0:01

So there's a new CIS in town.

0:04

Normally we think of CIS as carcinoma in situ,

0:07

but for the neurologists,

0:10

CIS refers to clinically isolated syndrome.

0:15

This is a monophasic presentation with a

0:19

suspicion of an inflammatory

0:21

demyelinating disorder.

0:23

Symptoms are typically of rapid onset

0:25

and last for more than 24 hours.

0:27

So this is the first event, if you will,

0:30

in someone who potentially will have

0:33

multiple sclerosis down the road.

0:35

But this is a solitary event and that's why

0:38

it's called a clinically isolated syndrome.

0:42

Nonetheless,

0:43

these patients with clinically isolated

0:46

syndrome are often imaged because of this new

0:49

neurologic event and get an MRI scan.

0:53

The impact of MRI is very important because of

0:57

those patients who have an abnormal MRI,

1:00

82% will convert to multiple sclerosis

1:04

at some point in the next 20 years.

1:07

If, on the other hand,

1:08

they have a single neurologic

1:10

event with a normal MRI,

1:12

only 21% will develop the diagnosis

1:17

of multiple sclerosis.

1:19

And these are different authors showing that

1:22

the ranges can be 82% to 88%, 19% to 21%.

1:27

But by and large,

1:28

we say that four fifths or more of them with

1:31

an abnormal MRI will convert to multiple

1:35

sclerosis over the course of time.

1:37

If the MRI shows that there is a

1:41

gadolinium enhancing lesion,

1:44

then you have an even higher rate at which

1:48

these patients will convert to multiple

1:51

sclerosis from clinically isolated syndrome.

1:55

In addition, when they convert,

1:57

they have greater disability.

1:59

So this is CIS and you will see on

2:01

your request know CIS evaluation.

2:04

It is the pre-multiple sclerosis evaluation

2:08

hasn't yet fulfilled the clinical criteria of

2:11

multiple episodes of neurologic events,

2:14

but they are suspicious of it and therefore

2:17

looking at the MRI to help guide them.

2:20

In some cases,

2:21

it may help guide therapy because the patients

2:24

may be put on immunosuppressives

2:27

based on the MRI result.

2:29

Now we have CIS, but we also have RIS.

2:33

This is one of my favorite diagnoses.

2:36

These are patients who were not admitted

2:39

with a new neurologic event,

2:41

but have a radiology imaging pattern that

2:46

looks just like multiple sclerosis.

2:49

So these are patients that may be incidentally

2:52

discovered being evaluated, for example,

2:55

for migraine headaches. And lo and behold,

2:58

you find white matter lesions.

3:00

That look just like multiple sclerosis in

3:02

the periventricular and juxtacortical or

3:05

infratentorial location and or enhancing lesions

3:09

in the white matter and non-enhancing lesions.

3:12

But the neurologists and the clinicians have

3:16

no clinical history of a neurologic event.

3:18

This is what is known as radiologically

3:21

isolated syndrome, or RIS.

3:24

8.8% of healthy relatives of patients with

3:28

multiple sclerosis and 4.9% of non-familial

3:33

healthy control subjects may show

3:35

multiple white matter lesions,

3:37

and they may indeed fulfill McDonald criteria

3:41

for multiple sclerosis and yet

3:43

not carry that diagnosis.

3:46

If the patient has enhancing lesions,

3:50

the progression to multiple sclerosis

3:53

increases dramatically.

3:55

So we say if you show an RIS pattern that

3:59

is a multiple sclerosis-like pattern,

4:02

and yet you don't have MS in your diagnosis,

4:07

there's a one-third chance over the course of

4:09

the next three years that you will indeed

4:12

develop multiple sclerosis as defined by the

4:15

clinical criteria, not just imaging criteria.

4:18

If you have enhancing lesions,

4:21

that rate goes up three to fourfold.

4:24

And if you follow these patients,

4:28

even if they don't have neurologic

4:30

symptoms currently,

4:32

they may show progressive MR findings in that

4:34

they may have new MR lesions

4:36

and new enhancing lesions,

4:38

even though they may be asymptomatic

4:41

neurologically.

4:42

So this is radiologically isolated syndrome.

4:46

In fact,

4:46

I wrote a paper with one of my outstanding

4:49

research fellows, Gina Pakpur.

4:51

What we did was we looked at follow-up of

4:55

emergency department MRI scans in patients

4:59

who did not have a diagnosis

5:01

of multiple sclerosis,

5:02

but for whom we saw a pattern

5:05

that looked just like MS.

5:07

And what we found was if we in our reports

5:11

said that this looks like MS, period blank.

5:16

In other words,

5:17

a demyelinating disorder was placed as

5:19

the only differential diagnosis.

5:22

These patients ultimately had a final

5:26

diagnosis of multiple sclerosis

5:29

over the course of time,

5:30

and this was a six-month follow-up.

5:32

In 84.3%,

5:34

if MS was listed as the first in the

5:38

differential diagnosis of a list

5:40

of differential diagnoses,

5:42

then 37.5% of them over the course of the next

5:46

six months had the diagnosis of multiple

5:49

sclerosis made. If it was in the middle,

5:52

like the second or the third or the fourth

5:54

or the fifth th, then as you can see,

5:56

those rates went down precipitously.

5:59

So the point here being that these are

6:01

patients who show from an emergency room MR

6:05

scan not performed for demyelinating

6:07

disorder or even neurologic events.

6:10

If we say this looks like MS,

6:13

i.e.,

6:14

radiologically isolated syndrome,

6:17

and we say this is MS,

6:20

it will be MS in 84.3% as a diagnosis

6:25

within six months.

6:27

If you look out even further

6:29

over the course of time,

6:30

I imagine that this would be even higher.

6:32

But our look back was a six-month look back.