Professor Aksel Siva from the University of Istanbul, Turkey, discusses the considerations for starting patients on disease-modifying therapy early in the disease course. 

Radiologically isolated syndrome is people who are referred for an MRI study for a MS-unrelated neurological problem such as primary headaches, such as trauma or people who undergo some therapeutic trials for some other neurological disease and who turn out to have MRI lesions very suggestive of multiple sclerosis.

We know that some people, with RIS, are more likely to convert to clinical disease, especially if they are younger mainly male gender and if they have spinal cord lesions and certainly a combination of multiple lesions, gadolinium-enhancing lesions, positive oligoclonal bands but which by themselves are not very predictive but when they all come together they make the individual a high-risk individual to convert to clinical disease. So, whether we should treat these people or not we don’t know the answer. If a young lady comes with a mild attack of optic neuritis, which improves very quickly even without treatment, IV methylprednisolone, or with just a few days of treatment, and has only a few lesions in her MRI, no spinal cord lesions, then probably I would wait. Early treatment should be maybe defined as the initiation of a long-term treatment in a person with MS at the time that he or she is diagnosed with multiple sclerosis and has an ongoing activity which may be shown by MRI and the clinical manifestations of the disease.

So, we are now talking of the previously known CIS, clinically isolated syndrome, and in that sense we should keep in mind that not all CIS are MS and that even if some of them are MS, some of them won’t convert to the so-called Poser clinically definite MS in the future. There is now the term single attack MS which in fact describes people who present with the first MS attack and who are fulfilling the 2017 McDonald criteria. So if the individual has an MRI with lesions at critical sites such as the spinal cord, posterior fossa, corpus callosum and maybe juxtacortical many lesions gadolinium-enhancing lesions and has a CSF study which shows positive oligoclonal bands and high IgG index and high IgG levels this is evidence that this person has a very active inflammatory disease at that stage and we know that these people are more likely to respond to long-term treatments. So in those people I wouldn’t think twice and I would go on with one of the available treatments and it always should be, I guess, a shared decision together with the family and in, like in my country, we also involve the family not only the patient because they are very close with each other.