Table 2

Differential diagnosis of AxD in adults

Neurological and MRI features
DisorderOverlapping with AxDDistinguishing from AxD
Leukodystrophies
Adrenomyeloneuropathy8
  • Clinical features: Muscle weakness, spasticity, bladder and bowel dysfunction

  • MRI: Spinal cord atrophy

  • Clinical features: Sensory disturbance, neuropathy

  • MRI: Imaging of the brain may appear normal or may show minor abnormalities involving the pyramidal tracts within the internal capsules and brainstem

Metachromatic leukodystrophy8
  • Clinical features: Spasticity, gait imbalance

  • MRI: Periventricular white matter abnormalities, brain atrophy

  • Clinical features: Peripheral neuropathy

  • MRI: White matter abnormalities involving the corpus callosum and parieto-occipital regions

Vanishing white matter disease8
  • Clinical features: Ataxia, spasticity, neurologic deterioration after minor trauma or infections

  • MRI: T2 hyperintense signal changes involving supratentorial white matter, cerebellar degeneration

  • Clinical features: n/a

  • MRI: Progressive rarefaction and cystic degeneration of the supratentorial cerebral white matter, with radiating stripes on T1 and FLAIR imaging

Leukoencephalopathy with brainstem and spinal cord involvement8
  • Clinical features: Ataxia, spasticity, cognitive decline

  • MRI: Signal abnormalities involving the periventricular white matter and cerebellar white matter

  • Clinical features: Epilepsy, peripheral neuropathy

  • MRI: Signal changes involving the corticospinal tract, medial lemniscus and trigeminal nerves

Adult-onset leukoencephalopathy with axonal spheroids and pigmented glia8
  • Clinical features: Cognitive decline, spasticity, ataxia

  • MRI: Signal abnormalities involving the periventricular white matter and brainstem

  • Clinical features: Tremors, bradykinesia, prominent gait apraxia, parkinsonism

  • MRI: Thinning of the corpus callosum, convexity subarachnoid spaces, deep white matter diffusion restriction or microcalcifications, no contrast enhancement

Neurodegenerative disorders
Multiple sclerosis22 23
  • Clinical features: Muscle weakness, spasticity, dysarthria/bulbar dysfunction and gait imbalance

  • MRI: Frontal white matter involvement, periventricular rim, brainstem or spinal cord abnormalities

  • Clinical features: Vision loss

  • MRI: Generalised brain atrophy, absence of symmetry, spinal cord lesions involving the thoracic cord, optic nerve lesions

Spinocerebellar degeneration35
  • Clinical features: Muscle weakness, oculomotor abnormalities, ataxia, spasticity, hyper-reflexia

  • MRI: Atrophy of the cerebellum

  • Clinical features: Peripheral neuropathy, tremor

  • MRI: Ventricular enlargement

Myelitis36 37
  • Clinical features: Muscle weakness, spasticity, bladder dysfunction

  • MRI: Spinal cord lesions

  • Clinical features: Paraesthesia, sensory loss, acute or chronic pain

  • MRI: Spinal cord lesions extending over multiple segments and classically involving the thoracic cord

Adult-onset polyglucosan body disease8 31
  • Clinical features: Spasticity, paraparesis, gait disturbance, bladder dysfunction, orthostatic hypotension

  • MRI: Medullary and spinal cord atrophy, cerebellar atrophy, periventricular white matter abnormalities

  • Clinical features: Peripheral neuropathy, paraesthesia

  • MRI: Thinning of the corpus callosum, white matter lesions with occipital predominance, signal changes affecting the internal and external capsules and medial lemniscus

Neuromyelitis optica spectrum disorder24
  • Clinical features: Intractable vomiting

  • MRI: Lesions in the dorsal medulla

  • Clinical features: Normal height, no scoliosis

  • MRI: Absence of signal changes in the periventricular white matter, deep grey matter or cerebellar dentate

Myasthenia gravis38
  • Clinical features: Oculomotor abnormalities, bulbar signs, muscle weakness

  • MRI: n/a

  • Clinical features: No autonomic symptoms, lack of upper motor neurone signs or ataxia

  • MRI: n/a

Amyotrophic lateral sclerosis39
  • Clinical features: Hyper-reflexia, incoordination, spasticity, muscle atrophy, bulbar signs, autonomic dysfunction

  • MRI: n/a

  • Clinical features: Pseudobulbar palsy, paraesthesia, pain

  • MRI: Decreased signal intensity within the motor cortex on T2-weighted images, corticospinal tract lesions, decreased signal intensity within the precentral gyrus on susceptibility-weighted imaging, signal changes involving the corticospinal tract and internal capsule

Multiple system atrophy—cerebellar subtype40
  • Clinical features: Ataxia, spasticity, hyper-reflexia, autonomic dysfunction, oculomotor abnormalities

  • MRI: Cerebellar atrophy, hot-cross bun sign

  • Clinical features: Anhidrosis, visuospatial dysfunction

  • MRI: Hyperintense T2 cross-shaped signal within the pons due to transverse pontocerebellar fibre degeneration

  • AxD, Alexander disease; FLAIR, fluid-attenuated inversion recovery; n/a, not applicable.