Brain lesions characteristic of NMOSD and the impact of treatment on radiological evolution: a case report

Address for correspondence: Isadora Cunha Leão Figueredo (email: [e-mail]).

Abstract

Case Presentation: A 36-year-old woman presented with tetraparesis associated with paresthesia of her hands and feet. One year before, she had been experiencing significant weight loss associated with nausea and vomiting. Upon physical examination, she presented weakness of grade 3 in the upper and lower limbs. Her visual acuity was of 20/20 bilaterally. The rest of the neurological exam was normal. She underwent a cranial MRI scan, which evidenced hypersignal in the medulla, pons, periaqueductal predominance, and area postrema, in addition to involvement in the hypothalamus. The MRI scans of the orbit and spinal cord did not show changes. Anti-aquaporin 4 antibody was positive in the blood. Even before the antibody result, treatments with intravenous methylprednisolone for 5 days and plasmapheresis also for 5 days were started. The patient presented complete improvement of the symptoms, walking without changes, without other sequelae. We decided to start rituximab as a maintenance treatment. In a control MRI scan, the patient showed a significant reduction in signal changes in previously-presented lesions.

Discussion: Neuromyelitis optica spectrum disorder (NMOSD) is characterized by preferential involvement of the optic nerve and spinal cord. However, brain involvement can occur in at least half of the cases, generally with non-specific lesions. In less than 10% of the cases, it may present with typical and more serious lesions, in regions rich in aquaporin 4 channels, periaqueductal gray matter, the hypothalamus, and the periventricular region, lesions such as those presented by the patient herein described.

Final Comments: Rapid clinical suspicion based on typical brain lesions and introduction of treatment at an optimal time change the clinical outcome and reduce morbidity and mortality in patients with NMOSD, in addition to the impact on the radiological evolution of MRI lesions.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
02 October 2024