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Found two bilateral pontine hyperintensities in the pons. Numbness in upper lip and nose. Is it a stroke? What could cause bilateral pattern?

Nov 2013
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I have been going crazy for the last two years. In 2011 I had an attack where my left side face, ear, and back of head felt numb for approximately 4 weeks. It felt like someone injected me with novacaine. I went to the neurologist and they found 2 multiple ill defined bilateral pontine hyperintensities in the pons. One lesion was in pons and one in the dorsal pons. I had multiple mri's without contrast (due to allergies) and in 2012 one mri said the lesions were gone and I had a remarkable study. So I stopped going to the neuro. This summer August 2013, I was being treated for fibro? with rheumatologist I began to get numbness in my upper lip and nose. Gradually I became numb on the left side of face, ear, and back of head like in 2011 but this time I had leg numbness as well on left side. The doctor told me that I should go back to the neurologist because I was showing signs for MS. I was also checked for ana and came back positive with a low titer of 1:80 nuclear that fluctuates weekly however came back for all other ana tests.This time the attack lasted straight for 3 and a half weeks. I still get intermittent numbness however no chronic. I went to NYU and they feel that although I shows signs for MS these lesions did not look like the atypical MS lesions. I asked them if this could be a stroke they said no. I asked them if it could be a tumor they said no. However, the radiologist spoke to me on request and explained these lesions need to be monitored for life to make sure they do not turn malignant. She also kept implying that these are not tumors to further investigate MS. I also want to note that I had blood work done and my LD came up 218 when it should be between 100-200. On the front of the lab work it said that LD levels might be increased due to a problem with the blood was coagulated and spun. Now I am scared the LD could mean cancer, stroke, etc... Please help also can ill defined bilateral lesions in pons be glioma? What could cause a bilateral pattern? Please answer all questions I am at wits end!
Posted Sat, 2 Nov 2013 in Brain and Spine
Answered by Dr. Sudhir Kumar 2 days later
Brief Answer:
My replies are below

Detailed Answer:
Thank you for posting your query.

I can understand your concern on account of recurrent symptoms and lack of a clear cut diagnosis.

In my opinion, the most likely possibilities are demyelination or ischemia and not a brain tumour. The explanations are given below:

1. Demyelination: The most common condition to cause these recurrent symptoms and hyperintense lesions on brain is multiple sclerosis (MS), the commonest demyelinating disease of the brain. Myelin refers to the covering of nerves, and in MS, this covering gets damaged, hence, the term demyelination. MS is common in women and in young ages.

However, there needs to be multiple lesions in the brain including involvement of periventricular regions and corpus callosum to make a confirmed diagnosis of MS. So, at this stage, based on the pure involvement of pons, without involvement of other parts of brain (or spinal cord), we can not make a diagnosis of MS.

So, we need to follow you up and do a repeat scan after six months to see if any new lesions in brain have developed or not.

2. Ischemia- refers to lack of blood flow in the brain. This can result in hyperintense lesions in the brain, as in your case, however, typically they affect only one side of pons.
Moreover, ischemia or blood clot in the brain is uncommon at your age, in the absence of risk factors (such as diabetes, high blood pressure, high cholesterol or high homocysteine and smoking).

The MR angiogram of brain would be useful to exclude ischemia, as that would show narrowing of blood vessels in the brain.

3. Tumor- is unlikely as it would not disappear on MRI. You mentioned that one of the MRI s (the second one) showed normal brain and the pons lesion was not seen. This in unlikely to happen in a case of brain tumor, as tumors continue to grow and would increase in size over a period of time.
Also, the symptoms in a case of brain tumor would not resolve in 3-4 weeks, but they would continuously persist. So, I do not think these lesions are tumours including glioma.

Increased LD levels and positive ANA levels are possibly false positives, as they do not explain the clinical symptoms as well as the MRI lesions.

I hope it helps. I would be pleased to offer any help or provide you with any more information, if that can help you in any way.

Best wishes,
Dr Sudhir Kumar MD DM (Neurology) XXXXXXX Consultant Neurologist
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