Ask the Experts: MS Lesion Questions
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Q: Can you have lesions in other parts of your body other than your brain and spine with MS?
Q: I have had lupus for 10 years now, and for the last 8 months I have been experiencing numbness on the left side of my face and hand and leg. The doctor gave me an MRI and it showed a lesson on the left side of my spinal cord. They can't rule out MS. I was tested for MS before and it was normal. Can I still have MS? Also can I have both lupus and MS?
A: Lupus and MS often share symptoms. Either can cause lesions in multiple sites in the brain and spinal cord. It is likely that you have only one of these conditions and at times they can be difficult to differentiate.
I hope this is helpful.
Arthur Safran, MD
November 2012
Q: I was recently told that I have two lesions, one at the bottom of my spine and one at the top. What type of problems can I expect? Do inactive lesions cause everyday problems? Are spine lesions just as normal to MS as brain lesions?
A: It depends on what the brain scan shows. If that shows no lesions, and you have only the two spinal cord lesions, then the following points apply:
- Some patients actually have an "MS-look-alike" named neuromyelitis optica. That has a different prognosis, and a different kind of treatment. Your neurologist can order a blood test for that.
- If you don't have that, and do have MS, and your brain scan shows no lesions, them most patients like you do quite well---better than the average patient with MS. Spinal cord lesions often are not symptomatic, they are just found by chance. And they often go away or become less obvious with time.
- The symptoms connected with spinal cord lesions are numbness, tingling, or tingling when the neck is flexed, and unsteady walking. Or, as mentioned, no symptoms at all---just found by chance.
David M. Dawson, MD
October 2012
Q: I have a lesion in my corpus callosum (and other brain and spinal lesions). My doctor said that a corpus callosum lesion is always attributable to MS. Can anything else cause a lesion in the corpus callosum (like migraines)?
A: While lesions in the corpus callosum are especially seen with MS they are NOT seen exclusively in MS. This is where the clinical context is very important, because the other potential causes of lesions in that location might have very different clinical presentations from MS. If the history and exam are suggestive of MS, then lesions in the spinal cord and multiple brain areas as well as the corpus callosum would be very suggestive of MS.
If the history suggests a single event (or no actual event of symptoms) then one alternative explanation might be a single "event" of demyelination involving multiple parts of the central nervous system. This is called a "clinically isolated demyelinative syndrome". Many (but not all) patients with this condition do turn into MS later. Migraine does not cause lesions in the corpus callosum, but (rarely) other conditions might do so. Most of these (e.g. tumors, infections, etc) would appear clinically distinct from MS and would not be a cause of confusion about the diagnosis.
Peter Riskind, MD., PhD
October 2012
Q: I just turned 25 I was diagnosed about 3 years ago with MS, and shortly after epilepsy. My MRI showed more than ten lesions about the size of a nickel. My short term memory is shot and I have balance problems. How fast is this progressing?
A: It sounds like you may be having a relapse, which may respond well to a course of intravenous steroids. Relapses in the early stages of disease often recover with minimal disability. You should follow up with your neurologist about this issue.
Tanuja Chitnis, MD
September 2012
Q: During MRI (for hyperprolactinemia) I was shocked to discover multiple lesions on my brain. This was 7 years ago and I had no MS symptoms before or since - neurological or otherwise. I have MRI every 2 years but still - no change and no symptoms. JUST LESIONS. What are the chances I will develop MS? By when?
A: There are many reasons to have MRI abnormalities which resemble those seen in MS, including migraine, prior infections, and a difficult birth among others. While it is true that some people go thru life with MS which is found at autopsy after an accident having caused no symptoms in life, there is very rare.
Other confirmatory tests could be done to attempt to establish a certain diagnosis if indicated after a careful examination by a neurologist. A second opinion in an MS center might be helpful. You might consider discussing the idea with you physician.
Arthur Safran, MD
September 2012
Q: Is a lesion from my C2-C5 too long to be an MS lesion or is it more likely to be NMO- neuromyletis optica?
A: MS patients can have long lesions in the spinal cord, particularly if multiple smaller lesions "coalesce" into a single long lesion. SO, the length of a lesion from C2-5 is not by itself sufficient evidence to make a diagnosis of neuromyelitis optica (NMO). Having said that, the NMO blood test is not perfect- it will miss about 30% of patients that actually have NMO. THEREFORE, the distinction between MS Vs NMO should be made by an MS specialist, with knowledge of the exam, history, labs, and MRI's (all taken into consideration). If you need help locating an MS Specialist in your area, pleas call the Soceity's Information and Resource line at 800-344-4867, and ask for the names of MS Specialists in your area.
