Question: I have a number of specific questions about my MRI results. I received a quality evaluation from Dr. XXXXXXX and have enclosed each of the evaluations I have received for reference as well as the specific MRI images that help explain my specific questions -- I am attaching a pdf with images and questions as well as an image file containing the entire flair series.

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Are the small white ovals (2mm or so) in these flair images lesions?
Is the crescent shaped hyperintensity in an attached image a lesion of the corpus callosum?
etc.

Dr. XXXXXXX

I am pleased that you were able to answer my new questions. I missed the "follow up question" time and was afraid I my question would go to someone else.

I would be pleased to understand which image you saw the corpus callosum involvement.

Also, in your experience, do old lesions fade away or do they always stay hyperintense or become 'black holes' that I read about? Especially since so many of the lesions are so small, I am trying to understand if the MRI represents my all-time lesion load or if this is an ongoing scarring/healing/rescarring type of process.

I read somewhere in my research that often MRI misses MS lesions because it is unable to see the smaller hyperintensities (though example MS lesions I have seen are in the 10mm plus size range) -- I am wondering if since my brain lesions are so small, would the 1.5tesla images I have of the c-spine that were evaluated as "clear of lesions" be of questionable value and re-taken with the stronger machine used in this series?

As I see these white areas throughout the brain in smaller numbers, I am wondering if this is also common in ischemic disease? I have been unable to locate information on ischemic disease that discusses the numerous tiny lesions as opposed to large areas of bleeding. If they are ischemic lesions, would recently lesions be hyperintense on the contrast (gad) images similar to MS?

If these lesions are due to ischemic disease, could they still explain MS-like symptoms ( primarily my disabling fatigue and cognitive issues ) or do these lesions have a different impact on brain function altogether? And, if ischemic disease, what is the prognosis? I am not diabetic and I have only had blood pressure measured as high a few times in my life when I was under great distress and then a then recently a few times since April.

I was given a 100mg/day for two weeks prednisone course in May. Many of my symptoms improved considerably from this treatment. Does that indicate MS as more likely or could Ischemic damage/inflammation respond similarly?

I am glad that I was fortunate enough to have this question return to you.... I have one additional question on my NCV study. my lower extremity f-wave latencies were all in the 97-99 millisecond range. What do you think of this?

I apologize if I put too many questions in each correspondence, I have such a strong need to understand and my local neurologist can be less than willing to spend time addressing my list of questions. Understanding my disease and prognosis is so important. I am not afraid of bad news, I always invite the truth. Thank you so very much for your valuable time.

Dr. Kamur,

I would love to provide you with the entire MRI series if that is possible? I know I can only post a small number of files of limited size - I guess I can try zip the dicom folder for upload or is there another way that I could send you the images with contrast as well as t1 and t2, EG, etc...

You are far more knowledgeable than my local neurologist seems to be. I will try to upload a zip file now, I truly appreciate if you are able to take the time and point out specifics such as the corpus callosum lesion you mentioned earlier this week and anything else noteworthy that I need to be aware of to compare with future MRIs.

I truly appreciate your help and hope that I am not asking too much of your valuable time.

Dr Kamur,

You are incredible! I tried to upload the DICOM series and it appears that it failed. I will upload it to my own web server and send you a link. I will also include the T1.5 c-spine series in a separate file if you are inclined to view them to see if anything was missed.

My neurologist told me I had "5 or 6 small lesions" -- which is obviously not true. I am so thankful for you to be helping me.

I need to run an errand but will upload and send you the link when I am back in an hour or two.

I posted them to my website at the following link: WWW.WWWW.WW
Thank You!
Dr. XXXXXXX

I was looking at the flair series again and noticed something that I hadn't seen before. There (to my completely untrained eye) appear to be a number of small, similar ovals of high intensity in my cerebellum. They are most apparent in sagittal(series 7) #12, #10. Your thoughts on this?

If these are lesions, does the addition of infratentorial lesions increase the chance of this being demyelination? I'm referring to my limited understanding of the revised McDonald criteria's dissemination in space requirement.

I can't tell you how much I appreciate how helpful you are!

XXXX

I was a photographer before the fatigue got so bad... I think its detecting the ipad and serving the mobile version of the site. since my site is blocked at work, can you share an email address so I can use dropbox to share? I will be home in 5 minutes and can repost to another url. sorry about that. and thanks for the compliment on my work

I uploaded and sent via dropbox. You should have the links by now. Don't hesitate to contact me directly via my personal email, YYYY@YYYY

Again, Thank You.
Hi Dr. XXXXXXX

I just wanted to verify that you and your wife did receive the dropbox link and were able to download the images.

Thanks,
XXXX

Thank you very much for taking the time to review the entire MRI. I do have a follow up discussion:

How uncommon is an MRI that looks like mine for a 40 year old? Would small vessel ischemic disease also explain the larger lesions? Would occasional blood pressure spikes like anger and pain cause either type of lesion?

Could this kind of damage from small vessel ischemic disease cause the fatigue and any of the other symptoms I have been experiencing? (pain, paresthesia)

Is there any other explanation (other than MS) for the huge improvement I experienced in May when I took a course of prednisone?

Even though my blood pressure is usually not high, would it make sense to lower it with medication so that it doesn't spike as high just in case?

As I was thinking about my images, I thought of some things that I would like to rule out:
1. I was struck by lightning years ago. twice.
2. I practiced wrestling and martial arts and later raced motorcycles. Could this damage be from repeated minor injury?
3. Could this damage possibly be caused by many brief periods of hypoxia such as swimming underwater well beyond my limits?

Thank you so much, My family appreciates your help incredibly!
I'm sorry -- I thought of another question.... (Since you've seen my photography work, you know that I have a critical eye and would notice problems) -- my two eyes saw color slightly differently for a long time. It was extremely consistent so I thought it was just something that is fairly normal but I only notice it due to the critical color work I do... but after the prednisone, it went away. Of course I believed it was optic neuritis associated with MS, but am now trying to correlate if I don't actually have MS.

More than anything, I am wanting to know if my symptoms are caused by my lesions or if I'm still on my search for a cause. That is definitely the most important question. If so, I can just monitor my BP and watch for MS.

Again, thank you so much!

Thanks! I'd like to summarize to make sure I understand and have a concise summary to share with my primary care doctor.

The MRI findings are suggestive of either Multiple Sclerosis or Small Vessel Ischemic Disease, but it isn't possible to determine between them based on this MRI alone.

My major symptoms can be explained by the lesions regardless of the cause of the lesions.

Suggested course of action: Relax. Exercise. Manage Stress. Consider treating BP to a goal 100/70 as preventative measure in case cause is ischemic. Re-evaluate in 6 months with MRI. If symptoms change, consider evoked potentials and lumbar puncture as well.

Prognosis: There are no active lesions, so my current condition will not likely improve greatly beyond today's baseline. If ischemic, stress management should prevent or reduce future lesions. If MS, there's really no way to know when lesions will occur or what they will affect. In either case: stress, exercise, and diet are extremely important.

Thank you so much for all the time you have spent on my case. If I have this correct, I will close the discussion and give you a well-deserved 5 stars.