Multiple sclerosis (DWI)

Case contributed by David Mitchell

Presentation

Right facial and bilateral arm sensory changes.

Patient Data

Age: 30 years
Gender: Female

Stroke CT

ct

Brain: No acute intracranial hemorrhage or evidence of brain ischemia/infarct. 

CTA : No large vessel occlusion.

CT Perfusion: Normal and symmetrical CBV/CBF and MTT/T-max.  

DWI only stroke protocol MRI

mri

14x9 mm ovoid lesion with a thin rim of peripheral smooth restricted diffusion and central T2 shine-through in the left corona radiata in a perivenular alignment is more suspicious for a demyelination plaque than acute infarct. Furthermore, on the B0 images, there are multiple white matter lesions, many periventricular and in perivenular alignment. Further MS/demyelination workup suggested.

mri

MRI features are highly suspicious for a demyelinating disorder with the left corona radiata lesion demonstrating contrast enhancement and therefore satisfying criteria for dissemination in time. 

Case Discussion

A new diagnosis of MS presenting as an acute stroke syndrome. The patient has an unremarkable CT stroke protocol and perfusion study on admission. The patient then underwent a DWI only stroke protocol MRI which demonstrated abnormal restricted diffusion in a plaque of active demyelination. Additional typical MS-type lesions are visible on the B0 sequence. 

Learning points:

  • there is a differential for abnormal restricted diffusion on DWI that extends beyond an acute infarct
  • always review the B0 sequence thoroughly, especially if using a limited stroke protocol

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