. The MRI can miss things too.

I understand your point, but to me, if a 3T could give me my diagnosis, I would hop on one right now. I started out with spinal lesions symptoms. Would they be seen on a 3T since they were being missed on a 1.5T? IDK..and I'm not sure if I'll ever find out. After several years of trying to find the cause of my neuro symptoms, a G2 vena cava filter was placed in my chest during a surgery unrelated to my neuro symptoms.

I've had radiologist techs argue..saying that my filter is only approved for a 1.5T and my vascular surgeon say that the manufacturer said it's approved for a 3T. I just want to sit back and be a patient for a change. I want to trust my doctors & trust that they care enough about me as a person to not allow me to loose more and more of my abilities before stepping in and doing something.

I don't think the suggestion of a 3T IS a requirement that all neuros do this. I have seen many post suggest that "if available to try to get it on the highest available tesla strength especially the spine"..If a 1.5T is as good as it gets..then go for it. If you can get a 3T and nothing has shown on 1.5T...great. I think this suggestion is more about education than a requirement. Like I said, I had no idea that there was a difference. I thought all MRIs were the same and in many cases that we've seen on the forum..the 3T saw things the 1.5T missed.

Many people can be diagnosed on the regular 1.5T...but I've often wondered if a 3T were readily available how many more could be. It's taken me 3 nonstop years to actually have some changing in my test results. I had an SSEP come up abnormal. Will something show in my spine on the 1.5T?..IDK..I guess I'll find out soon enough because this is what my neuro uses. What is more disheartening to me is that I've watch my abilities go with no answers. To me, there has to be a better way.





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I'd take a 1.5T and a good neuroradiologist over a 3T and a general radiologist. By changing the window and level of the DICOM images, I have been amazed at what a neuroradiologist can pull out of an image.  Good people and good techniques seem to win out over good equipment.  Your best chance at a diagnosis is good people. No one should ever have any neuro imaging done on an open MRI. They are good for shoulders, hands knees and ankles (and I know a couple of ortho docs that would disagree with that.)  OpenMRI is pretty much a waste of money for Neuro Imaging.

Bob
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Great debate.

My Ms Neuro rather have a 3T MRI  for the spine..

As a contractor I've  build some facilities for DR'S, as far as the cost goes,  most DR'S lease the MRI'S  and even a few hospitals also,   not to many DR'S  have the capital for that type of investment,  the R.O.I  just isn't there.  
There is market for used CAT & MRI'S & XRAY'S  if they aren't sold here, they are shipped oversea's.

The true cost of an MRI in U.S.A.  on a 1.5T  is around $400-$625 per scan in the Chicago area.   My local hospital charges nearly $5,000  for same W/O contrast.


It's  kinda  of funny the first Neuro I saw was my customer & she  told my lesions were age related,  I fired her once I found this forum & moved on.

John
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I think renting is always better than buying, when you're talking about high-tech equipment.  That way you can stay ahead of technological advances, and if it breaks, then the company comes out and fixes it.
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Most are done under a lease.  Sometimes with a buyout at the end of the lease.  The lease is typically more costly than an out-and-out buy.  Most federal facilities buy.  MRI also has a pretty steep bill in maintenance and consumables.  They go through a pretty hefty amount of Liquid Nitrogen to keep the magnet coils superconducting.  

As far as fixing, true within reason.  I was at a site that did $100K worth of damage to a leased system when someone brought in a cart with a steel cylinder.  Took about a week to pry it put of the core and about two weeks to repair and re-ramp the magnet.

They don't pay for that or if you let the magnet run out of cryo.  
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This is certainly an interesting discussion and one that I have thought about repeatedly, especially as the software for the 1.5T machines has improved.

However, Bob you make a couple of basic mistakes in your fundatmental reasoning.  First, Cervical lesions are NOT known for causing symmetrical symptoms.  In fact, they more often do not, except in the cases of transverse myelitis.  There is little to no crossover over of fibers occurring in the cervical spinal cord except possibly in some of the internuclear ganglia.  So people with unilateral symptoms who have had a negative MRI on a lower resolution MRI have a very good reason to request a higher powered scan read by the most qualified radiologists available.

