Brain Lesions

[Janitor]

Hey Doc,

This year I experienced a tremor in my left hand, cognitive problems including; feeling foggy, short term memory problems, a general sense of malaise and uneasiness and balance difficulties. I had an MRI which stated "Multiple T2 hyperintense lesions are identified within both cerebral hemispheres, the largest in the periventricular white matter of the right temporal lobe. No definite diffusion abnormality or abnormal contrast enhancement to suggest active lesions. Although non specific the differential diagnosis includes foci of ischeaemia, vasculitis, sequelae of previous inflammation/infection or demyelination. Clinical correclation and progress imaging recommended."

I've also had the following tests:

EEG, Visual Evoked Potentials, Auditory Evoked Potentials, Sensory Evoked Potentials: All normal.

I also had a blood test for Lupus which came back normal.

I have a history of head trauma from boxing/street fights and my neurologist believes that this is the cause of the lesions, however, I have some doubts due to the following:

I was experiencing these symptoms last year, I also had been experiencing severe pins and needles last year where my hands/feet would be numb and I'd be in terrible pain whenever my hands/feet were in the same position for a period of time. I've also noticed that my fingers have been swollen and I've always had blotchy skin on my palms which leads me to suspect some sort of vasculitis. Furthermore, the report from the radiologist did not mention 'trauma' as a differential diagnosis and I feel that if I had received lesions as the result of trauma I would probably have known about it at the time. I'm concerned that the neurologist has ruled out MS and will now just attribute the lesions to head trauma without exploring other diagnoses.

What tests should be undertaken to rule out the differential diagnoses? Is it possible that it is vasculitis or something viral like herpes?

Thanks for your time.

[Christopher R Newey, DO]

Thanks for using the forum. I am happy to address your questions, and my answer will be based on the information you provided here. Please make sure you recognize that this forum is for educational purposes only, and it does not substitute for a formal office visit with a doctor.

Without the ability to examine and obtain a history, I can not tell you what the exact cause of the symptoms is. However I will try to provide you with some useful information.

It is difficult to say what the diagnosis is or isn’t. Trauma can certainly cause scarring (i.e., gliosis) of the brain that will show up as T2 hyperintensity. Multiple sclerosis (MS), as you know, is an inflammatory demyelinating disease that affects the central nervous system. To make the diagnosis there are specific criteria, in which objective neurologic findings are present affecting 2 or more locations in the nervous system in 2 or more episodes. In order to make this diagnosis, a detailed history and neurologic examination are required. MRI is very helpful and needed as it helps determining the presence of white matter lesions in 2 or more locations, however there are multiple conditions producing MRI changes that could be mistaken for MS, and the MRI should be reviewed properly and correlated to the symptoms. This is why radiologists usually give a differential diagnosis. When the diagnosis is in doubt, lumbar puncture (LP; or spinal tap) to study the CSF is helpful.

I would recommend that you have an LP performed. You should have a demyelinating workup, but also send for cytology, syphilis, and herpes simplex. Also, if the MRI was not performed with vessel imaging (i.e., MRA), you should have your vessels evaluated if vasculitis is in the differential.

Thank you for this opportunity to answer your questions, I hope you find the information I have provided useful, good luck.

[Janitor]

Thank you very much for your advice, I will follow up with my neurologist on the matter.