Shirafuji Toshihiko, Oya Yasushi, Nakamura Harumasa, Ogata Katsuhisa, Ogawa Masafumi, Kawai Mitsuru
Department of Neurology, Graduate School of Medicine, Kobe University.
Rinsho Shinkeigaku. 2008 May;48(5):321-7. doi: 10.5692/clinicalneurol.48.321.
A 26-year-old woman noticed gradually progressive, right lower leg weakness over a 1.5-month period. Neurological examination revealed right hemiparesis with slightly increased deep tendon reflexes, Babinski's sign on the right side, loss of position sense in the right leg, and slight loss of superficial sensation in the right toes. MR FLAIR images showed a high intensity area measuring 5 x 2 x 3 cm in the left frontal lobe, extending to the outer surface of the body of the corpus callosum and the adjacent right cingulate gyrus. Gadolinium enhancement was seen along the cortex and the outer surface of the body of the corpus callosum. CSF findings showed no pleocytosis, a protein content of 32 mg/dl, a sugar level of 85 mg/dl, and an IgG index of 0.46. The biopsy specimen obtained from the superior frontal gyrus showed perivascular cuffing of T-lymphocytes and some B-lymphocytes, as well as multiple small foci of demyelination. Starting on the second day of admission, the patient was treated with methylprednisolone pulse therapy (1,000 mg/day for 3 days); she was then switched to oral prednisolone (20 mg/day). Thereafter, the patient had two clinical relapses: one was due to a lesion in the dorsal part of the medulla oblongata associated with a disturbance of deep sensation in both hands, and the other was due to a lesion involving the right internal capsule, the globus pallidus, and the caudate nucleus associated with left facial nerve palsy. Visual evoked potentials suggested a demyelinating lesion in the right optic nerve. We suspected a diagnosis of multiple sclerosis based on the presence of more than two clinical episodes of neurological deficits with identifiable lesions on MRI. Multiple sclerosis should be considered in the differential diagnosis of lesions located in the outer part of the corpus callosum and transcallosal bilateral hemispheres on MRI, even though inner callosal lesions are common in multiple sclerosis.
一名26岁女性在1.5个月内逐渐出现右下肢进行性无力。神经系统检查发现右侧偏瘫，深腱反射略亢进，右侧巴氏征阳性，右腿位置觉丧失，右脚趾浅感觉轻度丧失。磁共振液体衰减反转恢复（FLAIR）图像显示左侧额叶有一个5×2×3厘米的高强度区域，延伸至胼胝体体部外表面及相邻的右侧扣带回。钆增强见于皮质及胼胝体体部外表面。脑脊液检查结果显示无细胞增多，蛋白含量为32mg/dl，糖水平为85mg/dl，IgG指数为0.46。取自额上回的活检标本显示T淋巴细胞和一些B淋巴细胞的血管周围套袖状浸润，以及多个小的脱髓鞘病灶。入院第二天起，患者接受甲泼尼龙冲击治疗（1000mg/天，共3天）；随后改为口服泼尼松龙（20mg/天）。此后，患者有两次临床复发：一次是由于延髓背侧病变伴双手深感觉障碍，另一次是由于病变累及右侧内囊、苍白球和尾状核伴左侧面神经麻痹。视觉诱发电位提示右侧视神经有脱髓鞘病变。基于存在超过两次伴有MRI上可识别病灶的神经功能缺损临床发作，我们怀疑诊断为多发性硬化。即使胼胝体内侧病变在多发性硬化中常见，但在MRI上位于胼胝体外侧和经胼胝体双侧半球的病变的鉴别诊断中也应考虑多发性硬化。
