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“So this is a young woman who was being evaluated for follow up of known known multiple sclerosis when i look at the scans for multiple sclerosis. I generally have initially the axial flare scan the axial t2 weighted scan and the axial diffusion way it scan and what i do is i generally scroll through these in order to identify the demyelinating plaques in the axial plane initially as i mentioned on t2 weighted scanning demyelinating plaques are better seen in the info tutorial area so initially we re going to look at the cerebellum and the brain stem on the t2 weighted scan focusing and then as we shift to the supertintin space the flare scan becomes the dominant most accurate way of evaluating because of the veer karabast base perivascular space issue as described previously initially. I will also have the diffusion weighted scan up to look and see whether there is active demyelination with cytotoxic edema and also to exclude another entity such as a stroke that could potentially be simulating multiple sclerosis so here we go we re gonna focus initially on the axial t2 weighted scanning so pretty early on we are seeing multiple white matter lesions that are coursing through the brainstem as well as affecting the middle cerebellar peduncle. Which is the main track that connects the ponds to the cerebellum and we are also seeing more peripheral white matter lesions in the left side of the cerebellum again these cerebellar white matter regions may be better seen on this t2 weighted scan.
Then looking at the flare scan to the left here. So these are the demyelinating plaques in the brain stem as well as in the cerebellum as we course more superiorly. We see that there is diffuse involvement of the left side of brain stem and the midbrain and now as we enter the supratentorial space. My eyes are going to shift a little bit more to the flare imaging.
Because as i said tends to show the demyelinating plex in a better fashion. Because csf won t to wait scan is the same signal intensity. As the demyelinating plaques. So let s just look at these relatively quickly here.
We have a large area of demyelination in the selenium of the corpus callosum. We have white matter lesions that are subcortical or juxta cortical and we have demyelination. Which is occurring in a periventricular region. When we talk about the macdonald criteria for multiple sclerosis.
We have to look at four different locations. Number one chuck s the cortical demyelination number two periventricular demyelination number three important oriole demyelination in the brain stem and cerebellum and finally in the spinal cord. If two or more areas are involved then it satisfies. The macdonald criteria for dissemination in space within the central nervous system.
So if you look at for example. This area of demyelination in the subcortical white. Matter of the left frontal lobe seen on the flare image. You can see how that might be mistaken for csf space want to teach away its gamma.
Which is why flare is generally relied on most in the super 10. Toriel region now currently we re on the b0 map on the diffusion weighted imaging and i will just scroll around until we get to the b 1000. Images. Which is here to look for areas that are bright and signal intensity.
And we would have to correlate that with the adc map in order to determine whether or not there actually is restricted diffusion or whether..
This is merely tea to shine through so remember on the adc map tea to shine through is bright in signal intensity. Whereas active cytotoxic edema is going to be dark and signal intensity. So if i stop on this image. What we see on flare image is a demyelinating plaque on the dwi.
We see it as bright in signal intensity. However on the adc map in the middle. We see that there actually is a small area of dark signal intensity in the periphery. Which might suggest that this has cytotoxic edema and therefore is more likely to be active plaque now we will also look at the gadolinium enhanced sequences to make that distinction.
But this is what we re looking for on the adc map. Combined with the diffusion way its gain. All the others demyelinating plaques are just bright in signal intensity without dark signal down here. We re just seeing some artifact in the left lateral temporal lobe.
I m going to pull down now the t1 weighted scans to show whether or not the demyelination is showing contrast enhancement indicating active blood brain barrier breakdown. So as we scroll. We see that much of what is seen in the brain stem and cerebellum is not showing contrast enhancement. However as we get further superior.
We come across a lesion in the left corona radiata. Which is showing bright signal intensity enhancement on the t1 way. It s can post gadolinium. And you note.
That based on all the other flare demyelinating plaques. There s no way for us to know that this one versus this one versus this one is going to show contrast enhancement. However when we do the t1 post cad. We are noting that this plaque seems to be an active plaque by virtue of its enhancement you might want to correlate that with the coronal scan.
And it verifies the contrast enhancement in that left sided plaque so on the coronal flare. What we re seeing is this lesion here. Which correspond to the more peripheral enhancement on the left side on this same coronal image. We see that there are going to be as we go further.
Superior additional plaques that are showing contrast enhancement..
So let s scroll up a little bit more superior and we re starting to see some of these plaques that did indeed show gadolinium enhancement on the t. One way it scan as well as peripheral and arcs of enhancement on the coronal scan. One two just focus on this coronal scan for just a moment because it demonstrates the different types of enhancement of demyelinating plaques you can have open arcs of enhancement you can have a peripheral rim. Complete rim of enhancement and as you can see in this subcortical.
