Ask the Experts: MS Lesion Questions
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Q: 3 months ago I was experiencing numbness and tingly sensations, with slight muscle twitching all over body. MRI showed small white lesions on the brain, a dye was used and it showed that the lesions were not recent. I was referred to a neurologist to see if I had MS. I had a spinal MRI which came back clean and normal. Doctor still wanted to make sure, so I had my eyes checked, that came back all clear too. Finally blood work and spinal tap were done, all blood work and spinal tap came back complete normal. Doctor doesn't know what else it can be, since I was tested for everything under the sun, and it all came back negative. What is the likely hood that I have MS?? I still have numbness in hands and feet and twitching, someone said I could have poor circulation, and the twitching can be caused by my issues with anxiety?
A: Without being certain of which other blood tests were done, my response is tentative. The presence of scattered spots in the brain MRI can be caused by a number of other conditions including migraine and age and hypertension hence a more complete set of information is needed. Your symptoms description suggests a problem in the spinal cord (assuming your face is not involved in the sensory symptoms) and it is often difficult to see spinal lesions in an MRI as they are quite small. A condition called transverse myelitis is also possible.
Given the uncertainty of diagnosis, you might ask your neurologist for a referral to an MS center for a second opinion, and be sure to bring your records, (indluding the actual MRI) with you. I hope this is helpful.
Arthur Safran, MD
January 2012
Q: In May of 2009 I was diagnosed with MS. My MRI showed I had four lesions. Now in 2011 I had another MRI. Two of my original lesions have disappeared and one small new one has appeared. Is this normal? Is my Avonex working? Or could I have been misdiagnosed?
A: Sometimes, lesions can be seen on one MRI and not on another because of differences in technique. You should ask your neurologist to review your diagnosis in view of the MRI changes.
James R. Lehrich, MD
December 2011
Q: I am 64 y/o. I had my first MS symptoms at age 32 - internuclear ophthalmoplegia / dyplopia. I had vague signs/symptoms off and on til age 58 at which time I had many symptoms after a bout with malaria. MRI was positive for demylinating lesions consistent with MS. Have atypical trigeminal neuralgia, have had uveitis, mild spastisity in legs, cognitive issues, balance issues,early bladder problems etc. Over past few years, MRI readings (total of 3) say normal for age. Is it normal 2 have normal mri after positive?
A: The plaques of MS regress in size over the years at a certain point may become very difficult to see. At age 64, "UBO's"- unidentified bright objects are commonly seen and may be considered normal, and depending on the location are very difficult to differentiate from MS plaques.
If you are able to obtain your earlier MRI studies, they could be compared with the current ones and a more complete interpretation may resolve the issue.
It would be helpful to raise this concern with your neurologist as well.
I hope this is helpful.
Arthur Safran, MD
December 2011
Q: I had Cushing's disease and have had 6 MRIs in the course of 8 years. In 2004 a lesion in the centrum semiovale was Hyperintense then faded months later in the next MRI. Another MRI in 2005 showed nothing. In 2008 T2 Flair Hyperintensities were on my report, possible demylentation. No mention of the centrum semiovale lesion. 2009 MRI read a pericallosal lesion, along with the same T2 Hyperintensites. 2011 new frontal lobe punctant foci of significance on my MRI report, along with the recurring scattered T2 lesions.
Are ms lesions the kind that show up and disappear to show up later? And if I have just been told of a "new" lesion does this show progression of demylentation? I have a lot of MS symptoms. I went to a great neurologist in my state in 09 but he couldn't diagnose me. Does this last MRI indicate I should return for more work up?
A: Sometimes in multiple sclerosis, MRI lesions can decrease in size or go away completely. Sometimes treatment with intravenous steroids at the time of a relapse can help this process. Although this is a good sign, it doesn't mean that the MS has gone away completely. You still remain at risk for future relapses and new MRI lesions.
Tanuja Chitnis, MD
November 2011
Q: My 25 year old daughter was diagnosed with MS in 2005. MRI's showed a lesion in her brain and one on her spine. A current MRI does not show those two but shows a different lesion in her brain. She has had two exacerbations since the original diagnosis and her symptoms from all three are still with her. Is it MS and why does she have symptoms if the lesions have gone away?