Peter Riskind, MD., PhD
August 2012
Q: I believe I have been having migraines. I usually get a blurry spot with squiggly line & then a headache. This last time I had only the eye problem in my right. It lasted about 15 minutes and went away no headache. About 30 minutes later it started in my left eye and lasted about 15 minutes still no headache. I went to the Dr who ordered a CT scan. It came back showing a vague hypdensity in the left periventricular white matter abnormal for my age (31). So I had to get an MRI. The MRI Impression says Multiple corpus callosum, periventricular, and subcortical foci o abnormal T2 and FLAIR signal w/o contrast enhancement concerning for a demyelinating disorder such as MS....Is it possible that these lesions are from migraines or are these prime areas for MS?
A: Patients with migraine sometimes have white matter lesions on MRI, but the report you describe sounds more suggestive of MS lesions. You need to have this evaluated by a neurologist, who should be able to establish the diagnosis. Should you need to find an MS specialist in your area, please contact the Society's Information and Resource Center at 800-344-4867, and ask for the names of MS Specialists near to you.
James R. Lehrich, MD
August 2012
Q: I’m a 30y.o. male. After some numbness throughout my whole body, and an ER visit, i got MRI's done of the brain, spine, and neck areas. The spinal cord shows one lesion and the brain shows one lesion. My Neuro quickly jumped to MS without even seeing results from the lumbar puncture. Those results came back normal, but he still wants me to start treatment for MS. I have a 2nd opinion scheduled in 2 months. Should I start treatment before i get my second opinion? The numbness has gone away.
A: The answer is complex. It would be useful to know if the MRI studies were made with and without contrast enhancement (gadolinium) so that the lesions could possibly be dated. Separation of time and space is a useful criterion for making the diagnosis of MS. Secondly, the results of the spinal fluid examination cannot be evaluated without knowing which tests were done.
I agree with your plan to have a second opinion since it is always helpful to have more than one view if there is any question of the diagnosis. Ask your neurologist about the urgency of starting treatment. The possibility of another episode which might not clear so easily is certainly a concern and the risk may be reduced by medication if MS is present. Most neurologists would agree with the advice you are being given even if the event was an isolated one, particularly in the face of more than one lesion.
Arthur Safran, MD
August 2012
Q: How many days or weeks do new lesions remain active, so that they will show-up as bright spots indicating current disease activity on gadolinium-enhanced mri scans?
A: generally 3-6 months. I hope this is helpful.
Arthur Safran, MD
August 2012
Q: I am 45 years old and diagnosed with MS in 2007. In June I became completely paralyzed waist down, weakness in my trunk and arms, no bowel/bladder control. My MRI showed 5 spinal lesions, the highest at C8. At this point I have not gotten any better and my neurologist is recommending use of chemo drugs. Have you seen much success and do you think I will get any return of function?
A: The purpose of the proposed drugs is generally to attempt to prevent or modify further damage. Most improvement after an attack occurs in the first 4 months, but further recovery is certainly possible even after that period of time. Much depends on what type of the demyelinating disorder is present and whether the new lesions are largely inflammatory.
I hope this is helpful.
Arthur Safran, MD
August 2012
Q: I was diagnosed with MS in 2007 & have only had a couple of exacerbations. Now I'm having trouble with my legs & feet not to mention a headache for a week. My MRI of the brain is not showing any active lesions. Could the trouble I'm experiencing with my legs be due to lesions in my spine?
A: Neurologists decide if you are having a relapse in two ways—changes in the MRI, especially with new and/or enhancing lesions—or by a sudden change in symptoms. The latter way is less accurate, but certainly a small spinal cord lesion can make your legs feel heavy, or a small (basically invisible) lesion in the brainstem can make you dizzy. Of course it is possible that you have something else causing your new symptoms—such as a slipped disc—but it sounds like MS to me. I hope you are taking one of the disease-modifying drugs. With only a few exceptions people with relapsing MS should be under treatment.
