Ischemic Foci?

[shannon]

Because of frequent headaches, I had an MRI scan of the brain several weeks ago.  I just got the results and need some help in understanding what they mean and what my next steps should be.

TECHNIQUE:

An MRI scan of the brain was performed in the sagittal, coronal and axial planes with T1 and T2 weighted spin echo pulse sequences and an axial FLAIR sequence.  Diffusion-weighted images with echo planar in the axial plane were obtained.

FINDINGS:

There is no intra or extra-axial mass lesion or fluid collection noted.  There are scattered foci of increased signal demonstrated in the white matter, most likely ischemic in nature.  The corpus callosum is normally formed.  The cerebellar tonsils are in normal position.  The pituitary gland is of normal size and configuration. Note is made of fluid in the mastoid air cells most consistent with mastoiditis.

IMPRESSION:

1) Bilateral mastoiditis, left greater than right.

2) Scattered foci of increased signal in white matter, most likely ischemic in nature. Foci such as these can also occur in the setting of migraine headaches.  This needs to be correlated with the patient's clinical symptoms.

HISTORY:

50 year old female presented complaining of headaches (3-4 times per week).  Headaches are present upon waking in the morning and occasionally late in the day.  Family has history of severe migraine headaches (mother and brother).  Patient has experienced migraine headaches, usually affecting sight, taste, smell and hearing - approximately 1 time per year.  Patient's father has history of TIA's (approximately 5-6 over a 20 year period).  

QUESTIONS:

1)  What further tests should be performed to determine the cause and extent of the ischemia?

2)  What treatments are appropriate?

3)  I am a breast cancer survivor (2 years) and wonder if this has anything to do with the BC.  I was diagnosed with duct adenocarcinoma and received a lumpectomy, chemotherapy and RT.  Is it possible that the treatment for BC could have caused this?

Thanks so very much for your help.

Shannon

[lord_mike]

Make sure you get a copy of the films.  The neurologist will want to see the films personally.

Thanks,

Mike

[cindymhi]

Dear Doctors,

Thank you so much for your wonderful reply!  Your answer gave me more information in one paragraph than spending 45 minutes discussing this with my primary care doctor gave me! All he seemed able to say was that this was "of concern" and might be caused by migraines...and basically ended by telling me to see a Neurologist.

Thank you again for taking time out of your busy schedules to answer my question. You'll never know how much you've helped! Now I can go back to the MRI people and ask them to give me a more detailed description of what the MRI showed, before I see a Neurologist.

You are the best!!  Believe me, if I ever need any Neurology work done, I'm going to hop a plane and get to The Cleveland Clinic!

Shannon

[CCF-Neuro-M.D.-RPS]

Dear Shannon:

It is wonderful that you are 2 years out from Breast Cancer and doing well.  Scattered increased signal areas in white matter can be a number of things.  Alot depends on how many, where they are located, the patients history, age of hyperintensities, whether they are all old or there seems to be some of recent vintage, etc.  There can be small ichemic events that occur without us knowing that they occur.  These may be, as suggested due to migraine headaches, small TIAs, collagen vascular disease, measles, viral illness, etc.  Some are a consequence of the aging process.  Some are due to demyelination disease.  So, as you can see there are multiple reasons for having these.  If the spots seem like there are too many for your age, or they are of different ages, then maybe a pursuit of the etiology may be important.  In a otherwise normal person, usually we do not find the etiology.  Yes, some of the changes might be in response to chemotherapy, however radiation is limited to the area of your breast cancer and would likely not be involved with your brain.  I don't think these spots are mets as usually these are at the gray white junction and would have been called as such.  There are common things to do, if you have high blood pressure then lower it, if you have a clotting disorder than correct it medically, if you smoke stop, if you have diabetes then keep yourself in good control, if you are overweight or have a lipid problem then go about correcting it, and ask your family physician about a baby aspirin a day.

Sincerely,

CCF Neuro MD