- Brain: Periventricular/perivenular, callososeptal interface, juxtacortical white matter/subcortical U-fibers, brachium pontis, brainstem.
- Spinal Cord:
- Cervical > thoracic cord
- Although most commonly dorsolateral aspect of cord, lesions are also often central and can be found anywhere.
- Typically seen in conjunction with brain lesions (90% of patients) but can be Isolated (10%).
- Nerves: Optic nerves. Involvement of other cranial nerves should raise suspicion for ADEM.
- General Appearance:
- Solitary or multifocal ovoid or wedge shaped T2 hyperintense lesions, asymmetric in distribution, most often located in the dorsolateral spinal cord.
- Length: Typically < 2 vertebral bodies in length (if > 2 vertebral bodies, consider NMO, ADEM, or idiopathic transverse myelitis)
- Width: Typically < ½ spinal cord in axial plane.
- Acute lesions: +/- mild cord swelling/edema which can mimic intramedullary neoplasm.
- Chronic Lesions: +/- cord atrophy, +/- residual STIR/T2 hyperintensity
- Modality-Specific (Spinal Cord Only):
- CT Myelography:
- Spinal cord not well evaluated. May see spinal cord swelling in acute phase (mimics intramedullary tumor).
- T1: Isointense or hypointense.
- T1 + Contrast: +/- Enhancement. Ring, homogenous, or nodular enhancement in the subacute/acute phase. Typically resolves after 6 months.
- T2: Discrete or vague hyperintense lesions.
- STIR: Hyperintense lesions. Increased sensitivity for detection of lesions.
- DWI: Typically, increased diffusivity.
- Not typically utilized for spinal cord MS
- Decreased NAA, Increased Choline seen in areas of normal white matter.
For more information, please see the corresponding chapter in Radiopaedia, and the Tumefactive Demyelination chapter in the Cranial Disorders sub-volume of the Neurosurgical Atlas.
Contributor: Jacob A. Eitel, MD
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