case_images: PMC9752005_01
case_images: Serial spinal cord MRI scans in Case 1 (A-C) and Case 2 (D-M). Case 1: Cervical (A) and thoracic (B) spinal cord MRI obtained 10 days after Ad26.COV2.S first dose showed a T2-weighted hyperintensity irregularly extending from C3 to medullaris conus with swelling from C4 to C7 (arrows) and no gadolinium enhancement (not shown). (C) 8-months MRI follow-up showing the complete resolution of the swelling and marked amelioration of the signal abnormality, barely visible on Short Tau Inversion Recovery (STIR) images. Case 2: (D) Spinal cord MRI performed 3 months after Tdap and IVP vaccine administration, showing a T2-weighted hyperintensity from C5 to C7 (arrow) with swelling and blurred contrast-enhancement on T1-weighted sequence (E) (arrow). (F) 6-months MRI control showing the cervical lesion shrinkage on T2-weighted sequences and no more contrast-enhancement (G). (H) Spinal cord MRI obtained 8 days after the BNT162b2 second dose, showing swelling on STIR (arrow) and gadolinium enhancement [(I); arrow] of the previously detected lesion. (J) 4-months MRI showed showing marked reduction of the signal abnormality and no more enhancement on the T1-weighted image (K). (L) Spinal cord MRI obtained 62 days after the BNT162b2 third dose, showing a new swelling (arrow) and gadolinium ring enhancement (M) of the known cervical lesion.
case_images: fneur-13-1018785-g0001.jpg
case_images: PMC9752005_02_fneur-13-1018785-g0001.jpg
case_images: F1
case_images: C7, with swelling and blurred contrast-enhancement (Figures 1D,E); the brain MRI was negative. CSF analysis revealed normal cell count/protein level and IEP showed the presence of three OCBs (pattern II, OCB exclusively in CSF). CSF PCR testing for the extensive infectious panel was positive for Enterovirus, but this result was not considered significant due to the absence of prodromal respiratory/gastroenteric illness and clinical/MRI/CSF findings not suggestive of Enterovirus-related ATM. At 6-months of MRI control the cervical lesion appeared shrunk in volume, with no more contrast-enhancing, and no other lesions were detected in the spinal cord and brain (Figures 1F,G). After 8 days, he underwent a brain and spinal cord MRI follow-up, showing the swelling and gadolinium enhancement of the previously detected cervical lesion (Figures 1H,I). At a brain and spinal cord MRI performed 4 months later, the cervical lesion appeared reduced in dimension and did not show enhancement (Figures 1J,K). He was admitted to our neurology unit and a new spinal cord MRI showed the swelling and contrast enhancement of the pre-existing cervical lesion (Figures 1L,M); the brain MRI was still negative.
case_images: PMC9752005_02
case_images: Serial spinal cord MRI scans in Case 1 (A-C) and Case 2 (D-M). Case 1: Cervical (A) and thoracic (B) spinal cord MRI obtained 10 days after Ad26.COV2.S first dose showed a T2-weighted hyperintensity irregularly extending from C3 to medullaris conus with swelling from C4 to C7 (arrows) and no gadolinium enhancement (not shown). (C) 8-months MRI follow-up showing the complete resolution of the swelling and marked amelioration of the signal abnormality, barely visible on Short Tau Inversion Recovery (STIR) images. Case 2: (D) Spinal cord MRI performed 3 months after Tdap and IVP vaccine administration, showing a T2-weighted hyperintensity from C5 to C7 (arrow) with swelling and blurred contrast-enhancement on T1-weighted sequence (E) (arrow). (F) 6-months MRI control showing the cervical lesion shrinkage on T2-weighted sequences and no more contrast-enhancement (G). (H) Spinal cord MRI obtained 8 days after the BNT162b2 second dose, showing swelling on STIR (arrow) and gadolinium enhancement [(I); arrow] of the previously detected lesion. (J) 4-months MRI showed showing marked reduction of the signal abnormality and no more enhancement on the T1-weighted image (K). (L) Spinal cord MRI obtained 62 days after the BNT162b2 third dose, showing a new swelling (arrow) and gadolinium ring enhancement (M) of the known cervical lesion.
