Current Series: Multiple Sclerosis Management

Fred D. Lublin, MD: So you mentioned CIS, which is clinically isolated syndrome, the first attack. One of the issues with misdiagnosis is that for those of us working in this era, when we think of that clinically isolated syndrome, we think of specifically an optic neuritis, a brainstem cerebella syndrome, or a partial myelitis.

One of the issues around misdiagnosis is when people try and apply more ephemeral or less characteristic onsets of that first attack when we see things of this sort. So Clyde, tell us a bit about what you expect to see in terms of when the patient presents to you with that first attack?

Clyde E. Markowitz, MD: Sure. It’s not uncommon for people to present with a unilateral optic neuritis as we describe it—painful eye movements, loss of vision, blurry vision in one eye usually. Patients usually go to the eye doctor for that and maybe ultimately end up coming to a neurologist because somebody said they were concerned it could be an optic neuritis. So they get an MRI [magnetic resonance imaging] scan maybe at the ophthalmologist’s, or maybe at the neurologist’s office And so, having that first MRI scan could be very important in terms of our ability to tell patients what the risk going forward is.

I think one of the things that Pat brings up is very important. When you think about the idea that we have criteria now that says somebody presents with a single event and you have dissemination in time, and you can use spinal fluid to be able to get that information, I’m finding, these days, that I’m doing many more spinal taps than I used to do. I think we went through a period where we weren’t doing as many. But I was talking with some people today in the clinic of the patient I just saw who presented with an optic neuritis who does not meet the criteria. He had the optic neuritis. He has an MRI scan with some lesions. He has a spinal cord lesion but does not have the dissemination in time, other than that he’s got different lesions in different locations. So this is a little problematic, and I said that I think we need to do a spinal tap to really address this issue. And I think it’s very helpful that we now can include that in the diagnostic criteria.

You mentioned, Fred, about a partial transverse myelitis being a very typical—whether it be sensory abnormality in both legs, 1 leg, arms, whatever—distribution. It could be weakness. It could be bladder involvement. So those are the very common things that you see, typically. But then people can present with significant weakness, and that could be just maybe a hand. And the piece that I think we have the greatest difficulty with is the patients who present with more of a progressive onset. People who don’t have the typical attack that shows up with a defined event over a couple of days that kind of reaches a plateau and then starts to get better.

It’s these patients who have more of a slow progressive myelopathy. In the summer they were having difficulty at the golf course. They went into the club afterwards and they seemed to feel a little bit better and they didn’t really seek the attention of a neurologist. So that’s a little bit more challenging. But the typical signs and symptoms are referable to where this lesion is. As neurologists, we love to be able to localize an area to be able to make a determination. MRI, by far, has really made a huge impact in our ability to find an abnormality and find changes consistent with MS [multiple sclerosis].

Fred D. Lublin, MD: So James, why don’t you tell us a little bit about what the MRI criteria are for space and time?

James M. Stankiewicz, MD: So regarding MRI criteria for dissemination in space, we really carve a brain into 4 different regions. There’s the spinal cord, the posterior fossa—so brain stem and cerebellum—the periventricular area, and then there’s the cortical/juxtacortical area. And so, really to establish dissemination in space, you need to see lesions in 2 of those areas. And dissemination in time, this is something that with the variations or revisions of the McDonald criteria has changed a bit. One of the things that’s more recent is that you can establish dissemination in time based on 1 MRI, where you see that there are some lesions that are enhanced and some that don’t enhance. Whereas if you go back years ago, you would have to have a second MRI showing that there were new lesions a month later. And so, this is an advancement. I think it allows us to diagnose MS earlier.

Fred D. Lublin, MD: Great. And now we can use both the symptomatic and the asymptomatic lesions.