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State of the Art - It's a changin'
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State of the Art - It's a changin'

This is just a thought.  I found this old article discussing the state of MS diagnosis.  The 1.5T MRI machines had just arrived on the scene, and neurologists were in love!  It showed so many more MS lesions than the weaker, older models.  The discussion was that they finally had a great tool for definitively diagnosing MS.

Now we are having the same discussion about the 3T versus the 1.5T.  The whole discussion sounds the same, except the numbers have been changed to protect the innocent, lol.  Our 3T is the Holy Grail and if it is negative, you are really unlikely to have MS.

Is this true?  Are we there?  Can we rest on this as the door that closes in the face of people who are undiagnosed?

What will we be talking about in 10 years or so?  Will we be laughing at the faith we had in the "great" 3T machines and marveling at the new test that finally shows us.  The current studies looking at 7T machines are showing an increased pick up of lesions.  Though it seems that the increase is not as much as in the past.  We've heard about facilities getting more powerful machines.  The field of "functional MRI"  (fMRI) is showing new ways to find abnormalities in, not only white matter, but gray also.  What we know about MS and how to see it is mushrooming.

I know that we can only be diagnosed by the tools we have at hand.  But, I mourn for all the people who were left out in the cold by absolute reliance on MRI over the last 25 years.  I still feel there are a large number of them out there now.  Perhaps it is because I was almost one of them.  It makes me want to scream at the world that there is one tool that is still available and seems to be ignored so often.  That is a thorough history and physical.  

I really don't have an answer, but wanted to throw this out there.

Quix
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572651_tn?1333939396
Q- this makes me think that it would be an interesting experiment to unplug the doctors and see how they would function using their own diagnostic skills.  We had the remnants of a hurricane pass through Ohio in September, wiping out power to several million homes, some up to 2 weeks.  It was an interesting lesson to see how people adapted to doing without and having to figure out their own resources.  I can picture doctors having to do the same ....  

I'm not sure what the curriculum is like in medical schools these days, but I  have to wonder where the art of hearing the  patient's history and performing the physical ranks in importance since we seem to rely so heavily on the *tests*.

So many of the basics seem to be lost - as an example, with all of the medical problems and tests I had this past year, not one doctor looked in my ears until I saw the ENT at the end of December.  I even commented to him that not another doctor had done that, and it used to be standard practice when you went to the doctor - they would look in your ears, make you open your mouth and say "ah", two very basic physical exams.  

This is a good one to stretch our lesion riddled brains.

Thinking is good,
Lulu
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333672_tn?1273796389
Coincidentally, the following showed up in my feed reader today:

First clinical study on ultra-high-field MR imaging in patients with multiple sclerosis: comparison of 1.5T and 7T

summary: This study compared conventional strength MRI to scans which used a much more powerful magnet in people with MS. It was found that the latter technique was more precise in detecting and defining brain lesions.

http://www.msif.org/en/research/ms_research_news/first_clinical_s.html

(click on the weblink for a little more info)

sho
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378497_tn?1232147185
This is interesting and the timing is funny because yesterday I started a post about "getting unplugged" again for MS diagnoses. I got too tired to finish it, so I just deleted it.

I've been wondering about these questions, too. And a corollary is...will there be a point when we detect things in "normal" brains that are "normal" and don't indicate a disease state at all? That'll get confusing.

Bio
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Avatar_m_tn
I have often wondered if the medical students of today still take a History and Physicals class.  Or do they just take MRI  101?????

Elaine
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195469_tn?1388326488
It's funny you should say that....my first Neuro actually was sure that I had MS before he did the follow up MRI's, just based on my symptoms, exam and presenting history.  Too bad this Neuro had an office staff that didn't know how to deal with patients, or I never would have left his care.  He was sharp.....and I don't mean good looking.

Interesting discussion Momma Bear.

Heather
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195469_tn?1388326488
I spent some time thinking about what Quix wrote and what my Neuro recently told me.  The Neuro said that when you see your MRI on a 7T, knowing you already have a diagnosis of MS, you would be shocked by what you saw.  She did not elaborate on that, but I get the feeling that she was trying to say that we will actually see more damage being done by MS, than we ever saw on 3T.

