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What do these MRI findings indicate?

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Neurologist
Practicing since : 2004
Answered : 3044 Questions
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Hi Doctor,
I asked you a few weeks ago about hyperflexia in the knees. I thought I only had it in the knees but I apparently have it in the ankles as well (I'm not sure about the biceps or arms). I am curious if you could give me insight into MS.

I began having MS-like symptoms two years ago (though I'd had them off and on a bit before). They were dizziness, pins and needles, vision issues, and restless leg issues. I thought that I had a sinus infection because I always get dizzy when I have those and I had a headache as well. My doctor ordered a brain MRI just to see if anything was going on. I have had two others since and I will copy the report below:

First MRI in Dec 2015: There are several small foci of abnormally elevated T2 signal in the white matter bilaterally. One focus of elevated T2 signal is located in the left centrum semiovale. There is also a small focus of subcortical T2 signal abnormality in the right temporal lobe. Finally, there is a small focus of abnormal T2 signal in the left periatrial white matter. The brain parenchyma otherwise shows normal signal intensity throughout.

The remaining white matter structures are normal. There is no intracranial hemorrhage, mass effect, midline shift, nor extra-axial fluid collection identified. No diffusion abnormalities are seen to suggest recent ischemia.

Second MRI in 2016: A few (less than 10) ovoid foci of FLAIR hyperintensity are present in the bilateral supratentorial periventricular and subcortical white matter are unchanged compared to the prior study. No new demyelinating
lesions are identified. There is no abnormal intracranial enhancement
to suggest active demyelination.

The third MRI from this year basically said the same thing (lesions are present but nothing has changed).

I was advised to do a spinal tap and opted against it. We are instead doing a wait and see approach.

Lately, I haven’t had a ton of symptoms except for pins and needles in my mid back. It’s usually around my left shoulder blade but sometimes spreads to the other side and even to the front of my chest (though it’s much mildler in the chest) and it almost feels like a band but it doesn’t hurt. It’s very fleeting and I don’t have it all the time but I get it most every day for a minute or so. It’s usually present whenever I take a bath.

My neurological exam exhibits clonus of the ankles, hyper-reflexia (especially in the knees), and a billateral hoffman’s sign described as “mildly positive.” I also have thinning of my retina but only in my left eye.

I do not have any cervical compression or any cervical lesions on the spine.

I am curious as to your opinion on whether this sounds like MS. I know you can’t say for sure one way or another, but I’m just curious. I also had an MRI in 2014 for the brain that was normal.

Fri, 27 Apr 2018 in General Health
 
 
Answered by Dr. Olsi Taka 1 hour later
Brief Answer:
Not convinced of MS

Detailed Answer:
Hello again and thank you for your confidence in me and this site.

I read your story and the MRI reports carefully. As you seem to understand yourself there is no clear cut answer. When in front of multiple white matter hyperintensities in a young female patient, MS is always among the first possibilities and it is still a possibility even after these control MRIs. As the term "multiple" in its name suggests MS can affect many different sites and as a result it may manifest in many different ways in different patients. There are also variations in the age of appearance and evolution. So again MS remains among the main hypotheses.
That being said I am not convinced it is MS. The symptoms would fit although several of the symptoms you mention are very subjective, the objective neurological findings usually would include something more than only the increased reflexes, issues such as double vision, optic neuritis, limb weakness, ataxia etc. I wonder if you have had evoked potentials testing which is non invasive and is done routinely if MS is suspected.
However more than from the symptoms I am not convinced from the evolution in time. You seem to have had no lesions at all in 2014, then suddenly several lesions inside one year and then no lesions for the next couple of years. Usually in MRIs of MS patients there are some silent lesions found even before the symptoms appear. Later on as it is a progressive condition new lesions appear, in particular considering you've had no disease modifying therapy. The lack of spinal cord lesions and reports not mentioning corpus callosum lesions is atypical as well.
For those reasons I wouldn't be convinced of an MS diagnosis. Other possibilities might explain those hyperintensities such as a past infection or vasculitis. The fact that you mention some headaches in the past would be in favor of that as well (not diagnostic though, headache can have many causes). It would have been very useful if you had hap the spinal tap at the time (it may be useful now as well but may provide less data if a past nonactive issue) as it would've provided important information. Now at this stage I would opt for a wait and see approach as well.

I remain at your disposal for other questions.
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