DAVID MARKS, MD: Hi and welcome to our webcast. I'm Dr. David Marks. The diagnosis and treatment of multiple sclerosis has evolved over the years, but it can be complicated. So we have an expert to help us through the morass of MS treatment and diagnosis.

With me is Dr. James Miller. He is the director of the MS Center at Columbia Presbyterian Medical Center right here in New York City. Welcome.

JAMES MILLER, MD: How do you do? Nice to be here.

DAVID MARKS, MD: We're going to start with a case study, and you can take us through it and try to help people go about diagnosing and treating.

JAMES MILLER, MD: Okay, we'll give it a try.

DAVID MARKS, MD: Okay. So let's say that we have a 28-year-old woman who is referred to you. She has partial vision loss in one eye that's lasted for eight days, no previous history of vision problems at all and no infections.

Now her primary care doctor thinks she may have optic neuritis and possibly the beginnings of MS. That's why she's coming to you. What do you do next?

JAMES MILLER, MD: Well, the next step really is to confirm the physical examination, make sure that there is some visual type of loss that's consistent with optic neuritis. Very often we look for one of the cardinal features, which is pain in the eye, as being related to optic neuritis, as opposed to other loss of vision, and finding really that her examination doesn't show any other signs of neurologic issues that would be important to us, and having checked her history to make sure that there are no other issues there.

And this seems to be relatively straightforward, the next step is really to get an MRI scan of the brain, and then we consider other workup in terms of blood evaluation for other types of inflammation.

DAVID MARKS, MD: Okay. So you get an MRI, and that's really your first objective test, in a sense.

JAMES MILLER, MD: Really the most important one at this point.

DAVID MARKS, MD: Okay. So let's say it comes back, and it's a T-2 weighted -- you see T-2 weighted lesions. You see four of them. Nothing else. How do you interpret it?

JAMES MILLER, MD: That's a very potent indicator that this is an inflammatory demyelinating process and MS is by far the most likely diagnosis in this regard, although there are other things that you want to consider.

DAVID MARKS, MD: What are those other things?

JAMES MILLER, MD: Well, the other things are, for someone this age, are probably very rare, but there are other types of inflammations. Sometimes people worry about a systemic inflammation, such as a collagen vascular disorder that might do it. But the scenario here is pretty straightforward as being one related to multiple sclerosis.

Now there are questions about making the diagnosis of multiple sclerosis on a single clinical event. People have tended to shy away from that, even though the MRI scan can give some indication that this is very likely to be. Usually, we like to reserve the diagnosis of multiple sclerosis in a technical way for two events to have occurred clinically, but we've now found that the MRI can be a useful substitute, both in dissemination in time, and some of us believe that dissemination in space on the MRI is very important too.

By that, I mean that there is more than one lesion and including lesions -- some of those lesions don't relate to the optic nerve, so therefore some other things must be going on.

DAVID MARKS, MD: So you're already suspecting MS heavily.

JAMES MILLER, MD: Right. It has a very high probability. This is borne out by some of the studies that have been done following MRI scans for a period of time in people who present just like this person. Since it has ramifications for treatment and when you decide to offer treatment, these are very important issues.

DAVID MARKS, MD: Would you start treating her after only eight days of symptoms?

JAMES MILLER, MD: Well, the first thing is how are you going to treat, once we've done the blood test that would eliminate other possibilities of systemic inflammation, depending on the severity of the visual loss and how functionally important it was to the patient, we would probably elect to give intravenous corticosteroid treatment. There is good evidence that intravenous corticosteroid treatment will speed up recovery from an attack of multiple sclerosis and very marginal, and not totally convincing evidence, it affects the overall outcome whether you give the steroids or not.

DAVID MARKS, MD: And how would you follow up?

JAMES MILLER, MD: The followup from that is just to observe how the patient does after treatment. There is really nothing much more to offer in terms of treatment for the acute problem.

The next issue is whether they should be on long-term treatment. That depends on how likely you feel that the person is going to evolve into multiple sclerosis. This is where some of the information in studies that have been obtained recently provide some very potent arguments for going ahead with treatment.

