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Avatar universal

Help with understanding Brain MRI and MS Symtoms

Hi,

I am asking for your opinions while I wait to see a Neurologist. I am a male of 29 age.

Since 10 months, I have been having a mild tingling or sensitivity with my right hand fingers, also some hot/cold feeling in the palm sometimes. These symptoms would come and linger for couple of hours a day, and would leave for another couple days then come back. I started having the same symptoms with my left hand 3-4 months after the initial ones occurred on the right. EMG/NCS of both arms showed nothing. MRI of the cervical spine (1.5 Tesla, no contrast) was done to look for disc disease but showed nothing specific. Clinical checks for reflexes and strength is normal, as I am told by my doctor.

I also have isolated vibration feelings in random areas of my legs that come and go once in a few days. Only one area at a time. These areas would be at most as big as a 5cm in diameter, so not like big muscle contractions or spasms. Almost like a small internal vibrating plate is activated. These would have not bothered me at all but was bothering me since the onset (or me starting to feel these) was at a month or so after the hand symptoms started.

Finally, my Physical Medicine Doctor ordered a brain MRI because she thought the unexplained hand symptoms might be linked to the vibration feelings in the legs.

The MRI report showed two 4mm T2 hyper-intense lesions (MRI at a 1.5 Tesla machine with contrast), and my doctor wanted me to see a neurologist. Here is the exact Impression from the MRI:

IMPRESSION:
'Two 4 mm T2 hyperintense foci within the periatrial white matter are  nonspecific and can be seen in the setting of migraines, prior trauma, demyelination or due to changes of vasculitis. Clinical correlation is recommended. Otherwise, unremarkable MRI of the brain.'

Here are my questions:

1- Do these results already warrant a Multiple Sclerosis Diagnosis? What questions should I ask to the neurologist? What tests should I ask for?

2- What area is the periatrial area? I know that it is different from pariatal but couldn't find a good reference. Are lesions of MS commonly seen in this area?

3- The Brain MRI was done in a 1.5 Tesla machine, was this enough, should I have one more in a 3T to look for other smaller ones?

4- The No-Contrast Cervical Spine MRI was done for a disc disease problem, so would it be reasonable to think that they might have missed any lesions in that?

Thank you, and sorry for the long post.
20 Responses
987762 tn?1331027953
COMMUNITY LEADER
Hi and welcome,

To answer your questions.....

1- Do these results already warrant a Multiple Sclerosis Diagnosis? What questions should I ask to the neurologist? What tests should I ask for?

A- No, because your MRI finding, other test results so far and your sx's are none specific, and without any additional clinical evidence of lesions or neurological causation, there is definitely not enough evidence to warrant a dx of MS. At this stage i would wait until the neurologist has done the neurological testing and if there is some abnormal findings, he or she will determine what further testing will be needed.      

2- What area is the periatrial area? I know that it is different from pariatal but couldn't find a good reference. Are lesions of MS commonly seen in this area?

A- See http://en.wikipedia.org/wiki/Parietal_lobe    Ishemic vascular lesions in the pariental area of the brain, are common to contact sports from memory, MS lesions can develop just about anywhere in the brain but the pariental area isn't one of the specific locations listed in the diagnostic Mcdonald Criteria.  

3- The Brain MRI was done in a 1.5 Tesla machine, was this enough, should I have one more in a 3T to look for other smaller ones?

A- Technically the better strength machine produces approx 25% more lesions visible, but the 1.5T would typically be okay for a brain MRI, especially if MS protocol was used, which give smaller slices and also picks up more. I don't think at this stage MS would be the most likely cause of your sx's, so again i'd wait and see if the neurologist discovers any abnormal clinical signs.

4- The No-Contrast Cervical Spine MRI was done for a disc disease problem, so would it be reasonable to think that they might have missed any lesions in that?

A- See Q3 for an explanation but note MS spinal cord lesions are often difficult to pick up on a 1.5T, though again if you don't have any abnormal clinical signs of spinal cord lesion damage, your MRI would not be missing any  lesions because there would be none to find.

