A typical sign of neuromyelitis optica is longitudinally extensive transverse myelitis (LETM) (NMO). Not all LETM patients, nevertheless, have antibodies against aquaporin-4 (AQP4). Idiopathic isolated N-LETM is not that uncommon among first-ever LETM and differs greatly from P-LETM in which astrocytic damage is clearly present in many ways. Although neuromyelitis optica is the most common cause of longitudinally widespread transverse myelitis, there are several alternative possibilities.