Click here to watch Dr. Courtney Casserly discuss the case and the responses to the survey.
J.M. is a 28-year-old woman who had an MRI of the brain ordered by her nurse practitioner because of worsening of longstanding migraine headaches. The MRI demonstrated several lesions consistent with MS including two small enhancing lesions and multiple nonspecific supratentorial T2 hyperintensities. Your review of the history reveals nothing suggestive of a demyelinating episode. There is no family history of MS. She has an older brother with ulcerative colitis. The neurological examination was completely normal with borderline questionable pallor of the left optic disc.
J.M. says she is concerned and prepared for further investigation.
The survey is now closed. There were 40 responses. See below for a summary of the answers you provided.
Question 1: What is your diagnosis?
A majority responded that the diagnosis is radiologically isolated syndrome (RIS). A total of 12.5% said the diagnosis is MS and 2.5% said it is CIS. Another 17.5% remained with the initial diagnosis of migraine.
Question 2: What would be your next investigation?
Fifty percent said they would test oligoclonal banding in CSF, and 37.5% said they would obtain an MRI-spine. A total of 12.5% said they would not test further but would obtain a follow-up MRI in six months.
Question 3: What additional finding would support a diagnosis of MS?
A total of 17.5% said >1 spinal cord lesions, 12.5% said OCBs in CSF and 2.5% said >6 lesions with the central vein sign (CVS). The largest number of respondents said they would want SC lesions plus OCB+ (37.5%), or OCB+ plus CVS+ (30.0%).
Question 4: Would you start this patient on a DMT?
The largest proportion of respondents said they would start a DMT (42.5%), 22.5% said they would not, and 35.0% were unsure.
Question 5: If you were to treat her, what would be your preferred DMT?
The preferred treatment was an anti-CD20 agent (37.5%), followed by dimethyl fumarate (22.5%), teriflunomide (17.5%), an injectable platform therapy (12.5%) and oral cladribine (10.0%).
View the video commentary from Dr. Courtney Casserly.