Case of January 2023

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Clinical History:

A 71-year-old man, ex-smoker, complained of four limb weakness for a year, with progressive worsening, upper limbs affected more than lower limbs, urinary incontinence, mild visual blurring and frequent falls. Physical examination revealed hyperreflexia in the upper limbs and spasticity in the lower limbs and with generalized hyperreflexia, power is preserved. Blood tests showed anti-myelin oligodendrocyte glycoprotein (MOG) weakly positive and neuromyelitis optica (NMO) negative. Overall treated as anti-MOG related neuromyelitis optica spectrum disorder (NMOSD). Fair response to steroid and rituximab with progressive symptom worsening with reduced lower limb power. Rechecking of the anti-MOG came back negative. Repeat MRI thus done. DSA followed.

MRI C spine T2 Sag on first presentation

Post treatment MRI C spine T2 Sag

Left vertebral artery DSA angiogram