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*Sagittal T2 MR in a 9-year-old with optic neuritis shows multiple ill-defined hyperintensities in the medulla & cervical cord. Subsequent serum testing revealed antibodies to aquaporin 4, confirming a diagnosis of neuromyelitis optica spectrum disorders (NMOSD).*
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*Axial T1 C+ FS MR through the orbits shows diffuse bilateral optic nerve enhancement <img src='/img/arrows/WS.png'/> in this 9-year-old with vision loss. Clinical features were suggestive of NMOSD, but CSF analysis confirmed anti-myelin oligodendrocyte glycoprotein (MOG) disease.*
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*Axial T1 C+ FS MR through the orbits shows diffuse bilateral optic nerve enhancement <img src='img/arrows/WS.png'/> in this 9-year-old with vision loss. Clinical features were suggestive of NMOSD, but CSF analysis confirmed anti-myelin oligodendrocyte glycoprotein (MOG) disease.*
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*Axial NECT in a 16-year-old with progressive left-sided weakness after minor trauma shows a large, low-attenuation white matter lesion in the anterior right frontal lobe <img src='/img/arrows/WS.png'/> & a smaller one near the right motor strip <img src='/img/arrows/WO.png'/>.*
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*Axial NECT in a 16-year-old with progressive left-sided weakness after minor trauma shows a large, low-attenuation white matter lesion in the anterior right frontal lobe <img src='img/arrows/WS.png'/> & a smaller one near the right motor strip <img src='img/arrows/WO.png'/>.*
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*Sagittal T1 C+ MR in the same patient shows the borders of the large lesion nearest to the cortex to be nonenhancing <img src='/img/arrows/WS.png'/> as compared to the other margins <img src='/img/arrows/CS.png'/>. This open ring appearance can help distinguish tumefactive MS from abscess or neoplasm (which more typically have complete ring enhancement).*
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*Sagittal T1 C+ MR in the same patient shows the borders of the large lesion nearest to the cortex to be nonenhancing <img src='img/arrows/WS.png'/> as compared to the other margins <img src='img/arrows/CS.png'/>. This open ring appearance can help distinguish tumefactive MS from abscess or neoplasm (which more typically have complete ring enhancement).*
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### Additional Images
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*Sagittal graphic illustrates MS plaques involving the corpus callosum, pons, & spinal cord. Note the characteristic perpendicular orientation of the lesions <img src='/img/arrows/BS.png'/> at the callososeptal interface along penetrating venules.*
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*Sagittal graphic illustrates MS plaques involving the corpus callosum, pons, & spinal cord. Note the characteristic perpendicular orientation of the lesions <img src='img/arrows/BS.png'/> at the callososeptal interface along penetrating venules.*
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*Sagittal FLAIR MR shows numerous MS plaques with typical perpendicular orientation at the callososeptal interface along penetrating venules ("Dawson fingers") as well as in the subcortical white matter.*
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*Sagittal FLAIR MR shows perpendicular callosal/pericallosal MS plaques with hyperintense rims & hypointense centers (with corresponding hypointensities also demonstrated on T1 as "black holes," not shown). Note an additional posterior fossa lesion <img src='/img/arrows/WS.png'/>.*
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*Sagittal FLAIR MR shows perpendicular callosal/pericallosal MS plaques with hyperintense rims & hypointense centers (with corresponding hypointensities also demonstrated on T1 as "black holes," not shown). Note an additional posterior fossa lesion <img src='img/arrows/WS.png'/>.*
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*Axial T1 C+ MR demonstrates multiple nodular, enhancing multiple sclerosis plaques <img src='/img/arrows/CS.png'/>. Note the common periventricular location with perpendicular orientation as well as the involvement of subcortical white matter.*
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*Axial T1 C+ MR demonstrates multiple nodular, enhancing multiple sclerosis plaques <img src='img/arrows/CS.png'/>. Note the common periventricular location with perpendicular orientation as well as the involvement of subcortical white matter.*
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*Axial FLAIR MR shows confluent multiple sclerosis plaques in commonly seen periventricular locations.*
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*Axial FLAIR MR in a 9-year-old patient with altered mental status & hyperreflexia shows ill-defined, hyperintense lesions in the thalami <img src='/img/arrows/WC.png'/>, basal ganglia <img src='/img/arrows/WS.png'/>, & insula <img src='/img/arrows/CS.png'/>. Involvement of the deep nuclei is a relatively common feature of acute disseminated encephalomyelitis.*
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*Axial FLAIR MR in a 9-year-old patient with altered mental status & hyperreflexia shows ill-defined, hyperintense lesions in the thalami <img src='img/arrows/WC.png'/>, basal ganglia <img src='img/arrows/WS.png'/>, & insula <img src='img/arrows/CS.png'/>. Involvement of the deep nuclei is a relatively common feature of acute disseminated encephalomyelitis.*
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*Axial FLAIR MR shows large lesions in the thalamus & basal ganglia <img src='/img/arrows/WS.png'/> in this 16-year-old with a headache & weakness 2 weeks after a viral illness. Acute disseminated encephalomyelitis will frequently affect deep gray matter structures.*
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*Axial FLAIR MR shows large lesions in the thalamus & basal ganglia <img src='img/arrows/WS.png'/> in this 16-year-old with a headache & weakness 2 weeks after a viral illness. Acute disseminated encephalomyelitis will frequently affect deep gray matter structures.*
