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Nitin Sethi, MD
Braindisease's Weblog 
Dr. Sethi, I loved your article about MRI and the possible diagnosis of MS I was and still am worried since I had tingling, heaviness of the left side of my body at first they said it could be TA, then they told me about the chances to be MS, since on my MRI it shows a single punctuate focus of high T2 signal in the subcortical white matter of the superior frontal gyrus of the right frontal lobe and an additional single punctuate focus of high T2 signal in the periventricular white matter adjacent to the frontal horn of the right lateral ventricle. No additional significant signal abnormality of the brain parenchyma. No evidence of acute ischemia on diffusion weighted images. Now I was low in vitamin B12 and had history of migraines and they told me that could also be the reason of those two punctuate on my brain. I was released with no specific diagnosis since I had done a spinal tap to make sure if it was ms. I just saw a neurologist she said for all my history and the tests of the spinal tap ( Oligoclonal banding – CSF result was negative and the IgG Index – CSF is 0.53 which my neurologist said is normal) she concluded that the possibility of having MS is very low. I am still worried since I had a kind of the same symptoms like the needles sensation here and there in my left arm and the discomfort like in the bones in the same arm and pain in the joint of my arm which is weird and vary from the other and the needle sensation is not like when I was in the ER. what worries me is because it is in the same side left always. Now, the Neurologist found on my labs ANA Titer (a) 1:160 and ANA Pattern (a) SPECKLED, she asked me if they mentioned me about lupus I said no so now I am referred to a Rheumatologist to make sure it is not that or something else….I know lupus is bad but not progressive as MS and can be treated but still worries me the two punctuate in the brain and the lighter same symptoms in the same side…I am afraid about MS and praying God not to have that or lupus wish it will be just a rheumatoid arthritis and that’s it since my joints bothers and like the pain in the bone but just on the left arm…. This is killing me and guess because of reading a lot of articles about MS made me paranoid about the MS what u can advice me to help me out feel better but hey reading your article helped me somehow a lil bit….hope to read your response soon… thanks
Dear Elizabeth,
thank you for writing in to me. I am glad you found the post helpful. My advice to you would be to remain in follow up with your neurologist. As I have stated in my posts on multiple sclerosis NOT all white matter lesions on brain MRI represent multiple sclerosis. The diagnosis of multiple sclerosis is based on history, examination findings and if needed the results of tests such as MRI of the brain and cervical spine, CSF (spinal fluid) results and other tests such as visual and somatosensory evoked potentials. As for the ANA, your titers are low and again this has to be interpreted taking your history and examination findings into consideration. The ANA titer may also be a nonspecific finding. So follow up with your doctor. I send you my best.
Personal Regards,
Nitin Sethi, MD
hi Dr. Sethi
Thanks for your reply, yes I do have a follow up with my neurologist in six months and have also scheduled a MRI then so the Dr. can make sure it did not developed more. When I saw my neurologist she said by my history, and exam that she did that day everything was fine and that the posibility of MS was low she said that because she did not had my MRI from my head but I send it to her and she called me and said that by looking at them the white spots were very tiny and that from where they were located she did not seem to be associated with MS and now I have to see a Rheumatologist to make sure it is not lupus and I kind of expect that it could be arthritis for the symptoms I am having which comes and goes sometimes it bothers a lil bit sometimes it just feels weird and all the time is on my left side one day is on the toe, the other in the joints, the other in the shoulder or upper arm but I been fine just today I had a some disconfort on my upper arm and toes.. This is crazy and I still have to wait for my appt which will be on next month. As for the Oligocional Banding -CSF it came NEGATIVE and the IgG Index-CSF 0.53% which my neurologist told me is on the normal range and the MRI of my cervical spine is normal I reviewed it with her and she said it looks beautiful all normal, and my pupils were normal and that I do not have to worry about based on that I felt better but still somewhat worried until the rheumatologist see me and finally see what it is, since I have this weird funny pain not pain it is hard to describe but bothers, and yes I hope and pray I will be fine… thanks once again
