Recent MRI and Symptoms

[TwoYoung4This]

First of all I would like to thank everyone on this forum; it has already been a great resource for me over the last week or so.

I will start with my first major symptoms on April of 2008. Every morning for about a month I would wake up with left foot/ankle numbness most of the time this would only last for an hour or 2 after waking up each morning. Then one Sunday morning I woke up and my whole left side was numb, I wanted for a few hours for it to go away and then went to a local emergency medical office. They couldn't diagnose me but noticed I had high blood pressure and I think just assumed I had a minor stroke I was 28 at the time. Later that week my normal doctor referred me to a Neurologist based on my symptoms (Left side of my face was numb; nose was numb, left arm/hand, left foot/ankle). I had 2 sets of MRIs last summer with and without contrast, I think I had a few small "white spots" but nothing to diagnose for sure, the Neurologist basically said he wasn't sure maybe it was a small stroke. This was months later and most of my symptoms went away the only time I would really notice was days that I didn't get enough sleep or worse multiple days without much sleep.

So fast forward to this April... Major symptoms came back and worse this time. The biggest problem has been severe fatigue. I'm just going to list out the rest of the symptoms..

Muscle tightness on left side
Numbness in/on nose
Tight muscle on left side jaw muscles (like lock jaw but only left side) (1 week or so)
Left side of face felt swollen for a week or so but wasn't
Tightness in back of ankle when walking
Bicep muscle pain on left side
Weakness on left side of body
Trouble sleep because of leg/arm burning/itching/pain
Fatigue even with a full night’s sleep (caffeine doesn’t seem to help much)
Pain or numbness on heel and arch of left foot when walking
Left eye twitching, blurry vision in left eye
Tightness in chest, seems to wrap around to lower back, feels difficult to take deep breath

So I made another appointment with my Neurologist 4 weeks later I describe the above symptoms to him, he orders another MRI with and without contrast. I get a phone call 4 hours after my MRI that they would like to do a Evoked Potential Test because of some lesions spotted on my MRI, and they also tell my that I have a Pineal Cyst and have an appointment with a Neurosurgeon. So now I keep wondering how large and how many lesions do I have, and how large is my Pineal Cyst and if some or all of my symptoms are from the Cyst. I'm also wondering how many people with MS have or have had a Pineal Cyst.

I'm currently taken gabapentin around 1200 mg a day it seems to help some. I'm also taken some Soy protein and energy drinks to help with the fatigue on days when it's really severe.

Thanks again for listening and any help.

[Quixotic1]

oops!  :))

[TwoYoung4This]

Quix,

First off thank you so much for your very helpful response! I should have mentioned that I am a 29 yr old man not that it really matters. I also have mild hypertension but it is controlled by meds and has been for the last year, I feel the hypertension is why my symptoms have been dismissed as a small stroke. I have had migraines in the past but that's been 5 years ago or so.

As far as my symptoms some are the same such as left side numbness (hand, foot, face, nose). But I don't remember having such severe fatigue last year, the fatigue I have been having over the last 6 week is not like anything I have ever experienced before. Some of the symptoms did linger over the last year but I only really noticed them if I was very tired.

[Quixotic1]

Hi, I missed you last time around.  I'm glad you came back and gave us the results of your three scans.

First, pineal cysts are not tumors, but sacs of fluid.  They are incredibly common and do not typically cause symptoms.  Typically they are discovered incidentally when an MRI is done for various reasons.  Occasionally they can be quite large and be felt to cause some symptoms.  Also occasionally they are treated surgically.

Just to give you an idea of how incredibly frequent they are I found a good medical study from 2007 which took 100 healthy people between 19 and 39 and did MRIs on them to see how many had assymptomatic pineal cysts.  The amazing results were that 23% of this healthy group had them!!  That is almost 1 in 4!!  this agrees generally with what I was taught in med school.  Here is a great study to see this.

http://www.ajnr.org/cgi/content/full/28/9/1706

Now, your situation is more complicated, because you have neurological symptoms.  So, the question is whether any or all of your symptoms can be explained by a small pineal cyst.  In my mind the answer is an unequivocal "No."  When they are very large and pressing on the other adjacent tissue, they can cause a small list of symptoms, but not the list (maybe a few) that you gave us.  Since they are soooo common, I would make sure that no one is "knife-happy" over going at yours surgically.  If a surgeon wants to cut please get another couple opinions.

