I had my results appointment today ...

New diagnosis and before diagnosis
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I went to see the neuro for my MRI results today. He had the report in front of him which mentioned a lesion on my left optic nerve (I’ve currently got optic neuritis), a possible lesion in my cerebellum and one in my neck.

He felt the one on the brain might be scan interference rather than a lesion, and the one in my neck might be as a result of a small disc bulge.

I’ve been paying to go private up until this point. He said he’s going to refer me back to the NHS for further blood work to rule other things out, he mentioned sarcoid but nothing else. Any ideas what else he might be looking for?

He said he might do a lumbar but he’s not sure it would tell him much anyway and he’s not sure it’s worth putting me through it. I’m more than willing if it helps find out what’s going on!

Finally he said that he’d get a neuro-radiologist colleague of his to look at the images and see what he thought. He couldn’t have done this before the appointment as I had the CD with the images. I’d assumed that he would have been sent those as part of the report but he hadn’t. He said he’d follow up and let me know the outcome of that, and would send the report to my GP and (I assume) to me. I had my brain, orbits and full spine scanned so there are lots of images on the disc. During the appointment he just looked quickly at the images referred to in the report (I think).

So that’s the plan for now. He did explain that this can be a long process and that he’s sorry he’s been unable to say anything with certainty, but I understand why and realise that some people have this for years! He did say that if he was a betting man, he would say it wasn’t MS which both surprised and comforted me! I can’t help thinking though that whoever prepared the report felt there were further lesions, but my neuro disagrees.

Any thoughts?

Thanks :slight_smile:

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Um, bizarre.

Generally, I have an MRI and the neurologist reviews this, possibly in collaboration with a radiologist. I have never had an appointment where the neurologist sees the images for the first time in front of you and makes instantaneous judgements on the MRI.

Recently, I had an appointment with my neurologist, it was a week following an MRI. He said that it looks as though there were no significant changes, but, the scan hadn’t been ‘reported’. I’m not entirely sure what reported means, but I would assume putting your experience and mine together that a radiographer has to review in collaboration with the neurologist in order to get a complete picture.

He did of course tell you that he doesn’t think it’s MS. Which is great, but simultaneously leaves a wide open question of ‘so what the **** hell is / has been causing my symptoms then?’

Grrrrrr. And being told if he were a betting man, etc, etc, is no help either I shouldn’t think. Nor does the comment that people can go on for years.

To be perfectly honest, it leads me to question whether you’ve done worse than if you’d stuck with the NHS route all along. I know we often say that going private can speed up the process but if this neuro thinks it’s acceptable to say it can take years then clearly he didn’t get the message that you’ve gone private to speed things up, not slow them down.

At least he said he’d get a neuro-radiologist to look at it, and arrange for blood tests too. If you don’t hear for a few weeks, you’ll have to chase him up, either by seeing your GP and (checking that they didn’t get a letter that you weren’t copied into) get them to chase the info up, or phone his secretary and see what’s happening.

Sue

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Hi Sue

Yes it did feel a bit odd. I think the fact I had the MRI privately through another provider didn’t really help matters. The neuro should have seen the images prior to the very expensive appointment really. As far as I understand it, the report was prepared by a radiographer (?) at the scanning centre and sent to my neuro. Hopefully things will be a bit clearer once he’s chatted things over with his neuro radiology colleague. I’ve just remembered that he said it might be that I have a further brain MRI in a while and see if there are any changes.

I don’t think I explained the ‘it could go on for years’ bit well. The neuro didn’t say that, that’s what I’ve surmised from this forum and other things that I’ve read. I wasn’t expecting to go and have things concluded today, but was expecting a bit more clarity to be honest. Lesions that might not be lesions hasn’t really helped me much.

I don’t regret going private … I would still only be halfway through the waiting list time and would still have two months to go before seeing the same neuro. At least I’m in the system now, and from what he said things probably aren’t dire.

Pffffft. Limboland it is then! :slight_smile:

X

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Hiya Nic,

Neurology is not well understood as it involves the brain which is not fully accepted how this marvellous organ works.

There are many complaints it could be from Charcot-Marie-Tooth Disease Fact Sheet | National Institute of Neurological Disorders and Stroke

To Lyme disease - NHS

You could associate; neither of these is you.

I remember my limbo years and like you searched for reasons. Even then without the worrying Dr. Google though I had sleeping sickness but couldn’t figure out where I had been bitten by a mosquito?

The favourites are http://www.aps-support.org.uk/ or Sjögren's syndrome - NHS

But really you could go on for a long time and get nowhere.

Your problem revolves around the MRI. I’d like to say the Neurologist sounds very good; stick with him if you can.

The MRI machine was probably a 1.5 Tesla; to get a good image you really need at least a 3T machine. You must get a good image and I will show you an email from Rizzo; she who must be obeyed on MRIs that will explain why lesions sometimes don’t show.

The last T2 FLAIR scan I did of my brain used 70 slices (on a 3T scanner). The one I had done today - 13 (on a 1.5T scanner). THIRTEEN. THIRTEEN!!!

Thankfully I wrote it out the voxels/T2 reply in Word before posting - to avoid the dreaded time-out! So here it is…

A MRI image typically consists of voxels (3D pixels). Slice thickness is one dimension (on the z-axis if you think of maths). The images you see on the CD show you the other two dimensions (on the x- and y-axes). You can set the voxel size to anything you want, in any dimension; all that happens is that it changes the time the scan takes to run (and therefore, of course, how much it costs). The smallest voxel size used in everyday MRI is typically 1mm x 1mm x 1mm. The “off the shelf” scan that I used to use for this size of voxel had 176 slices. The voxels (and slices) cover the whole brain irrespective of what the voxel size is – nothing is missed out (but see later).

