Neuromyelitis optica


  • A 28 years old lady
  • First 2 presentations were optic neuritis
  • Third presentation with lower limbs weakness
  • Current presentation with bilateral lower limb weakness and urgency.
  • Clinical examination shows bilateral lower limb power 4/5.
  • Sensory level reduction at T2-T11 and L5-S1.
MRI of spine in sagittal plane; (A) T1WI, (B) T2WI and (C) T1+gadolinium


Repeat MRI 2 years later, sagittal plane (D) T2WI and (E) T1+Gadolinium


MRI spine in axial plane at different level T1+Gadolinium

MRI findings:

  • Initial MRI shows diffuse long segment high signal intensity within the cord (yellow arrows) with superior most margin at C4/C5 level and inferior margin at T8/T9 level. Faint abnormality also seen at C2-C3 level. There is  no enhancing lesion on post Gado.
  • Repeat MRI during current admission shows lesion at C2-C3 level, more conspicuous and almost of CSF density as compared to previous MRI. It is already hypointense on T1. No cord expansion.
  • Hyperintense signal is also seen at C5 to T8 level, similar extension of involvement as compared to previous findings.
  • However, there are multiple foci of enhancement seen at level of C7 to T2 on post contrast (red arrows). These enhancing lesion are peripherally and mostly posterolateral in location.
  • There is cord expansion with the largest AP diameter of the spinal cord measures 0.7cm at T2 level
  • MRI brain is normal (images not shown).

Diagnosis: Correlating with clinical presentations, features are in consistent with neuromyelitis optica.

Discussion: Neuromyelitis optica (NMO)

  • NMO is an idiopathic, autoimmune, inflammatory, demyelinating condition
  • It is characterised by bilateral optic neuritis and myelitis resulting in blindness and paraplegia
  • Involvement of optic nerve and spinal cord is common
  • The brain and brainstem are generally spared (10%)
  • 23% mortality rate
  • Women in their 30s and 40s

Comparison Neuromyelitis optica and multiple sclerosis:

More severe presentations with poor recovery (irreversible impairment) Mild to moderate presentations
Optic nerve and spinal cord Multiple lesions in the brain
Free of oligoclonal bands Oligoclonal bands
NMO-IgG (73% sensitivity) Seronegative on NMO-IgG
Attack water channel in astrocytes Attack immune T-cell
CSF: more cell response CSF: normal cell count, even during exacerbations
Women:men=4:1 Women:men=2:1
Late 30s Early 20s
Non-caucasian background Northern europe/caucasian
Author: radhianahassan