Figure 1. MRIs.

(A and B) Axial FLAIR images of the brain demonstrate multifocal parenchymal lesions including the right hippocampus, right midbrain, left temporal-occipital and left anterior temporal areas, and the left thalamus (arrow heads). There is also evidence of intraventricular debris with a fluid level in the bilateral occipital horns (C, arrow heads). Although there were some confluent changes to the parenchyma in a periventricular distribution, other lesions appeared more leptomeningeal (C, arrow head pointing toward a linear hyperintensity, which on closer inspection is localized to the leptomeningeal zone of a left parietal gyrus lesion). (D) T1 post-gadolinium images demonstrated enhancement of the optic chiasm, several other cranial nerves, and the tentorium (arrow heads). (E and F) Sagittal and axial T2-weighted images of the thoracic spine reveal a longitudinally extensive, centrally predominant hyperintensity (arrow heads, seen in NMO), although enhancement was not observed. We further illustrate the caudal extent of the lesion, which clearly involves the conus and the exiting nerve roots of the cauda equine, both of which demonstrate enhancement on T1 post-gadolinium images (G and H, respectively; arrow heads). FLAIR = fluid attenuation inversion recovery.