MRI abnormalities?

[brandi1977]

I've been having multiple symptoms for quite some time now and after going to multiple doctors, I finally went to a neurologist. Initially I thought I had a sleeping disorder because I fall asleep all of the time, particularly if it's quiet. I don't fall asleep during driving or while talking so narcolepsy was ruled out. After 2 all night sleep studies and an MSLT, the dr determined I dont meet the criteria for pathological hypersomnia, but I am on the border. I also have difficulty concentrating, memory problems, tingling in my legs and arms, muscle soreness, extreme fatigue and weakness. I get tired very easily. My words are messed up when I speak, although they sound normal when I'm thinking them. The neurologist ordered a ton of blood work and an MRI. I also have to do an EEG when I go back for my followup appointment with him. I have not received the results of my blood work but the neurologist office did call to tell me my MRI showed abnormalities. I have included the findings for better clarification.

There is a very minimal hazy T2 high signal in the periventricular white matter. There is a small 3 to 4 mm nodular area of T2 high signal in the posterior aspect of the left external capsule. There is a 2 mm nodular focus in the right temporal occipital periventricular white matter. The findings do not fulfill the McDonalds criteria for demyelinating process and are likely idiopathic white matter hypersensitivities. The remainder of the brain parenchyma is normal in signal intensity. The ventricles are normal in size. There is no mass effect. There is no midline shift. No extraaxial fluid collections are identified. No abnormal areas of enhancement are seen in the head. The paranasal sinuses are clear. There is a miniscule amount of fluid in the inferior tip of the right mastoid air cells. Otherwise, the mastoid and middle ear cavities are clear. Good flow voids are demonstrated in the cerebral vessels and the dural venous sinuses. There is a 1.2 cm rounded cyst in the posterior superior midline of the nasopharynx felt to be a benign incidental Tornwaldt cyst.

I have no diea what any of this means and have tried to research it, but I'm coming up with information that I'm not sure pertains to me. I see the neurologist in a few weeks but I'm really curious as to what all of this means. The neurologist sent me for the MRI because he suspects MS but the report says I don't fulfill the McDonalds criteria. To add on to this, I recently completed some neuropsychological testing that revealed cognitive impairments as a result of brain injury from 2 separate head traumas as a child. However, I don't know that the injuries are related to my current symptoms. I would think that injuries occuring 17 years ago would not just now be showing up. Then again, I'm not a doctor. Any help would be greatly appreciated.

[MG (Admin)]

Thanks for your question.

Do you have a few MRI pictures (the FLAIR sequences would be best at this stage) that you could attach to your response .
All the best

[brandi1977]

I have them on CD but I'm not sure which are FLAIR pictures. There are a ton of them. II've attached a few. I hope they are what you are looking for. I saw the neurologist today and he said he's pretty sure he can rule out MS because I don't meet the criteria. He ordered a lumbar puncture just to be sure but he doubts it will show anything relating to MS. He also wants to check for chronic meningitis. I had meningitis as a kid but from what I've read, I don't have the symptoms of meningitis now. He said the white "spots" on my MRI were from a vascular issue. He didn't say what type, whether a disease/disorder or even a name. I was getting a bit aggravated, although not his fault, that he can't find anything significant to give a formal diagnosis. He said he was literally without answers. It's so frustrating because I'm still having the symptoms, yet no name to put with it. He took me off of the Adderall because it was barely helping, but not providing enough relief to justify taking it.

[MG (Admin)]

Well the pictures you sent seem to fit-in with what yuor neurologist told you (although he saw all the pictures of course).

What was the exact result of the MSLT / polysomnography?
Have you tried provigil (modafinil) for the sleepiness?

[Dr_prakesh]

The symptom of falling when eyes closed is usually due to a loss of position sense from the lower limbs (called Romberg's phenomenon)

you can find-out more about this at http://www.asktheneurologist.com/Sensory-System.html and at http://www.asktheneurologist.com/neurol ... cture.html.

Has vibration and position sense been tested?
Can you send us the NCV results?