8/11/2011
Thank You for creating your site! I will get to the point so this isnt any longer. I noticed my left eye viewed everything dimmer, went to Optometrist, he found atrophy. ( Vision problem in left eye but he saw damage in right eye) He sent me for MRI, I will post at end of this. He read it.. He said 2 lesions like 20% MS and 10 Lesions 50 % ( I am only guessing right now the exact percentages, dont remember exactly the %’s) He than said I had too many lesions to count. I have had slight balance issues, numbness in left arm and leg, when I have to go to the bathroom its right now, hurry ( but if I dance around a minute I can hold it, I drink lots of ice tea) memory issues and understanding conversations difficult ( have always been that way) Calf and ankle once in awhile cramp to where my foot is lifted and turned a bit, really hurts, ( seems when I lay on right side on couch and when feeling dehydrated.) Three days ago head felt like someone gave shot of novocane, some times head feels to heavy for neck. My neck is extremely stiff. I hear squishy sounds ( like the sound when milk is poured on rice krispies) when I turn neck left and right. Lower back pain going left to right. Feels slightly like when I got kidney stones years ago. Pain level on scale of 1-10 is like 2 so shouldnt even call it pain as much as streched feeling? One or two months before this I had horrible very back left tooth infection (tooth was pulled) Same time I had sinus infection. ( I still feel like somethng draining down into my throat) I have mild aortic regurgitation. I thought maybe sinus infection spread to brain but MRI showed all that clear ? I for obvious reasons dont want this to be MS. Hypothetical…*Is there a realistic chance this is something else. Tommorow I get spinal tap but will take three weeks for results. ( what if it is infection wont that be along time to wait?) I still havent seen Doctor other than eye Doctor nor will I until results back from spinal that confirms MS, than the Optometrist will refer me to University of Utah per my request. I live in very small town and Medical Help is very limited. In my opinion the chances of this being MS is 90%. Im not really believing it to be anything else just hoping. If it is I will deal with it well. I still would like to know how likely something else…P.S. Father had Diabeties, I am a chochoholic and sometimes I will feel a little sick and actually feel like I need chocholate. I am always tired but always have been, Have always been housewife now with kids grown. ( I think I am suggesting I have not had alot of excersize) The Longer I write these symptoms the more stupid I feel for trying to think its something else. Thank You for reading this and will appreciate response. I know without testing me and all you cant make diagnosis so Im requesting hypothetical answers with realistic outcome.
FINDINGS…MRI OF THE BRAIN SHOWNS NO EVIDENCE OF ANY HEMMORAGE OR ACUTE INFARCTION. NO SHIFT IS NOTED. NORMAL FLOW VOIDS ARE SEEN IN THE INTERNAL CAROTID ARTERIES AND THE VERTEBRAL BASILAR SYSTEM. THE VISUALIZED SINUSES ARE CLEAR, AS ARE THE MASTOIDS. THE BASE OF THE BRAIN IS UNREMARKABLE AND THE PARASELLAR AREA APPEARS NORMAL.
ON THE FLAIR IMAGING, THERE ARE MULTIPLE BILATERAL HYPERINTENSE AREAS DEMONSTRATED.
THESE INVOLVE THE LEFT CEREBELLUM, RIGHT AND LEFT FRONTAL, DEEP WHITE MATTER, AS WELL AS THE LEFT PARIETAL AREAS AND IN THE PERIVENTRICULAR REGIONS AS WELL, ESPECIALLY ADJACENT TO THE LEFT FERTILE HORN IN THE MID AND POSTERIOR ASPECT. THE LARGEST ONE IS ABOUT 6 MM IN THE LEFT OCCIPTAL LOBE. NO ENHANCING LESIONS ARE SEEN.
MRI OF THE ORBITS SHOW NO DEFINITE MASSES. CANNOT SEE ANY DEFINITE ABNORMALTIES ON THE FLAIR IMAGING. ORBITAL STRUCTURES ARE GREOSSLY INTACT. OPTIC NERVES APPEAR UNREMARKABLE,EXCEPT ON THE POSTCONTRAST SCAN THERE IS AN AREA ALONG THE POSTERIOR ASPECT OF THE EFT OPTIC NERVE BEFORE IT GETS INTO THE INTRACANALICULAR PORTION. IT MEASURES ABOUT 3 MM IN DIAMETER. NO OTHER ABNORMALTIES ARE DEMONSTRATE.
THE FINDINGS IN THE OPTIC NERVE AND THE BRAIN CERTAINLY COULD BE DUE TO WHITE MATTRER CHANGES, SUCH AS MULTIPLE SCLEROSIS. NONE OF THE PLAQUES IN THE BRAIN ARE SEEN TO ENHANCE.THESE FINDINGS ARE NOT SPECIFIC AND CERTAINLY CLINICAL COPRRELATION IS SUGGESTED. THE OPTIC NERVE ABNORMALTIES COULD ALSO BE ENHANCING PLAQUE, OR THE PATIENT COULD HAVE OPTIC NEURITIS DUE TO OTHER CAUSES AS WELL. THIS COULD BE FOLLOWED WITH MR.
