Neurology Follow Up #3/3 by and for Keith Torkelson, MS, BS

 

Contents

• Work Done
• Requirements
• Summary – MRI - Notes
• Time Line & Notes – 2025 – 2026 (June)
• Integrated – STR – July through October (2026)
• Results Up Front – 8 Pages – Semi-anonymized Medical Records
• Reasons to Share Medical Records by the Consumer
• FYI – Reporting Costs
• Content – Sharing of Medical Records
• Findings
• A Heterogeneous Pituitary Gland
• MRI’s of The Cranium
• How long does it take a neurologist to review a set of cranial MRI images?
• Can an MRI reveal why I have balance issues?
• Brain Pathologies that an MRI can Detect
• MRI detects lesion on Pituitary Gland – Ruled Out
• How are an MRI and Transcranial Magnetic Stimulation related?
• Does an MRI have any therapeutic value?
• Off label TENS Treatments
• Aside-FYI--MRI Forbidden Frequencies

Work Done

Initial

https://healthman2059.blogspot.com/2026/08/making-most-of-neurology-consult-by.html

Follow up 1/3

https://healthman2059.blogspot.com/2026/08/neurology-follow-up-1-by-and-for-keith.html

Follow up 2/3

https://healthman2059.blogspot.com/2026/09/neurology-follow-up-2-by-and-for-keith.html

Auto Link

Follow up #3/3 (Hopefully Final)

https://healthman2059.blogspot.com/2026/10/neurology-follow-up-33-by-and-for-keith.html

FYI - MRI--How long does it take and other factors

https://precisionmrigroup.com/how-long-is-a-brain-mri-scan/

 

Summary – MRI – Notes – Includes Preparation

Affiliated with > In House > Metadata >

ASK_Medications_RX_26010801_Notes

 

Integrated – STR – July through October (2026)

Results Up Front – 8 Pages – Semi-anonymized Medical Records

Reasons to Share Medical Records by the Consumer

[DECIDED NOT TO SHARE DUE TO ANXIETY]

• Combat Stigma
• Complete a Report
• Offset/Balancing Costs
• Guarded Transparency
• For Use in Education
• Other Opinions

 

FYI – Reporting Costs

The Doctor's Retainer/Hourly Structure: Neurologists rarely charge strictly "per page" for the final document they write. Instead, they structure fees by an hourly rate or a flat package. For instance, a typical expert retainer might run $2,500 to $4,500, which covers up to a set amount of record pages (e.g., 500 pages) and the creation of the final report, with excess hours billed at $350 to $600+ per hour.

 

In House > Metadata >

BMBBS_Neurology_Medical_Records_26102701_Actual

Content – Sharing of Medical Records

Medical data can be shared broadly in specific, controlled contexts—most notably through de-identification (removing all personal identifiers). The reasons for sharing anonymized or aggregated medical data with the public, researchers, or public health entities include:

1. Advancing Medical Research and Science

Population Studies: Anonymized data pools help researchers study disease trends, track rare conditions, and understand how illnesses spread across different demographics.

Clinical Trials & Drug Safety: Sharing aggregated health outcomes accelerates the development of new treatments, vaccines, and medical devices while supporting post-market drug safety monitoring.

2. Public Health Surveillance and Policy

Disease Outbreak Tracking: Public health agencies (like the CDC or local health departments) use anonymized or statutory data reporting to monitor infectious diseases (e.g., flu, COVID-19) and issue community safety advisories.

Healthcare Quality Benchmarking: Public health dashboards help evaluate hospital performance, regional treatment success rates, and healthcare resource allocation.

3. Personal Advocacy or Transparency (Voluntary Disclosure)

Lived Experience / Rare Disease Communities: Some patients choose to share their personal diagnostic journeys publicly to raise awareness, build support communities, or help others facing similar rare diagnoses.

Open Notes Initiatives: Patients have a legal right to access and share their own complete medical notes with whomever they choose, though this is distinct from broadcasting records to the general public.

Important Risks and Safeguards

Loss of Privacy & Discrimination: Unfiltered public sharing exposes sensitive health history, risking employment, insurance, or social repercussions.

De-identification Requirements: Legitimate public or research sharing requires strict compliance (such as HIPAA safe harbor rules) to strip names, birthdates, SSNs, and geographic markers before data becomes public.

