Focal cortical atrophy following transient meningeal enhancement in a progressive multiple sclerosis
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ORIGINAL ARTICLE
Focal cortical atrophy following transient meningeal enhancement in a progressive multiple sclerosis Mickael Bonnan 1 & Paul Money 2 & Pauline Desblache 2 & Raluca Marasescu 1 & Lise-Marlène Puvilland 1 & Stéphanie Demasles 1 & Camille Dahan 1 & Elsa Krim 1 & Alan Tucholka 3 & Senan Doyle 3 & Bruno Barroso 1 Received: 29 May 2020 / Accepted: 24 September 2020 # Fondazione Società Italiana di Neurologia 2020
Abstract Recent studies identified chronic leptomeningeal enhancement (LME) in late-acquired FLAIR sequences in secondary progressive (SP) multiple sclerosis (MS). These LMEs correlate with focal cortical inflammation and demyelination observed by pathology, which are supposed to drive long-term cortical atrophy. We report a spontaneously remitting meningeal uptake in a patient suffering from SP MS. No cortical lesion was visible on FLAIR or DIR sequences, but the rate of cortical atrophy was higher in this area. This case suggests that conventional 3-T MRI, by contrary to white matter lesions, may be amnesic with regard to the potential burden of previous regressive meningeal lesions. Moreover, T1-enhanced sequences underscore the real inflammatory activity. LME could be more than passive markers of SP MS, but is also directly responsible for focal cortical atrophy and could be an early manifestation of cortical lesions. Keywords Multiple sclerosis . Leptomeningeal contrast enhancement . Relapse . Cortical atrophy
Case A secondary progressive multiple sclerosis (MS) patient in her fifties was examined before inclusion in a research trial. She had been suffering from indolent relapsing-remitting MS since her twenties. During the previous 3 years, her gait had progressively worsened from EDSS 5.0 to EDSS 6.0, and she was using a walking stick. The screening 3-T MRI included standard sequences, a T1 structural protocol for morphometry, and 3D FLAIRgadolinium sequences, acquired 20 min after contrast injection. No contrast uptake was observed on T1-gado sequences (acquired at 5 min, using standard gadolinium dose). Apart from the typical periventricular MS lesions, late FLAIR-gado sequences demonstrated a unique leptomeningeal (LM)
* Mickael Bonnan [email protected] 1
Neurologie, Centre hospitalier de Pau, 4 Bd Hauterive, 64000 Pau, France
2
Radiologie, Centre hospitalier de Pau, 4 Bd Hauterive, 64000 Pau, France
3
Pixyl Medical, La Tronche, France
enhancing lesion (EL) in the right superior frontal sulcus (Fig. 1). The patient denied having any recent symptoms. As a part of the screening, an Elispot was found positive against Mycobacterium tuberculosis (TB) without any lung lesion, suggesting latent TB. She was given Rifater (isoniazide, rifampicine, pyrazinamide) three months before randomization. Biological screening was normal, and lumbar puncture demonstrated intrathecal IgG synthesis without cellular reaction. This LM lesion had spontaneously disappeared on the control MRI performed 3 and 9 months later. No cortical lesion was observed with FLAIR and DIR sequences. The patient
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