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Why Don’t My MRI Images Match My Symptoms?

Why Don’t My MRI Images Match My Symptoms?

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,


This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.


  • eva
    3 years ago

    Magnetic resonance imaging, MRI, was developed for research in quantum physics. To suggest that an MRI is confined to looking only at white matter is inaccurate; hydrogen atoms are in all tissues.
    Each point on an MRI represents the statistical treatment of the nuclei of hydrogen atoms in excited spin states, and should not be interpreted as real tissue.
    Physicists suggest that 3% of hydrogen atoms respond, engineers think that perhaps 9% do, and the medical system believes that every hydrogen atom responds.

    My MRI done in 1995 has too many spots to count, with some in the thalamus and parietal lobe suggesting that I cannot process any sensory information. In other words, I do not understand what I see, hear, smell, taste and touch. The MRI has been interpreted to mean that I require 24 hour care.

    Hah! I am 72 years old, and fully mobile – and I always find my way home!

    When diagnosed in 1967 I found research detailing electron microscope slides that proves myelin heals with movement. I have recovered from every symptom by being persistent in moving to my limit, then resting to recuperate energy. Many authors have observed that lack of movement is far more damaging than the disease process.
    In light of evidentiary research that has been done with electron microscope slides of real tissue, the interpretation of MRI studies is in need of review.
    I have to keep reminding myself that this is the 21st century!
    Eva Marsh BSc Physics, MEng Electrical Engineering

  • Perilune
    3 years ago

    This is exactly the question I wanted to ask at the last appointment for my son. He has ups and downs with symptoms seeming to increase, then decrease, depending of course on the weather, activity, overall health, and emotional condition. We are reassured by our University of Vermont MS Neurologists that no new lesions are found, and they recommend longer time between MRI’s (that’s a good thing), unless something arises.

    Thank you for asking the right question and sharing your information.

  • joanee
    3 years ago

    I had other symptoms of MS before I was diagnosed. All my fault. I kept talking about my feeling tired all the time and my GP thought it had to do with my depression. Most times I was depressed because I could not function because I was tired.

    I do suffer from a form of depression so we were all going around in circles.

    I finally, after years mentioned the tingling I had for years. My GP”s reaction was go to a neurologist. I knew a great one, who I had dealt with because of a friend. I made an appointment.

    While waiting, I mentioned this to a friend in the final months of becoming a nurse practitioner. She said, “I’m not diagnosing you but my feeling is that you have MS because I do.”

    After the usual tests and a spinal puncture, I was diagnosed nosed and at last learned my energy had flown the coop because of MS. Not that my clinical depression doesn’t add fuel to that fire. But I had an answer as to why no antidepressants fixed my fatigue: because it is MS add a symptom called lassitude.

    Sorry to babble on and on but your article helps my explanations to my friends. I emailed it to a few of them in terms of the difference between just feeling tired (or lazy, which caused my guilt) and lassitude.

    In other words: thank you so much. <3

  • Julie
    3 years ago

    This is always what I want to ask.
    Does MS cause depression? Or am I depressed because I have MS?

    Which came first, the chicken or the egg.

  • Mjvig3
    5 years ago

    Thank you! This is the most helpful (in terms of reassurance, which is very helpful) article I’ve read on this page, or anywhere, in a long, long time. We all think the MRI can see everything, but we know ourselves best!

  • Laura Kolaczkowski author
    5 years ago

    Mjvig3, thank you so much for taking the time to let me know this was helpful. All I want out of my MS advocacy work is to help others, as I have been helped through education and support. Your comments have made my day and reaffirm I am on the right path. be well, Laura

  • Pam
    5 years ago

    thank you so much for this article. finally, some answers! why aren’t all ms drs. able to give a complete answer to questions we have? I’ve gotten several times from my neuro, that my symptom is not ms related. only to return in 6 months and have him say that yes, it is ms related. kinda frustrating and confusing! but he is a good dr I think..

  • Jef
    5 years ago

    Honestly, I thought I was the only one that ever felt like getting worse was all in my mind.

  • Laura Kolaczkowski author
    5 years ago

    no, Jef…. you are not alone in being confused about this one. -Laura

  • Karen
    5 years ago

    Thank you! It sort of makes sense, too bad I didn’t hear it from my Doc!

  • JeanS
    6 years ago

    Very insightful. I didn’t know any of this. Thank you!

  • VC
    6 years ago

    Thanks for posting!! When I was first diagnosed, I had severe optic neuritis requiring IV steroids. Then a few months later I got it in my right eye. I had a spinal tap that was positive for myelin proteins, I had a severe case of L’hermittes, vertigo, numbness, and fatigue. AND I have two siblings with MS. But I did not have visible lesions on my MRI. I had additional tests including VER and SER. All tests except the MRI confirmed MS.
    A few years ago I had spinal cord stimulator implanted, so I can no longer have MRIs. But that did not stop my neurologist from effectively treating my recent exacerbation that included a new symptom–bowel incontinence–so just because your MRI is not showing lesions does not mean you don’t have MS. On the upside, few to no lesions can lead to a better prognosis.

  • Laura Kolaczkowski author
    6 years ago

    You are another example of why doctors must listen to the patient and not just rely on tests. Thanks for sharing your story. Laura

  • ScarlettOH
    6 years ago

    Thanks for this reminder, Laura. For years now the docs have been searching in vain for cervical lesions to explain various deficits that keep showing up in my neuro exams. Great as MRIs are, we forget they have severe limitations as well.

    Thanks too for your comments about subjective vs. objective effects of MS.There’s no way to measure some aspects of this disease. It has riled me in the past to see relative ability to move held up as the one criterion upon which some important medical decisions are based.

  • Lamarfreed
    6 years ago

    It was only recently, with advanced MRI technology that is not available many places, that damage in the grey matter was found in MS. This was initially thought to be the result of the death of demylinated neurons downstream from the damaged grey matter. Now it as raised questions bout whether demyelination is the thing that starts th process of MS. Which only goes to show that for those of us that don’t have advanced medical research training MS is a very hard disease to understand. It seems that it is hard to understand for the researchers, too. Sometimes it is rocket science.

  • joanee
    3 years ago

    I guess while it’s not all in my mind it is all in my brain.

    Thank you for the MRI update. I will talk to my md about this. He is not adverse to giving me more time.

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