The techniques are improving, but are not yet to the point that all 1.5T machines can compensate for the difficulties in imagining the spinal cord.  It's small mass and relatively large amount of fluid surrounding it, couple with the motion artifact introduced by the puslations of the CSF and the close-lying aorta, along with the persons chest motion from breathing, still make the entire spinal cord difficult to scan.

Your point is well taken that one's own experience should not be the entire justification for anyone's belief's.  However, my experience was coupled with a discussion with my neurologist, who was quite smart and experienced.  He was very frustrated by the poor results of spinal cord MRIs done on 5T machines.   I had zero spinal cord lesions after three 1.5T scans.  But, a scan done on a 3T immediately following the last 1.5T scan showed 6 lesions.  I have since heard from numerous MS specialists who feel the same way.  So, my diagnosis languished also until I was imaged on a higher resolution machine.  The difference delayed my diagnosis by two years.

Despite this discussion, I will continue to recommend that people get their spinal cord scanned by the higher resolution machines, in a major center, and read by neurorad's, if earlier scans have been negative and they have suggestive symptoms. Since my earlier times on the forum when I did readily recommend going directly to the highest resolution available, I have learned that the brain is well imaged on a 1.5T as long as the MS protocol is followed.  It's the spinal cord that is the sticky one.

Even the group that continually fine-tines the MS protocol has dropped the requirement that there is a bottom limit on the strength of the MRI to be used in diagnosing MS.  The requirement is that there be a certain clarity - I think a certain signal to noise ratio that should determine whether a given machine is adequate.  

But here is the rub.  We have already seen that an unacceptable number of neurologists seem incapable of assessing what is and what is not "adequate".  Certainly we have seen evidence that a HUGE number of labs perform the O-Band testing inadequately (72%).  If the neurologists were checking on this that number would be much lower.  We know that between equivalent 3T and 1.5T machines, the 3T will pick up more lesions.  If we are languishing in limboland, have suggestive symptoms, and lower powered scans have not been revealing, I see a good reason to push for 3T scanning, especially for the spinal cord.

So, I hear the discussion on economics and such, but I do not see that I will turn back from recommending the higher resolution in certain situations.  Earlier we did recommend it from the beginning and that may have been overkill.

I just wanted to present the other side.

Quix
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To a point, I agree.  I really do understand gradient signal differentiation and signal to noise better than most.  Yes, going from 15,000 Gauss to 30,000 Gauss,  doubles the magnetic flux and better excites the protons, but is much more sensitive to movement artifact and doubles the noise.  Looking for heavily water laden myelin, and a slightly less water containing lesion, in CSF is a pretty good trick.   MRIs already use a great deal of signal averaging to pull useful signal out of all the noise.  On a 1.5T machine, we are listening for a signal (Larmor frequency) from the proton spin at 63.8 MHz.  For a 3.0T MRI, that frequency we listen for is 127.6 MHz.   This requires different detector and receiver technology, different software, and a different understanding on the part of the person reading the study.

Radiologists have cited several limitations with 3T related to the increased field strength, such as a greater amount of noise, imaging contrast issues, and safety concerns (stainless steel unaffected at 1.5T may be affected at 3T.)   As I have said before, the MRI image is called derived, like a SPECT or PET image.  In medical terms, the image can not be used for surgical planning or radiation therapy planning by itself.  You have to overlay MRI images with a primary image like a Digital Radiograph or a CAT scan.  While you may see what looks like a lesion, it really takes a trained neuroradiologist to figure things out.  Someone on this forum was misdiagnosed with a syrnix when it was actually a cord surface lesion.  

A 3T machine with 5mm slices is no better than a 1.5T machine with 3mm slices. Technique matters.  Much of the success in imaging with MRI is technique and the person reading the study.  If you neurologist can't do an adequate neuro exam, reading an MRI study requires even more discipline.  I will stand by my assertion that a 1.5T with good technique and a good neuroradiologist is more useful than a 3T with marginal technique being read by a general radiologist  or marginally trained Neurologist,

In my current business,  I talk a lot about Systems Architecture requiring three components: People, Process and Technology.  The over all level of the system maturity is based on the level of the lowest component.   If the technique or the software or doctors reading the the 3T study don't rise to the standard, 3T MRIs, make no difference.  So if I were paying for a 3T scan out of my pocket, or recommending that people go for a 3T study, I;d shop around to make sure that the Technicians are accredited, and the my study was going to be read by a Neuroradiologist (or a Neurologist with accreditation in Neuroimaging as a subspecialty.) So let the buyer beware.

