Optic Nerve MRI T2-Hyperintensity: A Nonspecific Marker of Optic Nerve Damage

Abstract

Background: MRI abnormalities are common in optic neuropathies, especially on dedicated orbital imaging. In acute optic neuritis, optic nerve T2-hyperintensity associated with optic nerve contrast enhancement is the typical imaging finding. In chronic optic neuropathies, optic nerve T2-hyperintensity and atrophy are regularly seen. Isolated optic nerve T2-hyperintensity is often erroneously presumed to reflect optic neuritis, frequently prompting unnecessary investigations and neuro-ophthalmology consultations. Our goal was to determine the significance of optic nerve/chiasm T2-hyperintensity and/or atrophy on MRI. Methods: Retrospective study of consecutive patients who underwent brain/orbital MRI with/without contrast at our institution between July 1, 2019, and June 6, 2022. Patients with optic nerve/chiasm T2-hyperintensity and/or atrophy were included. Medical records were reviewed to determine the etiology of the T2-hyperintensity and/or atrophy. Results: Four hundred seventy-seven patients (698 eyes) were included [mean age 52 years (SD ±18 years); 57% women]. Of the 364 of 698 eyes with optic nerve/chiasm T2-hyperintensity without atrophy, the causes were compressive (104), inflammatory (103), multifactorial (49), glaucoma (21), normal (19), and other (68); of the 219 of 698 eyes with optic nerve/chiasm T2-hyperintensity and atrophy, the causes were compressive (57), multifactorial (40), inflammatory (38), glaucoma (33), normal (7), and other (44); of the 115 of 698 eyes with optic nerve/chiasm atrophy without T2-hyperintensity, the causes were glaucoma (34), multifactorial (21), inflammatory (13), compressive (11), normal (10), and other (26). Thirty-six eyes with optic nerve/chiasm T2-hyperintensity or atrophy did not have evidence of optic neuropathy or retinopathy on ophthalmologic examination, and 17 eyes had clinical evidence of severe retinopathy without primary optic neuropathy. Conclusions: Optic nerve T2-hyperintensity or atrophy can be found with any cause of optic neuropathy and with severe chronic retinopathy. These MRI findings should not automatically prompt optic neuritis diagnosis, workup, and treatment, and caution is advised regarding their use in the diagnostic criteria for multiple sclerosis. Cases of incidentally found MRI optic nerve T2-hyperintensity and/or atrophy without a known underlying optic neuropathy or severe retinopathy are rare. Such patients should receive an ophthalmologic examination before further investigations.

Case report: dengue fever associated acute macular neuroretinopathy

“…Although electrodiagnostic examinations, such as visual evoked potential (VEP), were not performed on our patient, she had no typical symptoms, such as retro-orbital pain, and MRI and fundus examination found neither a sequela of past ON nor evidence of acute ON OS. As lack of pain is almost indicative of intracranial ON (19,20), which is not found in our patient's MRI, and MRI images are sensitive for ON (21), we concluded that optic neuritis may not be the diagnosis for our patient. Moreover, she was diagnosed with comorbidities, including type 2 diabetes mellitus, hypertension, and hypertriglyceridemia, during DF infection.…”

The Study of Remyelinating Therapies in Multiple Sclerosis: Visual Outcomes as a Window Into Repair

“…MRI imaging of optic nerve lesions may complement existing measures of optic nerve de/remyelination, described below. Double inversion recovery has emerged as a more sensitive technique for detecting acute optic neuritis compared with FLAIR 81 —which may also be less specific for inflammatory injury 82 —but none of these methods resolve inflammation, astrogliosis from myelin injury.…”