 

Are you looking into anonymized medical research data, patient rights to access your own records, or something else? Let me know so I can give you more specific details.

 

[DECIDED TO HOLD BACK ON SHARING MY RECORDS DUE TO RISK]

 

Findings

• Exams are normal
• Lab work is normal
• Low ALZ Risk
• MRI results normal except report of heterogeneous pituitary gland
• No follow up planned
• Unfortunately I did not get any MRI slices to look at

A Heterogeneous Pituitary Gland

A heterogeneous pituitary gland on an MRI means that the tissue of the gland shows an uneven appearance or pattern of contrast enhancement rather than a smooth, uniform texture.

What "Heterogeneous" Means

Normal Gland: A healthy pituitary gland typically enhances smoothly and looks uniform (homogeneous) when a dye (contrast material) is injected during an MRI.

Heterogeneous Gland: An uneven or patchy pattern means certain areas absorb the contrast dye differently, or the signal intensity varies across the gland.

Common Causes

A heterogeneous finding is descriptive, not a final diagnosis on its own. Potential causes include:

Pituitary Adenomas: Small (microadenomas) or larger (macroadenomas) benign tumors that can alter tissue density and contrast uptake.

Cysts: Fluid-filled structures like Rathke cleft cysts or cystic adenomas.

Pituitary Hyperplasia: An enlargement or increase in cells, sometimes triggered by conditions like primary hypothyroidism.

Inflammation (Hypophysitis) or Bleeding: Autoimmune inflammation or small areas of micro-hemorrhage within the gland.

Normal Variations: Sometimes mild variations or artifacts can make a small portion of the gland look slightly uneven even if it is clinically insignificant.

Next Steps

Correlation with Symptoms: Radiologists and doctors evaluate whether you have signs of hormone imbalances (such as changes in energy, weight, or vision).

Hormone Testing: Blood tests are typically ordered to check pituitary and target-organ hormone levels.

Follow-up: Depending on the size and context, a doctor may recommend a repeat or follow-up MRI.

 

FYI – II - To help narrow this down, are you experiencing any headaches, vision changes, or unusual fatigue, or were you having blood hormone levels checked?

MRI’s of The Cranium

A normal cranial (brain) MRI displays clear views of the brain tissue, ventricles, and surrounding structures across three primary imaging planes.

Key Planes and Anatomy in Cranial MRIs

Sagittal Plane:

Provides a side-view profile showing midline structures like the corpus callosum, pituitary gland, brainstem (pons and medulla), and cerebellum.

Coronal Plane:

Provides a front-to-back vertical slice detailing the symmetry of the right and left cerebral hemispheres, orbits (eyes), and nasal cavities.

Axial Plane:

Provides horizontal cross-sections from the top of the cranium down to the base of the skull, showing the ventricles, gray-white matter boundaries, and major blood vessels.

Common MRI Sequences

T1-Weighted:

Best for evaluating normal anatomical details and structural boundaries.

T2-Weighted & FLAIR (Fluid-Attenuated Inversion Recovery):

Best for identifying pathological changes, such as areas of inflammation, multiple sclerosis lesions, strokes, or fluid accumulations (where fluid or damage shows up bright).

Where to Find Sample Scans and Atlases

Radiopaedia Normal Brain MRI Cases:

Open-access radiology library featuring real patient scan examples across T1, T2, FLAIR, and DWI sequences.

IMAIOS e-Anatomy Brain MRI Atlas:

Interactive cross-sectional human brain atlases with labeled anatomical structures on 3D T1-weighted images.

Radiology - Appreciating the Expert(s)

https://radiopaedia.org/cases/normal-brain-mri-6

 

How long does it take a neurologist to review a set of cranial MRI images?

A neurologist can visually review and examine the actual images from a brain or cranial MRI set in a few minutes (typically 2 to 10 minutes) if they are focused and undisturbed, though comparing them against past scans or complex clinical histories takes longer. However, the overall timeline depends on different parts of the review process:

Direct Image Viewing by a Neurologist:

2 to 10 minutes for a standard look-through, or up to 20 to 30 minutes if they are carefully measuring lesions or evaluating fine anatomical details.

