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The central vein sign (CVS) and paramagnetic rim lesions (PRLs) aid in diagnosing multiple sclerosis (MS). These MRI biomarkers, now in the 2024 McDonald criteria, help identify atypical MS cases, potentially avoiding brain biopsies.

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Area of Science:

  • Neurology
  • Radiology
  • Immunology

Background:

  • The 2024 McDonald criteria incorporate the central vein sign (CVS) and paramagnetic rim lesions (PRLs) as key diagnostic biomarkers for multiple sclerosis (MS).
  • These susceptibility-based MRI findings offer moderate (CVS) to high (PRLs) specificity, proving valuable in complex or atypical presentations.
  • Diagnosing MS can be challenging, particularly in late-onset or atypical cases, necessitating advanced imaging techniques.

Purpose of the Study:

  • To illustrate the diagnostic utility of CVS and PRLs in a challenging case of late-onset multiple sclerosis.
  • To highlight how these advanced MRI biomarkers can support diagnosis when conventional criteria are ambiguous.
  • To emphasize the potential of these biomarkers to reduce the need for invasive procedures like brain biopsy.

Main Methods:

  • A case study of a 61-year-old woman presenting with subacute ataxia and dysarthria.
  • Comprehensive cerebrospinal fluid (CSF) analysis and extensive differential diagnosis workup.
  • High-resolution 7-tesla MRI to identify CVS and PRLs, alongside histopathological examination of brain biopsy tissue.
  • Correlation of imaging findings with clinical presentation and laboratory results.

Main Results:

  • The patient exhibited numerous enhancing lesions, atypical CSF findings (lymphocytic pleocytosis, elevated protein, absent oligoclonal bands), and initially ambiguous MS diagnosis.
  • Brain biopsy confirmed active demyelination with a macrophage-rich inflammatory infiltrate.
  • A 7-tesla MRI revealed the presence of ≥12 CVS and ≥1 PRL, confirming the diagnosis of relapsing late-onset MS.
  • The identified biomarkers (CVS and PRLs) were crucial in establishing the diagnosis.

Conclusions:

  • Susceptibility-based imaging biomarkers, CVS and PRLs, are instrumental in diagnosing challenging cases of multiple sclerosis.
  • Integration of CVS and PRLs into the 2024 McDonald criteria may streamline the diagnostic process for atypical demyelinating diseases.
  • These advanced MRI markers can potentially obviate the need for brain biopsy, facilitating earlier diagnosis and treatment initiation in MS.