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This was a patient who presented with the

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combination of imaging findings of

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optic neuritis and transverse myelitis.

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The patient had an MRI of the brain,

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of the spine, as well as of the orbits.

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Let's look at the brain MRI

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with the FLAIR scan to the left.

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So in this situation,

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what we have is a patient who doesn't readily

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demonstrate very many demyelinating

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white matter lesions at all.

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If we look at the periventricular subcortical regions,

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nothing much is being demonstrated.

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We do see a lot of artifact from patient motion.

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If we look at the T2-weighted scan,

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we see a lesion,

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a linear lesion in the cerebellum.

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This is an old stroke.

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It's not a pattern of demyelination.

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It goes all the way out to the

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periphery of the cerebellum.

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But we do see some indistinct

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high signal intensity within the pons

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and in retrospect,

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some high signal intensity at the

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cervical medullary junction

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and posterior medulla.

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The next thing that was scanned was the spine.

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On the T2-weighted spine image,

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you can see a white matter lesion

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of the spinal cord,

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a spinal cord lesion which is quite extensive.

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Let me just magnify this a little bit more.

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The area of abnormality extends

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from the C1 level

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through the spinal cord

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down to the top of C4.

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So this is longitudinally extensive transverse myelitis,

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a long segment disease.

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Not what one would typically see in

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a patient with multiple sclerosis.

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It looks like it's a solitary lesion.

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Let's look on the axial scans.

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On the axial scans,

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you see that the lesion does

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indeed extend from C1,

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from centrally to the right

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side of the spinal cord,

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going down the spinal cord to the top of C4.

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And then, we have a more normal appearance

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to the spinal cord.

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As we went into the thoracic spine,

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no additional lesions were identified.

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Right now, we have just a few lesions in the

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infratentorial portion of the brain,

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and we have a lesion in the spinal cord,

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which is a long, extensive,

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longitudinally extensive white matter lesion.

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Let's look at the post-gadolinium-enhanced

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examination of the optic nerves.

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We follow the optic nerves backward,

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and as we proceed through the optic canal,

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we start to see something showing contrast enhancement,

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representing the left optic nerve

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in its prechiasmal portion.

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So, this is abnormal enhancing

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left optic nerve through the optic canal

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to the prechiasmal optic nerve

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representing left optic neuritis.

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We now have fulfilled our criteria for

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neuromyelitis optica spectrum disorder.

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We should also check to see the spinal cord

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lesion to see whether it shows

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contrast enhancement.

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On post-gadolinium scans,

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just going to magnify once again,

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you can see that there is faint contrast

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enhancement in the uppermost portion

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of that demyelinating process.

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So this is monophasic disease in that you have

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optic neuritis at the same time as enhancing

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transverse myelitis spinal cord lesion

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in a patient who has neuromyelitis

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optica spectrum disorder.