Neuromyelitis Optica Spectrum Disorder (NMOSD), an inflammatory condition of the central nervous system with a predilection for optic nerve and spinal cord involvement, predominantly affects women in their 30s to 40s, though later onset disease may occur. Very late onset cases are rare and are more likely to present insidiously with extensive cord lesions. We present the cases of two octogenarian women with progressive lower extremity weakness days-weeks following fall/trauma who were ultimately diagnosed with NMOSD.

The first patient presented at 88-years-old with progressive left leg weakness following a fall one month prior. Spine MRI demonstrated T2 hyperintense cord changesat T9-T11 with irregular enhancement and DWI changes.  She presented again 12 months later with new progressive right leg weakness. Repeat MRI demonstrating new cord signal changes extending from T3-T6. Serum NMO/AQP4 antibodies were 1:10000; CSF titer was 1:16. She declined recommended disease modifying therapy (DMT) and had 2 subsequent attacks of longitudinally extensive transverse myelitis at 30 and 42 months.

The second patient presented at 81-years-old with progressive left > right lower extremity weakness 3-days after ground-level fall. Spine MRI demonstrated T2 cord signal abnormality extending from C4-T12 with mild cord expansion and heterogeneous enhancement; as well as moderate to severe spinal stenosis at C4-C5 and C5-C6. Serum NMO/AQP4 antibodies were 1:100000; CSF titer was 1:512. Initiation of DMT was recommended.

Very-late-onset cases of NMOSD in patients over 80 are rare, whereas compressive/traumatic myelopathy is exceedingly more frequent in this age group. We present 2 cases of NMOSD in octogenarians who had experienced antecedent falls/trauma. Rare cases of multiple sclerosis post spinal cord injury have been reported with blood-brain barrier disruption suggested as putative mechanism. This may be of potential significance in patients with very late-onset NMOSD given increased incidence of traumatic/compressive myelopathy in this age demographic.