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Dr. Andrew Rynne

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What does "ILL define CSF intensity small lesion noted" mean?

Answered by
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Dr. Dariush Saghafi

Neurologist

Practicing since :1988

Answered : 1764 Questions

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Posted on Wed, 20 Aug 2014 in Brain and Spine
Question: My wife MRI results show ILL define CSF intensity small lesion noted in left gangliocapsular region involving posterio part lentiform nucleus,external capsule and posterio limb. What does this mean to me?
doctor
Answered by Dr. Dariush Saghafi 2 hours later
Brief Answer:
Could be radiographic artifact based on symptoms

Detailed Answer:
Good morning. My name is Dr. Saghafi and I am a neurologist interested in answering your question. The particular finding you mention would be more easily interpretable in the context of clinical information; especially why she had the scan ordered initially.

The radiographic finding itself without any other data to look at suggests the presence of a LESION (abnormally appearing entity) located deep within the substance of the brain on the left side in an area called the BASAL GANGLIA. The balance of the terminology "involving posterior part lentiform nucelus, external capsule and posterior limb" is simply a further description of the localization for this lesion that the radiologist is reading so that others such as myself could look at the scan and know where they were "pointing".

The comment of it being "ill defined with CSF intensity" simply refers to the doctor's opinion that the lesion itself does not have WELL DEFINED borders. In other words it is not easy to tell exactly where it begins or ends in the area where it has been spotted. Furthermore, the density within the lesion is watery in appearance (CSF density).

In my opinion that type of a read is most consistent with either an artifact (i.e. machine generated BLIP if you will which is not really there) or a small LESION which is cystic (i.e. contains water). If the study were done without any IV contrast then, one suggestion that radiology may make is to repeat the study with the contrast. Your wife should be screened for good kidney function before receiving gadolinium contrast which is now a recommendation by the FDA.

If your wife were being treated in my practice I would make such a decision only after considering the clinical picture and the reason I initially ordered the scan. In the majority of cases such as this, the lesion under discussion turns out to be nothing of importance. In fact, if she is re-scanned I would not be surprised to hear they had trouble finding the lesion for the reasons I stated above. Either it is a machine generated artifact or it is so small and insignificant that it will simply not show up again. If it does, still no worries necessarily until we see what the contrasted study showed as well as what your wife's clinical evolution would be with her present symptoms.

I hope this explanation answers your questions. I would very much appreciate your time in providing feedback on our interaction.

This response required 55 min. of specialty physician dedicated time and your effort at CLOSING THE QUERY would be greatly appreciated so that it may show as having been satisfactorily completed.

All the best! Dr D
Above answer was peer-reviewed by : Dr. Raju A.T
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Follow up: Dr. Dariush Saghafi 29 hours later
She began having severe headache in 2009 when a CT scan was order nothing showed upon that scan.In 2010 a MRI was recommended and again nothing showed up this was a plain MRI.The headache continued along with a sensation of off balance, weakness, heat radiating from the body(the body temperature is hot but not fever).She also experience heaviness in the body,a loss in weight and appetite,extreme fatigue.She is a nursery school teacher who was on the job all this time except for about 4 in 2011 in 2010 july she was admitted for ectopic pregnancy. All these time various blood test were done but noting entrigue the various doctors that she saw.Last week a MRI with contrast was order providing the results that i sent to you yesterday.
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Answered by Dr. Dariush Saghafi 16 hours later
Brief Answer:
Would recommend further workup and head scan.

Detailed Answer:
Good morning to you and your wife. Thanks for the additional clinical information. Since the scan does not specify the presence of a contrast enhancing lesion it is difficult for me to get a clear idea of what they're looking at without physically seeing the films. However, I can tell you that it certainly doesn't sound as if the radiologist is making the call of this lesion being DEMYELINATING in any way. Examples of demyelinating diseases are MS, SARCOIDOSIS, and DEVIC'S disease. However, without the presence of a clear cut demyelinating lesion in the brain it would virtually be impossible to make such a call with the given information.

Given her history of sudden weight loss and fatigue has she been looked at for possible occult malignancy such as breast, colon, cervical, or uterine? If she is a smoker then, I would also look at the lungs.

Has she seen a neurologist and if so, what has their opinion been?

In conclusion, my next steps to help identify what's going on in your wife's case would be to do the following:

1. MRI of the cervical spine with contrast (sometimes demyelinating diseases do not clearly show up in the brain but early detection of lesions in the cervical spinal cord is possible)

2. Search for occult malignancy or other metabolic problems such thyroid panel function testing, cortisol levels, urine and serum testing looking for an abnormal plasma electrophoresis result (part of the occult malignancy workup)

3. I would initiate a treatment plan for the headaches by having her keep track of them carefully on a log or diary putting that together with information from her sleep habits, presence or not of nightmares, insomnia, and caffeine intake. After identification of the headache type (i.e. migraine, tension type, caffeine withdrawal, etc.) I would begin a regimen of either medication or other other intervention appropriate to the headache

4. If her metabolic workup is entirely normal but she still continues to be symptomatic then, further consultation with a neurologist would be advisable. They can decide upon the merits of further diagnostic testing which could including lumbar puncture or PET scanning.