A: Sometimes in multiple sclerosis, MRI lesions can decrease in size or go away completely. Sometimes treatment with intravenous steroids at the time of a relapse can help this process. Although this is a good sign, it doesn't mean that the MS has gone away completely. Your daughter still remains at risk for future relapses and new MRI lesions.
Tanuja Chitnis, MD
November 2011
Q: When I was diagnosed with MS in 2009, they found 6 lesions, then i had another MRI and found that i had 2 more lesions, to make a long story short, i now have over a dozen lesions. is this a lot? How many lesions can a brain have?
A: The brain can have a great many lesions in ms and if they are not in eloquent areas they often produce no symptoms. The development of 2 new lesions in the past 2 years suggests relatively mild activity. If the diagnosis is definite then a disease modifying agent should be strongly considered. I hope this response is helpful and should be discusses with your neurologist.
Arthur Safran, MD
October 2011
Q: My friend is 38 and was diagnosed with MS 8 months ago. Since her diagnosis it seems like she is getting worse, not better with flare ups every few weeks. One thing she mentioned is that she had something like 6 lesions at diagnosis and now has 14. Is that more than twice as bad?
A: Your friend should ask her neurologist these questions. If she is having flareups every few weeks, she may need a change in her medications. However, the episodes of worsening may not all be flareups. Often, symptoms may worsen temporarily, related to such factors as heat, infection or stress, without there being any new damage to the nervous system. An increase in numbers of MRI lesions usually does indicate worsening, although there is not an exact correlation with the absolute number; i.e., 14 lesions are worse than 6, but not necessarily twice as bad.
James R. Lehrich, MD
August 2011
Q: In December, 2005 my 12 year old daughter got sick with symptoms similar to MS. She fully recovered in 2 weeks, and then contracted optic neuritis. There were no bands in her Spinal fluid. In June of 2006 she had another flare-up, and MS was confirmed. She spent months in the hospital, was discharged, and by January 2007 began to experience memory problems. By June 2007, she had almost no short-term memory. She is currently on Rebif, after trying Avonex and Cytoxen and high dose steriods. Her MRI shows many lesions on the frontal lobe causing severe cognitive delays among other things. Can these brain lesions be reversed or go away?
A: Brain lesions in children with MS can sometimes decrease in size during the acute phase of a relapse, or close to the time that they start. Intravenous steroids administered at the time of the acute attack can help with this process. However, the brain lesions that remain after this acute phase are generally more permanent. Sometimes, with time and prophylactic MS treatments like Rebif, Avonex or Cytoxan, can help to reduce the size of the lesions. We also think that with time, the brain "rewires" itself, and new connections are formed. We are not sure to what extent this happens in children with multiple sclerosis, and this is an important area of research which is being undertaken. Supportive services in school and at home, as well as cognitive rehabilitation can help with "rewiring" and the formation of new connections.
Tanuja Chitnis, MD
October 2009
Q: My fiancé has a contrasting lesion in the left temporal lobe that has been seen on his last 3 MRIs. This is in addition to multiplother lesions seen on the MRI. What does this mean in relation to his MS? Is this more severe brain damage?
A: If your fiancé's MRI continues to be contrast positive after 6 months, it may simply that there is another condition rather than MS. In general, a positive contrast study implies active inflammation and most revert to contrast negative over months. It is not a reflection of the degree of "damage" but rather reflects changes in the blood brain barrier usually caused by inflammation.
I would suggest asking the doctor to review the actual films with you and your fiancé. Some neurologists use serial MRI tests to help plan treatment programs and this information might effect decisions on whether further tests or consultation at an MS center might be helpful.
Q: Can you explain an active lesion versus a plaque? Is an active lesion also a new lesion? Can a plaque become an active lesion?
A: An active MS lesion is one in which there is ongoing inflammation around the blood vessels in the lesion, with impairment of the blood-brain barrier, as indicated by enhancement of the lesion on MRI after gadolinium injection. A plaque is a zone of damaged myelin in the brain or spinal cord. It can be old or recent. Recent plaques are usually active for up to a few weeks. A plaque can subsequently enlarge, with active inflammation around its periphery.