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147426 tn?1317265632

How MRI's Show MS Lesions


MY QUICK AND DIRTY EXPLANATION OF HOW MRI'S SHOW LESIONS IN MS

I am going to overexplain the MRI with contrast / without contrast thing again, so that you and your husband can have it as clear as possible in your minds.

MS does it's damage by causing the nerves in localized areas in the brain and spinal cord to lose their protective sheaths, called myelin.  At first, when the myelin is being attacked, the body brings a higher blood supply to the area to fight the attack and the area becomes inflamed.  These areas, now become lesions.  At this point they are called "active lesions."   At first the nerves haven't changed much and they appear (and have the same density) as the healthy areas around them.  At this point after some time, probably months, the body CAN repair the damage and remyelinate the nerve.  This repaired nerve still won't be as good as new, but the lesion "looks" like normal brain.  Sometimes later an old scarred lesion will "reactivate" and the adjacent areas will inflame and have increased blood flow.

If the attack on the myelin sheath is too strong for the immune system to repair, more and more myelin disappears and the area of nerves eventually dies.  Then it contracts and scars.  The blood flow is decreased to that area and the area becomes "less dense" then the surrounding normal nerve tissue.  After a longer time - probably years - the scar can reabsorb and the area becomes "empty."  It's called a black hole.

When you image these lesions with an MRI you can see different things, depending on the technique,the age (stage) of the lesion, the power of the MRI, and whether contrast is used.

The first image is done without contrast.  This technique will show old lesions that are big enough to be seen by the power of that MRI machine.  WE KNOW that many lesions in MS are too small to be seen.  If the newer, more powerful MRI with a 3 Tesla magnet is used many more lesions will be seen (by at least 25%) than on the older 1.5 Tesla machines.  The classic old, mature MS lesion is a little bit oval, will have well-defined borders and will be in the white matter.  Characteristic places are subcortical, peri-ventricular and in the corpus callosum.  The classic MS lesion will also have it's long axis perpendicular to the ventricles of the brain.  Also, important and very symptomatic lesions are found in the brainstem, the cervical and the thoracic spine.  The spinal cord ends at the bottom of the thoracic spine, so there is no such thing as a lumbar spinal cord lesion in the normal spine.

These scarred lesions will show up as light, bright areas.  These are the classic, MS lesions or "plaques."

Now the very old, scarred ones that have been reabsorbed will show up as a black (empty) space or black hole.  If there are many of these empty areas the brain will contract around them eventually and show up as a loss of brain volume.  This is also know as brain atrophy.  This is particularly seen in the progressive types of MS.

However, a newly active MS lesion may not show up on a regular MRI because the area of nerves, though inflamed, is still pretty much intact and has normal brain density.  On the MRI it will look like normal brain.  Without contrast it won't show up and will be missed.

When the next phase of MRI is done the contrast is in the blood vessels.  So the large blood vessels show up, too.   Anywhere the tiny blood blood vessels are more dilated than usual, as in inlfammation, the areas will "highlight"  or "enhance."  They show up as even brighter.  So new lesions will show up as enhancing, or active.  Also, older lesions, that have undergone new attack right around them will show an enhancing rim or ring.  When you compare the regular MRI to the Contrast MRI you can see this reactivated, old lesion.

That's how some reports can call active lesions or some report no newly enhancing lesions.  Also since some new ones heal they can be compared to old films and show they disappeared.  In addition, between different sets of MRI done after a time has passed, the radiologist can see an increase in old and in new activity.

Please ask question where I haven't been clear.

Quix
71 Responses
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Avatar universal
Hi,
I have been having what looks like relapsing/remitting symptons that look like MS since 2002, My neurologist at the time did not do a spine MRI though I had MRI on my brain, this showed 2 areas of heightened activity!  I am unsure what that means. My GP always treated me as if I had MS and had written several times to the Neurologist saying that they need to diagnose me. I have never been diagnosed despite having positive tests on my neurological examinations such as positive Rombergs, upgoing planters and a very ataxic gait. I have since moved to a different area and had quite a bad relapse of my undiagnosed condition and referred to a neurologist. my question is that after almost a month of being unable to walk, urine retention and other symptoms I am starting to feel better, will the neurologist see any evidence of lesions if I am better when I get the appointment through.

