Clinical question: Optic neuritis versus ADEM versus MS; eye weakness, pain and visual loss. Signs and symptoms: As above. Nonenhanced brain MRI:Examination demonstrates multiple patchy large foci of flair/T2 hyperintensity nearly symmetrically involving the white matter of bilateral parietal cingulate gyri, splenium of corpus callosum with resultant increased caliber, extensively the periventricular white matter of the left anterior and mid temporal lobe with resultant subtle mass effect and partial collapse of the left temporal horn, medial aspect of right temporal lobe and extending into the right cerebral peduncle, right cerebellum and right middle cerebral peduncle which subtle increased caliber and to a lesser degree of the left middle cerebral peduncle and a small additional focus in the anterior pons in the midline.Findings in proper clinical setting could represent ADEM however possibility of tumefactive multiple sclerosis cannot be entirely excluded.Additionally examination demonstrates small foci of flair hyperintensity in the periventricular white matter of lateral ventricles and minimally of the subcortical white matter and left frontal lobe without convincing evidence of increased volume or appreciable mass-effect. There is suspected flair hyperintensity signal change of the right optic nerve only on sagittal T2 flair series 201 images 176 through 182.Nonenhanced MRI of orbits:Examination is severely degraded due to motion artifact. However as detailed above there is suggestion of increased flair hyperintensity of right optic nerve in its cisternal and through the right optic nerve canal (sagittal T2 flair series 201 images 176 through 182).Within the limitation of extensive motion artifact there is no convincing evidence of any additional finding on MRI orbits
1.Nonenhanced brain MRI demonstrate multiple large foci of flair/T2 hyperintensity with subtle associated mass effect in bilateral cerebral hemispheres (left greater than right) and including extensively of the splenium of corpus callosum, bilateral cerebellar peduncles and right cerebellum and pons. Findings could represent ADEM or tumefactive multiple sclerosis. Few additional smaller bilateral hemispheric (left greater than right)periventricular white matter foci of flair hyperintensity are also present.2.Unenhanced MRI of orbits is nondiagnostic due to motion artifact. Sagittal T2 flair series 201of brain study however demonstrates suspected flair hyperintensity of right optic nerve as detailed. Unremarkable MRI of orbits otherwise. Please correlate with neurological exam regarding this suspected finding.