• Ulrike W Kaunzner, Elliott Salamon, Elena Pentsova, Marc Rosenblum, Sasan Karimi, Nancy Nealon, Ehud Lavi, and Dara G Jamieson.
• Department of Neurology, NewYork Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065.
• J Neuroimaging. 2017 May 1; 27 (3): 306-311.

IntroductionAcute disseminated encephalomyelitis (ADEM) is a rare demyelinating disease of the central nervous system (CNS) that classically occurs in children and adolescents. It characteristically presents with acute inflammation, resulting in demyelination, often following an infectious disease. ADEM has been described in adult patients, but the incidence in the adult and especially elderly population is low.CasesWe describe five older adults (age 57 to 85) who presented with acute neurological symptoms. Three patients presented with an infectious illness preceding the event, 4 patients were encephalopathic, and oligoclonal bands (OCBs) were negative in all tested cases. The clinical scenario and imaging studies suggested alternative diagnoses, such as metastasis, primary CNS tumor, or stroke. Two patients had contrast enhancing lesions, two other patients had lesions with restricted diffusion on diffusion-weighted imaging. Neuropathologic diagnostic from biopsy or autopsy was eventually conclusive, showing perivascular zones of myelin loss with relative axonal sparing in all five cases.ConclusionEach of these patients was found to have pathological findings of acute demyelination on tissue diagnosis, suggesting ADEM or ADEM-like disease. The initial presentation and imaging was pointing toward other diagnoses. Broad differential diagnosis is important, especially for older patients, and pathological proof might be warranted for a conclusive diagnosis.Copyright © 2016 by the American Society of Neuroimaging.

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