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You, Song, Park, Lee, and Son: Magnetic Resonance Imaging Features of Neuromyelitis Optica
Neuroradiology
Journal of the Korean Society of Radiology

Journal of the Korean Society of Radiology 2013; 68(5): 375-383.

Published online: 20 May 2013

DOI: https://doi.org/10.3348/jksr.2013.68.5.375

Magnetic Resonance Imaging Features of Neuromyelitis Optica

Sun Kyoung You, MD1, Chang June Song, MD1, Woon Ju Park, MD1, In Ho Lee, MD1, Eun-Hee Son, MD2

1Department of Radiology, Chungnam National University College of Medicine, Chungnam National University Hospital, Daejeon, Korea.

2Department of Neurology, Chungnam National University College of Medicine, Chungnam National University Hospital, Daejeon, Korea.

Corresponding author: Chang June Song, MD. Department of Radiology, Chungnam National University College of Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 301-721, Korea. Tel. 82-42-280-7834, Fax. 82-42-253-0061, cjsong@cnu.ac.kr

Received 10 May 2012       Accepted 22 February 2013

Copyright © 2013 The Korean Society of Radiology

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To report the magnetic resonance (MR) imaging features of the spinal cord and brain in patients of neuromyelitis optica (NMO).

Materials and Methods

Between January 2001 and March 2010, the MR images (spinal cord, brain, and orbit) and the clinical and serologic findings of 11 NMO patients were retrospectively reviewed. The contrast-enhancement of the spinal cord was performed (20/23). The presence and pattern of the contrast-enhancement in the spinal cord were classified into 5 types.

Results

Acute myelitis was monophasic in 8 patients (8/11, 72.7%); and optic neuritis preceded acute myelitis in most patients. Longitudinally extensive cord lesion (average, 7.3 vertebral segments) was involved. The most common type was the diffuse and subtle enhancement of the spinal cord with a multifocal nodular, linear or segmental intense enhancement (45%). Most of the brain lesions (5/11, 10 lesions) were located in the brain stem, thalamus and callososeptal interphase. Anti-Ro autoantibody was positive in 2 patients, and they showed a high relapse rate of acute myelitis. Anti-NMO IgG was positive in 4 patients (4/7, 66.7%).

Conclusion

The imaging findings of acute myelitis in NMO may helpful in making an early diagnosis of NMO which can result in a severe damage to the spinal cord, and to make a differential diagnosis of multiple sclerosis and inflammatory diseases of the spinal cord such as toxocariasis.

Keywords: Neuromyelitis Optica, Magnetic Resonance Imaging, Spine, Brain, Sjögren Syndrome

Figures and Tables

Fig. 1
Type of enhancement pattern of spinal cord on sagittal image.
Type A. No enhancement.
Type B. Subtle diffuse heterogenous contrast-enhancement without solitary or multiple strong contrast-enhancing foci.
Type C. Subtle diffuse enhancement wit h strong solitary nodular- or tumefactive peripheral rim-enhancing foci.
Type Da. Subtle diffuse enhancement with multiple posterior nodular enhancement foci.
Type Db. Subtle diffuse enhancement with multiple posterior continuous longitudinal enhancement foci.
Type Dc. Subtle diffuse enhancement with multiple central nodular enhancement foci.
Type E. Diffuse strong contrast enhancement without disruption.
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Fig. 2
Type B. 1st attack of acute myelitis in patient 7. Contrasted enhanced T1-weighted sagittal image shows subtle diffuse heterogeneous contrast enhancement. There are no solitary or multiple nodular enhancement.
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Fig. 3
Type C. 10th attack of acute myelitis in patient 5.
A. T2-weighted image shows high signal intensity in the cervical cord at the level of C1-2 (arrow).
B, C. Contrasted enhanced T1-weighted sagittal (arrow) and axial image (arrow) shows tumefactive peripheral rim enhancing nodular lesion at C1-2.
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Fig. 4
Type D acute myelitis in patient 3 and 5.
A, B. Type Da. At 5th attack of aucte myelitis in patient 5, contrast-enhanced T1-weighted sagittal image shows multifocal nodular (arrows) and continuous longitudinal enhancement (empty arrows in B) mainly along the posterior aspect of cervical and upper thoracic spinal cord.
C, D. Type Db. At 5th attack of acute myelitis in patient 3, contrast-enhanced T1-weighted sagittal image shows multiple continuous longitudinal enhancement (arrows) along the spinal cord at C1 to C2 (C). Simultaneously the similar lesion were along the spinal cord at T4-T6 (arrows) (D).
E, F. Type Dc. At 1st attack of acute myelitis in patient 3, contrast-enhanced T1-weighted sagittal and axial image shows nodular enhancement (arrow) in central portion of thoracic spinal cord at the level of T4.
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Fig. 5
Type E. Acute myelitis in patient 2, without recurrence of acute myelitis. Contrast-enhanced T1-weighted sagittal image shows subtle diffuse contrast-enhancement in whole spinal cord (arrows) with diffuse strong contrast-enhancement.
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Fig. 6
Variable located high signal intensity lesions of the brain on fluid attenuated inversion recovery (FLAIR) or T2-weighted image in patient 7 (A-C) and patient 6 (D).
A. T2-weighted axial image shows focal high signal intensity (SI) in medulla oblongata.
B. FLAIR axial image shows high SI in left periventricular white matter.
C. FLAIR sagittal image shows edematous white matter lesions involving the corpus callosum, particularly the splenium.
D. FLAIR axial image shows high signal intensity lesion in periaqueductal area of midbrain.
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Fig. 7
In patient 2, optic neuritis at first attack. T2-weighted axial image (A) shows high-signal intensity foci in the minimally expanded left optic nerve. These lesion enhances following intravenous contrast administration on fat saturated T1-weighted image (B).
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Table 1
Proposed Diagnostic Criteria for Neuromyelitis Optica
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Note.-Diagnosis requires absolute criteria plus at least 2 of the 3 supportive criteria. Data from Wingerchuk et al. (8).

Table 2
Summary of Clinical and Imaging Findings of 11 Patients with NMO
jksr-68-375-i002

Note.-L = left, NMO = neuromyelitis optica, MO = medulla oblongata, R = right, × = do not exam

Table 3
Location of Brain Lesions; 5 of 11 Patients
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Note.-Aque = periaqueductal, BS = brain stem, CC = corpus callosum, Lat = lateral ventricle, T = thalamus, WM = white matter, 3rd = 3rd ventricle, 4th = 4th ventricle, × = do not exam

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