Neuromyelitis optica mimicking intramedullary tumor

Cervical neuromyelitis optica with thoracic ependymoma

Background:

The occurrence of cervical neuromyelitis optica (NMO) in a patient with a thoracic ependymoma is uncommon. Here, we present a patient with a spinal ependymoma who developed the new onset of NMO 2 months later.

Case Description:

A 66-year-old male presented with right lower limb weakness. The magnetic resonance (MR) revealed an intramedullary spinal cord tumor at the T2-T4 level. It was surgically excised and proved pathologically to be an ependymoma. 2 months later, the patient presented with an acute partial quadriparesis and a high signal intensity cord lesion at the C2-C3 level attributed to seropositive NMO (i.e. additional diagnostic studies confirmed this diagnosis).

Conclusion:

Patients with intramedullary thoracic ependymomas may also develop NMO resulting in recurrent/ new neurological deficits. Critical studies utilized to diagnose NMO include brain and spine MRs showing unique intramedullary brain/cord lesions, aquaporin-4 positive serology, and classical abnormal visual studies. If the diagnosis of NMO is established, multiple additional medical therapies are warranted.

Pediatric inflammatory demyelinating disorders and mimickers: How to differentiate with MRI?

Multiple sclerosis (MS) is a chronic, immune-mediated, neurodegenerative disorder of the central nervous system (CNS).While the clinical symptoms of MS most commonly manifest between 20 and 40 years of age, approximately 3 to 10% of all MS patients report that their first inaugural events can occur earlier in life, even in childhood, and thus include the pediatric population. The prevalence of MS onset in childhood/adolescence varies between 2.0% and 4.0% of all MS cases according to several extensive studies. The main imaging patterns of pediatric inflammatory demyelinating disorders and mimicking entities, including multiple sclerosis, neuromyelitis optica spectrum disorders, acute disseminated encephalomyelitis, MOG (myelin oligodendrocyte glycoprotein) antibody-related disorders and differential diagnoses will be addressed in this article, highlighting key points to the differential diagnosis.

Clinical, neuroimaging and therapeutic response in AQP4-positive NMO patients from India

BACKGROUND

Neuromyelitis Optica (NMO) is an autoimmune astrocytopathic disorder due to AQP4 antibodies.

OBJECTIVES

To analyse clinical, neuroimaging features in NMO patients and assess the efficacy of various therapeutics.

METHODS

AQP4+ve NMO patients were diagnosed based on consensus diagnostic criteria.

RESULTS

101 AQP4+ve NMO patients were seen with female (90) predominance. Adult population (71.3%) formed the larger group followed by pediatric (19.8%) and late-onset (8.9%). Myelopathy (36.2%) was most commonly seen followed by optic neuritis (19.1%), brainstem (17.1%), opticomyelopathy (16.1%), area postrema involvement (10.5%) and encephalopathy (1%). Encephalopathy and brainstem/cerebellar involvement were most common in pediatric population while opticomyelopathy was more common in late-onset patients. Hyperintensities of lower medulla was seen in 67.3% subjects and 49.5% had involvement of obex. Differential T2 hyperintensity of the long segment myelitis was found in 30.7%. Plasmapheresis was given in 71 subjects followed by maintenance therapy. Most of them showed significant improvement with EDSS score of 1 in 30.7%.

CONCLUSIONS

Clinical manifestations in AQP4+ve NMO patients may vary depending on the age at onset of illness. MRI features affecting cervicomedullary junction, obex, differential T2 hyperintensities of the spinal cord may form a useful diagnostic clue. Plasmapheresis is helpful in achieving remission along with immunomodulation.

A practical approach to the diagnosis of spinal cord lesions

Every neurologist will be familiar with the patient with atypical spinal cord disease and the challenges of taking the diagnosis forward. This is predominantly because of the limited range of possible clinical and investigation findings making most individual features non-specific. The difficulty in obtaining a tissue diagnosis further contributes and patients are often treated empirically based on local prevalence and potential for reversibility. This article focuses on improving the diagnosis of adult non-traumatic, non-compressive spinal cord disorders. It is structured to start with the clinical presentation in order to be of practical use to the clinician. We aim, by combining the onset phenotype with the subsequent course, along with imaging and laboratory features, to improve the diagnostic process.

Neuromyelitis optica: atypical clinical and neuroradiological presentation

The extreme variability of clinical and MRI findings in the suspicion of Devic's disease always requires the detection of specific antibodies (AQP4). MRI scans were performed with a high-field MRI scanner (1.5T General Electric Signa Horizon): the MRI protocol of the brain employed axial DP, T2, T1, FLAIR and DWI weighted images (wi) and coronal T2-wi. After intravenous administration of contrast medium axial and sagittal T1-weighted images of the brain were repeated. The spine protocol employed after contrast medium included sagittal T2-wi, T2-wi with fat suppression and T1-wi. In May 2004, a 64-year-old healthy Caucasian woman began to suffer loss of motor and thermal sensitivity in the left lower limb. MRI showed non-specific areas of abnormal signal intensity on the deep left frontal and right frontoparietal white matter with no pathological enhancement after contrast medium and a small intramedullary area of altered signal at metameric level C2-C4 with a diagnosis of post-viral transverse myelitis. The patient had two similar episodes years later so the neurologist decided to search for circulating IgG AQP4 with the definitive diagnosis of neuromyelitis optica. In this case, compared to a clinical presentation of atypical deficit neurological involvement, the neuroradiological results of a progressive diffuse involvement of the white matter were atypical.