PMC6849071_01
Timeline and summary of the clinical, paraclinical, and MRI findings. Orbital MRI demonstrates bilateral optic neuritis with perineural sheath swelling on T2 fat-saturated sequences (arrows, A) and bilateral optic nerve enhancement on T1 sequences with contrast (arrows, B). Brain MRI reveals fluid attenuated inversion recovery (FLAIR) abnormalities (arrows) in the right parietal (C), right frontal (E), and left frontal cortical regions (G) consistent with cortical edema and the corresponding T1 hypointense abnormalities with minimal contrast enhancement in the same regions (D, F, H, respectively). CSF, cerebrospinal fluid; EEG, electroencephalogram; WBC, white blood cells; MBP, myelin basic protein; IgG, immunoglobulin; OCB, oligoclonal bands; NMDAR, N-methyl-d-aspartate receptor.
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Magnetic resonance imaging (MRI) of the orbits demonstrated contrast enhancement and perineural sheath swelling in bilateral optic nerves (Fig. 1); brain MRI was normal. Brain MRI demonstrated right parietal cortical hyperintensity on fluid-attenuated inverse recovery (FLAIR) sequences consistent with cortical edema (Fig. 1 C, D). Cerebrospinal fluid analysis showed lymphocytic-predominant pleocytosis, elevated protein, decreased glucose, and elevated IgG and albumin (Fig. 1 E, F). Brain MRI showed cortical hyperintensity in the right frontal region (Fig. 1 E, F). Cerebrospinal fluid analysis revealed pleocytosis with mixed cellularity, two OCBs, and a minimally elevated titer of anti-NMDAR antibodies (1:1; normal titer is < 1:1; Fig. 1 G, H). Brain MRI revealed two new areas of hyperintense signal abnormalities in the left frontal region (Fig. 1 G, H).