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*Coronal FLAIR MR in a 12-year-old patient with neuromyelitis optica & bladder dysfunction shows large lesions extending across the corpus callosum <img src='/img/arrows/CS.png'/> & left cerebral peduncle <img src='/img/arrows/WS.png'/>.*
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*Coronal FLAIR MR in a 12-year-old patient with neuromyelitis optica & bladder dysfunction shows large lesions extending across the corpus callosum <img src='img/arrows/CS.png'/> & left cerebral peduncle <img src='img/arrows/WS.png'/>.*
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*Axial NECT in a 14-year-old patient with vomiting shows a nonspecific, low-attenuation lesion <img src='/img/arrows/WO.png'/> in the left posterior frontal subcortical white matter.*
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*Axial NECT in a 14-year-old patient with vomiting shows a nonspecific, low-attenuation lesion <img src='img/arrows/WO.png'/> in the left posterior frontal subcortical white matter.*
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*Axial FLAIR MR in the same patient acquired the next day shows several ovoid MS plaques <img src='/img/arrows/WS.png'/>. Active lesions will also show contrast enhancement & restricted diffusion.*
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*Axial FLAIR MR in the same patient acquired the next day shows several ovoid MS plaques <img src='img/arrows/WS.png'/>. Active lesions will also show contrast enhancement & restricted diffusion.*
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*Axial FLAIR MR in a 14-year-old with MS shows multiple ovoid lesions oriented perpendicular to the long axis of the lateral ventricles <img src='/img/arrows/WS.png'/> with hazy ↑ signal intensity in the white matter between them.*
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*Axial FLAIR MR in a 14-year-old with MS shows multiple ovoid lesions oriented perpendicular to the long axis of the lateral ventricles <img src='img/arrows/WS.png'/> with hazy ↑ signal intensity in the white matter between them.*
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*Axial T2 MR in a 17-year-old with Baló concentric sclerosis <img src='/img/arrows/CS.png'/>.*
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*Axial T2 MR in a 17-year-old with Baló concentric sclerosis <img src='img/arrows/CS.png'/>.*
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*Sagittal T1 C+ FS MR shows an enhancing MS lesion in the dorsal aspect of the cervical cord <img src='/img/arrows/WC.png'/>. Approximately 2/3 of spinal cord MS lesions are found in the cervical cord. Typical features include a dorsal intramedullary lesion spanning < 2 vertebral segments in length.*
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*Sagittal T1 C+ FS MR shows an enhancing MS lesion in the dorsal aspect of the cervical cord <img src='img/arrows/WC.png'/>. Approximately 2/3 of spinal cord MS lesions are found in the cervical cord. Typical features include a dorsal intramedullary lesion spanning < 2 vertebral segments in length.*
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*Axial FLAIR MR shows numerous peripheral white matter & cortical lesions that exhibited robust contrast enhancement (not shown) in an 18-year-old woman with malignant (Marburg) MS. The patient presented with a 2-week history of behavioral changes & leg pain & died 3 weeks after presentation. The autopsy showed typical demyelinating pathology.*
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*Axial T1 C+ FS MR in a patient with MS shows ring-enhancing masses of active demyelination. The rings of enhancement are incomplete with each ring defect pointing towards an adjacent cortex.*
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*Coronal T1 C+ MR shows a superficial hypointense mass in the left parasagittal posterior frontal region with a peripheral crescent of incomplete or "horseshoe" enhancement <img src='/img/arrows/WS.png'/>. This enhancement pattern is classic for tumefactive demyelinating disease, most commonly MS.*
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*Coronal T1 C+ MR shows a superficial hypointense mass in the left parasagittal posterior frontal region with a peripheral crescent of incomplete or "horseshoe" enhancement <img src='img/arrows/WS.png'/>. This enhancement pattern is classic for tumefactive demyelinating disease, most commonly MS.*
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*Axial FLAIR MR shows a case of proven tumefactive MS <img src='/img/arrows/BC.png'/> with extensive surrounding white matter edema <img src='/img/arrows/WS.png'/>. Note that the imaging features present in this case could also be seen with neoplasm.*
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*Axial FLAIR MR shows a case of proven tumefactive MS <img src='img/arrows/BC.png'/> with extensive surrounding white matter edema <img src='img/arrows/WS.png'/>. Note that the imaging features present in this case could also be seen with neoplasm.*
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*Long TE MRS in a case of tumefactive MS reveals elevated choline <img src='/img/arrows/WS.png'/>, ↓ NAA <img src='/img/arrows/WO.png'/>, & a lactate doublet <img src='/img/arrows/WC.png'/>. These MRS findings could be consistent with acute demyelination & probably reflect a combination of membrane disruption, neuronal loss or dysfunction, & inflammation. Note that the MRS findings in MS are not specific. The spectral pattern of demyelination & low-grade neoplasms can be similar & should therefore be interpreted cautiously.*
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*Long TE MRS in a case of tumefactive MS reveals elevated choline <img src='img/arrows/WS.png'/>, ↓ NAA <img src='img/arrows/WO.png'/>, & a lactate doublet <img src='img/arrows/WC.png'/>. These MRS findings could be consistent with acute demyelination & probably reflect a combination of membrane disruption, neuronal loss or dysfunction, & inflammation. Note that the MRS findings in MS are not specific. The spectral pattern of demyelination & low-grade neoplasms can be similar & should therefore be interpreted cautiously.*
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*Axial T1 C+ MR shows numerous enhancing MS plaques that were present throughout the infratentorial & supratentorial brain. MS lesions may show homogeneous enhancement but may also exhibit ring or incomplete ring patterns of enhancement.*
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