case_images: PMC10702587_01
case_images: Event timeline for the case and MRI of the brain and spinal cord in January 2022 and June 2022. (A) The timeline showing the relevant events in the case. (B,C) T1WI and T2WI showed bilateral optic nerve enlargement and signal abnormalities. (D,E) The T2Flair displays small lesions located in the left posterior limb of the internal capsule and the cortical spinal tract area near the body of the left lateral ventricle. (F,G) T2WI revealed signal abnormalities in the cervical cord at the C3-6 vertebral plane. Diagnosed as a clinically isolated syndrome. (H-J) MRI of the brain and spinal cord in June 2022 with disease recurrence and T2Flair revealed new small lesions in the right cerebral peduncle, near the temporal horn of the right lateral ventricle, and in the hippocampal region. (K) T1WI-C shows right hippocampal lesion enhancement (active phase) in June 2022. (L,M) T2WI showed cervical spinal cord lesion shrinkage. Diagnosed with relapsing-remitting multiple sclerosis in June 2022.
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case_images: PMC10702587_01_fnins-17-1287480-g001.jpg
case_images: fig1
case_images: An optical coherence tomography (OCT) for both eyes, a visual evoked potential (VEP), and brainstem auditory evoked potential (BAEP) all returned normal results. MRI examination of the optic nerve, brain, and spinal cord was performed (Figures 1B-G). A cerebrospinal fluid (CSF) examination revealed positive oligoclonal bands, while serum oligoclonal bands, routine CSF tests, proteins, glucose, and chloride were all normal. The MRI of the brain and spinal cord revealed an increase in demyelinating lesions in the brain (Figures 1H-M).
case_images: Brain MR on February 2023 after SARS-CoV-2 infection and in May 2023. (A,G,M) T1WI, (B,H,N) T2WI, and (C,I,O) T2 Flair showed multiple newly formed tumorous lesions around both ventricles and a small patchy lesion in the left basal ganglia region. (D,J,P) DWI showed high signal intensity from these lesions. (E,K,Q) ADC revealed a decreased signal at the lesion margin (with diffusion limitations). (F,L,R) T1WI-C revealed ring-shaped enhancement of tumorous lesions (active stage). Indicating intracranial TDLs. (S-U) After steroid pulse therapy, brain MR was rechecked on May 2023.T1WI, T2WI, and T2 Flair showed that intracranial tumorous lesions were smaller than before and another lesion appeared near the left lateral ventricle horn. (V) DWI revealed a markedly decreased signal around both ventricles and diffusion limitation was found near the left lateral ventricle horn. (W) ADC revealed a slightly decreased signal from the lesion near the left lateral ventricle horn. (X) T1WI-C revealed no enhancement, lesions around both ventricles liquefied, and the lesion near the left lateral ventricle horn enhanced (active stage).
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case_images: PMC10702587_01_fnins-17-1287480-g002.jpg
case_images: fig2
case_images: An enhanced MRI of the brain and spinal cord (Figures 2A-R) revealed multiple speckled, mass-like nodular shadows in the right cerebellar hemisphere, left temporal lobe, left basal ganglia, periventricular white matter, right frontal lobe, and right portion of the genus and splenium of the corpus callosum. An enhanced MRI of the head on May 2, 2023 (Figures 2S-X), showed that the multiple TDLs had become smaller than before, some lesions appeared to soften, and new lesions were found under the left lateral ventricle triangle area, with limited diffusion and enhancement.
case_images: Follow-up Brain MR on July 2023. (A,D) After two months of treatment with Teriflunomide DMT: T2Flair revealed a new right thalamic lesion, the lesion near the apex of the left lateral ventricle had enlarged compared to the previous image, and the remaining intracranial lesions had shrunk and softened compared to before. (B,E) DWI showed high signals. (C,F) T1WI-C revealed spotty enhancement in the right thalamus and open-ring enhancement near the left lateral ventricle (active phase). [(G, I), TE = 135 ms] MRS showed that the demyelinating lesion near the right anterior horn of the lateral ventricle is in the non-active phase (G), Cho peak is elevated, and the NAA peak is slightly reduced, Cho/NAA ratio: 1.97; he demyelinating lesion near the left apex of the lateral ventricle is in the active phase (I), the Cho peak is mildly elevated, and the NAA peak is mildly reduced, Lip and Lac peaks can be observed, Cho/NAA ratio: 0.69.Metabolite imaging CSI (H,J) shows that most of the lesion near the right anterior horn of the lateral ventricle, and a small part of the lesion's center near the left posterior horn of the lateral ventricle are in the non-active phase (decreased NAA, increased Ins).
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case_images: PMC10702587_01_fnins-17-1287480-g003.jpg
case_images: fig3
case_images: After two months of DMT medication, the enhanced MRI + MRS of the head on July 9, 2023 (Figures 3A-J) revealed that although the tumefactive lesion in the right frontal lobe of the patient's brain had diminished and partially softened, a new lesion was found in the right thalamus and the lesion next to the triangle-vertex-posterior angle of the left lateral ventricle was larger than the previous film, and the enhanced group-like open-loop enhancement next to the left lateral ventricle was in the active phase.