Bob
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I wanted to make a couple final comments and wrap this discussion up - or fire it up again, lol.

In the beginning I always recommended that non-diagnosed people try to get 3T MRIs.  In the interim I have become aware that the brain is pretty well imaged by the average 1.5T machine given that the software is decent, the tech competent and the radiologist not hung-over - as long as the MRI protocol is followed.  The slices need to be small enough, and the techniques that show lesions the best need to be included.

I have NOT been convinced that this is true of the spinal cord.

Many people that show up here have been sent a packin' due to a negative brain MRI alone.  IF their symptoms and neuro exam are at all suggestive of MS, then the group that advises the neuro profession on the proper diagnosis of MS recommends that a spinal MRI be done.  A small number of people have visible lesions in the spinal cord only - about 5%.  I don't think anyone should be told "definitely no MS" without a spinal cord MRI.

The spinal cord is technically harder to image than the brain and too many neuros that I respect have stated that one cannot count on the 1.5T machines to do the best - and most reliable job.  They recommend the 3T machines which are plentiful in some areas of the country and apparently scarce in others.  I stand on my recommendation that the spinal cord be done on a 3T if the clinical picture is suggestive and nothing is showing up.

It is funny, given all of this that some medical centers ration the use of their 3T machines.  One of our largest geoup of hospitals here in Portland reserve the use of the 3T machines for imaging of the brain only.  The spine MUST be done on a 1.5T.  Sigh....

We should not be approaching our undiagnosed newbies with the advice to get MRIs on a 3T machine.  That really isn't the basic problem with people not getting a diagnosis.

The first thing we should talk about with the frustrated in neurological limboland.  The most important factor in getting to a diagnosis (be it MS or not) is finding a physician who takes you seriously.  This doctor should listen intently to the patient and be interested in what they have to say.  I was taught that if you listen to a patient long enough, they will usually tell you the diagnosis with with their mouths or their exam.  the ideal doctor should do a thorough neurological exam and repeat it at each visit and especially with any new symptoms.

The doctor should do a careful workup and be able to think about the results.  A diagnosis is the sum of all the information available.  

A gentle, compassionate doc is wonderful, but I would give up those qualities for a doc that listens to me, takes me seriously, looks hard at me and the evidence and who thinks hard.

The MRI should be secondary and not primary.

Well, I have digressed.

Those are my thoughts.  In general I agree with Bob with the sole exception of the imaging of the spinal cord.

Quix
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Interesting debate,

Gem Australia
Super Mum Australia

I am amazed that I live in a little area and have access to the best MRI machines, all T3.  Where I live in Australia we have 2 or 3 reporting on the images so that if something is missed etc. it hopefully won't be.  It costs me nothing to have a T3 MRI and I don't have to request it on a T3 machine because the tiny Island I live on has 4 of them that I know of.

As for diagnosis:
My neurologist has been confident enough to diagnose me with a normal MRI.  He has made his diagnosis on clinical examination, a very good history, an extremely thorough examination on lots of occasions, tests, tests and more tests to rule out or rule in the other things.
As I said early he tells me that he "knows I have lesions on my cord" he does not need a MRI to prove that they are there, he can tell from what I tell him and what abnormalities he finds on examination.  He said that even T3 machines are not showing lesions that are detected on the T7s and sometimes with TM your lesions can disappear but you still have the damage and problems.  At least he has not said go away your MRI is normal so you must be insane! He said that it is like looking at Mars with a telescope you will not see everything.
But I think his logic is that if I had MS the lesions would eventually start showing up and they haven't.
Cheers,
Udkas.
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I agree with you, I have been having tests (lots of them) for three years, including a couple mri's. finally my neuro sent me for the mri on the 3" and found 15 lesions, 3 which are deep periventicular . I have not been back to the neuro yet, but in my mind I know it is MS because of all the research I have done.
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