Thursday, December 21, 2017

Technology-The Perils of Early Adoption

When knowledge, experience and technology
fall into place concurrently amazing things happen.
Sometimes this takes time.

The latest and greatest in new technology provides contemporary hospitals health care entities with
ample fodder for advertisements and bragging rights.  Lack of experience and knowledge with technological capabilities can produce some unforeseen problems; antibiotics cure infections, but microorganisms fight back, X-ray treatments of enlarged thymus glands in children gave rise to cancer later in life, and bone marrow transplants for metastatic breast cancer were a big disappointment.

This is my personal tale of an encounter with a brain MRI done back in the good old days of the 1980's when these gigantic imaging machines were called NMRI-the "N" was short for nuclear. The neuro radiologists of today were likely in Kindergarten and ordinary run-of-the-mill radiologists interpreted these vintage scans.

After a fusillade of neuro problems including confusion, right upper extremity weakness, and visual field distortions I had one of those new fangled NMRI imaging studies performed. While I was reclined in the tight confines of that sewer pipe of a machine, I was aware of a commotion commencing in the procedure room. Turns out mine was one of the very first NMRIs that showed significant pathology at this facility and an audience had gathered to witness the premier event. I walked into the NMRI room and left on a Gurney for an acute neuro ward-not a good sign.  Here is the radiologist's interpretation.

The striking finding is an increase in T2 signal intensity in the right occipital area and to a somewhat lesser extent in the right frontal area. Differential might include CNS lymphoma, primary demyelinating process, encephlopathic or infectious etiology less likely. Correlation with clinical findings is suggested.

Now the real fun began. Neurosurgery was consulted and felt the scan was consistent with a glioma and a stereotactic biopsy would be necessary to determine the type. Alas, this was impossible because of the unavailability of a non-ferrous stereotactic head frame. Using the standard head frame would wind up with my head plastered to the magnet like a bug on a windshield. I remember thinking about calling Jack Kevorkian to see if he could squeeze me in as the prognosis seemed more grim as time passed, but there were many more consultants waiting in the wings so let's wait and see.

Next on the parade of consultants was a neurologist whose primary area of expertise was MS, of course he concluded that MS was the diagnosis and a spinal fluid study for monoclonal antibodies would be the confirmation. The studies later proved negative for monoclonal antibodies so the diagnosis was changed from MS to "demyelination syndrome," whatever that means.

Let's consult a clinical pharmacologist to get his opinion. I was taking Azulfidine for Crohns Disease and a review of the literature suggested an encephlopathic process could be a result of taking this drug. The final diagnosis: Azulfidine induced encephalopathy. Stopping the Azulfidine made no difference in my neuro status, but jump started the Crohns, not a pleasant situation.

I slowly recovered and started backing away from follow-up appointments, figuring that whatever it was would take its course. My  neurosurgeon died about 5 years ago and I started to marvel at my survival skills having outlived him. He had given me a prognosis of 5-7 years.

So 28 years after the original excitement  a  NMRI  MRI was scheduled and it was nothing like the old time days. The machine had a wide bore and I actually missed the intimacy of being stuffed in that old sewer pipe of an NMRI machine. The technician also insisted that I use ear plugs to muffle the signal generator. I missed the booming and banging. This time sure was different.

A genuine neuro radiologist interpreted this MRI and there was none of that old school beating around the bush. This lady knew what she was looking at, no bones about it. I certainly could have benefited from her expertise 28 years ago. Here is her impression.

abnormal foci of T2 hyperintensity within the subcortical and periventricular white matter are much greater in size and number in the right cerebral hemisphere compared to the left. There is a more confluent area of abnormal T2 hyperintensity posterior to the right lateral ventricle. The asymmetrical appearance of these lesions effectively rules out classic multiple sclerosis. This MRI is indicative of an acute disseminated encephalomyelitis.

It's nice to have a definitive diagnosis even though it required a 28 year wait. Some problems cure themselves if you can wait them out. Time is the most valuable commodity and the neuro Gods have cut me a break. I'm still vertical and my foolishness remains intact but sometimes I wonder about my cognitive abilities.


  1. Ye gods and little fishes, my friend! Thank the universe for the not-so-lethal Dx ~
    And Merry Winter Solstice!

  2. Your cognitive abilities seem to be intact to me OFRN but sounds like you've been through a bit of prolonged rough patch - glad after 28 years you've got a diagnosis at last - and that you are thankfully very much still vertical!

    And as you have the Winter Solstice we here in Australia are having our Summer Equinox - which just means it's about to get even hotter - oh dear what a heatwave we are having!

    Wishing you a Happy Christmas from the sweltering sub-tropics of northern New South Wales.

  3. Sorry, but medical ignoramus here. I googled acute disseminated encephalomyelitis and was told it is cured with Corticosteroid therapy. So can I infer that you should have been given Corticosteroids 28 years ago (if they had them then) but weren't because you didn't get an accurate reading of your NMRI and that this condition has continued for 28 years? It doesn't sound like it cured itself if it can still be seen in an MRI. So what am I missing?

  4. My encephalomyelitis was caused by a virus, Hildy and 28 years ago there were no antivirals available for treatment. The encephalomyelitis I had was a time limited illness with the brain damage occurring over about a 3 month period while the infection was still active. The initial brain MRI with abnormal findings was in June. In October a follow up MRI showed progression so the disease was still active. There were no further MRI changes in annual follow ups so the disease process ceased but did leave behind the damage which will always be there just the same as a scar remains after wound healing. Steroids are widely used in many neuro problems to reduce swelling and cerebral edema. They really don't cure the underlying problem but are given on a theoretical basis.(my opinion)-I've never seen anyone cured by steroids.

    When I worked in neuro years ago, many patients were also on phenobarbital for the reasoning that it slowed brain metabolism which would also slow whatever pathology was cooking.
    Results were not real impressive. Sometimes dire situations invoke a kitchen sink response when everything but is tossed at the disease entity.

    When I was blabbering about self-cure, I did not mean to infer the brain lesions disappeared, but that with time I was able to overcome most of the deficits. With time, brain flexibility can come up with ways to rewire and work around lesions so there is functional improvement even though the MRI might continue to look bad.

    Happy Holidays and/or Merry Christmas with a festive Winter solstice to all my loyal readers and thanks for perusing my foolishness

  5. It seems to me that technology is usually far ahead of the knowledge necessary for optimal use. The daVinci surgical robotic procedures for all without studies to back their efficacy come to mind.