[brandi1977]

The first one says: The study showed evidence suggestive of underlying mild obstructive sleep apnea syndrome. This is based on a respiratory disturbance index of 6.1 events per sleep hour as compared to a normal of 5 or less. The study showed no prolonged hypoxia, but there were transient desaturations with the lowest saturation of 89%. Diagnosis: Mild Obstructive Sleep Apnea

The second one says: The study showed no evidence suggestive of underlying obstructive sleep apnea syndrome. This is based on a respiratory disturbance index of 4.8 events per sleep hour as compared to a normal of 5 or less. The study no prolonged hypoxia, but there were transient desaturations with the lowest saturation of 87%. The patient spent 0.0 percent of sleep time with oxygen saturation less than 89 percent, as compared to a normal of 90 percent or above. Diagnosis: 1) Mild Obstructive Sleep Apnea (based on Feb. 8, 2008) a) Not demonstrated on this study. 2) Dysfunctions of sleep. 3) Hypersomnia (Epworth=14)

MSLT: The above study shows evidence suggestive of hypersomnia. This is based on a mean sleep latency of 9.7 minutes as compared to a normal of 10 minutes or greater. There were 0 naps with REM episodes. The above MSLT shows evidence of hypersomnia not due to substance or known physiological condition.

I am currently on Provigil with very little improvement. He started me on 200 mg but it soon stopped working. He increased it to 300 mg and it has barely improved my sleepiness. I have told him this and he said that my results do not coincide with my Epworth score. He feels I shouldn't be as sleepy as I describe based on my test scores.

I have not had vibration and position sense tested as far as I know. The neurologist did some basic tests during his exam and I have had an EEG (normal results) but nothing else. How do they test for vibration and position sense?

[Dr_prakesh]

May I ask how many hours you actually sleep at night, how often you are disrupted and how long it takes you to fall asleep?

Also..how is your mood, ado people say you are more irritable or look "down"?

Have you had blood tests such as general blood count biochem and thyroid tests?

[brandi1977]

On average, I sleep 7-8 hours per night with no interruptions. It usually takes me about 5-10 minutes to fall asleep. Despite being exhausted all of the time, my mood is generally very good. I've been to a neuropsychologist and a psychiatrist, who both felt there was nothing clinically wrong with me.

I have had my thyroid checked. It was normal. I had an extensive amount of blood work done and have posted the results below. I tested positive for EBV but the neurologist doesn't feel the levels are high enough to explain the severity of my symptoms. He has referred me to an infectious disease dr. From everything I have read and talking to my doctor, there is usually an underlying issue that causes the symptoms and not actually the EBV virus itself.


WBC 8.51 Reference: 4.50-10.70 K/Cumm
RBC 4.40 Reference: 3.90-5.20 Million
Hemoglobin 14.2 Reference: 11.9-15.5 gm/dL
Hematocrit 40.0 Reference: 35.6-45.5 %
MCV 90.9 Reference: 80.5-98.2 fL
MCH 32.4H Reference: 26.9-32.0 pg
MCHC 35.6 Reference: 32.4-36.3 %
RDW 12.7 Reference: 11.7-13.6 %
Platelet 246 Reference: 140-500 K/Cumm
Neutrophils 61.1 Reference: 42.7-76.0 %
Lymphocytes 31.6 Reference: 19.6-45.3 %
Monocytes 3.5 Reference: 3.0-8.2 %
Eosinophils 1.7 Reference: 0.3-6.2 %
Basophils 0.7 Reference: 0.0-1.5 %
Unstained cells 1.4 Reference: 0.0-6.0%
Abs Neutrophil 5.2 Reference: 1.9-8.1 K/Cumm
Abs Lymp 2.7 Reference: 0.7-4.8 K/Cumm
Abs Mono 0.3 Reference: 0.1-0.9 K/Cumm
Abs Eos 0.2 Reference: 0.0-0.7 K/Cumm
Abs Baso 0.1 Reference: 0.0-0.2 K/Cumm


Sed rate 7 Reference: 0-20 mm/hr

Vitamin B12 300 Reference: 180-914 pg/mL
Folate 8.4 Reference: 6.6-20.1 ng/mL
Ferritin 63.1 Reference: 11.0-306.8 ng/mL


