Multiple sclerosis, case 7

Clinical history
This 41-year-old male presented with rapidly progressive sensory symptoms involving the left arm, and subtle motor deficits involving tips of the fingers of the left hand. No urinary disturbances were noted and the patient's gait was normal. Degree of disability: McCormick I.

Neurological examination was virtually normal, except for a slight asymmetry of the deep tendon reflexes of both arms.

First MRI
Image 1: Sagittal T1WI. Do you see any cord enlargement? Do you identify any signal abnormalities?
Image 2: Sagittal T2WI. Describe precisely the characteristics of the lesion now clearly visible.
Image 3: Sagittal Gd T1WI and image 4: Axial Gd T1WI. Characterize the type of enhancement shown in this image.
Image 5: Axial PD/T2WI image of the brain. Do those images confirm your suspected diagnosis?

Follow-up MRI (3 months later)
Image 6: Sagittal T1WI.
Image 7: Sagittal T2WI.
Image 8: Sagittal Gd T1WI.
How has the lesion evolved? What treatment if any has been undertaken?

DIAGNOSIS:

Multiple sclerosis

First MRI
Discrete spinal cord enlargement is visible at the C2-C3 level. On the T1-weighted image, the lesion is ill-defined and slightly hypointense. On the T2-weighted images the lesion is clearly visible as a well-defined, oval-shaped hyperintense area with subtle cord enlargement. After Gadolinium injection this MS plaque shows ring-like enhancement. The axial images equally well demonstrate the lesion, involving the left hemicord.
Brain MRI shows typical periventricular lesions, supporting the diagnosis of MS, which was confirmed by CSF examination.

Follow-up MRI (3 months later)
In this case, the upper cervical lesion almost entirely disappeared on MRI after high-dose corticosteroid therapy.

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