IMPRESSION MULTIPLE BILATERIAL PLAQUES SEEN PRIMARILY IN THE WHITE MATTER AND ALSO ONE IN THE LEFT CEREBELLUM; MORE ON THE LEFT SIDE THAN THE RIGHT WITH NO ENHANCEMENT SEEN IN ANY OF THESE. ETIOLOGY IS UNCERTAIN; CANNOT RULE OUT ANY KIND OF ETIOLOGY FOR THE WHITE MATTER DISEASE, INCLUDING MULTIPLE SCLERSOSIS.ENHANCING AREA IN THE LEFT OPTIC NERVE POSTERIORLY BEFORE THE INTERCANALICULAR AREA COULD REPRESENT OPTIC NEURITIS. IT COULD ALSO BE DUE TRO MULTIPLE SCLEROSIS, BUT AGAIN ETIOLOGY IS UNCERTAIN. CERTAINLY CLINICAL CORRELATION IS SUGGESTED. THIS SHOULD BE FOLLOWED WITH MR.
I want to add I am 49 years old
Dear SD,
thank you for writing in to me. To maintain your confidentiality I have removed your whole name and hidden your email address. Like I have urged before to the readers of my blog, if you do decide to write in to me please please change your name (use an alias) and create a new email id. Now to answer your question. Your MRI scan certainly raises concern for a demyelinating disease such as multiple sclerosis. That said (as I stated in my post) the diagnosis of multiple sclerosis is made based on history (history of two clinical attacks separated in time) and examination findings (neurological examination suggests that the disease process is disseminated in space meaning that the clinical findings cannot be explained by a single brain lesion). If this dissemination in time and space cannot be documented by history or examination findings then your doctor may request further tests such as MRI of the brain and spinal cord, spinal tap (lumbar puncture) to look at the spinal fluid and other tests such as visual evoked potentials (VEP) and somatosensory evoked potentials (SSEP).
So my advice to you is this: follow up with your doctor. He and the neurologist shall help determine the significance of the MRI white matter lesions. If you need any other advice, please feel free to write in again to me here.
Personal Regards,
Nitin Sethi, MD
I am 20. My symptoms consist of visual floaters, balance issues, dizziness, vision loss, double vision, numbness and pain in my left leg, pain in my right arm, tingling in my hand. Went to the doctor, they did head CT, saw spot. Sent me to neurologist, did an MRI, spinal tap, and blood test. Saw deep white matter lesion in left frontal lobe. Spinal tap and bloods were normal aside from increased protein and neutrophil levels and decreased lymphocyte levels. Said they don’t know, still a possibility it is MS. Where should I go from here?
Hello. I have a question. I am a 30yo female with history of Epilepsy (confirmed by EEG). I have recently had breakthrough seizures (despite good seizure control previously, using Dilantin) due to pregnancy/recent delivery. This last time, I had a seizure and was transported to the ER via EMS. A couple hours after I got to the ER, they gave me Ativan IV. A couple minutes after that I had a pseudoseizure. This isn’t the first time this has happened after getting Ativan IV. If I get the Ativan while seizing, this doesn’t happen. Is this common? Why does this happen?
Interesting question Kate and for which I do not have a good answer. Ativan is a strong sedative as well as a quick acting anti convulsant when pushed IV. Some patients have both true seizures as well as pseudoseizures. The pseudoseizure may be induced by suggestion–as when the patient is given normal saline.
Nitin K Sethi, MD
Hello Doctor.
Thanks for your great blog which could be soothing and assuring in many occasions. I have a question about my MRI report. There is a one sentence that I’m wondering what does it really mean: “There is no evidence of acute intraparanchymal hemorrhage no significant extra-axial collections are noted flow voids are maintained within the internal carotid arteries bilaterally as well as within the vertebrobasilar system.” This a long sentence! but my concern is about “flow voids”. Are they normal? or in normal state?
I’ll appreciate your help.
Regards
V.
Dear VS,
thank you for the words of encouragement. Now to your question. Flow voids are “normal” and are in fact artifacts which appear on the MRI scan and represent flowing blood in a major artery such as the internal carotid artery. The other part of your sentence basically states that there was no bleed (hemorrhage) seen in the scan either inside the brain (intraparenchymal) or outside the brain but inside the skull (extra axial).
Personal Regards,
Nitin K Sethi, MD
Dear Doctor.
Thank you so very much for your time and reply. Your answer was a quite relief.
You are very welcome Vahid.
Nitin K Sethi, MD
Sure V, i just did that.
Nitin K Sethi, MD
Hello. I have symptoms that started about 4 years ago that are now increasing and starting to worry me: I have an odd squishy sensation that seems to be in my head at the point where my skull attaches to the spine. I also have frequent bouts of dizziness or vertigo and on 5 or 6 occasions I have experienced a very sudden feeling like i am about to pass out but I never do. For a split second I feel like I’m passing out and falling to the left ( always the left) but I’m not actually moving, which is very worrying. The frequency of the squishiness and the dizziness is now daily and for longer periods of time. Any ideas what could be causing this?