Multiple sclerosis, case 6

Clinical history
21-year-old female patient with rapidly progressive paresthesia of both lower extremities progressing to paresis. On clinical examination there was a sensory deficit corresponding to the level of TH2. Sphincter disturbances occurred and the patient was referred to MRI with the differential diagnosis of spinal cord tumor versus multiple sclerosis.

Image 1: Sagittal T1WI.
No major abnormalities are seen on this pulse sequence.
Image 2: Sagittal T2WI.
In contrast, on this sagittal T2 weighted images an intramedullary lesion at the level of C5, C7 is seen. Only minor cord enlargement is associated with this lesion. Note that there is a second small hyperintense round lesion present within the medulla oblongata (arrow).
Image 3: After Gadolinium injection, the lower cervical lesion enhances moderately, predominantly at its periphery.
Image 4: Axial T2WI. This axial image shows a large intramedullary lesion involving almost the entire cord, which is unusual for multiple sclerosis. Considering the clinical information and the presence of a second intracranial lesion, MR examination of the brain is necessary.
Image 5: Axial FLAIR images. These images indeed confirm the presence of multiple high signal intensity round lesions scattered around the periventricular region.
Image 6: Axial Gd T1WI.
These T1 images are obtained immediately after Gadolinium injection during the spinal study. Most of the lesions enhance either homogeneously or with a ring pattern. Considering the multiple enhancing lesions, the diagnosis of acute disseminated encephalomyelitis must be discussed. Still, considering the clinical presentation and the overall good general clinical status of the patient, this diagnosis of acute disseminating encephalomyelitis is less likely. The final radiological diagnosis of multiple sclerosis was made and was eventually confirmed by CSF study.

Search also:
- Multiple sclerosis

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