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Re: MRI interpretation

Posted By CCF MD mdf on August 19, 1998 at 12:23:18:

In Reply to: MRI interpretation posted by SG on August 19, 1998 at 11:08:18:

I posted a question on 81198 regarding an MRI clarification.  I have more precise
information about my MRI and would really appreciate any guidance I can have
at this stage in the game.  
My small white spot is located in the white matter, adjacent to the ventricle
in the central right frontal lobe (the doctor pointed to the crown area of my head,
a bit to the right).
1. I asked if there were any other causes of white spots on an MRI?  And, have
you had cases where people exemplify
sensory symptoms (as my symptoms listed in the 81198 message)along with
this white spot BUT it IS NOT a demyelinating disease, maybe a virus or something
2. Why do they need 3 spots to diagnose MS, why not this 1 spot?
3. I am only a 24 year old female who is aspiring to live a productive
and healthy life like everyone else, and I am trying to do anything that I
can possibly do to treat whatever condition I have (unknown at this point)
-- if MS is a possibility why can I not take action now and treat it with
something that could help slow the progression??  I find it incredibly
difficult to wait and do nothing when I am really wanting to make a go of
my career in a fast-paced environment.  
4. Are there any clinical studies underway for people under suspicion of developing this disease and
who are wishing to take preventative action right away?
5.  Does your clinic take any alternative approaches in treating neurological
6.  Is ir true that Alpha Lipoic Acid and marijuana can assist in nerve
generation?  Is it also true that hepatitis and chicken pox have been linked
to the causes of MS?  I show antibodies to Hep A although I have never tested
positive, and I had chicken pox along with Mono at 21 yrs old.
Thanks again for your time and consideration in dealing with such delicate matters, you've been a wonderful help already!
- I don't want to be a nag, if
these questions can't be answered please just state so.
My  best,
I have reviewed the original post of 08-04, the response by MD/in of 08-08, your post of 08-11, and the reply by * of 08-11.
We see many patients who have small white spots on MRI with uncertain significance. In fact, there is a term "UBO" for "unidentified bright object" which is in common use. The radiologists usually report something like "punctate area(s) of hyperintensity on T2-weighted images, significance uncertain, could consider demyelination, microvascular ischemia, or normal variant; clinical correlation is advised."
MS lesions certainly could show up as such a white spot, and there is where the difficulty lies. The radiologist, of course, just sees the films and tells us what kinds of things look like it, but doesn't know anything about the patient. The neurologist has gathered information about symptoms and signs, and should form a hypothesis about where in the nervous system the problem(s) arise. If the image doesn't match the hypothesis, then it has to be thought through. Often, the conclusion is that the abnormality (such as a white spot) is not related to the symptoms. Of course, if the hypothesis and image match, then we usually assume one has to do with the other.
So the question is, where should your symptoms be originating? Both neurologists answering your questions thought the localization was in the peripheral nerves, that is, not in the brain or spinal cord. This is sensible, given the distribution in all four limbs of the body. NO SINGLE LESION in the CNS could account for the symptoms you report, in the absence of other specific symptoms. It's not clear to me that you have a neuropathy either, but that is a reasonable starting point, and an EMG/NCS should settle the issue. An MRI of brain or spine would be irrelevant in diagnosis of neuropathy.
The white spot you mention doesn't correlate with the symptoms.
You mentioned an intestinal viral syndrome. Viruses can cause a lot of nonspecific symptoms, such as what you mention. This includes numbness, and one doesn't need to prove widespread damage to the CNS or peripheral nervous system (PNS). I don't know if the viral illness triggered your symptoms or not, but it could be. If the viral illness is really over, then you may just be experiencing residual. The important implication of that is that the symptoms should not increase with time. They may stay the same, or more likely decrease gradually. Will they go away completely? Don't know.
Let me answer your questions point by point.
1. See above. Demyelination is NOT the only explanation for the white spot. They are commonly unexplained, and yours does not correlate with your symptoms. Is it possible that it is the earliest sign of MS? Yes. Is it likely? No.
2. There is no magic criterion for "3 spots" to diagnose MS. MS is defined as more than one demyelinating lesion in the CNS, over time. So 3 spots might be more consistent with MS, but not necessarily. We have people who get quite a few such bright spots and not one of them means anything.
3. Treatment for MS, including that aimed at slowing down the progression, has plenty of risks and side effects. For any illness, one must weigh risks and benefits. The risk at your stage of causing harm currently outweighs the benefits of possibly (no guarantee) suppressing a demyelinating illness. Current practice is to have a diagnosis in hand prior to initiating treatment. And then there are the complexities related to what form of MS, and what treatment is appropriate. Shooting from the hip is hazardous.
4. I don't know. Physicians at the Mellen Center at CCF (a specialty group dedicated to MS) might know the answer.
5. I don't believe so, but I personally don't stand in the way of alternative treatments suggested by my patients, as long as my judgment is that such treatment would cause no harm.
6. I don't know.
I hope this helps. As you know, this information is posted for your medical education. Specific comments regarding diagnosis, prognosis, and treatment options must come from your doctor after appropriate evaluation. CCF MD mdf.

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