• 24-year-old female presents with sudden onset of decreased vision. Denies headaches or other neurologic symptoms.
    • PMH – neg
    • PsurgHx – neg
    • Meds – none
    • PE
    • AF VSS
    • Neurologically intact except for L homonymous hemianopia

    Figure 1: T2

    Figure 2: T1+contrast

    Figure 3: T1+contrast

    Figure 4: Diffusion

    Figure 5: ADC

    1. Which is highest on your differential based on the history and imaging?

    2. What further testing would you recommend?


    3. What treatment would you offer?

    4. Which of the following describes you?

    5. I practice in one of the following locations.

    6. Please add any suggestions or comments regarding this case:
    • Stereotactic biopsy should be considered to establish the diagnosis before starting any treatment.

    • quite interesting, curious about diagnosis

    • Only 1 image would expand

    • Sudden onset in a young woman is most consistent with MS.  There are no other brain lesions visible which speaks against MS.  However MS can present with mass effects and some enhancement as this lesion has.  The lesion  appears to be primarily white matter so the differentail would include astrocytoma though the sudden history makes that less likely.  I would do the MR of the spine to look for other lesions and get an LP for oligoclonal band and IgG index.  The chance of NMO is very low, but I would still get blood for an NMO antibody. 

    • Multiple Sclerosis ( Soltanian Nina )


    This patient is a young woman with sudden onset of a neurologic deficit. This is classic first presentation of multiple sclerosis. Her imaging shows a minimally enhancing lesion confined to the white matter representing a demyelinating lesion. Often these patients undergo a lumbar puncture to confirm an MS diagnosis. CSF will show oligoclonal bands. First line treatment for an MS relapse is high dose steroids. Management of the disease course includes disease modifying treatment (DMT) such as IFN-beta (immunomodulator) or glatiramer acetate (resembles myelin basic protein and binds to MHC molecules, competing with myelin antigens for T cell presentation).

    For this case, the patient presented with the lesion shown on imaging. She had neurologic worsening over several weeks despite steroids and plasma exchange. She underwent repeat imaging that revealed the lesion had expanded. She underwent a stereotactic biopsy and the diagnosis of a demyelinating lesion was confirmed.


    • Dhib-Jalbut S. Mechanisms of action of intererons and glatiramer acetate in multiple sclerosis. Neurology, 2002.
    • Kamm et al. Multiple sclerosis: current knowledge and future outlook, Eur Neurol, 2014.

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