MRI White Matter Lesions: MS and Neurological Symptoms

Brain MRI white matter lesions / Multiple sclerosis

Hello Dr.
Jiang, due to long-term headaches and sudden changes in my symptoms, I paid out of pocket for a brain MRI.
(1) The attending physician said that my images showed no issues, and I even asked her to review them again, but she still said there were no problems.
(2) Subsequently, I consulted three different neurologists, including one who performed an electromyography (EMG), and they all indicated that there were issues with the MRI images, noting the presence of white spots, some large and some small.
One doctor suggested that it could be caused by an autoimmune attack, while another doctor ordered blood tests, an EEG, and visual evoked potential tests, which I am currently awaiting.
One neurologist could not provide a diagnosis or answers, only stating that there was a problem with the MRI, but I am puzzled as to why the original attending physician did not mention this at all.
I apologize for my confusion and lack of direction, as none of the doctors have provided me with guidance on what to pay attention to.
One doctor even suggested that I "look it up online." I would like to understand what conditions I should evaluate given this situation.
If it is multiple sclerosis, what specific symptoms should I be aware of? If it is neuromyelitis optica, what clear symptoms should I look for? What can I do for a comprehensive evaluation, including any out-of-pocket tests? What should I be cautious about in my daily life to prevent the worsening of these "white matter lesions"? Additionally, I have been experiencing headaches upon waking, with pain on the right side, which improves with movement.
In the past week or two, I have had sharp pains in my right eye and tightness in my right face (which I have experienced before but had not for a while).
I also notice my right eye becoming moist and tearing, and I have nasal discharge on the right side, especially in the morning while still asleep.
I sometimes feel a pressure in my right eye upon waking.
I have also experienced twitching during sleep or while falling asleep, sometimes causing my whole body to jerk, my knees to bend, my wrists to twist, fingers to curl, or swallowing movements.
This can happen multiple times in one night, or 2-3 times during a 20-minute nap, and I also feel twitching in the muscles of my thighs and buttocks.
Currently, I am taking half a tablet of Olanzapine (2mg) before bed, but I still wake up at night.
I apologize for the numerous issues I have presented.
If possible, I would greatly appreciate your advice on what tests I should consider or what I should observe and pay attention to.
Thank you!

Amy, 30~39 year old female. Ask Date: 2021/09/30

Dr. Jiang Junyi reply Neurology

Dear Ms.
Amy,
You mentioned that the MRI showed numerous white matter lesions.
It may be necessary to consider some central nervous system inflammation and myelin injury.
Myelin is an insulating substance that surrounds nerves, and if it is damaged, the inflammatory process (pathologically referred to as plaques) occurs.
The diagnosis of multiple sclerosis is based on clinical history and examination, which shows multiple lesions in the nervous system.
The diagnosis of multiple sclerosis is made after excluding other diagnoses.
Laboratory tests can assist in the diagnosis, such as MRI of the brain and spinal cord, cerebrospinal fluid analysis, and electrophysiological tests (evoked potentials), among others.

As the inflammatory tissue affects different areas of the brain or spinal cord, it can lead to various symptoms, such as vision loss, numbness, weakness, unsteady gait, double vision, fatigue, heat intolerance, paralysis, and sensations of electric shock when bending the neck.
Medications, aside from immunomodulatory drugs, are generally used to alleviate symptoms, including reducing muscle stiffness, improving fatigue, controlling bladder symptoms, and pain relief.
This type of disease is considered rare in Taiwan, and most patients choose to seek diagnosis at medical centers.
I recommend consulting specialists in this field, such as Dr.
Liao Yi-Chu at Taipei Veterans General Hospital or Dr.
Lo Rong-Sheng at Chang Gung Memorial Hospital, among others.
Thank you for your inquiry.
If you have further questions, feel free to discuss them! Wishing you good health.
Sincerely,
Dr.
Jiang Jun-Yi
Peach Blossom Medical Care

Reply Date: 2021/09/30

More Info

Understanding MRI white matter lesions can be quite complex, especially when considering conditions like Multiple Sclerosis (MS) and Neuromyelitis Optica (NMO), also known as Devic's disease. Both of these conditions can present with white matter lesions on MRI, but they have different clinical implications and symptoms.

Multiple Sclerosis (MS)
MS is a chronic autoimmune disease that affects the central nervous system (CNS). It is characterized by the formation of plaques or lesions in the white matter due to the immune system attacking the myelin sheath that insulates nerve fibers. Common symptoms of MS include:
1. Visual Disturbances: Blurred vision, double vision, or loss of vision, often due to optic neuritis.

2. Sensory Changes: Numbness, tingling, or a "pins and needles" sensation, often in the limbs.

3. Motor Symptoms: Weakness in limbs, difficulty walking, or coordination problems.

4. Fatigue: A common and debilitating symptom that can significantly affect daily life.

5. Cognitive Changes: Memory issues, difficulty concentrating, or mood swings.

6. Spasticity: Muscle stiffness or spasms.

The diagnosis of MS typically involves a combination of clinical evaluation, MRI findings showing lesions in specific patterns, and sometimes lumbar puncture to analyze cerebrospinal fluid (CSF) for oligoclonal bands.

Neuromyelitis Optica (NMO)
NMO is another autoimmune condition that primarily affects the optic nerves and spinal cord. It is often confused with MS due to overlapping symptoms, but it is distinct in its pathology and treatment. Key symptoms of NMO include:
1. Optic Neuritis: Severe vision loss in one or both eyes, often accompanied by pain.

2. Transverse Myelitis: Sudden onset of weakness and sensory loss in the limbs, often with bladder and bowel dysfunction.

3. Severe Symptoms: NMO attacks can be more severe than MS, leading to significant disability.

Diagnosis of NMO often involves the presence of specific antibodies (AQP4-IgG) in the blood, along with MRI findings that typically show longitudinally extensive lesions in the spinal cord.

MRI Findings and Next Steps
In your case, the presence of white matter lesions on MRI raises the possibility of either MS or NMO, among other conditions. The fact that different neurologists have varying interpretations of your MRI suggests that further evaluation is necessary. Here are some steps you might consider:
1. Follow-Up MRI: Regular follow-up MRIs can help determine if new lesions are forming, which is critical in diagnosing MS or NMO.

2. Blood Tests: Testing for specific antibodies related to NMO (AQP4-IgG) and other autoimmune markers can provide additional diagnostic clarity.

3. Lumbar Puncture: Analyzing CSF can help identify inflammatory markers or oligoclonal bands that are indicative of MS.

4. Electrophysiological Studies: Nerve conduction studies and visual evoked potentials can assess the functional impact of lesions on nerve pathways.

Daily Management and Monitoring
While awaiting further evaluations, it’s important to monitor your symptoms closely. Keep a diary of any new symptoms, their duration, and severity. This information can be invaluable for your healthcare providers. Additionally, consider the following:
- Lifestyle Modifications: Engage in regular, low-impact exercise to maintain mobility and reduce fatigue.

- Stress Management: Stress can exacerbate symptoms, so practices like yoga, meditation, or mindfulness may be beneficial.

- Diet and Hydration: A balanced diet and adequate hydration can support overall health and well-being.

Conclusion
Navigating the complexities of neurological symptoms and MRI findings can be challenging. It’s crucial to maintain open communication with your healthcare providers and advocate for your health. If you feel uncertain or unsatisfied with the explanations provided, seeking a second opinion from a neurologist specializing in demyelinating diseases may provide additional insights and reassurance. Your health and peace of mind are paramount, and thorough investigation and management of your symptoms are essential.

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