Why Don't My MRI Images Match My Symptoms?
Last updated: September 2023
This is the burning question asked over and over. We often feel a physical decline due to our multiple sclerosis (MS), 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, Dr. Aaron Boster, now located at the Boster Center for Multiple Sclerosis, took the time to talk to me about this question. He could have just given me the answer "because of the clinical-radiographical paradox," and left me dumbfounded. Instead, he took 20 minutes to explain it in detail. The other people waiting to see him might have been irritated at the delay, but this was important to me. I hope it's also useful to you, the reader.
Dr. Boster didn’t acknowledge that glazed-over look in my eyes as he said 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.
The clinical-radiographical paradox
The clinical-radiographic paradox occurs when symptoms from a clinical exam don't match MRI images. Dr. Boster said that MRIs for diagnostic purposes are lesion-centric. The doctor explained that this means MRIs only focus on the normal-appearing white matter of the brain. The MRI at the strength commonly available and the current software packages and training don’t capture images of the grey matter.1
White matter versus grey matter
The white matter is where the demyelinated axons are located. That is what shows with current imaging techniques since MRIs only look 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.2
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 poor. 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 the study Clinical correlates of grey matter pathology in multiple sclerosis.
No single test tells the whole story
The most important takeaway I have from this conversation with Dr. Boster is no single thing tells the whole story when it comes to treating MS. Our MRIs, 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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