Then I think about what Bio said about the 7T MRI.  How do we know what is normal in a brain and what isn't normal...with this stronger MRI?  I wonder what the U.S. population overall has lurking in their brains?  What if every person age 15 and over had an MRI on a 7T?  Would we then realize what is "normal" and what is true disease activity?  Interesting thoughts, Bio.

This thread really makes you do some thinking.  I have to be honest with you all.  I've had an MRI using the 3T and what I saw, scared me enough...I think I would be too chicken to see what my Swiss Cheese brain looked like on 7T.  That might be something for the Neuro's eye's only....  Being a layperson, I wouldn't know what I was seeing and sure it would scare the daylights out of me.

Heather  
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721523_tn?1331585402
This is thought provoking!

I have seen several neuro's over the years as you all know.  I have film from 1996-2008.  They verry in strength.  They all have had comments in their reports about demylanating (sp?) disease.  So, the spots have been there since 1996.  The reports comparisons began to make notes of changes in 1998-1999.  Always, they suggested MS, Migrain, or vascular problems.  In 2007, I saw another neuro because I was having double vision, and migrains every day.  Before the visit, my opthomologist suggested to me that it may be MS. Quix, it was just from her exam and history, she had not seen the films.  The neuro, with the spotty films in hand (25 or so lesions), basically laughed at me and my optho.  

In 2008, my opthomologist sent me to my current neuro, because she said that she trusted him.  From reading the optho's notes, doing and exam, and taking a history, he mostly Dx me on the spot.  he ordered a new MRI to check for changes. I had 5 new spots.  

All of that to say, Q-you are on to something.  LuLu- the only ones who got it right were the ones who were unpluged first!  HUMMMM
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279234_tn?1363108849
I have 2 problems...the availability of a 3T ..and that filter in my chest.

I would love to be on a 3T...I think It would show something but for some reason it's not in the cards for me. CC didn't put me on one because of my filter in my chest and they said it hasn't been proven "safe". I had to settle for a 1.5T which did show some enhancement in the t-spine but of course they said it was normal vascular structures.

When I told the CC doctor of my disappointment of not being able to go on the 3T and that if it would have made a difference in what they would pick up..he said no. He doubled talked from the last visit because he said a 3T was the best thing to see the spine and was literally quoting the forum. I guess he did it because I wasn't able, according to them, to be on one.

I did some research on whether or not I could be put on a 3T and from what I've read, it did say that as long as it was no higher than a 3T it would be safe. I plan on calling my vascular surgeon to find out what he thinks so I won't be put in that position the next time.

I think all neuro should be educated in the use of a 3T machine. I think it would be a helpful tool when trying to DX people who can't be DX on the 1.5T machines. Most of the neuros I've spoke to.. don't believe there is a difference between the 1.5T and the 3T in seeing lesions..but look at the research. There is so much proof and it makes so much since in using the most powerful machine that you can use.
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738075_tn?1330579444
I agree the careful history and physical is the gold mine - always treat your patient, not just the numbers.

I work in cardiology, and at a good teaching hospital, especially if you have an old timer helping to teach, the skills of LISTENING to your patient, and your stethoscope will tell you volumes.  Then get an echo and/or a Cardiolyte and go from there.  So many cardiologists go straight for the diagnostic toys instead of listening.  I'm seeing through this forum many Neurologists rely strictly on the MRI findings before listening.  This is not to say the McDonald Criteria are BS, I'm only saying it's part of the picture.8^).
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649926_tn?1297661380
Thanks for the post! I didn't remember the excitement over the 1.5 but now have have two questions for you since I don't remember.

1) Was there ever an MRI less than the 1.5 because maybe I had one in the years of searching.

2) Is there a difference in quality between a closed MRI and an open MRI?

I figure if I don't know then there has to be at least a few other people out there in limbo land that don't know either.

Thanks,
Erin
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147426_tn?1317269232
Oh, yeah, there were and still are much weaker machines out there.  I have heard of MRIs as low as 0.1T.  The strength of the Open machines is low as is their resolution.  Dr. Kantor just commented that the open machines are a waste of time and money.  No matter what the manufacturers say, the open MRI is useless for this purpose.

For a long time the standard MRI was 1T.  When they wrote the MRI Protocol for MS, in 2003 (2005?) the most common machines around were 1T and that is considered the weakest strength appropriate to use for diagnosing MS.  Personally I would not trust the info given by a machine of that strength for seeing MS lesions, especially for the spinal cord.