I would be happy to look at any films of this lesion if you can upload them and consider other information such as neurological examination results either by her primary medical doctor or neurologist if she has one.

Otherwise, if you feel this information has provided you with timely advice on next steps to undertake I would greatly appreciate your feedback of our interactions and your efforts to CLOSE THIS QUERY so as to demonstrate satisfactory completion of the case.

This response utilized 35 min. dedicated physician case review and response time.

All the best to your wife with the hope she recover quickly.
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
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Follow up: Dr. Dariush Saghafi 2 days later
Hi Doctor last night was not rest full at all my wife head ache was bad.I am looking at a lab test she did on 16 06 2014 and I notice her Total Bilirubin 0.8 Direct Bilirubin 1.8 globulin 1.7 and LDH 321 does these figures indicate any thing to you
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Answered by Dr. Dariush Saghafi 25 hours later
Brief Answer:
Direct bilirubin may be elevated

Detailed Answer:
Good morning.

You did not provide me with either the UNITS (i.e. mg/dl, mmol/l, etc.) for the lab values. Units come directly after the numbers and help us know exactly how certain tests are being measured which then, tells us how far in or out of normal they are. Another important parameter to include with any test result that you wish a doctor to review would be the NORMAL ranges of values for that particular laboratory as it applies to the test you are looking at.

Although there are general thoughts on what constitutes normal findings written in any textbook or reference guide, when it comes to a specific laboratory it will always provide reference ranges of normal based upon the population of patients it serves and tests.

There is one question I would ask.

You have stated that the TOTAL BILIRUBIN is 0.8 while the DIRECT BILIRUBIN is 1.8. Are you certain those numbers are not REVERSED because otherwise, it doesn't make sense.

Here's why: TOTAL BILIRUBIN is calcuated by ADDING Direct Bilirubin and Indirect Bilirubin. Or to put it another way:

Total Bilirubin= Direct Bilirubin+Indirect Bilirubin.


Therefore, as you can see from the above equation the actual numerical value of a TOTAL BILIRUBIN result MUST BE greater than either the Direct Bili or the Indirect Bili value. They probably don't provide the Indirect Bilirubin measure on the lab report since it is merely a calculated difference.

What you presented I is reversed from what it should be.

By the way, bilirubin is a breakdown product of hemoglobin from red blood cells and is indicative of liver function and how it is processing the chemicals in order to detoxify your bloodstream. Stated ranges of normality in textbooks is taken to be anywhere from 0.3-1.9 mg/dl. Therefore, the value of 1.8 (which is what I predict you meant to write for the total bilirubin) would be considered normal. DIRECT bilirubin's range of normal is approximately 0.0-0.3 mg/dl. Therefore, the 0.8 value may be a bit high by comparison but we wouldn't know that for sure unless we also knew the reference range given by the lab for that test.

LDH stands for lactate dehydrogenase which is an enzyme that shows the amount of metabolic activity that is going on within the body at any given time. The higher the number the more metabolism (so to speak) is occurring within the body's cells overall. The normal range for LDH I am aware of range from 140-280 U/L.

So the results of her TOTAL BILIRUBIN appear to be normal to me (if I use the range I stated but that opinion could change if you were to tell me that the lab range only goes up to 1.0 etc.).

However, the results of her DIRECT BILIRUBIN appear a bit elevated at 0.8. This suggest that the liver is having some trouble clearing this product from its territory as might happen with a blocked bile duct which is where this substance usually tracks in order to get out and into the gut where it is then, reconverted for disposal in the feces.

In your wife's case it would appear that her LDH of 324 is slightly elevated over the norm but again hard to say unless you provide me with the normal range from the laboratory where she was tested.

An elevation of LDH by itself is almost always meaningless and should be taken in context with other liver function tests and other clinical information. In this case with what appears to be a mildly elevated DIRECT BILIRUBIN I might conjecture that there could be something going on within the liver such as an inflammatory process or blockage.

In conclusion, I believe you will want to set up a follow up appoint with your doctor who ordered the tests.

He or she can give a much more fine tuned idea of how these tests fit into the grander scheme of other blood tests she likely received as well as most importantly, how she's doing clinically.

And just to be clear I do not see any relationship at this juncture between these lab tests and the MRI finding you originally asked about at the top of our discussion.

I hope this discussion has provided you with more information and insight into your questions having to do with her lab tests. I wish your wife only the best and hope she feels better soon.

I would greatly appreciate your completing this conversation thread by providing a rating on our discussions and also not forgetting to CLOSE THE QUERY so as to indicate that this consultation was addressed and completed satisfactorily.

Be well and please feel free to look me up specifically in the future for other questions you'd like to ask.

This consultation response required 54 minutes of physician directed review, research, and final draft compilation.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
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