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My homework assignment - MRI Teleconference Report!
I listened in on the two Shared Solutions teleconferences this week – the topic was the Importance of MRI’s. The speaker was Dr. Salvatore Napoli. He seemed very personable and if I were in the Boston area I would check him out.
It was a bit frustrated because the call-in portion where listeners get to ask their questions seems to get high-jacked by people wanting to discuss their own personal situation rather than focus on the topic. The first night, very little of the 40 minutes Q&A had anything to do with MRIs.
The first session frustrated me so much by how little of the discussion was on MRIs, I tracked down his office fax number and sent him several of our MRI questions from here. He did acknowledge at the beginning of the second night’s talk that if Laura was listening, he did get the fax and would try to answer some of those questions in his talk. As most of you know, I can be pretty persistent and determined and this time it paid off. LOL
The second night was more focused. As Shell said from the MS talk she went to last week, we always learn something from these events. Here is the summary of what I took away from these two evenings:
He talked a lot about the history of MS, the diagnostic process, and the approved therapies for treating MS. Good basic stuff for anyone new to this disease or who hasn’t seen our health pages here!!
Bravo to any neuro who will say the MRI IS NOT THE WHOLE PIECE OF THE PIE. He said this both evenings and said that the MRI isn’t even the most important part. He says that the first 10-15 minutes of the initial visit with him is the most important piece because that is when he gathers the clinical history and establishes the relationship with the patient.
The dx path he uses is clinical history + neurological exam + MRI – and rated them in that order of importance.
He said the MRI technology we have access to allows doctors to diagnose MS earlier and begin drug therapy sooner. More than once he stressed the importance of beginning a therapy, even if it is just suspected MS with CIS.
Also he said that if someone is undiagnosed, but the lesions LOOK like MS, it almost always is MS. And of course he discussed the adage that how many lesions we have isn’t near as important as location, location, location!
He said it is not typical for people in their 50’s or older to come down with MS at that age, but said he has a handful of patients that age in his practice. His theory is they had MS for years, but it was maybe silent. As one of three Co-cl’s here who was dx’d after 50, I’m glad to hear he stays open to the possibility.
25-30 years ago CT Scans were used to dx MS. I liked his analogy that CT scans are like Polaroid photos while MRIs are the digital picture. Think millions of megapixels.
He talked a bit about emerging MRI measures that are being researched ---
BPF (Brain parenchymal fraction) is being studied to measure whole brain atrophy. He pointed out there is no standardized measure yet so the doctors can study brain atrophy but don’t necessarily know the normal brain volumes to compare the numbers with.
MR Spectroscopy is also being researched. MRS measures the chemicals in the brain for clues as to how the nerves are functioning.
DTI (Diffusion Tensor Imaging) is another emerging technique that he thinks we will see more once the test is standardized.
More than once on both nights he stated the MRI cannot detect MS on a molecular level, and he believes that the disease can often remain invisible to MRIs for long periods of time. He repeated that MRI is not perfect.
I had to laugh when he said that reading the radiologists’ reports can be dangerous for patients. He elaborated that most radiologists list EVERY possibility when reading films and it can be quite frightening for an undiagnosed patient to read all those possible diseases. That is something we say here quite often and it is good to have that verified by an expert.
He said that after the age of 40, a good percentage of people have spots on their brain MRIs. Unfortunately I didn’t get a chance to question that, but he did repeat it the second night.
How often should we have MRIs? He said in the diagnostic process he has his patients imaged every 3-6 months, again acknowledging that the disease starts in the molecular level and may take time to become visible to the available technology.
He said he has all of his patients get baseline MRIs of the brain and the spine (all three sections).
Once diagnosed, he think MS patients should be imaged in MRIs every 1-2 years. That is the best way to tell the progress of the disease and the effects of the drug therapy. He said that often patients don’t necessarily feel the effect of the drug therapy and wonder why its not working for them. The MRI gives the evidence if it is or isn’t effective and offers a chance to try a different drug if indicated.
How many MRI’s can we get in a lifetime? He said that number is limitless because there is no concern about dosages, like we have with x-rays and radiation. Magnetic field exposure holds no possibility of permanent or accumulative damage, according to him.
There was a lot more, but most of it was points about MS that we discuss here regularly, so I won’t go on anymore.
Again, if you are in the Boston area and need an MS neurologist, you might want to check out Dr. Napoli. He seemed quite approachable and very kind. I'm a great believer in kindness!
I hope you learned something by reading through this ........
be well, be smarter,
Lulu
It was a bit frustrated because the call-in portion where listeners get to ask their questions seems to get high-jacked by people wanting to discuss their own personal situation rather than focus on the topic. The first night, very little of the 40 minutes Q&A had anything to do with MRIs.
