Case Contribution: Assoc. Prof. Dr Hilwati Hashim
Clinical:
- A 21 years old female
- Presented with 2 weeks history of right upper limb numbness and blurring of vision.
- She has had a similar episode 6 months previously which lasted for about 1 week and resolved spontaneously with no residual symptoms.
MRI findings:
- Bilateral T2/FLAIR hyperintense lesions at periventricular region which are perpendicular to the lateral ventricle (yellow arrows)
- Juxtacortical white matter at left frontal lobe (red arrow)
- A hypointense lesion on T1W at the left posterior parietal lobe “black-hole” (white arrow)
- A short segment lesion at T6 level of the spinal cord (blue arrow)
- No enhancing lesion is seen (images not shown)
Diagnosis: Multiple sclerosis.
Discussion:
- Distribution of the intracranial and spinal lesion fulfills the 2017 McDonald’s criteria for Multiple Sclerosis for Dissemination in Space.
- No enhancing lesion seen post contrast suggest that there is no active disease at the time of scan.
- Criteria for Dissemination in Time is not fulfilled in this case. If there is a baseline scan available (for example: done at the time of the previous attack), comparison can be made to look for new T2 hyperintense lesion, another criteria for Dissemination in Time.
- Lesions which are hypointense on T1WI reflects more tissue damage in term of demyelination as well as axonal loss.
- CSF analysis which demonstrates elevated IgG or oligoclonal bands is useful to support the clinical diagnosis, particularly when the clinical attacks are doubtful or MRI criteria is not fulfilled.
