Presentation
Recurrent left eye blurring of vision.
Patient Data
Enlarged left optic nerve comparing to the right side with perioptic fat streakiness.
No enlargement of superior ophthalmic vein or extraocular muscles.
Brain
Numerous hyperintense lesions on T2WI and FLAIR are mainly seen in periventricular and juxtacortical regions, especially at the callososeptal interface where these lesions are arranged perpendicular to the interface with "Dawson fingers" appearance. The periventricular lesions on axial views appear to be radiating laterally from the lateral ventricles following the perivenule distributions. Multiple hyperintense lesion on T2WI/FLAIR sequences at the inferior surface of the corpus callosum with "dot-dash sign".
Some of the lesions at both frontal lobes showed T1 black holes (hypointense on T1WI), which indicate a chronic stage.
Some of the lesions in right centrum semiovale and both corona radiata showed enhancement post-contrast, where some of them have "open-ring" enhancement, which is typical for active demyelinating lesions.
No lesions seen in the brainstem or cerebellum.
No restricted diffusion on DWI/ADC or blooming artefact on GRE demonstrated. No suspicious infratentorial lesion. New findings of bilateral superior ophthalmic veins enlargement. No filling defects seen in the SOV post-contrast to suggest SOV thrombosis. Both cavernous sinuses are well opacified with normal concave lateral wall configuration. No abnormal flow voids within the cavernous sinuses. Spine On post-contrast study, two spinal cord lesions showed enhancement, one at the C2 level and another at T6 levels. No abnormal leptomeningeal enhancement. Moderate degree of disc osteophyte complexes from C3/C4 to C6/C7 levels. Moderate degree of spinal canal stenosis at these levels without significant spinal cord compression. Spinal cord ends at the lower border of L1 vertebra.
Orbits
Left optic nerve (intraorbital and intracanalicular segments) appears swollen and higher signal intensity on T2 fat saturation coronal view. No significant abnormal optic nerve/sheath enhancement post-contrast. Optic chiasm and right optic nerve are normal.
On axial cuts of T2WI of the spinal cord, there are multiple peripherally located spinal cord lesions that demonstrate high signal intensity on T2WI, predominantly in the cervical and upper thoracic spinal cord. These spinal cord lesions are less than one vertebral body height.
Annotated images for the multiple sclerosis MR signs.
Case Discussion
This case showed many typical MR imaging features for multiple sclerosis: T1 black holes, Dawson fingers, dot-dash sign and open-ring.
Multiple T2-hyperintense lesions were seen at the juxtacortical, periventricular regions and spinal cord. Correlating with the clinical history of relapsing-remitting demyelinating attack (blurring of vision) and positive CSF oligoclonal bands (from lumbar puncture), these white matter lesions fulfill the McDonald 2017 criteria for dissemination in space for multiple sclerosis. The enhancement of brain and spinal cord lesions fulfills the criteria of dissemination in time.
In this case, the spinal cord lesions associated with multiple sclerosis are usually peripherally located and smaller in size (one to two vertebral heights) and the optic neuritis associated with multiple sclerosis is usually to be unilateral. Compared to NMOSD, the spinal cord lesions tend to be longer (more than 3 vertebral body lengths) and bilateral optic neuritis.
The incidental findings of dilated bilateral superior ophthalmic veins are likely to be idiopathic or inflammatory-related.
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