Are T-1 Hypointensities Specific for MS?

Here is My Question:
Are T-1 Hypointensities Specific for MS?

I’m currently going through the diagnostic process and had my second MRI on a 3-T machine. This set of scans showed more lesions than the first but none were enhancing or specific.

Out of 12 lesions that I found on my scans (report didn’t quantify them) I do have three lesions that show as hyperintense in T2 and FLAIR and hypointense on T1. They’re clear as day but the report didn’t mention any hypointensities outside of the automated Neuroquant/Lesionquant software used so they weren’t included in the impression. 

If these are indeed black holes (and they’re so obvious I don’t see how they’re not!), does this make it more likely to be MS? I can’t find a lot of information about other causes of black holes outside of multiple sclerosis. 

Answer:
The simple answer is to your question is no.

"Black Holes” are circumscribed dark (i.e. dark gray to black) areas within the white matter of the brain that usually correspond with a white area on FLAIR imaging. If the image that shows the “black hole” is obtained with a standard 2D T1 weighted image, it means that the underlying tissue matrix is severely disrupted as long as this region did not form as a gadolinium enhancing lesion in the prior 6 months. This is because new lesions that are enhancing often appear initially as a “black holes” in the scans without contrast but this dark area will resolve in most (> 60 %) within 6 months. A repeat scan 6 months or more later will then show  only a white spot on the FLAIR image with normal appearing brain on the 2D T1 weighted image.

Now this issue gets more complex with the 3D T1 weighted structural images that are used to measure brain volumes with NeuroQuant, LesionQuant and other image analysis programs. These 3D T1 weighted imaging sequences with names like MPRAGE and SPGR show many of the MS related white spots on FLAIR images as dark areas, even when they are not, “Black Holes”. This becomes more noticeable at higher MRI field strengths like 3 tesla (3T). Physicians and Radiologists not completely familiar with this phenomenon sometimes misidentify "black holes” using these 3D T1 weighted images that are not really present on standard 2D T1 weighted images

Hope this helps.

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego