Presentation
Recurrent left eye blurring of vision.
Patient Data
Enlarged left optic nerve comparing to the right side with perioptic fat streakiness.
Brain
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.
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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