Official Radiologist Report (The Formal Read):

A specialized radiologist typically takes 5 to 30 minutes to interpret the scan and write a formal report, which is then sent to your ordering doctor.

Total Turnaround Time (From Scan to Discussion):

Routine/Non-emergent scans:

1 to 2 weeks (or 3 to 7 days at many outpatient centers) for the report and review process to cycle through the clinic.

Urgent or emergency scans (e.g., acute stroke, severe bleeding):

Read and communicated within hours or the same day.

Consultation with the Neurologist:

If you are seeing a neurologist in an office setting, they may pull up and review the images live during your appointment (taking just a few minutes in the room), or they may wait for the formal radiologist interpretation before calling or seeing you.

Can an MRI reveal why I have balance issues?

An MRI can reveal why you have balance issues if the cause is a structural, vascular, or neurological problem in your brain, brainstem, cerebellum, or cervical spine, though many common balance disorders do not show up on a scan.

What an MRI Can Reveal

An MRI can detect central and structural causes of unsteadiness or vertigo, including:

Strokes or transient ischemic attacks (TIAs):

Reduced blood flow or tissue damage in the brain or brainstem.

Vestibular schwannoma (acoustic neuroma):

A benign tumor on the balance and hearing nerve.

Multiple sclerosis (MS) and white matter disease:

Areas of inflammation, demyelination, or chronic tissue damage.

Cerebellar or brainstem abnormalities:

Cysts, tumors, or degeneration affecting coordination.

Cervical spine compression: Nerve root compression or degenerative changes in the neck that disrupt posture signals.

What an MRI Might Miss

An MRI shows anatomy and structure, not how well your balance system actually functions. Many common and highly treatable balance disorders will result in a completely normal MRI, such as:

Benign Paroxysmal Positional Vertigo (BPPV):

Tiny calcium crystals loose in the inner ear canal.

Vestibular migraines: Migraine-related dizziness.

Meniere's disease or vestibular hypofunction:

Inner ear fluid or nerve signaling issues.

To diagnose these, doctors often use specialized vestibular function tests (such as VNG, VEMP, or the Dix-Hallpike maneuver) rather than imaging.

When an MRI is Typically Needed

Doctors usually order an MRI if your balance issues are sudden, long-lasting, unexplained, or accompanied by red flag symptoms such as:

Double vision or vision changes

Slurred speech or trouble swallowing

Sudden weakness, numbness, or facial droop

Unilateral (one-sided) hearing loss or severe headache

You can read more about imaging guidelines for dizziness on the Johns Hopkins Medicine Order Wisely Guide. [1]

Brain Pathologies that an MRI can Detect

A brain MRI can detect a wide range of structural, vascular, inflammatory, and degenerative brain pathologies.

Vascular Pathologies

Strokes:

Identifies both acute ischemic strokes (via restricted diffusion) and chronic infarcts or silent brain infarcts.

Brain Aneurysms:

Detects weakened or ballooning arterial walls before or after a rupture.

Hemorrhages and Hematomas: Locates acute and old bleeding, subdural hematomas, and cerebral microhemorrhages.

Vascular Malformations:

Spotlights developmental venous anomalies, arteriovenous malformations, and cerebral amyloid angiopathy.

Tumors and Masses

Primary Brain Tumors:

Characterizes gliomas, meningiomas, oligodendrogliomas, and vestibular schwannomas.

Pituitary Gland Abnormalities:

Highlights pituitary adenomas and related sellar/parasellar masses.

Cysts:

Identifies arachnoid cysts, Rathke's cleft cysts, colloid cysts, and epidermoid cysts.

Metastatic Lesions:

Detects secondary cancer growths spread from other parts of the body.

Inflammatory and Demyelinating Conditions

Multiple Sclerosis (MS):

Reveals characteristic white matter plaques and demyelinating lesions in the brain and brainstem.

Brain Infections:

Detects encephalitis, brain abscesses, and meningitis.

Inflammation and Swelling:

Identifies localized edema or autoimmune/limbic encephalitis.

Structural and Congenital Anomalies

Hydrocephalus:

Measures excess cerebrospinal fluid buildup and ventricular enlargement.

Chiari Malformations:

Evaluates low-lying cerebellar tonsils or craniocervical junction variations.

Developmental Issues:

Spotlights cortical development malformations and asymmetric ventricles.

