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Radiology/MRI for bilateral optic nerve swelling


Sag T2 Flair
Sag T2 Flair  
Ax T2 FSE  
QUESTION: Hoping you can look at my pictures and let me know if you see anything that might need further investigation, particularly with regard pituitary gland or anything in that general area (I have specific reasons for asking about this particular area.)  I am a 40-yr-old female, 5'4" 117 pounds.  
Ophthalmologist sent me for this MRI due to bilateral raised optic nerves.
(I can send other images if they would be more helpful.  I don't think I can attach more than 2 at a time here.  The series on the CD are titled: Localizer, Sag T2 Flair, Ax DWI, Ax T2 Flair, Ax T2 FSE, Ax T1 SE, Ax GRE, Apparent Diffusion Coefficient and Exponential Apparent Diffusion Coefficient.  There's approx 25 images in each of these series.


ANSWER: Hello Susan,
The images you uploaded are both normal.  Pituitary gland is normal is size. Obviously I only see two images our of many.  I do not see optic nerves as they are a few images lower on Ax T2 FSE sequence but raised optic nerves (ON) will not be necessarily seen on MRI.  What MRI looks for are causes for the finding.  Raised ON is what is called papilledema, and your doctor was looking inside your head to see if there is anything like a mass or other lesions that would cause increase in pressure that would make ON swell.  Sometimes we don't find anything and your doctor will run a few tests.  If there are no structural findings in the brain, and if your doctor still things you have ON swelling then one other test he/she may do is a lumbar puncture to measure the pressure in the spine and around your brain.  There is such diagnosis as pseudotumor cerebri which is basically increased pressure for unknown reason.  A neurologist is one of the specialists that I would recommend seeing.

Hope this helps.


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Ax T2 FSE  

Ax T2 FSE  
QUESTION: Thanks for your response!  I've attached the images that came a bit lower in the Ax T2 FSE set.  The doctor did suggest a lumbar puncture (which, frankly, I'm trying to avoid by exploring every other avenue possible first!)  After I wrote to you I spoke to my primary care doctor, who said she thought the ON swelling looked mild and she saw no evidence of pseudotumor cerebri (but that we should not assume anything and should be thorough in checking things out, which I agree).  She said this could just be the way my ON have always been.
She also said the ophthalmologist and radiologist were only looking at the ON and not at my sinuses or anything, so it would be good to have the MRI reviewed by other specialists.  She mentioned a possible cyst she called 'incidental,' that she saw in an area called the petrous apex (I may have that name wrong, but I think that's what she said) that she would ask both the ENT and neurologist that I'm going to see to take a look at.  I don't have any follow up appointments for several weeks.  Which sequence would the petrous apex be most visible on?


I think ON may be on image 8 or 9 but reality of it is is that I would not be able to see mild ON elevation/swelling.  MRI is really not good for that and the direct exam is much better.  MRI is great for looking at the potential causes though.
It is quite funny that your primary care doctor downplayed the role of specialists...kind of an unfortunate and a bit self serving. I have no doubt that he or she is a good doctor but lets face it, radiologists don't look at just the ON when we do the entire brain MRI, and ophtho docs are certainly trained well to think critically beyond the ON.  Of course your sinuses are on the MRI but I see no reason how sinuses cause ON swelling...orbital pressure/pain from sinus disease yes but that is about it...  Moving along...There is no evidence of pseudotumor cerebri because there is nothing to see except for an elevated pressure. the only way to see if the pressure MAY BE elevated inside the skull is to look at the ON for swelling.  Pseudotumor cerebri is a diagnoses of exclusion. Another words, if you truly have ON swelling, and there is no mass or other lesions in the brain that would cause an increase in pressures then we can make the diagnosis of it.  By the way, if you do see a neurologist, another things that may sometimes cause increased pressure is developmentally small dural venous sinuses (big veins that drain blood from your brain).  On occasion, doctors have evaluated this with MRV MR venogram.  Also, if a neurologist would also agree that ON are actually swollen (mild or not) rather than just being normal variant for you, and there is not other process that you have explaining it then I would concur with lumbar puncture to actually prove that you DO have increased pressures.  It is a fairly benign procedure even though it sounds scary and I am sure you read horror stories on the internet about them :)...It is much safer than driving a car on any given day.

From your prior images and these ones; your sinuses don't have any significant inflammation.  Is MRI of the brain the study of choice for sinuses?  No it is not, however, with the information at hand, I am not sure pursuing sinus problems would be my priority.  Neurologist is your next stop in my opinion as a neuroradiologist.

I do see your petrous apex region very well on the images. The asymmetric appearance is totally developmental and normal.  The region is basically part of the bone along the bottom of your skull. It has various degrees of aeration in it (just like sinuses and air cells around middle ear.  Your left apex is aerated, your right one is not.  this is no significance to this findings whatsoever.

Hopefully not too much of information...



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Michael K.


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