DAVID MARKS, MD: But would you get an MRI at a certain time?

JAMES MILLER, MD: Yeah, that's one of the strategies we use. One of the things that you have to consider when offering people treatment is how interested they are in getting treatment for a single episode and they are very hopeful at this point that they're never going to be bothered again.

So one of the strategies is to enlist the patient and find out what they want to do. And a very reasonable strategy if the patient doesn't want to accept treatment at this point, or you're a little bit unsure whether this actually is multiple sclerosis is to get another MRI scan in about three months after the original one.

The value of three months afterward, is that any acute inflammation that's seen on the scan, if there happened to have been gadolinium enhancement on the original scan, if you still see gadolinium enhancement three months later, you can't attribute it to a previous episode, this now becomes a fresh lesion or an active lesion, I should say.

If there are certainly more T-2 lesions on the new scan, then again, this can't be considered part of a single episode and would have to be considered a fresh episode, warranting treatment.

DAVID MARKS, MD: Let's say that her MRI came back just like that. She had no symptoms. Her initial symptoms had gone away, they resolved, but her follow-up three month MRI shows a new lesion.

JAMES MILLER, MD: Then I certainly would push very strenuously with this patient to accept some type of prophylactic treatment. Then it becomes clear that she does have multiple sclerosis, even by the most stringent current criteria.

DAVID MARKS, MD: A lot of people might say, "Well, she's not symptomatic. Why subject her to treatment?" What kind of studies are out there that might back up your decision to coax her along to accept treatment?

JAMES MILLER, MD: Well, there are very convincing studies now that the treatments that are available do effect the progression of the disease, to some extent. They are not perfect treatments. They don't cure people. And since we know that there can be a buildup of lesions, which will come back to haunt people in the future, even if it's not clinically apparent, that it's well worth starting people as soon as possible in order to decrease the amount of difficulty that they're going to get into over time.

For example, in the study from Queens Square in London, it was shown that people with greater than one lesion, at the time of the onset of a single clinical episode, such as this patient had, have a greater than 90% chance of developing multiple sclerosis after 15 years. The more lesions they had at the time of the discovery of the inflammation, based on the single clinical episode, the more likely they were to have significant disability at that time.

DAVID MARKS, MD: This is without treatment?

JAMES MILLER, MD: This is all without treatment. So there is good grounds for encouraging people to start medications as soon as the disease is discovered and the patient and the doctor feel comfortable with the diagnosis and not wait for further clinical episodes to evolve.

We also know that for every clinical episode, based on studies of serial MRI scans, there are probably five other episodes of inflammation that have occurred that people are totally unaware of.

DAVID MARKS, MD: Well, are there any studies about how patients do once they are treated after a first demyelinating event?

JAMES MILLER, MD: Yes, there is a very important study that was done several years ago where people were treated with Avonex, which is one form of the interferons. And they were placed on the medication, even though they wouldn't fulfill some of the criteria for multiple sclerosis at that time because it was only a single event.

And it was found that this delayed the time to the next event.

DAVID MARKS, MD: Is it hard to convince patients to be treated?

JAMES MILLER, MD: It's becoming easier over time, as people get more familiar with the medicine and this type of information gets out to doctors and the public, that early treatment does make a difference in decreasing the overall burden of disease, not just a matter of decreasing the number of attacks that they can perceive.

DAVID MARKS, MD: Well, that leads to the question of what is her prognosis in the long-run, if she accepts treatment?

JAMES MILLER, MD: Well, her prognosis and for most of the parameters that we know about with or without treatment, is probably reasonably good. That she has presented with a sensory symptom or optic neuritis and she has presented with only that sole symptom. She is relatively young. The burden of disease on the MRI scan was not particularly impressive. So all of those things would tend to indicate a good prognosis, although there can be no written guarantee given out with this.

DAVID MARKS, MD: Well, thank you for joining us. I think it was a big help in figuring out how to approach these patients.

JAMES MILLER, MD: Well thanks so much for having me.

DAVID MARKS, MD: All right. I'm Dr. David Marks. Thank you for joining our webcast.