Degenerative and White Matter Diseases

Dementia and Neurodegeneration:

Assesses structural atrophy linked to Alzheimer's disease and other dementias.

Chronic Small Vessel Disease:

Displays age-related white matter hyperintensities and perivascular space changes.

Traumatic Brain Injury (TBI):

Visualizes contusions, axonal shearing injuries, and post-trauma swelling.

You can read more about what scans reveal through resources like the RadiologyInfo Patient Guide or Cleveland Clinic Diagnostics.

MRI detects lesion on Pituitary Gland – Ruled Out

An MRI-detected pituitary lesion most commonly represents a pituitary adenoma (a benign tumor), though it can also be a cyst, inflammation, or an incidental finding ("pituitary incidentaloma").

What This Findings Typically Means

Pituitary Adenoma: Most pituitary lesions are noncancerous (benign) growths. They are grouped by size into:

Microadenomas: Smaller than 1 cm (10 mm).

Macroadenomas: 1 cm or larger, which can push against nearby structures like the optic nerves.

Alternative Possibilities: Not all lesions are tumors; they can include Rathke's cleft cysts, lipid/inflammatory changes, or normal anatomical variations (such as an empty sella).

Next Steps & Evaluations

Your healthcare team will typically evaluate the lesion by looking at several key areas:

Hormone Blood & Urine Tests: To check whether the lesion is functional (producing excess hormones like prolactin, ACTH, growth hormone, or cortisol) or non-functional (making normal or low levels of hormones). Guidance is available via the American Cancer Society.

Vision Testing: If the lesion is large enough to press upward near the optic chiasm, an eye doctor or ophthalmologist will check for side-vision (peripheral) changes.

Specialist Referrals: You may be referred to an endocrinologist (hormone specialist) and/or a neurosurgeon to interpret the exact scan characteristics.

 

FYI – II - To help me provide more relevant information, do you know: What size or description was mentioned in your MRI report (e.g., microadenoma, cyst)? What symptoms or reasons led to getting the MRI?

 

How are an MRI and Transcranial Magnetic Stimulation related?

An MRI (magnetic resonance imaging) and Transcranial Magnetic Stimulation (TMS) are related because MRI scans (both structural and functional) are frequently used to map a patient's brain and guide the exact placement of the TMS coil.

How They Work Together

Target Selection (Neuronavigation):

An anatomical MRI provides a detailed 3D structural baseline of a person's unique head and brain shape. A functional MRI (fMRI) maps active or resting-state brain networks to find the exact functional spot (such as within the dorsolateral prefrontal cortex) that connects to deeper circuits involved in mood or other conditions.

Precision Placement:

Because everyone's brain organization differs slightly, clinicians use these MRI-derived maps in a computer-guided system to pinpoint where to place the TMS electromagnetic coil. This practice is known as MRI-guided neuronavigation.

Shared Magnetic Principles:

Both technologies rely on magnetic fields, though for different purposes—an MRI scanner uses strong, steady or gradient magnetic fields to image brain anatomy and activity, while TMS uses a localized electromagnetic coil to briefly stimulate specific nerve cells and alter neural activity.

Simultaneous Research:

In advanced research settings, specialized TMS and fMRI setups can be interleaved or combined to stimulate a brain circuit and immediately monitor how the rest of the brain's network responds in real time.

You can learn more about personalized treatment targeting through resources like the Cognitive FX MRI-Guided TMS Guide or technical overviews on NCBI PMC.

 

Does an MRI have any therapeutic value?

An MRI (Magnetic Resonance Imaging) is a diagnostic tool, not a direct therapeutic or treatment procedure, meaning it does not treat or cure a disease by itself.

How It Supports Treatment

Guiding Medical Decisions: An MRI provides high-detail images of soft tissues, the brain, spine, and joints. This actionable information helps doctors choose the correct medical, surgical, or physical therapy.

Real-Time or Interventional Guidance: Specialized MRI systems (such as intraoperative or interventional MRI) can be used inside operating rooms to guide surgical tools or target procedures like tumor ablations.

Monitoring Treatment: Doctors use serial MRI scans to track how well a patient is responding to therapies like chemotherapy, radiation, or multiple sclerosis treatments.

