What is the meaning of multiple scattered foci at the subcortical white matter of both cerebral hemispheres?

Question

Hi doctor,

I had an MRI, and I need help understanding the report.

No acute infarctions regarding DWI.

There are multiple scattered foci of abnormal signal alteration seen mainly at the subcortical white matter of both cerebral hemispheres, where there are multiple well-defined foci showing high signals at FLAIR and T2-weighted images, mainly at the frontal and parietal regions. The appearance is non-specific; however, there is a sparing of the temporal lobes and no periventricular lesions to suggest multiple sclerosis. The appearance and distribution are non-specific. Possibilities like small vessel disease, chronic hypertension and diabetes-related changes, and vasculopathy changes are more likely.

Otherwise normal appearance of the brain parenchyma.

Normal brainstem and cerebellum.

No mass effect or transalpine midline shift.

The ventricular system and subarachnoid spaces have normal size and configuration.

The brain stem and cervicomedullary junction appear normal.

No sellar or parasellar lesions.

Maintained vascular flow void.

A complimentary MRI of the cervical cord is unremarkable.

Impression

As detailed above, multiple scattered foci of abnormal signal alteration were seen at both cerebral hemispheres. Appearance is non-specific; however unlikely to be multiple sclerosis as it does not follow McDonald’s criteria, with no evidence of infratentorial plaques or cervical cord lesions, and sparing of the temporal lobes, yet clinically isolated syndromes is suspected (CIS). Differential includes microangiopathy/vasculopathy and changes related to chronic hypertension and diabetes.

Further investigation is recommended, and a one-year follow-up is recommended.

Thank you.

Answer 1

Hi,

Welcome to icliniq.com.

I read your history and saw your uploaded materials (attachments removed for patient's identity protection).

The report says that the radiologist had seen some abnormal tiny areas in your brain lobes, mainly frontal and parietal. He added that due to their non-specific shape and distribution, they are not related to stroke or multiple sclerosis. Nevertheless, the report says that it cannot completely omit the possibility of clinically isolated syndrome, which is the initial stage and first attack of MS. Considering the shape and distribution of the tiny lesions, he supposed that they might be related to some conditions that cause small vessel diseases like diabetes or hypertension and recommends more pataclinic evaluation in this regard.

The above-mentioned are the simplified facts from your radiologist report.

If you are interested to know my interpretation of your MRI (magnetic resonance imaging), I need the following data:

Your physical details show your weight as 52.9109 lbs. Is it true? If yes, are you on a special diet? Do you have loose weight recently, or have you been at this weight for years?
Do you have diabetes or hypertension?
You indicated migraine. What is the frequency of your headache attacks in a month?
Your second image of MRI is the most useful one. However, I need the complete series of that sequence of MRI images to see the mentioned lesion by myself. Please upload all images of that sequence (a.k.a FLAIR sequence)

Thank you.

Answer 2

Hi,

Welcome back to icliniq.com.

I saw your MRI (magnetic resonance imaging)(attachments removed for patient's identity protection). Considering the findings on the MRI and your symptoms, the following evaluations are necessary:

A thorough cardiac evaluation is needed, Including echocardiography with contrast.
Screening for systemic vasculitides by a complete blood laboratory analysis, including the tests for: ANA, Anti dsDNA, ESR, CRP, Anti RO, Anti LA, Anti-phospholipid panel antibodies, ANCA-C, ANCA- P, C3, C4, CH50, Anti CCP.
Waiting to do the above studies, I recommend you to take ASA 80 milligrams pill daily.

In summary, the first diagnosis for your MRI findings is small vessel disease that may be due to micro-infarcts or the result of distributed vessel inflammation. The second and more benign diagnosis (if all the above-mentioned studies turn out to be normal) would be the effect of frequent migraine headaches, as a frequent uncontrolled migraine could also create such image finding and needs to be treated. In any case, your MRI should be repeated after six months to follow up on changes in the findings.

Thank you.