The first session frustrated me so much by how little of the discussion was on MRIs, I tracked down his office fax number and sent him several of our MRI questions from here. He did acknowledge at the beginning of the second night’s talk that if Laura was listening, he did get the fax and would try to answer some of those questions in his talk. As most of you know, I can be pretty persistent and determined and this time it paid off. LOL
The second night was more focused. As Shell said from the MS talk she went to last week, we always learn something from these events. Here is the summary of what I took away from these two evenings:
He talked a lot about the history of MS, the diagnostic process, and the approved therapies for treating MS. Good basic stuff for anyone new to this disease or who hasn’t seen our health pages here!!
Bravo to any neuro who will say the MRI IS NOT THE WHOLE PIECE OF THE PIE. He said this both evenings and said that the MRI isn’t even the most important part. He says that the first 10-15 minutes of the initial visit with him is the most important piece because that is when he gathers the clinical history and establishes the relationship with the patient.
The dx path he uses is clinical history + neurological exam + MRI – and rated them in that order of importance.
He said the MRI technology we have access to allows doctors to diagnose MS earlier and begin drug therapy sooner. More than once he stressed the importance of beginning a therapy, even if it is just suspected MS with CIS.
Also he said that if someone is undiagnosed, but the lesions LOOK like MS, it almost always is MS. And of course he discussed the adage that how many lesions we have isn’t near as important as location, location, location!
He said it is not typical for people in their 50’s or older to come down with MS at that age, but said he has a handful of patients that age in his practice. His theory is they had MS for years, but it was maybe silent. As one of three Co-cl’s here who was dx’d after 50, I’m glad to hear he stays open to the possibility.
25-30 years ago CT Scans were used to dx MS. I liked his analogy that CT scans are like Polaroid photos while MRIs are the digital picture. Think millions of megapixels.
He talked a bit about emerging MRI measures that are being researched ---
BPF (Brain parenchymal fraction) is being studied to measure whole brain atrophy. He pointed out there is no standardized measure yet so the doctors can study brain atrophy but don’t necessarily know the normal brain volumes to compare the numbers with.
MR Spectroscopy is also being researched. MRS measures the chemicals in the brain for clues as to how the nerves are functioning.
DTI (Diffusion Tensor Imaging) is another emerging technique that he thinks we will see more once the test is standardized.
More than once on both nights he stated the MRI cannot detect MS on a molecular level, and he believes that the disease can often remain invisible to MRIs for long periods of time. He repeated that MRI is not perfect.
I had to laugh when he said that reading the radiologists’ reports can be dangerous for patients. He elaborated that most radiologists list EVERY possibility when reading films and it can be quite frightening for an undiagnosed patient to read all those possible diseases. That is something we say here quite often and it is good to have that verified by an expert.
He said that after the age of 40, a good percentage of people have spots on their brain MRIs. Unfortunately I didn’t get a chance to question that, but he did repeat it the second night.
How often should we have MRIs? He said in the diagnostic process he has his patients imaged every 3-6 months, again acknowledging that the disease starts in the molecular level and may take time to become visible to the available technology.
He said he has all of his patients get baseline MRIs of the brain and the spine (all three sections).
Once diagnosed, he think MS patients should be imaged in MRIs every 1-2 years. That is the best way to tell the progress of the disease and the effects of the drug therapy. He said that often patients don’t necessarily feel the effect of the drug therapy and wonder why its not working for them. The MRI gives the evidence if it is or isn’t effective and offers a chance to try a different drug if indicated.
How many MRI’s can we get in a lifetime? He said that number is limitless because there is no concern about dosages, like we have with x-rays and radiation. Magnetic field exposure holds no possibility of permanent or accumulative damage, according to him.
There was a lot more, but most of it was points about MS that we discuss here regularly, so I won’t go on anymore.
Again, if you are in the Boston area and need an MS neurologist, you might want to check out Dr. Napoli. He seemed quite approachable and very kind. I'm a great believer in kindness!
I hope you learned something by reading through this ........
be well, be smarter,
Lulu
JJ - he really skirted the issue - I don't believe intentionally - by talking about pre-MRI we only had CAT scans available as a diagnostic tool. And CAT scans were not very good at showing brain disease. I would like to know if the dx of CIS existed 30 years ago or if that is a new designation since the availability of MRIs to most people.
The question about why it is not treated more agressively when you only have CIS to work with may be answerable with how current is the neurologist on treatment recommendations. Here in the US the FDA in the recent past has approved a couple of the DMD's for CIS. Until it is officially endorsed like this, doctors have a hard time justify the off-label use. And of course we can't overlook the financial implications of being on a dmd.
DV - the only way I can do this is to find a quiet spot to listen. If I were in a conference setting like you were with all the distractions around me, it would be much harder. Its as if ADD kicks in. For these teleconferences I put the phone on speaker and then force myself to pay attention by taking notes. I find my mind wandering and then I force myself to pay attention again. It really is a good mental exercise for me.