Quix
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BTW I love the expression "unplugged" for the doctors relying more heavily on their skill and less on the lab tests.

This will become part of our lingo!

Our Greek House, Hypo Gamma Chondria, will have it's own dialect within the MS community!  Let's Party!

Q
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Avatar_f_tn
Thanks Quix, this is a very good thread.  Very thought provoking.  

doni
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195469_tn?1388326488
There seems to be a HUGE difference in resolution from the 1.5T versus the 3T.  I just had a follow up MRI a month ago, on the 3T.  This is my first time on a 3T.  My previous MRI on a 1.5T a year ago, showed 12 lesions, the one last month showed 23 lesions.  My neuro is sure that 11 additional lesions were probably there, (but not seen) on my MRI of a year ago.  Only a few appear newer....

I'm going to be the first in line for the 7T when it comes around.  Since I live near a teaching hospital, there's a chance that it might be available by the first of next year.  I am very anxious to know from my Neuro, what she sees as compared to the 3T.  It might be scary, so I would not ask for a CD of the films this time.

As MRI's advance, I am truly fascinated how many lesions can be in the brain and the patient actually function pretty well.  I would also be anxious to have a spinal MRI done on a 3T, which I have not yet done.  I will be asking the Neuro to go ahead and order it.  I am convinced that there is more than one lesion there due to all the problems and pain I have with my legs.  To date on a 1.5T there has only been one lesion in the thoracic region.

To the Neuro's that think there isn't much difference in resolution from the 1.5T and the 3T.....all I can say is that they will be included in the "Neuro Weenie Roast"....which should be coming up shortly.  There are alot of new Neuro's mentioned on the Forum lately and in 'other' Forums, that should be barbequed...post haste.  Charbroiled actually. Hope none of their family members never have to be put through what alot of us have been through.  Even though I am diagnosed now, I HAVE been in LimboLand.  I doubt their family members would be put through the wringer like alot of us, have.

Big Hugs,
Heather
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486038_tn?1300066967
I love the thought of neuro's going up-plugged. I remember when I went to my neuro-optholmalogist dr. he was training new doctor wanna-be's (smile) and he took to explain how they diagnosed O.N. before MRI's (unplugged) he took someone's round decorative pin and put it on the end of a string and swing in in front of me. First with one eye closed than the other. And, i don't exactly remember, but when i was looking at it it seemed to me out of the one eye istead of it going back and forth like a pendulum it went round. Hard to explain but freaky to see. The students got a bang out of it and he diagnosed me. :) I did get the MRI's and the follow-up tests, of course.
I like this thread on the MRI's, by the way, it's neat.
~Sunnytoday~
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721523_tn?1331585402
I think that the coolist part of my physical exam my my optho-neuro is the follow my finger test.  I can actually feel my left eye lagging behind.  He says to let him know when I see double.  I can't help but giggle when he gets two fingers.  When I am tired, I laugh alot.... He only has one finger dead cener at leist 3 feet from me.  I had no idea that my vision problem was as bad as it is until he starts the finger test... :-)
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Avatar_f_tn
As I said in my earlier post, I'm glad this discussion was started by Quix.  Especially since I found out yesterday that all my MRIs were done on a 1.5T instead of the 3T that I thought.

Could I possibly have lesions that the 1.5T just didn't pick up?  Or would lesions show up anyway, since I've had symptoms for so long?  I know no one can really answer those questions, it's just me thinking aloud.

Should I ask my neuro at my next appt what his opinion is of the difference between the 1.5T and the 3T?  If I knew his views on this maybe it would help me get to know him better and find out if he is strickly a MRI worshipper or a true clinical neuro who goes by other things besides the MRIs.

I don't know what I feel right now or what the symptoms are caused by.  Just wish the MRIs had been on a 3T and then I would be more prone to believe there really are no lesions.  Now I just feel like I'm back to square one again.

doni
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147426_tn?1317269232
I realized that you meant that your most recent MRIs were on a 1.5T!!  Oh, no!  Especially for the spine, as it seems to me you have a large number of spinal-related symptoms!  I am as dismayed as you!

This is a bigger blow than thinking that images from a 3T are normal.  We really don't know much more, then do we?  But you are still out the $$ to pay for them!  Wasn't the brain MRI you had in Oct truly a 3T?

I think a discussion on the merits of the 1.5T vs the 3T with regard to spinal lesions might be in order.

