Clinicians should consider early treatment for asymptomatic patients with brain MRI suggestive of multiple sclerosis (MS), according to a study in the February Journal of Neurology, Neurosurgery, and Psychiatry. Christine Lebrun, MD, PhD, Coordinator of the MS clinic at Centre Hospitalier Universitaire in Nice, France, and colleagues based their findings on a retrospective study of 30 patients with subclinical demyelinating lesions who were followed for five years.

The patients (26 women and four men; mean age, 29) were advised by their general practitioner to have MRIs for various medical events that were not suggestive of MS, including headaches, migraine with or without aura, craniocerebral trauma, depression, dysmenorrhea, epilepsy, and cognitive changes. Nine patients showed gadolinium enhancement, 10 had infratentorial lesions, and all 30 patients met Barkhof-Tintoré criteria on their MRI. The patients were subsequently recommended by a neurologist to undergo extensive neurologic examinations, which were found to be normal.

Twenty-five patients also consented to the recommended paraclinical studies. “All patients had a normal examination and biologic screening (serologic panel, antinuclear and antiphospholipid antibodies),” reported Dr. Le-brun and her coauthors. However, the mean CSF cell count was two cells per mm²—with three patients’ counts greater than four cells per mm²—nine patients had oligoclonal bands, and all had increased immunoglobulin levels. Eight patients also had abnormal asymptomatic evoked potentials. Among those patients with more than nine T2 hypersignals, six had abnormal visual evoked potentials, all associated with positive CSF findings.

A mean of six months later, the patients returned for a second MRI. “Twenty-five patients had temporospatial dissemination (nine with gadolinium enhancement, with five patients who already had active lesions),” said the researchers.

CONVERSION TO CLINICALLY ISOLATED SYNDROME

Eleven patients experienced clinical conversion a mean of 2.3 years after the first brain MRI, in the form of optic neuritis (five patients), brain stem (three patients), sensitive symptoms (two patients), and cognitive deterioration (one patient). Eight of these patients (72%) already had criteria of dissemination to space and time before the clinical event, although the researchers noted that no particular event was found in the three months before the clinically isolated syndrome.

“For the pre-MS patient without clinical events but with evidence of dissemination in space and time, medical discussion on the therapeutic options of immunomodulatory agents for reducing the risk of MS should be conducted, with the knowledge that subclinical MS can evolve into relapsing remitting MS in the majority of cases,” asserted Dr. Lebrun and colleagues. They reported that at the time of publication, four of the converted patients had received treatment, with interferon or glatiramer acetate. However, the researchers noted that prospective follow-up studies are needed, as many patients with clinically isolated syndrome and MRI lesions experience a benign course of MS.

CLINICAL MANAGEMENT OF INDICATIVE MRI

In an accompanying editorial, Jeremy Chataway, PhD, of the Department of Neurology at St. Mary’s Hospital in London, noted that as MRI scanning becomes more frequent in patients with any neurologic symptoms, clinicians will need to weigh the findings that appear to indicate inflammatory demyelination with asymptomatic clinical examinations. He noted that the fulfillment of Barkhof-Tintoré criteria by the patients—“they did not just have a smattering of high signal lesions,” he said—was an important indicator that follow-up on the MRI was needed.

“If your patient truly does [fulfill the criteria], then a simple workup for other inflammatory conditions would seem to be in order,” recommended Dr. Chataway. However, he asserted that any additional discussions should be refocused on the presenting symptom rather than on the presenting scan, as a diagnosis of MS is not automatic.

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