case_images: fneur-13-1018785-g0001.jpg
case_images: PMC9752005_02_fneur-13-1018785-g0001.jpg
case_images: F1
case_images: C7, with swelling and blurred contrast-enhancement (Figures 1D,E); the brain MRI was negative. CSF analysis revealed normal cell count/protein level and IEP showed the presence of three OCBs (pattern II, OCB exclusively in CSF). CSF PCR testing for the extensive infectious panel was positive for Enterovirus, but this result was not considered significant due to the absence of prodromal respiratory/gastroenteric illness and clinical/MRI/CSF findings not suggestive of Enterovirus-related ATM. At 6-months of MRI control the cervical lesion appeared shrunk in volume, with no more contrast-enhancing, and no other lesions were detected in the spinal cord and brain (Figures 1F,G). After 8 days, he underwent a brain and spinal cord MRI follow-up, showing the swelling and gadolinium enhancement of the previously detected cervical lesion (Figures 1H,I). At a brain and spinal cord MRI performed 4 months later, the cervical lesion appeared reduced in dimension and did not show enhancement (Figures 1J,K). He was admitted to our neurology unit and a new spinal cord MRI showed the swelling and contrast enhancement of the pre-existing cervical lesion (Figures 1L,M); the brain MRI was still negative.
case_images: PMC9752005_03
case_images: Serial brain and spinal cord MRI scans in Case 3 (A-H) and Case 4 (I-Q). Case 3: (A) Brain MRI performed 25 days after BNT162b2 second dose, showing a T2-weighted hyperintensity (arrow) in the left paramedian mid-pons with blurred enhancement on T1-weighted images [(B); arrow] and a non-enhancing spinal lesion at C2-C3 level [(C); arrow]. (D-H) 2-months MRI follow-up showing two new brain lesions:one juxtacortical in the left frontal hemisphere [(D); arrow] and one periventricular abutting the right lateral ventricle occipital horn [(E); arrow], both with contrast-enhancement [(G,H); arrows] and two spinal lesions at the dorsal level [(F); arrows], with no contrast enhancement (not shown). Case 4: (J-L) Brain MRI obtained 10 days after BNT162b2 second dose, revealing T2-weighted hyperintensities in both centra semiovale (CSO) [(I); arrows] and left thalamus/posterior limb of the internal capsule (IC) [(J); arrow]; lesions in the right CSO [(K); arrow] and left IC [(L); arrow] showed blurred contrast enhancement on T1-weighted images. (M-P) 20-days MRI control showing the enlargement of the left CSO lesion [(M); arrow] and a new lesion in the right peritrigonal area [(N), arrow], both with gadolinium-enhancement on T1-weighted images [(O,P); arrows]. (Q) Spinal cord MRI:obtained 10 days after the brain exam:showing three blurred areas at C2, C3, and C5-C6 levels on STIR sequences, with no enhancement (not shown).
case_images: fneur-13-1018785-g0002.jpg
case_images: PMC9752005_04_fneur-13-1018785-g0002.jpg
case_images: F2
case_images: CSO and left IC showed blurred contrast enhancement (Figures 2I-L); spinal cord MRI was negative. CSF analysis revealed normal cell count/protein level and a negative extensive infectious panel, while IEP showed the presence of OCB (pattern II). A new brain MRI revealed a new active lesion in the right peritrigonal area and an increase in the size of the previously detected lesions in the left CSO:this time gadolinium-enhancing:whereas areas in right CSO and left IC showed no more enhancement (Figures 2M-P). A spinal cord MRI:performed 10 days after:revealed the presence of three not enhancing cervical areas (at C2, C3, and C5-C6 levels; Figure 2Q).
case_images: PMC9752005_04
case_images: Serial brain and spinal cord MRI scans in Case 3 (A-H) and Case 4 (I-Q). Case 3: (A) Brain MRI performed 25 days after BNT162b2 second dose, showing a T2-weighted hyperintensity (arrow) in the left paramedian mid-pons with blurred enhancement on T1-weighted images [(B); arrow] and a non-enhancing spinal lesion at C2-C3 level [(C); arrow]. (D-H) 2-months MRI follow-up showing two new brain lesions:one juxtacortical in the left frontal hemisphere [(D); arrow] and one periventricular abutting the right lateral ventricle occipital horn [(E); arrow], both with contrast-enhancement [(G,H); arrows] and two spinal lesions at the dorsal level [(F); arrows], with no contrast enhancement (not shown). Case 4: (J-L) Brain MRI obtained 10 days after BNT162b2 second dose, revealing T2-weighted hyperintensities in both centra semiovale (CSO) [(I); arrows] and left thalamus/posterior limb of the internal capsule (IC) [(J); arrow]; lesions in the right CSO [(K); arrow] and left IC [(L); arrow] showed blurred contrast enhancement on T1-weighted images. (M-P) 20-days MRI control showing the enlargement of the left CSO lesion [(M); arrow] and a new lesion in the right peritrigonal area [(N), arrow], both with gadolinium-enhancement on T1-weighted images [(O,P); arrows]. (Q) Spinal cord MRI:obtained 10 days after the brain exam:showing three blurred areas at C2, C3, and C5-C6 levels on STIR sequences, with no enhancement (not shown).
