Case scenario (MRI: A Window into the Relentless Storm of MS)

1- I discussed a newly diagnosed MS case based on the clinical relapse, CSF study, and MRI activity.
2- We initially diagnosed the case as ADEM based on the initial clinical symptoms, the initial MRI results, and the absence of any other explanation.
3- On follow-up visits, the patient still progressed clinically in spite of treatment.
4- The MRI lesion is progressing, showing black hole lesions and new spinal lesions.
5- Repeated CSF showed +ve OCB.

1. Case scenario (MRI: A Window into the Relentless Storm of MS) By Dr. Mostafa M. Meshref Assistant lecturer of Neurology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.

2. Case presentation A 19-year-old University student He is an athlete (play Bodybuilding and basketball) No history of chronic medical illness Onset: September 2022 Complaint: Fatigue Increased sleepiness Ataxia to left side Loss of consciousness Precipitancy of micturition

3. 1 st imaging results (MRI brain and spine) MRI brain showed: Extensive large patchy areas of white matter signal intensity affecting: Periventricular Deep gray matter areas (both thalami and BG) Infratentorial and brain stem lesions In post contrast study the lesion showed thin smooth ring enhancement

4. T1 imaging T2 imaging

5. FLAIR Brain stem lesions

6. Diagnosis The patient was diagnosed based on radiology and clinical presentation as ADEM. He took pulse steroid therapy for 7 days with marked improvement. The patient discharged on oral corticosteroid with gradual tapering.

7. Case follow-up (After 3 months, December 2022) The during oral steroid tapering he developed recurrence of mild ataxia . Repeated MRI brain showed: Mild regression of the previous brain lesions with disappearance brain stem lesions. CSF analysis was requested and showed : mild pleocytosis (10 cells). OCB 0 Serum Anti-MOG negative. He continued the oral corticosteroid with prolonged periods of tapering.

8. 2 nd follow-up (March 2023) The patient still on oral steroid dose oral therapy. He still had some: Fatigue Ataxia Precipitancy Also, he developed: Mild distal weakness of both hands Tremors of both hands We counseled him for: Tapering the steroid therapy till stoppage Do a new MRI brain and cervical spine New CSF (1.5- 2 months) after stoppage the oral steroid therapy.

9. 3 rd follow-up visit (July 2023) The patient did new MRI brain and spine: The MRI brain results showed: Evidence of black holes in T1 images Still demyelinating patches supratentorial and infratentorial

10. FLAIR Sagittal FLAIR

11. The MRI spine showed: C2-C3 demyelinating patches.

12. NEW CSF results The new CSF showed: OCB 4 bands Pleocytosis (cells 10) IgG index 0.5

13. The patient was diagnosed as Active RRMS He started on DMT (ocrelizumab every 6 months) He took 2 cycles of therapy, and he is improving and stable clinically.

14. For more information and feedback please, contact me at: [email protected] [email protected]