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Images in Neurology |

Cranial Neuropathies in Multiple Sclerosis Defined by Magnetic Resonance Imaging and Fludeoxyglucose F 18 Positron Emission Tomography

Dimitri Renard, MD; Alina Poalelungi, MD; Laurent Collombier, MD; Pierre Labauge, MD, PhD
Arch Neurol. 2012;69(4):541-542. doi:10.1001/archneurol.2011.1936.
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A 50-year-old woman with a history of transient brachial monoparesis lasting for months presented with subacute diplopia, left-sided facial palsy, and gait instability with the tendency to fall toward the right side. Clinical examination showed left abducens palsy, left-sided peripheral facial palsy, and left eye hypertropia and left-beating nystagmus. Tendency to fall toward the right side, left eye hypertropia, and left-beating nystagmus were interpreted as a vestibular tilt reaction to the right. Magnetic resonance imaging in our patient showed a gadolinium-enhancing left dorsal pontine tegmentum lesion, together with other lesions, fulfilling revised multiple sclerosis (MS) McDonald criteria (Figure, A-C). Results of cerebrospinal fluid analysis were normal, apart from the presence of 2 oligoclonal bands. To exclude a neoplastic lesion, brain fludeoxyglucose F 18 positron emission tomography (FDG-PET) was performed (Figure, D) showing hypometabolism in the pontine lesion, making a diagnosis of high-grade tumor improbable. According to the 2010 revised McDonald criteria, a diagnosis of relapsing-remitting MS was made. High-dose intravenous methylprednisolone (1 g once daily for 5 days) was given, leading to clinical remission 2 weeks later. Three months later, magnetic resonance imaging showed absence of gadolinium enhancement of the dorsal pontine tegmentum lesion, persisting on fluid-attenuated inversion recovery sequences.

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Figure. A 3-T brain magnetic resonance image showing the left dorsal pontine tegmentum lesion (arrow) on fluid-attenuated inversion recovery sequences (A) and ring enhancement on gadolinium-enhanced T1-weighted imaging (B). Multiple other periventricular lesions were seen on sagittal fluid-attenuated inversion recovery sequences (C). On fludeoxyglucose F 18 positron emission tomography, the pontine lesion (arrowheads) shows hypometabolism (D).




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