 

Off label TENS Treatments

While Transcutaneous Electrical Nerve Stimulation (TENS) is primarily cleared by regulatory bodies for acute and chronic musculoskeletal pain relief, medical professionals and researchers have explored its use for several off-label treatments. Because standard TENS units can modulate neural pathways, alter neurotransmitters, and influence autonomic functions, they are frequently repurposed or studied for the following non-pain and systemic conditions:

1. Neurological & Cognitive Enhancement

Dementia and Alzheimer’s Disease:

Multiple clinical trials indicate that long-term, consistent application of TENS to the head or back can alter neurotransmitter activity, enhance brain blood flow, and stimulate gamma-wave activity (associated with focus). This has shown potential in temporarily improving memory, verbal fluency, and behavior in patients with early-stage Alzheimer’s or mild cognitive impairment (MCI).

Stroke Recovery:

When paired with physical therapy exercises, TENS is used off-label to improve gait, walking speed, and balance by enhancing neural plasticity and helping rewire motor pathways.

Adult ADHD:

While specific eTNS (external Trigeminal Nerve Stimulation) systems have received targeted FDA clearance for children, standard TENS units are occasionally used off-label by adults to stimulate cranial nerves in an attempt to mirror those focus-boosting effects.

2. Psychiatric & Mood Disorders

Depression and Anxiety:

Modified applications of TENS—specifically via transcutaneous vagus nerve stimulation (tVNS), which targets the ear or neck—are actively studied for treating treatment-resistant depression. The electrical pulses help release endorphins, serotonin, and GABA to promote autonomic balance and reduce anxiety.

3. Urological & Pelvic Health

Overactive Bladder & Incontinence:

Sacral or posterior tibial nerve stimulation (using a TENS unit on the lower leg or sacrum) is highly utilized off-label to treat refractory bladder dysfunction and lower urinary tract symptoms. It assists in modulating the nerves that control pelvic floor muscles and bladder contractions.

Premature Ejaculation (PE):

Emerging urological studies explore trans-perineal electrical nerve stimulation to extend coital latency time as a non-pharmacological alternative to SSRIs.

4. Other Investigational Uses

Gastrointestinal Issues:

TENS units applied to specific acupoints (such as the P6 point on the wrist) have been studied to reduce nausea and improve chronic gastroparesis.

Parkinson's Disease:

Some researchers use TENS to provide peripheral nerve feedback to diminish severe resting tremors.

Crucial Safety Warning:

Standard over-the-counter TENS instructions explicitly warn against placing electrodes on the head, neck, face, or chest due to the risk of seizures, strokes, or dangerous heart arrhythmias. If you are exploring off-label TENS therapy for cognitive, mood, or vagus nerve stimulation, it must only be performed under strict medical supervision or using specialized devices designed for cranial placement.

FYI—AI--Are you looking into TENS for a specific condition (like anxiety, gut issues, or memory support), or are you trying to figure out how to safely place the pads for a non-pain condition?

 

Aside-FYI--MRI Forbidden Frequencies

In MRI physics, forbidden frequencies refer to specific acoustic and mechanical resonance frequencies of the gradient coil assembly and hardware structures that must be avoided during pulse sequence design.

Why Forbidden Frequencies Exist

Mechanical Resonances:

Rapidly switching gradient coils experience strong Lorentz forces inside the main magnetic field, causing the hardware to vibrate.

Acoustic & Structural Feedback:

If the gradient waveforms hit the natural mechanical or acoustic resonance frequency of the coil mounts, shims, or housing, the vibrations amplify sharply.

Image Artifacts:

Unmitigated resonance causes severe mechanical ringing, fuzzy ripples, ghosting, or trajectory imperfections in sensitive sequences like echo-planar imaging (EPI) or layer-fMRI.

Common Examples and Ranges

EPI & Shim Resonances:

In high-field setups (such as 3T or 7T systems), specific frequency bands—like 339.5–394.4 Hz, 500–600 Hz, and 950–1250 Hz—are often flagged as forbidden bands when third-order shims or specific echo spacings are active.

Mitigation Strategies:

Scanner software and sequence programmers automatically adjust echo spacing (ES), truncate or reshape gradient slew rates, or shift the bandwidth to step cleanly over these mechanical gaps. In some research setups, hardware components like third-order shim cables are manually disconnected to bypass specific resonance couplings.