2024_06_10 Splain that Name [Part I]

Now let’s remember what the title of my blog is. (Pause.) Perceived… Distinctions, yeah?

It has to do with neuroimaging.

Over the last six years I’ve had six MRIs, three CTs of my brain.

For the most part, all were reported Normal. But what goes on an imaging report depends to a substantial degree on who is looking, their training, their visuospatial acuity. MRIs continue to improve in accuracy; yet interpretations of the results do not. [ Analysis of Perceptual Expertise in Radiology – Current Knowledge and a New Perspective https://doi.org/10.3389/fnhum.2019.00213]

My very first CT was acquired less than a month after my overall symptom onset, at an ER with one of the lowest ratings in the nation. Poor morale and hostile attitudes were evident in how I was treated by multiple employees, including the doctor (technically a contractor?), whose first harshly spoken words to me, “what exactly about this situation constitutes an emergency?” confirmed my initial misgivings.

People make mistakes. Bias factors. In my observation it was likely there was some reinforcement of hostility between players. Anyway, if my upbringing taught me one valuable lesson it’s that it’s not rational to expect people to act rationally. 

So I acquired a copy of my imaging on CD (from a refreshingly friendly and professional person from the records department).  If someone had missed or– my fear at the time–dismissed something because they were busy reveling in shared contempt for a presumed malingering patient… the data might someday help me, at least. 

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Now I had this CD in my hands, an important part of the health record I’d been collecting as my symptoms unfolded. But… also a super cool high tech image, not just of a brain, but of MY brain. At times I have the sense that excitability or enthusiasm towards certain areas of scientific study is verboten. But I was excited to see my images. I am enthusiastic about (applied) visuospatial puzzles. That little CD called out to my strengths and my interests, and though I knew I’d be overwhelmed by the sheer unfamiliarity of neuroanatomy, I was compelled to look.

I didn’t know what I was looking at, but I noted distinctions in texture, value, and symmetry. I went about learning some fraction of anatomy by scrutinizing the details of my brain’s wholly unfamiliar appearance. A disproportionately large right jugular vein is common. The little hole in the back of my skull is a mastoid foramen– an optional feature, as is the asymmetrical pneumatization of my petrous bone. 

Over the years I acquired more imaging CDs.

I found salivary stones,

2019 Maxillofacial CT bone window (sagittal, axial, coronal) showing salivary stones

a jugular diverticulum,

December 2020 T1 Gadolinium (coronal, sagittal, and axial) views of a R jugular diverticulum

and finally in 2022: 

A possible jugular foramen lesion and potential explanation for my health’s deterioration; the start of treatment, a way back to abledness!

Following up with doctors, I was cautiously informed I was probably right about the salivary stones and diverticulum. But concerning the jugular foramen, I’d found a study with an image of a lesion that struck me as nearly identical to my own. Where the study subject’s jugular foramen contained areas of starkly contrasting signal, mine contained areas of high signal surrounded by softer transitions to just slightly hypointense. But I hadn’t found any high T1 jugular foramen contents in the normal MRI examples I’d reviewed. And I was hopeful.

T1 MRI axial slices showing my jugular foramina

T1 MRI from case study, Dural arteriovenous fistula of the anterior condylar confluence and hypoglossal canal mimicking a jugular foramen tumor https://doi.org/10.3171/JNS/2008/109/8/0335 

The high T1 signal in the jugular foramen was a flow artifact, I learned in September of 2022. The neurologist who delivered this news, I had selected based on his blog, which was full of clearly-explained complex information. That, more than anything, inspires my trust: An interest in discussing details. So I was excited to have secured an appointment with someone of that caliber, and because I was treated with regard and given a chance to ask specific questions…I was able to put one concern aside, having been given a sufficient answer.

That’s not to say I wasn’t crushed, having felt myself so close to the answer. Against the ensuing undertow of ineffectuality, this line near the end of his report was a needed anchor: “-- I believe that continuing to look for explanations is important.”