CLINICAL CASES IN MS – CASE 3: MS-LIKE MRI LESIONS IN A WOMAN WITH MIGRAINE

 

Click here to watch Dr. Virender Bhan discuss the case and the responses to the survey.

Elizabeth, 28, is referred by her family practitioner with a note that her MRI report is suggestive of MS. She is married with two children and is currently employed as a middle school teacher. She has a history of episodic migraine but is otherwise healthy. She reports no neurological symptoms. There is no history of recreational drug use. There is no family history of demyelinating diseases including MS. Elizabeth tells you she has a maternal aunt with fibromyalgia.

The neurological examination is normal. A non-contrast MRI brain shows approximately 15 T2 hyperintense lesions: four periventricular, two juxtacortical, two in the corpus callosum, one in the middle cerebellar peduncle and the rest in the subcortical white matter.

The survey is now closed. We received 29 responses. See below for a summary of the answers you provided.

Question 1: What is your clinical impression and plan?
Respondents stated that the diagnosis was RIS (63%) or probable RIS (37%) and planned to order an MRI brain with contrast + spinal cord. No one would initiate a DMT at this time.

Question 2: An MRI brain with contrast obtained six months later shows two gadolinium-enhancing lesions and one new T2 lesion; MRI spinal cord shows two short-segment eccentrically located lesions in the posterior cervical cord. During this time period, Elizabeth reports experiencing occasional migraines but no other neurological symptoms. The neuro exam remains normal. What is your diagnosis and plan?
Most respondents (83%) would investigate further with MRI (now or in 6 months), blood work and lumbar puncture.

Question 3: Six months later, non-contrast MRI brain shows three new T2 lesions. CSF shows 12 cells/HPF (all lymphocytes); positive OCB and increased IgG index; normal protein and glucose. Elizabeth reports a migraine one month ago but no neurological symptoms. The neuro exam is normal. What is your diagnosis and plan?
Most respondents (87%) would diagnose RIS; 13% would diagnose MS. About 53% would start vitamin D and instruct Elizabeth to contact the clinic if she experiences any neurological symptoms. About 47% would initiate a DMT (either for RIS or MS).

Question 4: What would you estimate to be Elizabeth’s risk of conversion to definite MS over the next five years?
Most respondents (63%) said the risk varies from 30-90% depending on various factors.

Question 5: What are the factors that increase the odds of conversion to definite MS in patients with RIS?
The most commonly-cited factors were the presence of spinal cord lesions (90% of responses); presence of oligoclonal bands in CSF (79%); and the presence of Gad+ lesions in the brain (69%). Less common responses were younger age (34%) and the presence of infratentorial lesions (34%).

View the video commentary by Dr. Virender Bhan.

Click on the link to view the article (Lebrun C. Rev Neurol (Paris) 2015;171:698-706) cited by Dr. Bhan in the video commentary: www.em-consulte.com/article/1007587/alertePM

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