Pearls & Oy-sters: Radiologic Lag in Pediatric-Onset Multiple Sclerosis

Recognition of radiologic lag, the presence of clinical symptoms despite absence of a visible corresponding lesion on MRI, is essential when evaluating a patient suspected to have a demyelinating disease. In this report, we present the case of a 16-year-old girl with bilateral internuclear ophthalmoplegias (INO), in whom initial high-resolution 3T MRI failed to reveal an abnormality within the brainstem. Repeat MRI performed 2 months later demonstrated a lesion in the paramedian midbrain tegmentum, corresponding to the anatomical localization of her clinical symptoms. This case aims to raise awareness that radiologic lag can occur in pediatric-onset multiple sclerosis, similarly to what has been described in other demyelinating conditions such as myelin oligodendrocyte glycoprotein antibody-associated disease. The absence of a visible lesion on imaging in the context of an acute INO does not exclude the possibility of underlying demyelination, and short-interval follow-up imaging should be considered in these patients to establish the correct diagnosis and guide additional investigations and treatment.