Thank you kindly for your help.
Helpful - 0
987762 tn?1331027953
COMMUNITY LEADER
Hi and welcome,

Quix has not been active for some time, please consider posting a new question (green box at the top of the page), introducing your self and explaining your situation, so the community can offer you some constructive advice.

Cheers.......JJ
Helpful - 0
18646657 tn?1466601016
I need your help, i have had ms symptoms for years, can hardly walk, finally got my mri, i can see lesions and black areas, dr says it looks "good" no ms he says....im so upset, i need to get treatment!
Helpful - 0
5112396 tn?1378017983
Quix doesn't regularly contribute to this community anymore, though we all still benefit from her contribution. If you click on her name, you can read her past posts.

Your doctor may be waiting on another episode or MRI changes to take place in accordance with the McDonald criteria.
Helpful - 0
Avatar universal
Thank you for the clearly written posts they are wondering, I presented with optic neuritis, disc pallor numbness, positive Rhombergs, dizziness , RAPD LP clear the first Neuro said supratentorial multi focal white lesions maybe vascular or migraine, 3 more at same hospital want a Brain MRI and SpineMRI - I have a lot of tightness round my ribs and creeping , burning tingling in feet especially right side and weak hand . They think 50/50 ms lesions what is your opinion please ?
Helpful - 0
1831849 tn?1383228392
I agree with ess. There were not MS meds available in pill form 10 years ago. If she had placques 10 years ago, and none since, I would put her in the Clinically Id=solated Syndrome category. It's absically a single "MS" like episode that never recurs.

Kyle
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Avatar universal
Why did she have the first MRIs 10 years ago?
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Avatar universal
Well, how can you be sure she doesn't have MS? Have you considered that the reason she hasn't had flares or worsening symptoms may just be that the Avonex has worked amazingly well?

By the way, Avonex is not available in pill form, and no pill treatments for MS have been marketed for more than a couple of years. Please re-check with her regarding the treatment she's on.

ess
Helpful - 0
Avatar universal
More than 10 years ago a neurologist told my sister she has MS based on the MRI of the brain she did back then. The doctor said she sees plaques in her brain that represents MS and she has been taking Avonex Pills all these years, though she has NO symptoms of having MS whatsoever. She does MRI of the brain, CT of spinal cord, eye exam, coordination exam, blood work and any other exam that you can think of every year and every time EVERYTHING comes out normal (the MRI still shows the Plaques but not a single plaque has been added since 2004). we are just wondering if she really doesn't have MS and the doctors have made a mistake in diagnosing the disease just based on the MRI results. We really need help of what we need to know to prove that she doesn't have MS.
Helpful - 0
9871228 tn?1406394007
I am unable to have any more MRIs due to a Pacemaker.  So how can my neurologist tell my MS isn't active slowly progressing when all he does is check my reflexes.  It's quite frustrating.  He has ordered CT scans, but apparently they don't show anything. Help....what should I do or say
Helpful - 0
5112396 tn?1378017983
Hi rt66gv. A couple of things here; Quixotic1, a great resource to the community, is no longer actively participating on MedHelp. She would not likely see your message.

Secondly, this is a patient-led forum. There are no doctors here, at least in the relevant area. Also, giving this kind of information/advise in the manner you mention (via email) would questionable in the ethics area. A neurologist needs to see you in person in order to assess how the MRI imaging fits into your physical presentations.

However, if your scans came with a radiologist's report, we do have some members here who have a knack of turning 'doctor-speak' into 'plain-English' if you're having trouble understanding the findings.

Here we can give pointers, a sounding board, support and personal experiences, but we can't diagnose.