Hepatitis:
HbsAg Non Reactive
Hep C Virus Ab Non Reactive

ANA Screen Negative



Heavy Metals Panel 3:
Creatinine, UR Mg/DI 66
Creatinine, UR Mg/Day Not APPL
Total Volume Random
Arsenic Urine 13.6 Reference: 0.0-35.0 ug/L
Arsenic Urine (24 hr) Not APPL
Arsenic per gram of creat 20.6
Mercury Urine (ug/L) 0
Mercury Urine (24 hr) Not APPL
Mercury per gram of creat 0.0
Lead, Urine (ug/L) 1
Lead, Urine (24 hr) Not APPL
Lead per gram of creat 1.5


SSA (Ro) (ENA) Ab, IgG 2 Reference: <40 AU/mL

SSB (La) Ena Ab, IgG 9 Reference: <40 AU/mL

Lyme Abs Detection 0.47 Reference: 0.00-1.20 LIV



EBV Ab Early AG 1.20H Reference: 0.00-0.99
EBV Ab/Nuclear Ag 6.84
ABV Ab VCA IgG 6.30
EBV Ab VCA IgM 0.08

Acetylcholine Binding Ab 0.0 Reference: 0.0-0.4 nmol/L
Acetylcholine Block Ab 0 Reference: 0-15 %
Acetylcholine Mod Ab 0 Reference: 0-20 %


Neut Cytoplasmic <1.20 Reference: <1.20

[clinicalguru3]

I would be interested to know what the infectious diseases specialist thinks....please let us know.

[brandi1977]

I will see the infectious disease dr on June 4th. I will post results of what she says/thinks.

As I was looking through my insurance claims, I noticed my neurologist put MS as my primary diagnosis when I initially saw him for the diagnostic visit. After he performed the testing, he decided it wasn't MS. I'm assuming he put the diagnosis as provisional on my first visit since he did think MS was a possibility. I guess it shocks me because I work in medical billing and have never saw such a diagnosis given without first ruling things out. That's a hefty diagnosis on my insurance that will probably ding me for high risk.

[brandi1977]

I wanted to add the results from my neurologicalist exam, as well as EEG results. I'm not sure that they will provide anything additional but here they are anyways.

First visit with the neurologist:

MENTAL STATUS: The patient is alert and oriented x3. The patient could name the day, date, month, year, season, place, floor, town, county, and state. The immediate recall was intact for three objects. Calculation was intact for five steps of serial seven. Short-term memory revealed that the patient could remember two out of three objects after one minute. The patient could name a watch and pencil, could repeat phrases without difficulty, and could perform three-step commands without difficulty. The patient could read a sentence and follow it and could write a sentence and copy pentagons. Overall Mini-Mental Status Examination was 28/30.

SPEECH: Speech was fluent without evidence of sensory, motor, repeating, or naming aphasia.


CRANIAL NERVE EXAMINATION:

CRANIAL NERVE II: Visual fields were intact to confrontation. Funduscopic examination showed sharp optic discs bilaterally, normal A/V ratio, no hemorrhage or exudate.

CRANIAL NERVES III, IV, & VI: Pupils were equal, round, and reactive to light and accommodation. Extraocular muscle movements were full, without evidence of lateral or vertical nystagmus.

CRANIAL NERVE V: Corneal reflex was intact bilaterally.

CRANIAL NERVE VII: There was no facial movement asymmetry noticed.

CRANIAL NERVE VIII: Hearing was intact bilaterally.

CRANIAL NERVES IX & X: Pharyngeal reflexes were intact bilaterally. Palatal elevation was symmetrical.

CRANIAL NERVE XI: SCM and the trapezius muscle strength were equal bilaterally.

CRANIAL NERVE XII: Tongue was midline without atrophy or fasciculation.


MOTOR EXAMINATION: The patient had 5/5 strength throughout. There were no pronator or vertical drifts noticed. Muscle bulk and tone were normal. There were no fasciculations, tremors, or abnormal movements noticed during the examination.

REFLEXES: Deep tendon reflexes reveal slight hyperreflexia was noticed mainly in the lower extremities, but no pathological reflexes. Plantar reflexes were down bilaterally.

GAIT: Gait was wide based. Normal tiptoe, heel, and tandem walking.

COORDINATION: Nose to finger, heel to shin, and rapid alternating movements were intact bilaterally, without evidence of intention tremor or dysmetria.

