Dizziness, giddiness and orthostatic hypotension. Also peripheral neuropathy. Question autoimmune process.Additional clinical history from the electronic medical record: History of anxiety, palpitations, and dizziness in the past (on Xanax). Presented with orthostatic tachycardia with syncope and dizziness on standing, in the context of recent foot dysesthesias. Workup at Methodist Hospital revealed high ANA, >12 CSF oligoclonal bands, but no CSF leukocytosis. She also has a few asymptomatic white matter lesions with no corresponding neurological exam findings, of uncertain significance. Her nonfocal neurological examination, history of orthostatic tachycardia and symmetric distal LE dysesthesias are suspicious for an underlying autoimmune disorder such as MS with transverse myelitis (vs a small fiber neuropathy), SLE, Sjogren's, or a paraneoplastic antibody syndrome. Brain:There is a relatively well-defined, juxtacortical T1-hypointense, T2-hyperintense lesion in the inferior left parietal lobe. In addition, the lesion shows a targetoid or concentric morphology on T2 imaging with a hyperintense center surrounded by a relatively hypointense ring and a hyperintense rim. There are at least three T2-hyperintense lesions in a periventricular distribution. The largest is just anterior to the frontal horn of the left lateral ventricle and measures up to 9 mm. Additional ones are present along the body of the lateral ventricles.There are smaller, less specific T2-hyperintense lesions scattered in the white-matter of both cerebral hemispheres. There is no diffusion restriction or intracranial hemorrhage. The corpus callosum is unremarkable in volume and signal intensity as well as the brainstem, accounting for perivascular spaces. There is no mass-effect, midline shift or brain herniation. The ventricles and other CSF-containing spaces are normal in size.The orbits are unremarkable. Major intracranial vascular flow voids are preserved. There is no destructive skull lesion or significant scalp soft tissue abnormality.Cervical spine:There are two T2-hyperintense peripheral spinal cord lesions at the upper C5 level. One involves the right ventrolateral aspect and a smaller one involving the right dorsal aspect of the spinal cord. The larger, anterior lesion spans craniocaudally just under a full vertebral body height. There is no other cervical cord signal abnormality.Sagittal alignment is notable for straightening which can be positional. The vertebral bodies are preserved in height and there is no suspicious marrow lesion. There is disc desiccation at all the cervical levels. Disc heights are preserved except for moderate loss at C5-C6, where an eccentric to the left disc bulge causing mild-to-moderate spinal canal stenosis and minimally indenting the spinal cord, especially on the left side. However, there is no spinal cord signal abnormality and the CSF space posterior to the spinal cord at this level is preserved. A small ventral indentation of the thecal sac but no significant spinal canal stenosis is present at C6-C7 by a central disc extrusion with minimal caudal migration. There is no neural foraminal stenosis. There is minimal ventral indentation of the thecal sac by the C3-C4 disc but no signal spinal canal stenosis. There is also no spinal canal stenosis at the other cervical levels. There is suggestion of rightward deviation of the uvula. This can be better assessed clinically, as it may be adherent to adjacent mucosa. Included cervical soft tissues are unremarkable, otherwise. Major neck vessels show preserved flow voids.Thoracic spine:There is a fairly large central, T2-hyperintense lesion involving the spinal cord at T9-T10 level, measuring up to 5 mm transaxially. In addition, there are two peripheral T2-hyperintense cord lesions; small one on the left at T5-T6 level and a larger one on the right at the upper T8 level. Sagittal alignment is preserved. The vertebral bodies are preserved in height. There is no suspicious marrow lesion. There is a small fat-containing hemangioma in T4 vertebral body. The thoracic discs are preserved. The spinal canal is preserved. There is mild facet arthropathy in the lower thoracic spine. There is no spinal canal or foraminal stenosis.The thyroid gland is mildly enlarged, especially the right lobe, though without a dominant focal lesion.Lumbar spine:Sagittal alignment is anatomic. There is disc desiccation and height loss in addition to type II degenerative marrow signal at L5-S1 but only a small disc bulge, barely indenting the ventral aspect of thecal sac. There is mild facet arthropathy contributing to mild narrowing of the neural foramina. A small bulge is present also at L4-5 but without significant spinal canal or foraminal stenosis. There is no significant degenerative disease or stenoses at the other levels. Conus medullaris shows normal signal and morphology. The tip of the conus lies at L1-L2 level. Cauda equina roots are normal, symmetrically distributed in the thecal sac.Subcentimeter, well-circumscribed, homogeneously T2-hyperintense, T1-hypointense central right and peripheral left renal lesions are likely cysts though not completely assessed. A small T2-hypointense lesion within the fundic myometrium likely represent leiomyoma. A larger, more elongated T2-hypointense lesion involving the dorsal myometrium with mild distortion of the uterine outline is probably also a leiomyoma.
1.Few small cerebral white-matter lesions. The largest is juxtacortical in the left parietal lobe. In addition, there are at least 3 periventricular bifrontal lesions as well as a few smaller scattered nonspecific ones. 2.A few scattered spinal cord lesions. The largest is a central lesion at T9-T10 level. The other lesions are peripherally located.3.Mild degenerative cervical and lumbar spondylosis as described above.4.Suggestion of rightward deviation of the uvula. Please correlate with direct inspection.5.Suspected uterine fibroids. If further assessment is needed, please consider pelvic ultrasound. While each of the brain lesions in isolation is nonspecific, the constellation and the distribution of the brain lesions as well as the presence of the cord lesions is suggestive of a demyelinating disorder such as multiple sclerosis. However, dissemination in time cannot be confirmed on a single, noncontrast-enhanced MR examination.