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An increasingly common presentation of early MS

RIS
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Introduction and objectives


•A 25 year old woman with no significant PMHx presented to her PCP with intermittent right-sided pulsatile headaches X6 months associated with phonophobia, photophobia, and nausea.
•Based on these complaints, the patient underwent brain MRI, followed by cervical spine MRI.
•Her headaches spontaneously resolved shortly after MRIs were done.
•Based on MRIs, the patient was referred to our center
 

Case presentation


•Neurological exam was normal, and the patient denied any neurological symptoms.  

•Imaging showed several juxtacortical and periventricular lesions, a posterior fossa lesion, and a C6 right dorsolateral lesion.  No abnormal enhancement was seen.

Based on this data,

•what is the diagnosis?
•what is the optimal management?

The patient underwent a lumbar puncture which showed 8 WBCs, normal protein, and >5 unique oligoclonal bands.  Would this change management?

We recommended close monitoring with serial imaging and neurological exams.

Clinical presentation

•Repeat MRI 6 months after showed 2 new enhancing lesions.  Based on this new data, what is the optimal management of this patient?

•After careful review of pros and cons of treatment, the patient was started on an MS disease modifying agent.

Diagnosis

RIS

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Comments

This patient meets the DIS and DIT criteria (after the second MRI) and therefore MS is the presumed diagnosis after exclusion of mimics. She also has additional paraclinical evidence of OCBs in CSF. Either way, CIS at the initial stage or MS after the second MRI does mean that the patient ought to have been on DMTs. That is what the FDA approval for CIS treatment is - start DMDs. If the patient was not started on DMDs right away after a CIS dx, the authors need to tell us why. The optimal mgmt after the second MRI (no one knows why one has to wait for 6 mo, unless it is an insurance issue) is to TREAT, TREAT and TREAT more. Axonal loss, if one goes by Bruce Trapp's paper, would have LONG begun. We miss the bus if we do not treat CIS patients early. It is almost like stroke treatment, not quite, but similar. Urgency is called for. Delay of one second in treatment causes a loss of 1.9 million cells in acute stroke (Jeffrey Saver). Similarly, MS or CIS treatment delay produces deficits in the long run that are irreversible and chronic.