case_images: fneur-13-1018785-g0002.jpg
case_images: PMC9752005_04_fneur-13-1018785-g0002.jpg
case_images: F2
case_images: CSO and left IC showed blurred contrast enhancement (Figures 2I-L); spinal cord MRI was negative. CSF analysis revealed normal cell count/protein level and a negative extensive infectious panel, while IEP showed the presence of OCB (pattern II). A new brain MRI revealed a new active lesion in the right peritrigonal area and an increase in the size of the previously detected lesions in the left CSO:this time gadolinium-enhancing:whereas areas in right CSO and left IC showed no more enhancement (Figures 2M-P). A spinal cord MRI:performed 10 days after:revealed the presence of three not enhancing cervical areas (at C2, C3, and C5-C6 levels; Figure 2Q).
case_images: PMC9752005_05
case_images: Serial brain and spinal cord MRI scans in Case 5 (A,B) and Case 6 (C-I). Case 5: (A) Brain MRI performed 28 days after BNT162b2 first dose, showing a new left lateral periventricular T2-weighted hyperintensity (arrow) with contrast enhancement [(B); arrow]. Case 6: (D) Spinal cord MRI obtained 12 days after BNT162b2 second dose, showing a T2-weighted hyperintensity from C2 to C7 with swelling (arrow) and gadolinium enhancement [(E); arrow]. (G) Brain MRI performed few days later showed a T2-weighted hyperintensity in left lateral pons (arrow) with blurred contrast enhancement [(H); arrow] and confluent supratentorial bilateral periventricular hyperintensities on FLAIR images (C). (I) 7-days MRI controls revealed the complete resolution of gadolinium enhancement of the left pontine lesion and the volume shrinkage of the cervical lesion with no more contrast enhancement on T1-weighted images (F).
case_images: fneur-13-1018785-g0003.jpg
case_images: PMC9752005_06_fneur-13-1018785-g0003.jpg
case_images: F3
case_images: A spinal cord MRI showed a T2-weighted hyperintensity from C2 to C7 with swelling and gadolinium enhancement on T1-weighted images (Figures 3D,E). A brain MRI performed a few days later showed a T2-weighted hyperintensity in left lateral pons with blurred contrast enhancement and confluent supratentorial bilateral periventricular areas on FLAIR images (Figures 3C,G,H). A new MRI revealed the complete resolution of enhancement in the left pontine lesion (Figure 3I) and the cervical area:also appeared significantly shrunk in volume (Figure 3F).
case_images: PMC9752005_06
case_images: Serial brain and spinal cord MRI scans in Case 5 (A,B) and Case 6 (C-I). Case 5: (A) Brain MRI performed 28 days after BNT162b2 first dose, showing a new left lateral periventricular T2-weighted hyperintensity (arrow) with contrast enhancement [(B); arrow]. Case 6: (D) Spinal cord MRI obtained 12 days after BNT162b2 second dose, showing a T2-weighted hyperintensity from C2 to C7 with swelling (arrow) and gadolinium enhancement [(E); arrow]. (G) Brain MRI performed few days later showed a T2-weighted hyperintensity in left lateral pons (arrow) with blurred contrast enhancement [(H); arrow] and confluent supratentorial bilateral periventricular hyperintensities on FLAIR images (C). (I) 7-days MRI controls revealed the complete resolution of gadolinium enhancement of the left pontine lesion and the volume shrinkage of the cervical lesion with no more contrast enhancement on T1-weighted images (F).
case_images: fneur-13-1018785-g0003.jpg
case_images: PMC9752005_06_fneur-13-1018785-g0003.jpg
case_images: F3
case_images: A spinal cord MRI showed a T2-weighted hyperintensity from C2 to C7 with swelling and gadolinium enhancement on T1-weighted images (Figures 3D,E). A brain MRI performed a few days later showed a T2-weighted hyperintensity in left lateral pons with blurred contrast enhancement and confluent supratentorial bilateral periventricular areas on FLAIR images (Figures 3C,G,H). A new MRI revealed the complete resolution of enhancement in the left pontine lesion (Figure 3I) and the cervical area:also appeared significantly shrunk in volume (Figure 3F).