David M. Dawson, MD
June 2012
Q: I have had MS for 7 years and have MRIs performed annually. I have taken disease modifying drugs since diagnosis. I have not had any new symptoms (or any symptoms at all) but my most recent MRI showed a new lesion. Does this mean my disease is progressing? Is my medication no longer effective? Should I change anything?
A: In general the answer is to persist in the current treatment plan unless there is some other evidence that you are resistant to the current medication. None of the current disease modifying drugs cure MS. The development of a single spot without clinical effects is generally not considered a drug failure. Seven years without new symptoms and a single spot which might not even be MS should be considered an excellent response. Your neurologist might wish to repeat the test in 3-6months with a dye (gadolium) to more completely understand and define the situation.
I hope this is helpful.
Arthur Safran, MD
May 2012
Q: Earlier this year I started seeing a neurologist due to constant migraines that would last for weeks on end as well as numbness and tingling in my legs. I had a brain MRI w/o contrast that showed "very tiny and right anterior frontal linear white matter lesion, probably an atypical perivascular space though sequela of migraines is also possible.... The doctor feels they can rule out MS because the brain MRI is normal. Is it possible to have lesions on the spine and not the brain?
A: "It is possible that a lesion of the spinal cord could be a cause of tingling in both legs, whether the lesion were from MS or another cause. In the situation where a spinal cord lesion is causing the symptoms, it would be quite possible that the brain MRI would be entirely normal. So, to directly answer your question, you may still need to have MRI of the cervical and thoracic spinal cord -IF the examination and history do not point clearly to a problem in the "peripheral" nerves (i.e. the nerves in the legs, outside of the spinal cord). A neurologist usually is able to determine (by history and exam) whether the problem is likely to be from a lesion of the spinal cord versus the peripheral nerves. A peripheral nerve problem (confirmed by an EMG) would NOT usually require more MRI's to evaluate the spinal cord."
Peter Riskind, MD., PhD
May 2012
Q: I've had 5 MRI's, 2 lesions w/no changes in the last year, but my symptoms continue to progress over last 4 years. Most are treated with medications, no disease-modifying medications..........I had severe electric shock pain in upper body, controlled by neurontin and ultram, severe spasticity controlled by 3 medications. I'm still only listed as "Probable" MS rather than definite due to no changes on MRI. Question is can my unchanged lesions still cause exacerbation of current smptms without 2 lesions being "active" or inflamed?
A: This is a tough situation. From your description, I would imagine the trouble is coming from your upper spinal cord. That would account for your stiffness, the sensory symptoms over the upper back, and difficulty walking. You don't mention where the two MS-like lesions are. If they are in the brain they do not account for your symptoms. However, imaging the spinal cord is not straightforward, and you can have a lot of symptoms and little to show for it by MRI other than spinal cord atrophy.
I can see why your neurologists are reluctannt to use Disease Modifying medications(DMA). You may in fact have primary progressive MS for which the DMA's have shown next to no effectiveness. There are some----a few----primary progressive MS patients who have very little MRI abnormality even though symptoms are increasing. Have you had a lumbar puncture? It is indicated. And the neurologist might want to consider a spinal angiogram to look for abnormal blood vessels. Some of the MS centers are usisng rituximab and daclizumab on a trial basis, for situations like this.
David M. Dawson, MD
April 2012
Q: I was diagnosed with MS in 2002, in 1991 it was questionable as I only had 2 lesions. Six years ago, I was told I have over 30. The past four years no new lesions have formed. The past four years the mri was in the older version mri machines. My question is, is the newer version machines any better at finding lesions? I have been having more issues, not severe, but was very surprised at my last mri results. I really was expecting it to be quite a bit worse.
A: The short answer is yes, the newer equipment is more sensitive and accurate than older models. The absence of new lesions after 6 years is in general good news, however it is not uncommon for MS to progress without the MRI showing much in the way of change as over time the pathology changes from its initial inflamatory nature. It would be helpful to understand what changes you are experiencing to more fully answer your question. I assume you have described those changes to your neurologist. Finally, the presence of MS does not exclude the possiblity of other causes for different/new symptoms.
I hope this is helpful.
Arthur Safran, MD
April 2012
Q: At the age of 32 is 30 lesions in the brain a severe worry? I was diagnosed with epilepsy in 2010. In April 2011 they did an MRI and found about 30 lesions and one was active, and was diagnosed with MS. I have experienced pain since my teens. The doctors put a spinal cord stimulator in my back thinking my endometriosis was pushing on nerves to my back. I am curious if 30 lesions is a lot to have. I have not read one article with a person having that many.