Your symptoms are suggestive of MS.  And, they have appeared in two separate attacks.  They also involve widely separate areas of the central nervous system.  Of course, no one online can diagnose much of anything in anyone.  So, we depend on our neurologists to do the appropriate work up which needs to include a full history - and critically, your neurologist needs to be doing repeated VERY THOROUGH head to toe neuro exams on you.  Sometimes the best evidence for or against MS is to be found in the exam.

Also, you need to be thoroughly checked for the many mimics of MS.  Most of this is done through blood tests.  All of this must be done before ruling MS in or out.

Now, I have a few opinions about what I hear in the interpretations of your MRIs.  The first is that you have some good sized white matter lesions.  These are described as being mostly in the periventricular region.  The largest is measured at 8mm.  this is nothing to sneeze at, and is in a location frequently seen in MS.  It seems like the radiologist feels that because none of the lesions shows enhancement, that demyelination is an unlikely cause.  This is preposterous!  Most of us with MS have MRIs which do not show enhancement.  Lesions only enhance for 4 to 6 weeks when the immune-inflammation is new.  Catching enhancement is a cra pshoot.

Then the radiologist seems to think that these lesions, then are far most likely to be du to small vessel damage (small vessel ischemic disease).  If you have a history of significant high blood pressure or migraine disease, then this is possible.  However, at age 28 and in the absence of hypertension or migraines, then it seems silly to say that you have the lesions of small vessel ischemic (ischemic=starved for blood) disease.  the other possiblility is "microangiopathy" such as is seen in the vasculitis of an autimmune disease such as Lupus.   This is  why the blood tests for MS mimics are sooo important.

I wonder if the same radiologist read all three of these MRIs.

Not only that but, at your age, small vessel ischemic disease is not common.  When it does occur and shows lesions, these lesions are more often subcortical and not periventricular.  AND, they are typically asymptomatic.  Small vessel ischemic disease is not a good answer for a young woman with diffuse neurologic symptoms.

We have a good number of people here who have a confirmed diagnosis of MS with the type of lesions those reports are describing.  I think the radiologist seems to be thinking far too narrowly and is clearly not aware of your clinical story - which is normal.  It is not the place of the radiologist to make this diagnosis.

While I am sure you do not "want" a diagnosis of MS, you DO know that something very wrong is happening to you and you want to know WHY.  This is normal.  I am also not saying that MS is the answer, but I am trying to point out where the MRI reports seem to be making some odd conclusions and one's that make no sense to me.

So, I am suspicious of MS, as is your neuro who wants to do the EPs.  I agree with them.  An LP (spinal tap) might also be a good next test.  Along with this I would consider having the three MRIs re-read by a different neuroradiologist in a different center.  That is a different kind of "second opinion" that is often useful.

Be sure no one runs in to do surgery on the pineal cyst until you have spoke to other neurosurgeons.

And tell us more about how the symptoms have appeared - both the first time and then again this year.  Did any of the symptoms completely disappear, or did some linger in the year in between?  If they pretty much went away and reappeared, that makes it very unlikely that they were caused by the cyst, though the cyst has enlarged a tiny bit (3+mm).  

Well, I hope this was helpful in looking at your situation.  And, welcome again to our forum!

Quix, MD

[TwoYoung4This]

Thanks for the response, and the suggestion I called today and now have my images and reports. I'm going to post the report here, I have read over them and understand most of it, any suggestions or comments would be very helpful!

MRI BRAIN W/WO CONTRAST
REASON :LEFT HEMI NUMBNESS
-
MRI Brain with and without gadolinium

History: Left paresthesias.

Technique: Axial, sagittal, and coronal images were acquired utilizing
T1,T2, FLAIR, and diffusion weighted technique on a 1.5T super conducting
magnet. 17 cc Omniscan was administered intravenously.

Findings: Comparison is made with MRI dated 7/9/2008. The corpus collosum
is normally formed. No suprasellar or prepontine masses are present. No
diffusion restriction is present. Scattered occasional T2/FLAIR
hyperintensities are identified within the periventricular white matter.
These are similar in distribution in comparison to the previous exam..
Findings do not demonstrate corresponding enhancement and likely represent
small foci of microvascular disease. A 9mm T2 hyperintense lesion is
identified in the region of the tectum. Peripheral enhancement is present.
The appearance is most compatible with a pineal cyst. This lesion is more
conspicuous than on the prior exam, likely due to slice selection. It is
stable in size in comparison to the prior study. No mass or midline shift
is present. No extra-axial fluid collections are present. The ventricles
and basilar cisterns are normal. Expected flow related signal loss is
present within the intracranial vessels. No parenchymal or leptomeningeal
enhancement is identified.