Perhaps you could go back to the MSAA (I assume you mean the Multiple Sclerosis Association of America) and they can give you information about neurologists that accept pro bono work or alternative sources of helping fund some professional assessments. Perhaps others here can give feedback on that as well.

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Avatar universal
I have no income or insurance, but the MSAA paid for a cranial MRI as I have almost all of the symptoms of MS. If I could email you the scans, could you help interpret them? I'd appreciate it if you could. Email: ***@****
Helpful - 0
Avatar universal
I am in desperate need of some advice. I am a 38yr old female who has been suffering on and off for years with weird symptoms. However just recently with severe neck pain pins needles sore horrible legs and feet. Dropping smashing and spilling everything. Mri of brain showed many more then 9 lesions in periventricular white matter, but only a small suspected syrinx on c spine. Radiologist put strong consideration of demyelinating plaques. However neuro laughed at me said it was stress and smoking, regardless of pain in crazy spots under my skull big toe jaw patches of numbness blurry left eye leg giving out etc. I dont know what to do.... im not scared but cant ignore the symptoms. She wrote me off. Ive never felt so alone and almost crazy.
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Avatar universal
Thanks!  That's a great idea. =)

Quix did such an excellent job at explaining what so much of this means - and I hope that she is doing well!

I really wish there was a class we all could take that would walk us through all of the inner workings of this disease. The doctors just don't seem to have enough time to sit down and go through this kind of thing with us in a thorough manner.
Helpful - 0
572651 tn?1530999357
Hi Cancan, Quix did a lot to get this forum started, but she isn't around here these days because she is busy taking care of herself.  Your question is so good, I am going to copy it and start a new question - hypointensities (black holes) sound horrible and it might help to understand them a bit more.

Helpful - 0
Avatar universal
Anyone have any idea how radiologists differentiate between a "black hole" lesion in an MRI and something else?  I just got a brain MRI last week and the radiologist noted that the lesion on my frontal lobe is unchanged since last MRI... and there are several "punctate foci of hyperintensity in the inferior right frontal lobe" - which, in his opinion, is a "perivascular space" issue.  

I have a black hole lesion on my c-spine, so I know they show up dark in T1 and bright in T2 MRIs, which is exactly how these "foci" are presenting. I even found them in my MRI, before getting the results, because they stood out so much. They are clustered, and directly adjacent to my ventricle, which as I understand it, is a common feature of MS lesions.  I'm not saying these are, in fact, MS lesions, but am curious as to how radiologists tell the difference - and if it really is a judgement call.
Helpful - 0
Avatar universal
can u take a look at my MRI? i got Lyme 3 yrs ago, undiagnosed for 2 now have arthritis my hands and legs tremble i get sharp pins and needles in my legs feels like its twitching and before bad weather it acts up and i get a pain and numbness feeling i have constant migrains and the nurse said my MRI looks good but if its at the beginning maybe its to small to see, i feel like i see a couple white patches, small, please e mail me ***@****
Helpful - 0
Avatar universal
Hi,

I have been having strange symptoms in the past 3 months such as different sized pupils, itching all over, tingling in my face, fatigue, ppins and needles in my feet and hands and face, and sometimes in other places on my body, dizziness, panic attacks, fast heart rate, seeing floaters. These symptoms very in severity from day to day. Some days I don't have any symptooms or just a couple sharp pains in my feet.  I have had an MRI with contrast and it was normal. I have seen an eye nero doctor and he said I was normal. Pls give any advise I am woundering if I have ms but my mri was normal.
Helpful - 0
1 Comments
Hi, I know this is old, but what was your outcome?  This is similar to what I’ve been feeling.
Avatar universal
Thank you so much for your very informative explanation about MRI, I found it so interesting & explained in a very easy to understand format, which was not too technical. I have MS, confirmed about 15 yrs ago after an MRI scan. I had vague symptoms for many years, starting with Trigeminal Neuralgia & always being fobbed off by the different specialists over the years, culminating in an operation on my TM joint, years more pain etc. & it was many years later, after seeing the same Neurologist that I was told I did in fact have MS. My MRI scan result was never actually properly explained to me, so thank you. Shebubs
Helpful - 0
2090063 tn?1332764242
I have similar symptoms.  There is another autoimmune condition called Myasthenia Gravis.  It flares up with stress and often affects muscles of the neck and eyes first, then peripheral muscles (arms and legs, toes and fingers). It can cause spasms and severe cramps.

