Is a 7mm parieto-occipital lesion adjacent to cortex suspicious for MS?

[ontolome]

Some people on this forum seem really well-informed! I wonder if any of you can read this situation better than I can. Thanks, in any event :) And best of luck to you all...

In radiology terms, does "adjacent to the cortex" = "juxtacortical" (of MS fame)?

My neuro sees me every 3 months for suspected myasthenia gravis, but MG and muscular dystrophy tests have been negative. An MRI was ordered because of right hyperreflexia, which has since vanished. The Dr, a prominent MS specialist, assured me that the MRI was typical of young women with migraine. I do not have migraines.

Some of his comments seem a bit MS-tinged (e.g. making note of cold hands, asking about urinary symptoms). And yet he goes out of his way to say "we're keeping a close eye on you but we're finding nothing wrong."

I'm expecting either to be dismissed, or be told "surprise, we think it's MS." Would a doc hide it if he suspected it?

[HVAC]

What do the findings say? That is the important part.

[supermum_ms]

Hmmm i don't know about being 'confident' lol i'll give it a go but it's getting late over my side of the world so i may not be able to finish it until tomorrow...

MRI basics:
"Dark on T1-weighted image:
increased water, as in edema, tumor, infarction, inflammation, infection, hemorrhage (hyperacute or chronic)
low proton density, calcification
flow void

Bright on T1-weighted image:
fat
subacute hemorrhage
melanin
protein-rich fluid
slowly flowing blood
paramagnetic substances: gadolinium, manganese, copper
calcification (rarely)
laminar necrosis of cerebral infarction

Bright on T2-weighted image:
increased water, as in edema, tumor, infarction, inflammation, infection, subdural collection
methemoglobin (extracellular) in subacute hemorrhage

Dark on T2-weighted image:
low proton density, calcification, fibrous tissue
paramagnetic substances: deoxyhemoglobin, methemoglobin (intracellular), iron, ferritin, hemosiderin, melanin
protein-rich fluid
flow void"
http://www.med.harvard.edu/aanlib/basicsMR.html

WMLs are best visualized on T2-weighted or FLAIR (fluid-attenuated inversion recovery) MR images, your MRI has found a small number of very tiny-minuscule-microscopic ("mild punctate") lesions specifically in the left frontal, and bilateral occipital lobes (left and right) and the only larger sized lesion is the 7mm parieto-occipital lesion adjacent to cortex and this later MRI did not find a tiny T1 pituitary lesion.  

Typically, non specific lesions that are tiny (1-3 millimeters) are micro-vascular related, they are usually silent and not thought to cause symptoms, it's not particularly abnormal to have 'some or no' micro vascular lesions in your 20's, it kind of depends on your medical history and background and if there's a lot to be significant or not. The 7mm is also non specific so there isn't anything to indicate that it's unlikely to also be vascular or viral related, eg from a bump on the head during your life time or mono etc.  

The issues you've mentioned (autonomic disturbances, disconjugate gaze, thoracic pain/dyspnea, physical and mental fatigue-- all intermittent, recurring, and heat-sensitive) are not specifically MSish and could very well be associated with your diagnosed medical conditions.

Autonomic dysfunction is not a common MS issue, yes it can happen but it's just not very common. Respiratory issues like Dyspnea (shortness of breath-air hunger) is also uncommon in MS....

"the most common cause of respiratory problems is loss of muscle strength and endurance. Just as a person can experience muscle weakness in the arms or legs, weakness can occur in the ventilatory muscles of the chest and abdomen that are involved in breathing. And like weakness in the other parts of the body, weakness of the ventilatory muscles can begin to occur early in the disease course and gradually worsen over time.

People with weakened ventilatory muscles have to work harder to inhale and exhale. This extra effort can be quite tiring, particularly for people who already experience a significant amount of MS fatigue." http://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms/Respiration-Breathing-Problems

...and i think i noticed if another thread you actually mentioned fainting with exercise  (?), which off the top of my head is more related to hyperventilating and possibly even sport induced asthma or the like, mental health issue like anxiety can also cause breathing issues too.    

As far as i'm aware 'disconjugate gaze' is a type of accommodative convergence disorder and more to do with Strabismus, and if that's right strabismus is not an uncommon discovery in your 20's.

I've run out of time, but all told i don't think there is anything you've mentioned that would put a neurological condition like MS at the top of your possible list, so i think it's going to take more tests to work it all out.  

Hope that helps........JJ

[ontolome]

thanks again for all of your input, JJ, and sorry for the delay in responding!

i suspect you're right about needing further tests.

i'll be surprised if whatever is going on is entirely benign or accounted for by my other diagnoses, but all i can do now is wait.  

[supermum_ms]

Hi and welcome,

Whilst Juxtacortical does mean 'adjacent to the cortex', and it is 1 of the 4 specific identifying lesion locations for MS, it's not just that they are adjacent to the cortex but they are suppose to be touching the cortex.  

"Juxtacortical lesions are specific for MS.
These are adjacent to the cortex and must touch the cortex.
Do not use the word subcortical to describe this location, because that is a less specific term, indicating a larger area of white matter almost reaching the ventricles.
In small vessel disease these juxtacortical U-fibers are not involved and on T2 and FLAIR there will be a dark band between the WML and the (also bright) cortex (yellow arrow).

Temporal lobe involvement is also specific for MS.
In hypertensive encephalopathy, the WMLs are located in the frontal and parietal lobes, uncommonly in the occipital lobes and not in the temporal lobes.
Only in CADASIL there is early involvement of the temporal lobes."
http://www.radiologyassistant.nl/en/p4556dea65db62/multiple-sclerosis.html

It's highly possible that the white matter lesions are normal vascular ones or related to your dx thyroid condition, migraine and thyroid conditions can cause similar WML, what exactly does your MRI report state?

Without any other information to go by I'd simply expect that since you're a young women in her 20's, your MS neuro is erring on the side of caution, finding nothing wrong is exactly what you want to hear!

Hope that helps........JJ

[ontolome]

Thanks so much for your detailed and helpful response JJ/supermum_ms :)

I am not sure how confident people here feel about interpreting radiology-speak, but here is the impression:

1. There is a 7mm FLAIR hyperintensity of the left parieto-occipital junction white matter adjacent to the cortex.
2. There are nonspecific mild punctate FLAIR hyperintensities of the left frontal, left occipital, and right occipital lobe white matter.
3. The above findings are nonspecific with a differential which would include demyelination, vasculitis, and sequelae of prior inflammation or injury.

I'm not eager to have MS, but like many here, I am seeking explanations for as yet unexplained conditions (i.e. autonomic disturbances, disconjugate gaze, thoracic pain/dyspnea, physical and mental fatigue-- all intermittent, recurring, and heat-sensitive).

Chest MRI was clear. A previous T1 MRI found a tiny pituitary lesion (presumed to have caused my mild hyperprolactinemia, now medicated), and my thyroid disease is controlled. My high ANA titer was unconcerning to a rheumatologist.