case_images: PMC7593562_01
case_images: MRI scan demonstrated the DIS: (A) Cranial MRI T2 scans revealed three lesions in the cortex and juxtacortical lesions. (B) Cranial MRI T2 scans revealed multiple white-matter lesions in the periventricular lesion. (C) Cervical MRI scans revealed a cervical 3rd segment with hyperintensity signal in T2 and enhanced T2. Red arrows showed lesions, which was preliminary diagnosed demyelination. MRI, magnetic resonance imaging; DIS, dissemination of lesions in space.
case_images: fneur-11-516587-g0001.jpg
case_images: PMC7593562_01_fneur-11-516587-g0001.jpg
case_images: F1
case_images: This patient underwent a cervical enhanced magnetic resonance imaging (CE-MRI) at a local hospital, which showed a cervical 3rd segment with T2 high signal and with enhancement (Figure 1C). T2-weighted MRI revealed hyperintense signals in the cortex and juxtacortical and periventricular lesions (Figures 1A,B). This patient was primary diagnosed with MS and treated with methylprednisolone (120 mg/d).
case_images: Imaging features at different MRI scans. (A) New T2 lesions on EMRI (A-right) compared to the first MRI (A-left) which demonstrated DIT. (B) EMRI scan showed hyperintensity in the left frontal-parietal lobe and lateral ventricle nearby in DWI; however, these lesions were both hyperintensity and hypointensity signals in ADC. Red arrows showed hypointensity lesions. (C) Cranial EMRI scans revealed that lesion with an enhanced phase signal in the left frontal-parietal lobe (C-left), and also seed enhanced phase lesion in sagittal view (C-right). EMRI, emergency cranial MRI; DIT, dissemination of lesions in time; MRA, magnetic resonance angiography; ACA, anterior cerebral arteries; MCA, middle cerebral arteries; PCA, posterior cerebral artery.
case_images: fneur-11-516587-g0002.jpg
case_images: PMC7593562_01_fneur-11-516587-g0002.jpg
case_images: F2
case_images: EMRI scan showed several new T2 lesions (Figure 2, A-right) compared to the first cranial MRI (Figure 2, A-left), with hyperintensity in the left frontal-parietal lobe and lateral ventricle nearby in diffusion-weighted imaging (DWI); however, these lesions were both hyperintensity or hypointensity signals in apparent diffusion coefficient (ADC) sequence (Figure 2B). CE-MRI, which revealed several enhanced signals in white matter of the left frontal-parietal lobe (Figure 2C). Combined with these images, it demonstrated the dissemination of lesions in time (DIT) of demyelination in MS.
case_images: Image result of cerebral vessels. (A,B) MRA and DSA showed that right MCA was occulted as well as bilateral terminal ICA, and the left MCA, ACA, and PCA were narrow, which was accompanied with "puff-of-smoke" vessels. (C) CTA showed "puff-of-smoke" vessels and meningeal branch neovascularization after the 2-stage bilateral STA bypass surgery. ICA, internal carotid artery; MCA, middle cerebral arteries; ACA, anterior cerebral arteries; CTA, computed tomography angiography.
case_images: fneur-11-516587-g0003.jpg
case_images: PMC7593562_01_fneur-11-516587-g0003.jpg
case_images: F3
case_images: However, further evaluation with magnetic resonance angiography (MRA) confirmed that his right MCA was occulted, and the left MCA, ACA, and posterior cerebral artery (PCA) were narrow, whose findings were typically seen in MM according to the Research Committee on Spontaneous Occlusion of the Circle of Willis (moyamoya disease) in Japan (Figure 3A). DSA showed that right MCA was occulted as well as bilateral terminal internal carotid artery (ICA), and the left MCA, ACA, and PCA were narrow, which was accompanied with "puff-of-smoke" vessels (Figure 3B). This patient was reexamined through computed tomography angiography (CTA) after 1 month, which showed "puff-of-smoke" vessels and meningeal branch neovascularization (Figure 3C).