You need to keep in mind that MS is a complicated condition to diagnose, there are many other more common conditions, that mimic the symptoms of MS, so a persons clinical signs of neurological damage (caused by lesions) is very important, and places MS higher on your list of possible causation. Try not to assume more than what is evident, it may not be MS!

Cheers.........JJ
Avatar universal
Thank you for all the time you took to explain in detail. I appreciate your sincerity.
1831849 tn?1383228392
Hi TT- Welcome to the forum.

JJ has provided you with good info. The only thing I would add is that your symptoms seem to move around and come and go frequently. This is not how MS typically operates.

MS causes damage to individual locations in the central nervous system. Specific symptoms occur because information that passes through the damaged location gets corrupted. If the pathway that relays information to my left foot is damaged, I will have left foot symptoms. I would not have left foot symptoms one day and right hand symptoms the next.

MY symptoms also tend to last longer than you describe. The minimum time a symptom should be present,  to be considered an MS relapse, is 24 hours.

Kyle
1831849 tn?1383228392
Hi TT- Welcome to the forum.

JJ has provided you with good info. The only thing I would add is that your symptoms seem to move around and come and go frequently. This is not how MS typically operates.

MS causes damage to individual locations in the central nervous system. Specific symptoms occur because information that passes through the damaged location gets corrupted. If the pathway that relays information to my left foot is damaged, I will have left foot symptoms. I would not have left foot symptoms one day and right hand symptoms the next.

MY symptoms also tend to last longer than you describe. The minimum time a symptom should be present,  to be considered an MS relapse, is 24 hours.

Kyle
Avatar universal
Thank you for the additional info. I appreciate all the insight you guys are providing.
Avatar universal
Hey Guys,

Today was my first appointment with the neurologist. She looked at my Brain MRI and said that the two small lesions are periventricular in location and one reason might be demyelinating diseases including MS. She did a neurological exam, then said that my reflexes and muscle strength was good, and these lesions are 'probably because of migraines' ??!? (I don't really think I get a lot of migraines, if any). She said the sensory symptoms are not probably a result of the two lesions. She then added we should still keep you under surveillance and do another MRI in a year.

At this point I was confused and I told her that I do not want to be left in limbo. Then she offered to order a lumbar puncture. She said if that turns back positive, then it is an MS diagnosis. So, now I am going to get a lumbar puncture in near future.

Here is a question that came up to my mind after the appointment: why would a doctor choose to wait for another year to see changes in the MRI instead of doing the lumbar puncture and get more clues, or even a diagnosis? It is confusing because if I didn't expressed my concern about being left at with the unknown, that was definitely the route she would have taken.
Avatar universal
Bumping this up hoping someone will help me understand one thing: If the spinal tap shows Oligoclonal bands, together with the 2 lesions, will this be an MS diagnosis? Or, is there other things that need to be ruled out in the case of positive oligoclonal bands?
Avatar universal
Hi, I am new here. However based on my interaction with this forum if other mimics are ruled out a positive csf will take you nearer to the diagnosis. Other diseases apart from ms also produce obands in csf. You need to rule out others before ms diagnosis.
987762 tn?1331027953
COMMUNITY LEADER
Hi there,

The good news you should take from your appointment with the neuro, is that you don't haven't any clinical signs of neurological damage, because your assessment didn't show any abnormal results. At this stage, there isn't anything particularly suggestive of MS and with your sx being only sensory and the behaviour pattern not typically what happen's with sx's caused by lesions, neurological conditions like MS would probably be quite low on your list of possible causation.

Q)If the spinal tap shows Oligoclonal bands, together with the 2 lesions, will this be an MS diagnosis? Or, is there other things that need to be ruled out in the case of positive oligoclonal bands?

