Guess-a-Case
Demyelination; seizures
Sex: female
Age: 29 years
History
Unremarkable.
Laboratory data
EEG demonstrated a fronto-temporal epileptogenic source
Physical findings
None.
Case text
The patient presented with a six months history of complex partial seizures, which were unsuccessfully treated with drugs. The patient was referred to radiology to evaluate cause of epilepsy.
Image 1-7
MRI of the brain.
1- Axial, T1- weighted (520/ 10) image.
2- Axial, proton density (3000/ 19) image.
3- Axial, T2- weighted (3000/ 85) image.
4- Axial, FLAIR (8000/ 2000/ 157) image.
5- Axial, FLAIR (8000/ 2000/ 157) image.
6 and 7- Axial, contrast-enhanced, T1-weighted (520/ 10) images.
Image 1-7
1. What are the MRI findings?
Various hyperintense punctiform lesions of the centrum semiovale and the subcortical and periventricular white matter are demonstrated on T2- weighted sequences. there seems to be a right-sided predominance of the lesions. A larger left parietal lesion of the similar characteristics is observed. This lesion is hypointense on T1 and enhances peripherally while the center remains hypointense after contrast material administration. The smaller punctiform lesions also enhance after contrast administration.
2. Do these lesions correlate well with the clinical presentation?
There is no clear correlation between the topography of the lesions and the complex partial seizures of the patient.
3. What is your most likely diagnosis?
The lesions are limited to the white matter and are, therefore, compatible with demyelination (hyperintense on T2, enhance).The most likely diagnosis is multiple sclerosis. Note the pseudo-necrotic aspect of the left posterior parietal lesion surrounded by a small region of edema which represents a demyelinating plaque taking a pseudo-tumoral aspect.
Final diagnosis
Demyelinating lesions compatible with multiple sclerosis.
Differential diagnosis
his includes multiple metastatic lesions (location of lesions limited to white matter in this case); dilatation of the perivascular spaces (not the right localization and do not enhance); lacunar ischemic lesions (patient too young, different enhancing patterns).
Discussion
This case illustrates a case of multiple sclerosis revealed by the onset of seizures. There was no direct correlation between the topography of the lesion and the clinical symptom, which is classic in multiple sclerosis. The diagnosis was based on the topography and characteristics of the lesions as they appeared on MRI, the biological tests, and most of all, the evolutiveness of the lesions. It must be noted that 5 to 10 % of the patients with multiple sclerosis, have normal brain MRI at the time of their first clinical symptoms.
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Demyelination; seizures, Image 1 | | Demyelination; seizures, Image 2 | | Demyelination; seizures, Image 3 |
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Demyelination; seizures, Image 4 | | Demyelination; seizures, Image 5 | | Demyelination; seizures, Image 6 |
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Demyelination; seizures, Image 7 | |