Brain MRI Findings in Pediatric-Onset Neuromyelitis Optica Spectrum Disorder: Challenges in Differentiation from Acute Disseminated Encephalomyelitis

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Fig 1.
MR images of 2 patients in the NMOSD group. The axial FLAIR image (A) of an 11-year-old female patient shows a minimally expansile, large, hyperintense lesion involving the pons. The postcontrast T1-weighted image (B) reveals inconspicuous subpial enhancement in the lesion (arrow). The patchy areas of restricted diffusion can be seen on the DWI (C). The axial FLAIR image (D) of another patient shows extensive white matter lesions in the left occipital lobe. The axial (E) and the coronal (F) postcontrast T1-weighted images reveal accompanying leptomeningeal enhancement (circles).
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Fig 2.
MR images of 2 patients in the ADEM group. The axial FLAIR images (A and B) of a 5-year-old male patient show confluent pontine and symmetric thalamic lesions, respectively. The postcontrast T1-weighted image (C) reveals inconspicuous enhancement in the thalamic lesions (arrows). The axial T2-weighted images (D–F) of a 16-year-old female patient show extensive lesions involving the pons, cerebral peduncle, and posterior limb of the internal capsule along the course of left corticospinal tract.

Table 1:

The clinical features of patients with pediatric-onset NMOSD vs ADEM

Characteristics	NMOSD	ADEM
F/M ratio	7:3	2:8
Mean age at initial manifestation (yr)	10.3 ± 5.6	8.7 ± 5.3
Involvement at initial manifestation n (%)
Brain	4 (40%)	5 (50%)
Brain + spinal cord	2 (20%)	5 (50%)
Brain + optic nerve	2 (20%)	0
Brain + spinal cord + optic nerve	2 (20%)	0
Mean follow-up time (yr)	5.1	3.4

Table 2:

Brain MRI findings of patients with pediatric-onset NMOSD vs ADEM

Characteristics	NMOSD (n = 10)	ADEM (n = 10)	P Value
Lesion localization/infratentorial
Medulla	4 (40%)	2 (20%)	1
Area postrema	2 (20%)	1 (10%)	1
Cerebellum	2 (20%)	2 (20%)	1
Pons	4 (40%)	7 (70%)	.37
Middle cerebellar peduncle	4 (40%)	6 (60%)	.65
Periventricular	5 (50%)	6 (60%)	1
Mesencephalon	2 (20%)	4 (40%)	.63
Periaqueductal	1 (10%)	1 (10%)	1
Lesion localization/supratentorial
Diencephalon
Thalamus	1 (10%)	7 (70%)	.02^{^a}
Hypothalamus	0	3 (30%)	.21
Periventricular	0	5 (50%)	.37
Internal capsule	0	5 (50%)	.03^{^a}
Basal ganglia	1 (10%)	3 (30%)	.58
Corpus callosum	1 (10%)	2 (20%)	1
Cerebral white matter
Periventricular	3 (30%)	6 (60%)	.37
Juxtacortical-subcortical	5 (50%)	9 (90%)	.57
Cerebral cortex	0	3 (30%)	.21
Size (≥2 cm)	6 (60%)	8 (80%)	.63
T1 hypointensity	7 (70%)	6 (60%)	1
Expansion	7 (70%)	8 (80%)	1
Contrast enhancement	8 (80%)	5 (50%)	.35
Enhancement pattern
Patchy, nodular	5	2
Diffuse	0	3
Leptomeningeal	3	0
Ring-incomplete ring	1	1
Perivenular	1	0
Restricted diffusion	2^{^b}	3 (30%)	1