SENSORY EXAMINATION: Decrease in pinprick and light touch sensation distally in both upper extremities.

NEUROIMAGING STUDY: Medical records were brought by the patient with two neurological psychiatric testing, sleep study, and CT of the head, which were reviewed. Please see attached.

IMPRESSION:
1.Chronic fatigue, hypersomnolence, difficulty with concentration, dizziness, and memory deficits could be the aftermath of postconcussion syndrome and meningitis. So far, no strong evidence of myasthenia gravis. Always at this age group I would like to rule out the possibility of multiple sclerosis, especially with a history of diffuse nonlocalized neurologic symptoms separated in time and space.
2.Restless legs syndrome
3.Possible carpal tunnel syndrome


Second visit (after MRI):

Quite extensive laboratory work was done of the patient including an ANA titers, sed rate, vitamin B12, PANCA, ANCA, hepatitis B, hepatitis C, serum ferritin level, Epstein-Barr virus, serology, lyme disease titers, heavy metal screen of urine, acetylcholine receptor antibodies, anti-SSA, anti-SSB, all of which were negative with the exception of positive serology of old Epstein-Barr virus infection. MRI of the head with contrast was done. The patient brought this with her to the office today. This did show evidence of subcortical white matter on T2 and flare single intensity mainly in the posterior left extensor capsule and the right temporal occipital periventricular area. The overall characteristics did not meet the McDonald criteria for multiple sclerosis diagnosis. This was discussed with the patient.


EEG results:

The background activity is well developed and symmetrical, in the waking state consisting of 10 to 11 Hz alpha, which tends to be of low amplitude. Beta activity was seen throughout at 15 to 20 Hz and this remained of low amplitude and was symmetrical. In the latter part of the recording intermittent rhythmic theta was seen with a character indicating drowsiness and light sleep. There were no significant asymmetries, focal discharges, or epileptiform abnormalities noted at any time. Hyperventilation did not produce any significant changes. Photic stimulation produced a slight following response at a few flash frequencies, which was symmetrical. EKG showed a regular rhythm with a heart rate of approximately 90 beats per minute.

[MG (Admin)]

I will see the infectious disease dr on June 4th. I will post results of what she says/thinks.

[brandi1977]

The infectious disease dr felt the EBV is not the cause of my problems. She said it was not in active status and is a result of an OLD infection. She listened to my symptoms, looked at my medical records, and said that although she's not a neurologist and she doesn't have clinical experience in neurology, she has encountered patients with neurological disorders and has been in contact with neurologists as a part of her patient treatment plans, and believes I am in the early stages of MS. She suggested I seek a second opinion. She said the Cleveland Clinic would be best but it's a 6 hour drive one way so I'm looking at local neurologists for now until I'm able to make the trip. We would have to stay overnight since it is such a long drive and financial issues as a result of medical bills are preventing us from that at the moment. Most of our local neurologists are booked until at least November so it's a frustrating situation.

My PCP seems to think it's fibromyalgia (I don't think it is but I'll let the dr decide on that) so I've scheduled an appointment with a rheumatologist to rule out/confirm it. If he says it's not fibromyalgia, I will pursue a second opinion with the neurologist. If it is early stages of MS, a second neurological evaluation or MRI might reveal more. Right now, I'm just hanging in limbo...

[clinicalguru3]

It seems highly unlikely that any neurologist would give you a diagnosis of MS given your current situation. From all the discussion below it seems to me that your primary complaint is general fatigue....are there any other neurological symptoms which are significantly affecting you now?

[brandi1977]

I have other neurological symptoms, in addition to the fatigue: Numbness and tingling that initially started in my arms and legs and is now moving throughout my body, loss of balance at times, sensitivity to light and noises, difficulty finding the right words, words coming out wrong, difficulty with grasping and holding on to objects. These are just the major ones. The neurologist submitted a claim for my insurance and listed MS as the diagnosis. However, I think this was to get the claim paid. He never told me it was MS. He told me that it could possibly be MS but it was too early to tell, and that the lab work at the time is not enough to clinically diagnose me. He advised me to have another MRI done in 3-6 months.

I will see the rheumatologist this week to check for fibromyalgia. At least that can be ruled out or confirmed.