A: You should ask your neurologist about the particular features of your MRI. 30 MS-type lesions in the brain would be considered numerous, but the size, location and absence or presence of enhancement of the lesions also need to be taken into account.
James R. Lehrich, MD
April 2012
Q: I have been diagnosed with lesions in the brain and in both the cervical and thoracic spine. I have had no symptoms in the past year but went for my MRI last night...of only the brain to monitor for disease progression. If there are no new lesions in the brain are we to assume there are no new lesions anywhere?
A: Unfortunately that is not a safe assumption. Many lesions can be so small as to avoid MRI detection. The absence of detectable lesions (especially if the MRI is done with contrast enhancement-gadolinium) is that it implies that the MS is not active, or minimally active. That is a positive result which suggests that you have been on a good course. It does not however guarantee the future. I hope this is helpful.
Arthur Safran, MD
April 2012
Q: What is the biggest and smallest volume of an MS lesion seen on MRI in the white matter, spinal cord and optic nerve observed on MRI? what are the most common complications of Secondary Progressive MS?
A: The size of the lesion that is visible on MRI depends entirely two factors—on the location—easiest to see in the white matter of the brain, and the power of the magnet. Higher "Tesla" magnets see smaller lesions. In general, lesions of 3 mm. or more in size can be seen with ease.
Commonest complication of secondary progressive MS is trouble walking.
David M. Dawson, MD
April 2012
Q: I am a 46 year old female. 15 years ago, I had a post-strep infection that resulted in daily complex migraines for 2 weeks. Steroids cleared the migratory arthritis and migraines. I have had bouts of numbness in extremities. The initial MRI showed a possible lesion and the follow up was clear. I also have constipation issues. I was admitted to the hospital recently due to numbness in my right arm. An entire battery of tests were normal except the MRI which showed bifrontal T2/FLAIR abnormalities in the white matter. It was explained as scattered patchy bifrontal subcortical and deep white matter T/FLAIR signal abnormalities. But in the impression it included chronic ischemic change and migraines with a pattern not typical of demyelinating disorder. So, my question is, if my MRI 15 years ago was clear, no lesions and I haven't had a migraine in that time, why now all the lesions?
A: Can you develop "migraine white spots" in your brain even though you don't have recurrent headaches and other migraine features?
I believe the answer is yes. The white spots are not that well understood. In MS, they are local areas of inflammation, but in migraine, or people with high blood pressure, they are probably not inflammation, but just a small leak of fluid from a blood vessel. And you can have a leaky blood vessel even if you don't have headaches. Once there, they tend to stay thee. Sometimes they are so small that they are missed if the MRi image can bypass the, but usually, they stay there permanently.
Most of the white spots that you see in MS pateints look quite different. It is rare not to be able to disinguish MS from migraine by MRI.
David M. Dawson, MD
April 2012
Q: Can you have lesions in other parts of your body other than your brain and spine with MS?
A: MS only affects the central nervous system, the brain, spinal cord and optic nerves, but not other parts of the body.
James R. Lehrich, MD
April 2012
Q: Do most people with MS have MRI's that show lesions on the brain? Would a MS flare-up be 100% detectable on an MRI. That is, showing abnormal lesions?
A: This requires a complicated answer:
1. Over 95% of patients with active MS have abnormal MRI's cans, showing the lesions, whether old or new. Maybe higher than 95%, close to 100%. But these lesions may not match up with symptoms. Making a diagnosis of MS is a rarity if the MRI scans, inclluding the spinal cord, are completley normal.
2. The few patients with normal MRI's are
a.. Very early patients, with only a few tiny lesions in the spinal cord, or
b. . Patients with primary progressive MS, who are often very difficult to diagnose.
3. If you are a patient with established MS, you probably have a lot of lesions, and a new attack of MS (clinically apparent) can be hard to pick up because there are already plenty of lesions present. This can be particularly true if the lesion is in the spinal cord, where a small lesion can cause a lot of symptoms. A neurologist may tell you have a new lesion, even if the scan doesn't show it, especially if you have an MRI showing quite a few lesions already.
4. So you can have new lesion, without anyting new visible on MRI. But it's a rarity.
David M. Dawson, MD
February 2012
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.