No lesions or plaques show up on MRI.  It is trickier to diagnose, although there is a blood test which shows antibodies related to acetylcholine receptivity. This neurotransmitter becomes blocked, and is responsible for conductivity to muscles.  It feels like your muscles just can't hold a charge for very long, and you need to rest, then after an hour or so you can function a little better.

I have had these problems ever since cervical spine surgery eight months ago.  Apparently, severe physical or emotional trauma can begin the whole process.

Hanna
Helpful - 0
1999646 tn?1327364825
I had a minor neurological event in 1991 (fatigue and left leg weakness) my GP told me he didnt think I had an auto-immune disorder and sent me on my way. In 2002 I had a Major Neurological event. The Neurologists all said probable MS, but I didnt have any new activity in 3 years, no diagnosis. I recently December 2011 went to a New Neurologist in a different state who performed an MRI and she said there was vascular changes that were new compared to 2006 MRI. She couldnt diagnose me either with MS. She said it was probably Acute Demyenating Ensythro Mylitis (SP?) caused from a virus. I cant except that opinion due to the fact it occurs primarily in prepubescent children. Can the vascular changes be the "higher blood supply to the area to fight the attack" you explained above in your article? I am not experiencing any NEW neurological changes. Can this mean I am possibly going to have an event soon? I am going to seek a different opinion, of course.
Helpful - 0
Avatar universal
what if a person with ms has developed several black holes in a matter of weeks and is in a coma, is it possible to regain any of that information because of the short period of time or is it just gone?
Helpful - 0
198419 tn?1360242356
Hi there,

Thanks for joining us. Your tingling may not be related to lesions at all, nor may they be attacks. There are countless causes for what you describe.

In the context of MS, many cases of tingling does not constitute an attack. Just mentioning this to put your mind at ease where lesions and relapses, concerned.  Since your MRI shows normal, the doctor should be checking other avenues for you. Even small lesions will show when your not symptomatic.

I'm glad you found our forum here educational. Thank you for trusting us enough to post and say so. Hope we can help you move forward with next steps. When do you go back to the doctor? And, has the doctor mentioned what he/she is doing on your behalf to find out.

I agree with you - this can be super scary. Especially when a symptom rises and gets worse before it gets better, only to return.

Definitely don't let this doctor give you the run around,
Hope to help,
-Shell
Helpful - 0
1453990 tn?1329231426
Welcome to the forum.

There is no relation to the size of the lesions and the symptoms.  Little microscopic lesions can put someone in a wheelchair and big huge lesions can seem to have no effect.  In neuroscience, it is all about location.  

Symmetric symptoms, both feet, both hands, both arms are pretty rare in MS.  Given that you seem to have symptoms symmetrically in both the upper and lower extremities for relatively short periods of time, I'd think they would examine your neck for a problem (granted, the facial symptoms could not be explained by a cervical issue.)

MS lesions develop pretty slowly and resolve even slower.  So many People with MS (PwMS) have pain or  paresthesias that last in a single location for weeks or months.  Feeling better and symptom free, will not change lesion load much, if at all.  There are atypical presentations of MS, but at this point, this sounds like it would be something else. Many of us have worked with our doctors to "watch and wait."  Other tests and appointments with specialists go on and we get MRIs every 6 - 12 months watching for things to change.

Trust your body and keep looking for what is wrong, but you may need to cast a wider net and consider things beside MS.  B-12, Fibro, other Neurological and non-neurological causes.

Bob
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