A) Depending on which type of Oband testing you had, you would need to have 2+ general or 4+ Mayo, and the Obands need to be unique to the Cerebrospinal fluid (CSF). Would it be enough for an MS dx, personally i doubt it would because no single test is enough diagnostic evidence to dx MS. Though if you did test positive for Obands, MS would be high on your list of possible causation but you'd still usually need more evidence eg clinical signs, MRI changes etc to meet the Mcdonald diagnostic criteria for MS.

Q)"why would a doctor choose to wait for another year to see changes in the MRI instead of doing the lumbar puncture and get more clues, or even a diagnosis?  

A) Usually this happens when there isn't any 'suggestive test or clinical evidence', that the cause of a persons sx's is neurological and if they are confident the cause isn't neurological, they wouldn't expect further testing to change their mind. OR the neurologist doesn't think the cause is neurological but just in case something changes, a follow up appointment in a year (sufficient time for MS MRI changes) will confirm it's not or the changes will warrant further testing.

Cheers...........JJ        
Avatar universal
Thanks JJ, you are always thorough with your answers and it is apparent that you have quite a bit of relevant knowledge. In fact, as I have been observing this forum since the last couple of weeks, most residents are quite so. Whether I am diagnosed or not, I am glad that you guys are here to offer sincere help and support.

Cheers,
TT
147426 tn?1317265632
Hi, I'm going to add my two cents worth here.  JJ and Kyle have given you good consistent answers, but I read your posts a little differently.  This will like cause a little confusion, but MS diagnosis can be that way.

But I have a couple questions.  Did the symptoms in the right hand/fingers last  (recur) more than one day?  That is, did they come back ever in the same spot.  For lesions to be considered part of an MS attack they need to last more than one day.  From my own experience and my reading, the days don't have to be consecutive, but the symptoms do need to be in the same spot.  And yes, you can have symptoms that are sometimes on one side, sometimes on another and sometimes both sides on the same day.  But, the locations should not be moving around.  For example, on the right palm one day and the elbow the next.

The sensations on the hand could have been one attack and the ones on the other hand the next attack.

As for your areas of vibration, it does sound like these move around.  I know the feeling of that, but mine have always been in the same area.  If they are not in the same areas day to day, these are not consistent with an MS lesion.  Remember, the lesions are where they are and cause symptoms in the same place when they are active.

Two peri-ventricular areas (same as two areas near the atria/ventricles) that are hyperintense would definitely be enough to qualify for a diagnosis of MS in the hands of a confident neurologist.  Your descriptions of the tinglings and vibrations are a little vague in terms of how long they last and if they recur in exactly the same spots.

Were your MRI's adequate?  Often non-MS docs order MRIs but fail to specify that they be done using the MS Protocol which specifies how far apart the "slices" should be.  Generally, the interval is 5mm, but with MS it should be 2-3mm.  If the sampling is done too far apart small qualifying lesions (2mm and larger) may be missed by skipping over them.

Your neuro exam is normal and that is good, but does not rule out MS.  A lesion has to have some size or be strategically located to cause the neuro exam to be abnormal.

What is the thinking of waiting to see if new symptoms pop up?  Personally, I don't understand it.  The the lesions sound more demyelinating in nature unless you DO have migraines or high blood pressure.  If she is willing to do an invasive test like the spinal tap now, then her suspicion should be pretty high for MS.  I can't imagine a doc doing a tap just to reassure a patient - on the first visit.

So, if your symptoms are not fleeting in their location and did recur, that along with the two lesions would definitely be enough to make the diagnosis.  If the symptoms were kind of here today and there tomorrow it is unlikely.  So I would like to hear whether the bouts of tingling, temperature difference, or vibration lasted for more than a day at a time and remained in the same spots.

I think your doc's suspicions are fairly high for MS.  Given that what you are presenting with is so mild, she is not unusual is feeling comfortable waiting for more staff to happen or appear, but I would like to see neuros  bemore aggressive since we know that the damage in MS begins early and there is a strong benefit to early therapy.

Quix
Avatar universal
Hi Quix,

Thanks for taking the time to review my post.