The orbits are grossly normal in appearance. No marrow signal abnormality
is identified in the skull base or calvaria. The craniocervical junction
is normal in appearance.

Impression:

1. Scattered foci of T2/hyperintensity are present. They have a similar
distribution comparison the previous exam.
2. Stable probable pineal cyst. This is likely a benign finding. Consider
neurosurgical consultation.

July 9 2008

MRI-BRAIN W/WO CONTRAST
REASON :TIA
-
MRI of the brain for history of possible TIA. Today's exam is a followup
of the exam from April 23, 2008.

Technique:

Sagittal FLAIR and T1, axial T1, T2, DWI and coronal FLAIR images of the
brain were obtained on 1.5 Tesla system. As per request the patient was
injected with 17 mm Omniscan, and T1 fat saturation images were performed.

Findings:

DWI images fail to demonstrate acute brain parenchymal pathology. The
previous exam showed numerous foci of signal change in the white matter of
both cerebral hemispheres. These are still present today, but in general
are either stable, or slightly less well seen. These do remain
nonspecific. None of these lesions demonstrate definite abnormal contrast
enhancement.

There is no mass or mass effect shown. The midline structures remain
unremarkable. The slightly unusual appearance of the pituitary gland, with
increased CSF space anteriorly is again demonstrated, probably a normal
variation. Expected flow-voids shown at the base of the brain.

There is no significant sinusitis, or orbital pathology. Nasal septum is
slightly deviated to the left side. There is a small polyp/cyst in the
left anterior nasal passage.

Impression:

Essentially stable appearance of the white matter as described. Findings
are nonspecific.

4/23/08 MRI

Preliminary Report:

1. If no acute territory infarct.
2. No intracranial mass or mass effect.
3. Multiple areas of increased signal intensity on FLAIR and T2-weighting, nonspecific as to etiology, though most likely microangiopathic changes. A short-term followup six-month MR exam is suggested to make sure these areas remain stable.

MRI-BRAIN WO CONTRAST
REASON :TIA

Findings:

Clinical indication: TIA.

There are no prior exams for comparison according to the patient. There
are no previous exams related to today's problem.

On midline T1-weighted sagittal sequences, the corpus callosum, aqueduct,
fourth ventricle, pituitary, and craniocervical junction appear to be
grossly normal.

T1 and T2-weighted axial images were obtained. There is normal signal
flow-void within the vertebral arteries, basilar artery, and both internal
carotid arteries. There is tortuosity of the basilar and vertebral
arteries, a normal variant.

There is no intracranial mass or mass effect. No midline shift or downward
herniation. Suprasellar cistern and quadrigeminal cistern are well seen.
Orbits appear to be normal. There is slight undulation of the nasal
septum. Minimal paranasal sinus changes are present. There appears to be a
tiny cystic area in the nose on the left side on image #6 of the
T2-weighted sequence. This measures approximately 6.6 mm in diameter.
Etiology is nonspecific. Please correlate clinically. There is an area of
slight increased signal intensity in the right hemisphere just lateral to
the anterior aspect of the anterior horn of the right internal capsule.
This has a long axis dimension of 8.5 mm. The long axis parallels the long
axis of the brain. This is nonspecific as to etiology. Followup MRs to
monitor this area are recommended. Most likely, this will remain the same,
though etiology is nonspecific. This area is high in signal intensity on
T2-weighted images as well as on coronal FLAIR images. There are a few
other areas of increased signal intensity on FLAIR images within the
brain. Overall, these are probably manifestations of microangiopathy or
small vessel disease. A demyelinating process cannot be totally ruled out
but felt to be unlikely.

[sllowe]

Hi there,

Welcome to the MS forum!

You did the right thing - going back to the neuro.

The VEP will be painless.  I'm sorry I just do not know much about the Pineal Cyst and if it would cause the symptoms you describe that are MSish.

You can call the facility you got the imaging at and get the reports which should include the size and location of the lesions and the cyst. Those reports are yours as are the images.

When do you go to the neurosurgeon? Any chance of getting ahold of the reports before hand?  

Thanks for joining us - see you around!