Optic neuritis (in multiple sclerosis)

Case contributed by Dr Mohammad A. ElBeialy

Presentation

Visual loss.

Patient Data

Age: 19 years
Gender: Male

MRI Brain

Modality: MRI

MRI examination of the brain:

Multiple periventricular as well as deep white and juxta cortical demyelineating foci are seen scattered in both cerebral hemispheres, they are demonstrating hypointense T1 and hyperintense T2 and FLAIR signal intensity. A small left peritrigonal lesion is seen demonstrating restricted diffusion with hyperintense diffusion weighted image (DWI) and low ADC signal as well as subtle heterogeneous post contrast enhancement.  

A small demyelinating lesion is seen within the left medial cerebellar hemisphere demonstrating hypointense T1 and hypointense T2 and FLAIR signal with mild restricted diffusion yet with no significant post contrast enhancement.

Normal ventricular system, basal cisterns and posterior fossa.  

MRI Orbits

Modality: MRI

MRI examination of the orbit:

The left optic nerve shows mild enlargement with slightly hyperintense T2 and mild post contrast enhancement.   

Normal MRI appearance of right optic nerve. No orbital masses. Normal optic tracts and optic chiasma. Normal both eye globes. Normal ocular and extra-ocular muscles.  

Case Discussion

Multiple sclerosis with typical McDonald's criteria and left optic neuritis

The optic neuritis is seen in about one third of multiple sclerosis. Moreover, nearly 50% or greater (45- 80%) of patients with optic neuritis will develop multiple sclerosis within 15 years and the optic neuritis may be the only manifestation of multiple sclerosis.

The main differential diagnosis of MS with optic neuritis is the neuromyelitis optica (NMO); the main differential points are:

  • Optic nerve involvement in NMO is typically bilateral with possible involvement of the chiasm while unilateral in MS
  • The spinal cord involvement is typical and extensive usually extending to more than three vertebral levels and is central in distribution - MS spinal cord lesions (15% spinal cord involvement in MS) are short, focal and peripheral in location
  • Brain is typically normal in NMO, however different demyelinating lesions are reported
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Case Information

rID: 38584
Case created: 26th Jul 2015
Last edited: 17th Jan 2017
Inclusion in quiz mode: Included

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