Radiology/Lesion on Brain MRI
QUESTION: Hello. I have cervical stenosis of C5/C6 and incidental finding of Chiari I/9mm when working up for it. My symptoms of stenosis is occasional arm tingling and I also have bad neck and shoulder pain, but only with certain activities. It is very manageable. I don't have headaches. I had an eye twitch back in January(it since went away) and they had me do a CMR of the Brain W/O contrast in May of 2014 because it lasted a while. He wanted to rule out HFS. On that recent MRI in May they found a T2 hyperintense signal a the level of the medial right temporal lobe, predominately involving the right parahippocampal gyrus/collateral white matter. They said this is without appreciable change from 11/2012. This wasn't even noted on my 2012 radiology report. Hippocampi demonstrate symmetric signal intensity for patient positioning and suspected to be similar in size.
They noticed there is patent CSF flowanterior to the cervicomedullary junction while there is diminished CSF flow posterior to the level of the cerebellar tonsils at the level of the foramen magnum and patent CSF flow noted inferior to the level of the fourth ventricle.
I have two questions for you that I hope you can answer. My neurologist says that lesions can be from prior inflammation/infections. He ruled out seizures with an EEG and really isn't concerned about the lesion.
1. Is it possible to have a lesion and it not to ever cause problems? If so, is it common?
2. Is the Chiari causing diminished CSF flow and if so what are the symptoms of this? Thank you!
ANSWER: Hello Cindy,
I am sorry for the delay in replying. You have very good questions. I'll answer them with a caviat that I would need to look at the temporal hippocampal lesion to potentially give you even more info. So keep in mind that this is a general information.
Yes, Chiari is the cause of the diminished CSF flow. By itself, the diminished flow is not concerning. 9 mm Chiari is certainly prominent but apparently you don't have symptoms from it which is usually specific type headaches. These types of headaches can sometimes be elicited by straining while holding your breath (yep, just like you would for a bowel movement). Usually, people do have correlating symptoms from a 9 mm Chiari but Chiari doesn't read a book, so I guess you are lucky that you don't...and hence, the question is...do you need it fixed... Seems like you don't need it to be fixed since you are not broken from it. I understand that you also had MRI of the cervical spine which is good because we would also look for fluid inside the spinal cord, called a syrinx. If you would have a syrinx then potentially, you would still need it fixed. Of course, I would advise you get the advise from your doctors, neurologist or neurosurgeon regarding the best treatment option.
Now for a more intruiging question of a temporal lobe lesion. I would not say that it is common, however, I occasionally come across similar findings in patients who do not have any symptoms. It is difficult to say what it may be (especially without looking at it). It is possible that it is some sort of a scar/gliosis from a prior non specific insult. It is certainly reassuring that it is stable for the past two years. It would also be interesting for me to see where exactly it is. There are some very common totally benign developmental variants in the hippocampus. And depending on the subspeciality of a radiologist he/she may not be familiar with them. Luck would have it that I am a neuroradiologist so have a bit more training in brain MRI. You can actually upload a picture of the lesion as a follow up question if you'd like. It is great that you don't have seizures. In the interest of a full disclosure, I have to say that it is possible that similar lesions may represent very low grade glial neoplasia. Now, don't start to sweat but I need for you to know that, despite the rarity of the diagnosis. Yes these can be stable for years...so unless I am going to here from you again, I would adivse to have a follow up MRI in like 2 years (given that we already have a 2 year stability. That MRI needs to be with IV contrast.
Please feel to answer a follow up question if you'd like for me to clarify any points.
---------- FOLLOW-UP ----------
QUESTION: Attached is my MRI. Not sure which images I needed to upload. Thank you very much for reviewing this. By the way, didn't mention - I am a 40 year old female.
ANSWER: See other answer.
---------- FOLLOW-UP ----------
QUESTION: Hello. Here are a couple more images. Please let me know if you need earlier or later in the sequence. I numbered them as well. Thank you!
That may take couple of tries for us to see the lesion. You may want to send me several later images from the same sequence as the second image. Images with a higher number. Temporal lobe is not a small structure.
These images don't show the lesion.