Demanding plaque you can have solid enhancement. So. Multiple sclerosis plaques show a wide variety of contrast enhancing patterns. Including solid nodular peripheral.
Complete rim open rim enhancement and linear enhancement. Which is how i would characterize this demyelinating plaque. I want to just show the sagittal flare skin so after i ve looked in the axial plane. Which is my comfort zone.
I also look at the sagittal flare scan the sagittal flare scan shows the midline structures optimally here. We have the midline structures. Including the corpus callosum and we see this large area of demyelination. The selenium of the corpus callosum.
You also note the brain stem involvement as well as some areas of cerebellar involvement on the sagittal flare image one of the areas that you want to look at closely is what s called the colossal septal interface the costal scepter interface obviously is that interface between the corpus callosum and the septum pellucidum and it s this area right here. We look at this area for focal areas of demyelination. Because that is relatively specific for multiple sclerosis actually not identified in this particular case. But it s relatively specific for multiple sclerosis and allows us for the differential diagnosis of demyelinating disorders.
This patient also had susceptibility weighted images. Performed and you might get a sense here of the central vein identified in some of the plaques with the perry van euler demyelination indicative of multiple sclerosis finally. We should look at the cervical spine that was also included and the typical. Ms.
Protocol includes sagittal and axial scans through the cervical thoracic spine. We don t have to do the lumbar spine. Because obviously the spinal cord. Generally ends at around l1.
So let s look at the scans through the cervical spine and i will usually put up the t2 weighted scan..
The t1 way it scan and me stur scan and what one season scrolling through these is an area of bright singh ah intensity within the spinal cord at the c 45 level. This is on the sagittal scan. We re going to confirm this on the axial scan you also note another area of peripheral cord hi signal intensity at the c 23 level when we bring down the sagittal post get a team in hand scan and compare it to the pre gadolinium enhance can we are able to define whether or not these plaques are going to show contrast enhancement now let s look at the axial scans. So when i m looking at the axial scans.
I usually will have either the t2 weighted scan or the ster image available in sagittal plane as i scroll through the axials as you can see here. The patient was moving not the best study. However when we get down to where that large plaque was we can see that it was affecting the right side of the spinal cord. So here s the demyelinating plaque at that c.
45. Level here is the bright signal intensity in the spinal cord on the fast. Burn. Echo.
Motion. Degraded. Scan. And here.
It is on the gradient echo. Scan. Sometimes it s better on the gradient echo. Sometimes it s better on the fast burn echo.
But i think you should include both sequences in the axial plane just for the cervical spine for the thoracic spine. We only do axial t2 weights in with fast mineko technique. If we pull down the post gadolinium enhance can we are actually able to seem quite nicely. Better on the axial scan than on the sagittal scan that this is indeed.
A demyelinating plaque that s showing contrast enhancement. So it s in the periphery of the spinal cord. Not centrally. But in the periphery of the spinal cord.
You see that area of active demyelination demonstrated by gadolinium enhancement..
I want to finish this case. Which is actually a quite illustrative case with one other pearl from debut some. And that is usually the only thing. That is performed in the coronal plane is post gadolinium and hand scan you can reconstruct this the sagittal flare scans in two coronal planes.
But the one that is performed only in the coronal plane is usually post gadolinium enhance coronal images. This is the sequence that i look for demyelination or enhancement in the optic nerves. Optic neuritis. Is one of the manifestations of multiple sclerosis usually because the sections are too thick in the axial plane.
We usually don t see the optic nerves that well on axial scans in the multiple sclerosis protocol. However you get a chance to see enhancement in the optic nerves to suggest active optic neuritis on your coronal post gadolinium enhance scan. This is done for the brain. So we re looking at all the plaques here we re looking at the plaques.
But take the time to slow down at the level of the optic chiasm and then follow the optic nerves into the orbits to see whether they are showing. Contrast. Enhancement and in this case. This is the optic nerve on the right side.
Which is showing mild enhancement and it s under surface on the coronal image in the pre chiasma right optic nerve. You see. It s actually somewhat enlarged here. So let me just highlight that with my pen.
So this is the optic chiasm on the left side here on the right side were at the junction between the pre chiasma optic nerve. And the optic chiasm and you re seeing that it s enlarged and on its periphery. We are actually seeing a little bit of contrast enhancement so this patient also appears to have active demyelination in the optic nerve suggestive of right sided optic neuritis. So then the description.
But a great a straight of example of the different. ” ..
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