In today’s healthcare landscape, at least in the US, patients have near-immediate access to their test results and imaging reports through various online tools and smartphone apps. However, this immediate access can introduce new challenges, since many of these reports are difficult for patients to interpret and understand.

Patients trying to decode the ‘medical-ese’ of their brain scans is one of the most common phone calls or electronic messages I get, as a neurologist. However, there is an entire specialty of medicine (with multiple subspecialties) dedicated to looking at the imaging, and coming up with the report. The neurologist is left to translate what the radiologist saw, and what they wrote, into patient-friendly language. Below, you will find some of the common, typically benign findings and phrases that I see in my patients’ reports, and what they might mean from a clinical perspective.

“Mild to moderate white matter disease” or “microvascular ischemic disease”or “cerebral small vessel disease”

This typically refers to what is visible on an MRI brain scan as “white patches” in the white matter structures of the brain, as seen on specific imaging sequences, representing areas of microscopic scar tissue, sometimes with ‘holes’ within.

“White matter disease” on MRI (Source):

Whatever a radiologist sees must be noted somewhere in the report. Therefore, patients are often needlessly concerned when they see language like “mild white matter disease” and “small vessel disease” or the like, because - if it’s there, it must be bad, right?

Nope. In reality, as humans age, everybody’s brain starts to look like what we see above, which is typically referred to as “mild” microvascular ischemic disease of the white matter.

This is usually the result of normal ‘wear and tear,’ over time, to the smallest blood vessels in the brain, leading to either microscopic ruptures or blockages of those end vessels, and scarring of the tissue surrounding it. This happens in most of the organs in your body, including your skin (if you look closely enough!).

The risk factors for this process include normal aging, high blood pressure, a history of diabetes, and even a history of migraine headaches. Find a Mayo Clinic resource of this topic here.

Rarely is there cause for alarm, aside from perhaps a need for lifestyle changes such as monitoring blood pressure or blood sugars, as the ‘mild’ category is unlikely to represent a direct cause of cognitive decline or any other noticeable neurological issue.

Still, more extensive patterns of this “microvascular white matter disease” can represent a range of neurological problems, and this would be something to discuss with your neurologist, rather than staying up late into the night, researching on Google.

“Differential diagnosis includes demyelinating disease” or “cannot exclude demyelinating disease, such as MS”

These findings are often noted in conjunction with the phrases already discussed above. Again, while the possible reasons behind white matter disease in general are broad, the vast majority of reports featuring the categorization of “mild” disease should not be immediately concerning to the average patient. As I mentioned - radiologists have to write everything they see, and this can include lists of potential reasons behind a particular finding. Some of the worst possibilities could include autoimmune neurologic diseases that include multiple sclerosis - hence, their inclusion of these “code phrases” on a report. In any case, if you are a patient, please consider this before losing sleep while you wait for your physician to call you back about your results.

“Mild global cerebral atrophy” or “mild cortical atrophy” or “atrophy commensurate with age”

As we age, our brains gradually shrink after approximately age 35, initially averaging at a rate of about 0.5% of total volume loss per year, and accelerating into old age (1). This happens due to a multitude of factors, but the end result of these factors is gradual death and degeneration of multiple types of neurons, including supporting cells called glia; after all, we’re not immortal! Therefore, a certain amount of atrophy is expected, which radiologists do often comment on.

Here is an example of normal brain atrophy on MRI seen in a typical middle-aged and elderly patient (2) (Source):

In general, atrophy of the whole brain is less specific to particular neurodegenerative conditions than atrophy seen in just a few specific areas of the brain. Additionally, there are many conditions outside of neurodegenerative disease that can accelerate atrophy. Therefore, while seeing “mild global atrophy” on your radiology report shouldn’t cause a panic, everyone’s situation and clinical context is different, so it is always important to eventually speak to your clinician about your results.

What if there were another way?

Unfortunately, ‘translating’ written reports after brain scans doesn’t always solve the problem of patients understanding the results from an intuitive standpoint. Often, healthcare systems do not even provide a way for patients to view the actual images from their scans. That’s where BrainKey comes in.

The BrainKey software makes use of the data from a given patient’s brain MRI scan, and creates a three-dimensional visualization that patients can look at from every angle. Previously, software that could do this was realistically accessible only by researchers and experts with some programming knowledge; now, it’s possible for anyone to have their MRI scan data turned into something that they can rotate, zoom in on, and understand from a more intuitive standpoint.

If I were a patient, what would I rather look at - a bunch of lines of text, my doctor’s ham-fisted attempts at translating these lines into plain language, or an actual three-dimensional model of my brain? For me, the answer’s obvious:

Source

First of all, this makes it easier for a neurologist like me to talk about abnormal findings on a patient’s MRI, since it’s much easier to understand what area of the brain has a finding that I’m talking about when software like BrainKey can label key structures for me in a model I can rotate to any angle. However, it can be particularly useful in the context of reports mentioning brain atrophy, as BrainKey software automatically measures the actual volume of specific brain regions, and compares that to known averages based on patient’s age and sex.

In the future, as brain atrophy rates for particular regions of the brain are codified for particular neurodegenerative diseases, this type of information could become invaluable for diagnosis.

Some helpful patient resources for information regarding the above topics

• Mayo Clinic patient article on “small vessel disease”
• Mayo Clinic patient article on Multiple Sclerosis
• The Cleveland Clinic’s Six Pillars of Brain Health

References

1. Erten-Lyons D, Dodge HH, Woltjer R, et al. Neuropathologic Basis of Age-Associated Brain Atrophy. JAMA Neurol. 2013;70(5):616–622. doi:10.1001/jamaneurol.2013.1957
2. MacDonald, ME, Pike, GB. MRI of healthy brain aging: A review. NMR in Biomedicine. 2021; 34:e4564.

Jakob Mrozewski, MD is a practicing cognitive neurologist in the mountain West of the United States. He completed his subspecialty fellowship training in Behavioral Neurology and Neuropsychiatry, as well as Epilepsy, at the University of Colorado.

As one of a handful of clinically-focused cognitive neurologists in his region, one of his goals is gradual process improvement for optimizing patient education, health care delivery, and integration of multiple disciplines in the care of patients with cognitive manifestations of neurodegenerative diseases.