The question about why it is not treated more agressively when you only have CIS to work with may be answerable with how current is the neurologist on treatment recommendations. Here in the US the FDA in the recent past has approved a couple of the DMD's for CIS. Until it is officially endorsed like this, doctors have a hard time justify the off-label use. And of course we can't overlook the financial implications of being on a dmd.
DV - the only way I can do this is to find a quiet spot to listen. If I were in a conference setting like you were with all the distractions around me, it would be much harder. Its as if ADD kicks in. For these teleconferences I put the phone on speaker and then force myself to pay attention by taking notes. I find my mind wandering and then I force myself to pay attention again. It really is a good mental exercise for me.
Great post,
The more information we have, hopefully makes us able to make the right decision about our health care choices.
thanks
John..
The more information we have, hopefully makes us able to make the right decision about our health care choices.
thanks
John..
COMMUNITY LEADER
Thanks Lulu,
Very interesting, I think we've learned a lot more than we ever give our selves credit for, our health pages dont miss much, do they? Cudos to our health page contributers!!
A couple of nuggets to ponder....
1) "Bravo to any neuro who will say the MRI IS NOT THE WHOLE PIECE OF THE PIE. He said this both evenings and said that the MRI isn’t even the most important part. He says that the first 10-15 minutes of the initial visit with him is the most important piece because that is when he gathers the clinical history and establishes the relationship with the patient."
2) "More than once on both nights he stated the MRI cannot detect MS on a molecular level, and he believes that the disease can often remain invisible to MRIs for long periods of time. He repeated that MRI is not perfect."
Number 2 has me thinking, that if all your clinical signs are consistent with MS and its only the MRI thats not supportive for dx, well then what.......wait? I find my self in a confused state, if CIS is enough to warrent DMD's, then why why why is possible, probable and benign, commonly NOT treated with anything more than the wait and see aproach?
Wouldnt it be more logical to treat all with the DMD's, especially if the patient is dealing with 'perminent' issues already? What confuses me about this, is that CIS has the least amount of clinical evidence, and more likely to have minimal evidence on MRI compared to possible, probable, or benign MS.
Am I making sense here?
Cheers........JJ
Very interesting, I think we've learned a lot more than we ever give our selves credit for, our health pages dont miss much, do they? Cudos to our health page contributers!!
A couple of nuggets to ponder....
1) "Bravo to any neuro who will say the MRI IS NOT THE WHOLE PIECE OF THE PIE. He said this both evenings and said that the MRI isn’t even the most important part. He says that the first 10-15 minutes of the initial visit with him is the most important piece because that is when he gathers the clinical history and establishes the relationship with the patient."
2) "More than once on both nights he stated the MRI cannot detect MS on a molecular level, and he believes that the disease can often remain invisible to MRIs for long periods of time. He repeated that MRI is not perfect."
Number 2 has me thinking, that if all your clinical signs are consistent with MS and its only the MRI thats not supportive for dx, well then what.......wait? I find my self in a confused state, if CIS is enough to warrent DMD's, then why why why is possible, probable and benign, commonly NOT treated with anything more than the wait and see aproach?
Wouldnt it be more logical to treat all with the DMD's, especially if the patient is dealing with 'perminent' issues already? What confuses me about this, is that CIS has the least amount of clinical evidence, and more likely to have minimal evidence on MRI compared to possible, probable, or benign MS.
Am I making sense here?
Cheers........JJ
Thanks Lu, this is really great information, you must have been a great student in school. You're putting me to shame as I haven't written up my notes from the LA symposium and I didn't take down nearly as much as you. They did say that they be putting the entire 2 hour video up on WebMD at the end of the month so I'll keep an eye on it and let you all know when it's up.
I found his comment interesting re: MRI every 1 to 2 years post-dx to monitor DMD effectiveness. My neuro says his preference is only if there is unexpected worsening, otherwise he prefers to go by clinical signs and symptoms. I think he'd order one if I pressed it; I think we all are curious to know what's happening inside us, from time to time, once we get this dx.
I found his comment interesting re: MRI every 1 to 2 years post-dx to monitor DMD effectiveness. My neuro says his preference is only if there is unexpected worsening, otherwise he prefers to go by clinical signs and symptoms. I think he'd order one if I pressed it; I think we all are curious to know what's happening inside us, from time to time, once we get this dx.
Kathy,
Salvatore Q. Napoli, MD
Practice Location:
Norwood Hospital Multiple Sclerosis Center at Chestnut Green
15 Payson Road
Foxboro, MA 02035
( 78 1) 5515812
He is Italian descent but American born and schooled so don't let the name fool you! Let us know if you can get in to see him.
Salvatore Q. Napoli, MD
Practice Location:
Norwood Hospital Multiple Sclerosis Center at Chestnut Green
15 Payson Road
Foxboro, MA 02035
( 78 1) 5515812
He is Italian descent but American born and schooled so don't let the name fool you! Let us know if you can get in to see him.
I agree Lu, you get an A or perhaps an A+ since you spent 2 evenings of your time for our benefit. Thank you.
Ren
Ren
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