Multiple Sclerosis

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.