Click here to watch Dr. Jiwon Oh discuss the case and your responses to the quick poll.

Ellen is a 48-year-old elementary teacher with a history of migraine dating back to her twenties. She is perimenopausal with hot flashes and fatigue, and a recent increase in migraine frequency to 5-6 headaches per month. Her family physician diagnosed depression two years ago and started Ellen on a trial of sertraline.

She is referred to you after a recent fall with head trauma that resulted in mild confusion for one hour but no loss of consciousness. An MRI showed >20 white-matter lesions, including 10 periventricular, seven juxtacortical and three infratentorial lesions suggestive of MS. Ellen reports no symptoms suggestive of optic neuritis, myelitis or infratentorial syndrome. However, she has noticed increasing fatigue, ‘cog fog’ and depressed mood over the past two years, which she attributes to being perimenopausal. She says she has been less active lately and has gained about 7 kg over the past two years.

The survey is now closed. There were 35 responses. See below for a summary of the answers you provided.

Question 1: An MRI/CT-spine shows no spinal cord lesions. The EDSS score is 0. What other findings are needed to diagnose radiologically isolated syndrome (RIS)?
About 43% of respondents answered correctly – no other findings are needed since there are enough MRI features for an RIS diagnosis. Another 40% said they would perform a lumbar puncture for OCBs or kFLC. Another 17% said they would obtain another MRI in 6-12 months to demonstrate dissemination in time (DIT).

Question 2: Which factor is highly prognostic of this patient developing clinical symptoms of MS in the next 5 years?
The only prognostic factor in our list was infratentorial lesions, identified by 74% of respondents. Other respondents opted for juxtacortical lesions (14%) or periventricular lesions (9%), while 3% thought female sex was prognostic of MS symptoms.

Question 3: A follow-up MRI shows >6 lesions with the central vein sign. Would this patient meet McDonald 2024 criteria for MS?
The 2024 criteria require DIS with either DIT, CSF+ or Select 6. So this patient does meet the criteria since she has dissemination in space and meets the Select 6 requirement (74%). Lesions in only two topographies are needed for a diagnosis. So lesions in three topographies (14% of respondents) is not needed. About 95% thought that CSF+ would be required for an MS diagnosis, but CSF+ is not required if the patient is CVS+ or has DIS. About 3% would wait for clinical symptoms before diagnosing MS, but asymptomatic individuals can be diagnosed if the diagnostic criteria are met.

Question 4: Ellen says that she has difficulty tolerating medications. Would you recommend that she start a DMT?
About 72% would start a DMT because of the patient’s high lesion load or risk of early disability. Another 17% said they would start treatment only if a poor prognostic feature (e.g. PRLs) were present. Another 11% said they would not start treatment since Ellen has no relapses or disability progression.

Question 5: If you were to start a DMT, what would be your preferred therapy?
The preferred therapies were an anti-CD20 agent (40%) and oral cladribine (40%). Another 9% would opt for natalizumab while 11% would select teriflunomide or DMF, which were formally studied in the RIS trials TERIS (Lebrun-Frénay et al. JAMA Neurol 2023;80:1080-1088) and ARISE (Okuda et al. Ann Neurol 2023;93:604-614).

View the video commentary from Dr. Jiwon Oh.