If a standard T2 sequence is used for the scan, white matter gives off a poor signal and shows up as dark whereas lesions (which are full of fluid) give a strong signal and show up as bright.

However, the brightness of a voxel depends on the average of the response from the matter represented by that voxel. So a voxel that is 1mm x 1mm x 4mm will show the signal generated by all matter located in that 4mm3 cube. That is, if the voxel only contains white matter it will be dark in the image, if it only contains fluid it will be bright, but if it contains a mix of white matter and fluid it will look somewhere between dark and bright, depending on the proportion of the different matter types.

So if you have a large voxel (say 4x4x4) and a small lesion (say 1x1x1), the overall signal in the voxel will only be slightly higher than one without a lesion (and therefore look only slightly brighter, and therefore may be overlooked). [NB Small lesions would also not always be completely contained within one large voxel – it is more likely that it would be partially in at least two. So this makes it worse.]

But if you have small voxels and a large lesion, then you will get several very bright voxels (where the matter is all fluid), some intermediate voxels (where there is a mix of fluid and white matter), and some vaguely brighter voxels (that contain predominantly white matter).

In other words, small voxels are much better for detecting lesions.

So, can lesions be missed if you use thick slices? Basically, yes. It is entirely feasible. However, they would have to be much smaller than the slice thickness because if they are closer in size, they would contribute sufficient signal to make the voxels significantly brighter than the surrounding voxels and would (should!) be picked up by a decent radiologist. Saying that, it is possible that it might be missed if a small lesion, by chance, spans lots of voxels (e.g. if it is centred on where four voxels meet on that slice) and the signal is lost by the averaging with the white matter signal in those voxels.

However, there are new “pulse sequences” (the settings that programme the scanner) that are particularly sensitive to fluid. If you use one of these rather than a standard T2 sequence, you will be able to use bigger voxels and still be able to detect lesions relatively easily. And the power of the scanner makes a big difference too. A 3T scanner is much better than a 1.5T scanner.

So, if a hospital has a 1.5T scanner and a neuro is ordering a standard T2 scan, then he should be asking for a high resolution (i.e. small voxel size).

If the hospital has a 3T scanner and the neuro is ordering a FLAIR or another new type of pulse sequence that’s good for fluid, then he can get away with a lower resolution.

[NB A related point: it is possible to set gaps between slices. For example, the MRI may capture signal from 0-4mm, 8-12mm, 16-20mm etc rather than 0-4mm, 4-8mm, 8-12mm etc. This would DEFINITELY miss lesions!]

So the trick to not missing lesions is not so much about the number of slices, but about the voxel size, whether or not the slices cover the whole brain without any gaps, the power of the scanner and the choice of pulse sequence.

George

.

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Before now, I my Consultant Neurologist has said to me that there’s something on the scan he wants to raise at their regular review meeting with the Consultant Radiologist responsible for reporting on the scan from her/his side of the house, before deciding how to proceed. He also said that ‘whether something on the scan is a real thing or just an artifact of the scan process’ was something they would routinely consider at such meetings.

Alison

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Hi Alison

I’ve now received the letter following the appointment and in there he says that he’s going to discuss the images with a neuroradiologist at Kings so I do feel that I’m being looked after. Now you mention it, I think that term, ‘an artifact of the scan’ is the term he used. He said he’d follow up with me, so a case of sitting tight.

I’m still waiting for a copy of the report but will be interested to see what they think might be lesions!

x

1 Like
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Hi George

Thank you very much for your message :slight_smile:

I know the scan was on a 3T machine - a wide bore scanner. That said I’ve had a look at the images on the CD I was given to pass to the neuro, and there is nothing like that number of slices per scan. So maybe he ordered a fairly low res? I haven’t seen the referral letter unfortunately.

Hopefully I’ll have some more clarity once he’s discussed the images with his neuroradiologist colleague.

Thanks x

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Hi Nic,

This is only a presumption as you are thinking, but the number of images on your CD would correspond to the number of slices.

So if you have say 30 images; not enough; if you have 50-70 seems about right. But if you have more than 70 you probably have the other axis; voxels.

Such a shame Rizzo’s not on here anymore, but she deserves a life. I would ask your Neurologist or even your GP for a clear understanding of your MRI.

George

9

Hi all

I received a copy of the letter my neuro sent to my GP in which he’s said that he can’t rule MS in or out at this stage. He said in the letter than he doesn’t think it’s worth doing a lumbar puncture yet.

I chased his secretary to see if he’d managed to speak to the neuro-radiologist colleague and apparently the neuro is on holiday for a couple of weeks.

I’ve still got tingling toes on my right foot but it comes and goes a bit which makes me wonder if that particular symptom might be anxiety related? I’ve been under a bit of stress lately with one thing and another so possible I guess.

My ON is playing up a bit in the heat. Over the last week or so I’ve been getting a mild, sort of moving tingling sensation over my scap and upper arms. It’s gone again in a couple of seconds. Anyone else have that? Other than those things, nothing new or different is happening.

Well that was a rambly message, sorry … just feeling a bit fed up with all the waiting and not really knowing what’s going on.

x