Presentation
Right facial and bilateral arm sensory changes.
Patient Data
Brain: No acute intracranial hemorrhage or evidence of brain ischemia/infarct.
CTA : No large vessel occlusion.
CT Perfusion: Normal and symmetrical CBV/CBF and MTT/T-max.
14x9 mm ovoid lesion with a thin rim of peripheral smooth restricted diffusion and central T2 shine-through in the left corona radiata in a perivenular alignment is more suspicious for a demyelination plaque than acute infarct. Furthermore, on the B0 images, there are multiple white matter lesions, many periventricular and in perivenular alignment. Further MS/demyelination workup suggested.
MRI features are highly suspicious for a demyelinating disorder with the left corona radiata lesion demonstrating contrast enhancement and therefore satisfying criteria for dissemination in time.
Case Discussion
A new diagnosis of MS presenting as an acute stroke syndrome. The patient has an unremarkable CT stroke protocol and perfusion study on admission. The patient then underwent a DWI only stroke protocol MRI which demonstrated abnormal restricted diffusion in a plaque of active demyelination. Additional typical MS-type lesions are visible on the B0 sequence.
Learning points:
- there is a differential for abnormal restricted diffusion on DWI that extends beyond an acute infarct
- always review the B0 sequence thoroughly, especially if using a limited stroke protocol
Unable to process the form. Check for errors and try again.