The vibration like localized feeling happens at random places in my legs. one day it will be some small area of the calf, it will leave for couple days, and re appear at a different spot which might be a small area of the quad, right under the knee, near the ankle, and so on. totally random. Can't remember if I have had them at the same spot ever twice, but I doubt it.

The tingling/swollen feeling happens with thumb, index and middle finger. Never lasts more than a day, but if it comes back after a week or so, it will come back to the same finger tips.

The hot/cold feeling comes to almost half of the area of the palm that is far from the thumb. This again does not last more than couple hours generally, but if I get this again, it will be same area. Sometimes I feel the same thing on top of my hand as well though.

One thing that is interesting to me is: I never get the hot/cold feeling of the palm and tingling/swollen feeling of finger tips at the same time. I generally also don't have right and left at the same time, and right happens much more frequently than the left.

Another interesting fact is that if I take an Aleve (220 mg Naproxen Sodium) when I am having the hand or finger symptoms, they will go away in 15 mins, and would not come back as long as Aleve works which is almost around 8 - 12 hours.

If my hand/finger symptoms are due to lesions, could Aleve have had such a high efficiency in calming down the symptoms? This is a question I forgot to ask to my neurologist, need to remember next time.
Avatar universal
Forgot to add; I also have some occasional mild pain around the outer side of the wrist. This generally happens around a day before I get the hand/finger symptoms. The pain will go away and I would probably get hand/finger symptoms the next day or so. But I haven't been been able to link all come backs of the hand/finger symptoms to a wrist pain. Meaning that, they might happen without an apparent prior mild wrist pain.
Avatar universal
Sorry to be confusing, the mild transient pain is not around wrist, it is around elbow. I wrote this very late and got mixed up.
Avatar universal
Quix,

do you have any insights about the updates I tried to give?
147426 tn?1317265632
Sorry, I just saw this and will try to think about it soon. Q
147426 tn?1317265632
Hi, Sorry for the wait.  Your symptoms, especially the vibration ones seem less and less like neurological ones.  They are too fleeting and move around too much to sound like they are caused by stationary lesions in the CNS.  I wonder if you are just too focused on them trying to pick up on any altered sensation.

The symptoms that are relieved by an anti-inflammatory like Aleve are not neurological; they are inflammatory.  

Overall, this does not sound particularly like MS. The symptoms just are too short lived and move around too much.  Without any intention of dismissing you, I have to ask about anxiety and generalized worry about your health.  Do you tend to worry about health matters?

Also are you at risk for carpal tunnel problems?  Has this been checked out?  The distribution you described being on the thumb side might reflect compression of the median nerve which is the most common one involved in carpal tunnel.

I am kind of reversing my feelings about whether you are having neuro symptoms.

Quix
Avatar universal
Quix,

Thanks for taking the time and reviewing this.

For the hand/finger symptoms carpal tunnel and cubital tunnel have been considered, but since they couldnt pick up anything abnormal with the EMG, and not responding to the physical therapy made them to look for other stuff. They looked for cervical radiculopathy and didnt see anything abnormal with the discs in the cervical MRI. Hence, the last step was to look for something in the brain, and that is when the 2 lesions were discovered.

About the anti-inflamatories: up until getting the brain mri, I alwayd thought something was pressing onto a nerve and when I take the anti inflamatory, I was assuming that nerve irritation was temporarily halting. May be this is still the case.

However, is it correct to assume that the anti-inflamatory could not halt inflamatory activity at brain lesions because it is a small dose? I am asking this, because from what I read and from other peoples experience, I assume one would need much more stronger anti-inflamatories, such as high dose steroids are needed to calm down lesion activity.
Avatar universal
Forgot to answer the second part of your question: I do get some anciety from thinking about health problems, but I dont think it is more than the average joe's. It has not interfered with my daily life, and not freaking me out.
Avatar universal
Hey Quix,

hope you are doing ok. bumping this up to get your opinion especially about the anti-inflammatories part.
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