0:01

This next case is a 41-year-old

0:03

woman who had double vision.

0:05

While initially one might think about scanning

0:08

the orbits to look for optic neuritis

0:11

in a patient who might have multiple

0:12

sclerosis history.

0:14

For most patients who have double vision,

0:16

we scan the brain first,

0:18

and the orbits may not be separately included.

0:22

This patient shows a number of areas

0:27

of abnormal signal intensity,

0:29

as you can see in the white matter.

0:32

And if we look on the T2-weighted scan,

0:37

the infratentorial fossa and the brain stem look

0:40

pretty good, in that there are no areas of

0:43

demyelination seen on the T2-weighted scan.

0:46

As we shift to the FLAIR scan, however,

0:49

we see lots of white matter lesions that

0:53

are in the periventricular zone.

0:55

I'm going to stop on this case

0:58

on this image to identify the demyelinated

1:03

plaques on the FLAIR scans.

1:05

And again,

1:08

we would comment about the closeness this is

1:11

to the gray matter as a juxtacortical

1:13

or subcortical white matter lesion,

1:16

as well as some deeper white matter lesions.

1:19

And as we scroll these scans,

1:22

you see that some of them actually extend

1:24

to the periphery of the ventricle.

1:28

So a nice example of a large plaque,

1:31

which spans from the ventricle to the subcortical region.

1:35

The other thing I want to emphasize on this

1:37

particular case is the presence of cytotoxic

1:41

edema around some of these plaques.

1:44

So, if we go up into the higher portions of the

1:48

centrum semiovale and we look at the ADC map,

1:52

we do see a small halo of dark signal intensity

1:56

around the area where there is T2 shine

1:59

through in these demyelinating plaques.

2:02

So this is an example of ADC

2:04

positive demyelination.

2:07

And we would suggest that this implies

2:10

that this may be an active plaque.

2:12

If we pull down the postgadolinium-enhanced scan

2:16

and scroll to that same region,

2:26

we can see a small amount of peripheral and

2:31

nodular enhancement along these plaques that

2:34

suggest that indeed they are active.

2:39

We also see inactive plaques.

2:47

For example,

2:48

in the right temporal region,

2:51

we have an area of demyelination that

2:54

is seen well on the FLAIR scan,

2:56

but no evidence of enhancement.

2:58

And in this one,

2:59

along the periventricular region near the temporal

3:02

horn of the lateral ventricle,

3:03

no area of contrast enhancement.

3:06

Looking at the region around the

3:11

optic canal,

3:13

we get lucky here because, indeed,

3:16

on the postgadolinium-enhanced images,

3:20

one can see the optic nerve coursing to and through

3:24

the optic canal showing contrast enhancement,

3:28

suggesting that the patient

3:29

may have optic neuritis.

3:32

This patient had a prior study that showed a nice

3:36

example of the findings you might see

3:40

on the cervical spine examination.

3:44

So, what we're seeing is on the T2-weighted

3:48

scan to the far left and the STIR

3:51

image to the far right,

3:53

an area of demyelination in the

3:55

upper cervical spinal cord.

3:57

It happens that, in this example,

4:00

one sees that the cord is slightly expanded

4:04

in an anterior-posterior direction.

4:08

You might also suggest that there's likely to be

4:12

another demyelinating plaque lower down

4:15

on the periphery of the spinal cord.

4:17

So let's indeed look at the T2-weighted

4:20

and gradient echo scans.

4:22

So here we have the gradient echo scan,

4:25

and here we have the fast spin echo T2-weighted scan.

4:29

They're both T2-weighted but one sees the

4:31

area of demyelination in the right side

4:34

of the spinal cord.

4:35

In this case,

4:35

I'd say maybe a little bit better on the

4:38

fast spin echo scan than on the gradient echo scan,

4:42

and that is in the upper cervical

4:44

spine at the C2 level.

4:46

As we scroll the images down lower,

4:52

we can see that both of these sequences are

4:56

showing the demyelination in the right

4:58

side of the spinal cord quite nicely.

5:03

And as we get to the periphery of the spinal

5:07

cord lower down at that C4-5 level,

5:12

we can also see the area of demyelination along

5:16

the periphery of the right

5:17

side of the spinal cord.

5:18

So here, we see that on the fast spin echo,

5:21

the edge of the spinal cord is bright

5:23

in signal intensity.

5:24

This corresponds to that same location

5:27

on the sagittal STIR,

5:29

and the same thing is also

5:31

true on the gradient echo scan.

5:36

Some multiple areas of demyelination

5:40

in the spinal cord

5:43

on the

5:46

cervical spine examination.

5:50

By virtue of this patient having periventricular

5:54

white matter lesions,

5:55

subcortical white matter lesions,

5:58

as well as spinal cord lesions,

6:00

Some of which are showing contrast enhancement.

6:07

We have fulfilled the McDonald criteria for

6:09

dissemination in time and space,

6:11

and therefore,

6:12

meet the criteria for making a diagnosis

6:16

of multiple sclerosis.