A woman looks up in confusion as question marks float around her

Why Don't My MRI Images Match My Symptoms?

Last updated: March 2023

This is the burning question asked over and over - often we feel a physical decline due to our multiple sclerosis, but when the neurologist orders a new MRI to check our progress, the report often comes back ‘unchanged.’ I certainly don’t want my MRI to show new disease activity but I am always looking for an explanation as to why my walking has slowed or my fatigue has increased.

My neurologist took the time to explain

At my last Ohio State University MS clinic visit, my neurologist, Aaron Boster, took the time to talk to me about this question. He could have just given me the answer 'because of Clinical Radiographic Paradox,’ and left me dumb-founded, but instead, he took 20 minutes to explain it in detail. I’m sure the other patients waiting to see him might have been irritated at the delay, but this was important to me, and I hope is also useful to you, the reader.

Dr. Boster didn’t acknowledge that glazed-over look in my eyes as he said the first large medical terms and went into quite a bit of medical detail for an explanation. I took notes as he talked, and here is what I took away from our conversation in my own simplified language –

Clinical Radiographic Paradox

Clinical Radiographic Paradox occurs when on clinical examination there are symptoms that do not match the MRI images. Dr. Boster said that MRIs for diagnostic purposes are lesion-centric, focusing only on what can be seen by MRI imaging in the normal-appearing white matter of the brain. The MRI at the strength commonly available and the current software packages and training doesn’t capture images of the grey matter.

White matter vs. grey matter

The white matter is where the demyelinated axons are located, and that is what shows with current imaging techniques - the MRI only looks at this area of the brain. The brain’s grey matter also contains axons (the non-myelinated type) and all sorts of other critical parts that control speech, motor control, and memory, to name a few. All of those can be problems for people with MS but don’t show on MRI scans.

Physical and subjective symptoms

Dr. Boster also talked about the difference between physical and subjective symptoms – the subjective ones often deal with the MS Quality of Life index (MSQLI) – those things that make our lives better or worse. We can have no new disease activity but still have increased difficulties if our MSQLI is bad. Do we have support from our family and friends? Is depression from our personal health situation a factor? Does our financial situation impact our MSQLI? This list can go on and on, and I imagine you can add a few more.

Those problems can all manifest themselves as physical or subjective symptoms. Subjective symptoms require the neurologist to stop and really listen to the patient describe the problem and come up with a plan to treat those MSQLI items, too.

As I have often said, I am not the scientific, technical person of the group around here. If you would like to read more about this, I can recommend this article: Clinical correlates of grey matter pathology in multiple sclerosis .

No single test tells the whole story

The most important take-away I have from this conversation with Dr. Boster is no single thing tells the whole story when it comes to treating Multiple Sclerosis: our MRI, the doctor’s neurological exam, and the patient telling their story to the treating physician all come together to explain our current condition.

Wishing you well,


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