Wednesday, February 20, 2008
Date: Tue, 19 February 2008
by Will Boggs, MD
Patients with subclinical demyelinating lesions fulfilling MRI Barkhof-Tintoré criteria with a normal neurological examination are likely to develop multiple sclerosis (MS), according to a report in the February issue of the Journal of Neurology, Neurosurgery, and Psychiatry.
"Patients who fulfill the Barkhof and Tintoré MRI criteria, combined with CSF study, can be considered high risk for MS and have early treatment," Dr. Christine Lebrun-Frenay from CHU de Nice, France told Reuters Health.
Dr. Lebrun-Frenay and colleagues note that the concept of preclinical MS is now recognized. Silent brain T2 lesions are often seen on incidental MRI, they point out, but patients fulfilling Barkhof-Tintoré criteria are relatively uncommon.
The researchers report clinical and MRI findings after a five-year follow-up in 30 patients with subclinical demyelinating lesions fulfilling Barkhof criteria seen on MRI performed for medical complaints such as headache or trauma.
All patients had a normal examination and biological screening, the authors report, but all patients had increased CSF immunoglobulin levels (including nine with oligoclonal bands) and eight patients had abnormal asymptomatic visual evoked potentials.
Eleven patients clinically converted, including five with optic neuritis, three with diplopia or internuclear ophthalmoplegia, two with paresthesias in the lower limbs, and one with cognitive deterioration.
Four of these patients had their first clinical events during the first year after the first abnormal MRI, three during the second year, three during the third year, and one at five years. The mean time between the abnormal MRI and the clinically isolated syndrome was 2.3 years.
All 17 patients who underwent a second MRI during the first year showed MRI dissemination, the researchers note, as did eight of 12 patients whose second MRI was done between 12 and 24 months.
"For the pre-MS patient, without clinical events but with evidence of dissemination to time and space, medical discussion on the therapeutic options of immunomodulatory agents for reducing the risk of MS should be conducted, with the knowledge that subclinical MS can evolve into relapsing remitting MS in the majority of cases or more rarely into progressive MS," the investigators advise.
"Physicians and especially neurologists must really know Barkhof and McDonald criteria to not overestimate the diagnosis of MS," Dr. Lebrun-Frenay said. "A lot of abnormal MRI with T hyperintensities are classified MS, but a lot of physicians forget what Barkhof and Tintoré said in their principal publications on the way to interpret brain MRI."
If the patient does fulfill the Barkhof-Tintoré criteria, "then a simple workup for other inflammatory conditions would seem to be in order," writes Dr. Jeremy Chataway from St. Mary's Hospital, London, UK in a related editorial. "From there on, time and clinical evaluation would perhaps guide subsequent investigation."