Quix
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Avatar_f_tn
Hi Quix!!!

No, all the MRIs I've had were done on the same MRI machine....1.5T.........and yes, I feel like I'm no further than when I was $3,000 richer...hahaha

I do want your opinion on this, just really confused me when I found this out.  From my symptoms I have always thought more about there being spinal lesions than brain lesions, especially as I've learned more about all this over time.

Let me know what you're thinking.

Hugs,
doni
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147426_tn?1317269232
Well, I don't know that my thoughts are going to help any.

First off, I suddenly saw why Dr. R would want a new MRI of the brain.  He would have seen from the images what machine it was done on.  Perhaps his suspicion of MS was so high that he wanted a better image.  It is also possible that he was just hoping that there had been a change in the prior three months.

I think a good stategy to getting a glimpse into his head would be to put in a call to his office assistants, the one(s) that were helping you set up all of the testing.  Ask them, if Dr. R had had his "druthers" would he have scheduled the testing on a 3T machine there in Birmingham?  If so, then you know that he prefers the 3T machines, and you can have the conversation with him about whether a 3T, especially of the spine, is really what he wanted.

If he was just going to do them on a 1.5T, then it would seem that you are stuck.  You have no lesions on his preferred level of MRI and that is that.  Then it is just a matter of discussion with him about what he makes of all your results, and what his plan is.  Would he admit that some people with MS may present with no lesions.  He may agree with that, but he believes you have had 20 years of whatever this is.  Ask if there is any evidence of atrophy.

Or, it is possible when you go back that he will have a piece of info that takes him in another direction.

I think a conversation with his office assistants will tell you a lot.

About whether you could just have lesions the 1.5T didn't pick up, even late in the game.  Yes, I did, and three of mine weren't that small (definitely more than 3mm).  that is why so many of the top-notch MS neuros, including our Dr. K, insist on the higher resolution machines.  Dr. K won't say that a negative MRI negates MS unless it is a "repeated 3T".  That's how he repeatedly phrases it.  Dr. Herbert at NYU is the same and so is my neuro.  Others have been told much the same by the neuros who insist on getting 3T scans.

That's all my current bedraggled mind comes up with.  I forgot to take my Provigil today and my rear is a draggin.

Q
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147426_tn?1317269232
Doni, the whole nature of his first visit with you suggests that MS is very high on his list.  There would be no other reason to rescan the brain that I can see.

Remember that T-Lynn had repeated 1.5T MRIs that were negative and the first thing that finally showed was frank atrophy - After that the 3T was positive for lesions and it was pretty clear that she was already in SPMS.  We had another member report 10 years of negative MRI, but with clear progression of disease.  Her neuro was confident enough to diagnose her.

Quix
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Avatar_f_tn
Thank Quix.  I just wanted your view on things.  When I found out about it being the 1.5, I had mixed feelings.

I know what ever this is could be many things, but I still feel it is what you and I talked about months ago.  

Right side has been worsening and now left side has started, Things just keep getting worse and it really scares me.

I know I've just started testing and that it is a long road ahead.  I just hate that I feel I wasted my limited funds on the 1.5T.  I'll get over it.  I'm just praying that Dr R is as good a neuro as your Dr K, and looks at symptoms and is determined to give me answers.

I still feel that I'm with the right neuro, the fact that you and I both chose the same neuro office has got to mean something.

Thanks again for always being here to support, and believeing I'm not totally nuts...hahaha

Love & Hugs,
doni
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Avatar_f_tn
How available are the 3T machines?  Even at the MS center, my images were done on 1.5.

Sherry
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147426_tn?1317269232
I think the 3T are still pretty scarce.  When I first began talking about the 3Ts back in the summer of '07 few people could find one.  One, it seems a few more have found places that have them.

That is why Dr. Kantor's answer that "Repeated 3T MRIs and a negative LP (are enough to ensure that a person does not have MS)" is not that helpful for us.  Most people here still do not have access to a 3T machine.  It's an answer given from the vantage point of an ivory tower.  We can "infer" from that answer that MRIs from a lower resolution MRI still leaves some doubt in Dr. Kantor's mind, but he has shown no willingness to give more information on the topic.

My neuro insists on 3T images.  There is a private lah-dee-dah imaging center nearby that the clinic contracts with.

Quix
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