In 2008, a 31 year old previously well female presents with subacute onset ataxia and slurring dysarthria. Her symptoms evolve over 4 days, by which time she is unable to walk unassisted.
Her Expanded Disability Status Scale (EDSS) at the time of presentation is 6.0
Further tests reveal the presence of oligoclonal bands in the cerebrospinal fluid. Magnetic Resonance Imaging (or MRI) of the brain reveals multiple active (or gadolinium enhancing) lesions, including in the brainstem and spinal cord
Scan 1 (October 2009)
ACCESS point 1
The McDonald 2017 criteria permit a diagnosis of Relapsing Remitting Multiple Sclerosis (RRMS) to be made at the time of first clinical presentation, based upon evidence of dissemination in time on brain MRI. Positive oligoclonal bands provide supportive evidence in this case. At this first MRI, multiple active lesions and inactive lesions are present, including an active lesion in the brainstem and spinal cord
DMT: Injectable “The patient commences on an injectable Disease Modifying Therapy”
EDSS = 6.0 “The Expanded Disability Status Scale (EDSS) is a method of quantifying disability in MS and monitoring changes in the level of disability over time”
Scan 2 (December 2010)
PBVC: -1.12% “The patient’s annualised percent brain volume change (PBVC) since the last scan has decreased by 1.12%”
DMT: Injectable “The patient remains on an injectable DMT”
EDSS = 1.5
New Lesions: “The number of new active and new inactive lesions which are present in the currently displayed scan”
Scan 3 (May 2011)
PBVC: -1.2%
DMT: Injectable “The patient remains on an injectable DMT”
EDSS = 2.0
New Lesions: “The number of new active and new inactive lesions which are present in the currently displayed scan”
Scan 4 (December 2011)
PBVC: -1.4%
DMT: Injectable “The patient remains on an injectable DMT”
EDSS = 1.0
New Lesions: “The number of new active and new inactive lesions which are present in the currently displayed scan”
Scan 5 (January 2013)
ACCESS point 2
The patient experiences a clinical relapse, characterised by right scalp altered sensation and paraesthesia. MRI reveals a small brainstem affecting the trigeminal root entry zone on the right which may be responsible for the clinical relapse.
PBVC: -1.1%
DMT: Injectable “The patient remains on an injectable DMT”
EDSS = 1.0
New Lesions: “The number of new active and new inactive lesions which are present in the currently displayed scan”
Scan 6 (November 2013)
PBVC: +1.0%
DMT: Oral “Switch from injectable to oral in August 2014 due to tolerability issues with injectable”
EDSS = 1.0
New Lesions: “The number of new active and new inactive lesions which are present in the currently displayed scan”
Scan 7 (January 2015)
PBVC: -1.8%
DMT: Injectable “Patient-directed switch back to injectable in 2015 due to tolerability issues”
EDSS = 1.0
New Lesions: “The number of new active and new inactive lesions which are present in the currently displayed scan”
Scan 8 (September 2015)
PBVC: -0.83%
DMT: Injectable “The patient remains on an injectable DMT”
EDSS = 1.5
New Lesions: “The number of new active and new inactive lesions which are present in the currently displayed scan”
Scan 9 (May 2016)
ACCESS point 3
The patient experiences a severe relapse, involving progressive gait ataxia and lower limb weakness with minor right-hand weakness. Their EDSS rises to 5.5 during this relapse. Despite very active MRIthe patient has a good recovery over 3 months and their EDSS falls to 1.0
PBVC: -0.99%
DMT: Injectable “The patient was recommended to switch to an oral DMT however the patient elected to continue on the injectable DMT”
EDSS = 5.5 to 1.0
New Lesions: “The number of new active and new inactive lesions which are present in the currently displayed scan”
Scan 10 (July 2016)
ACCESS point 4
The patient experiences a clinical relapse characterised by bilateral hand numbness and a corresponding EDSS of 2.0. Three weeks after switching to an oral DMT the patient experiences a second clinical relapse with right hemiparesis and neuropathic left-sided pain and a corresponding EDSS of 4.0. This increase in disease activity is clearly reflected in the patient’s MRI scan which shows multiple new active lesions in the brain and also in the spinal cord
PBVC: +2.1% “The apparent increase in brain volume may relate to measurement error, confounding factors (like hydration status) or the presence of significant new brain inflammatory activity”
DMT: Oral “Switch from injectable to oral in June 2016”
EDSS = 2.0 to 4.0
New Lesions: “The number of new active and new inactive lesions which are present in the currently displayed scan”
Scan 11 (October 2016)
PBVC: +0.73%
DMT: Infusion “Switch from oral to infusion in May 2017”
EDSS = 2.0
New Lesions: “The number of new active and new inactive lesions which are present in the currently displayed scan”
Scan 12 (2018)
ACCESS point 5
Despite stabilisation of disease, this patient’s brain volume has decreased by 0.86% per year, amounting to total brain atrophy of -7.15% since diagnosis. This rate is 2.9 to 8.6 times the expected rate of brain volume loss in healthy controls. While many factors contribute to brain atrophy in MS, control of inflammatory activity is paramount and justifies treating to a target of No Evidence of Disease Activity (or NEDA).
PBVC: -0.48
DMT: Infusion “Now clinically stable, the patient remains on an infusion Disease Modifying Therapy and the focus switches to surveillance of disease and to side effects of therapy going forward”
EDSS = 2.0
New Lesions: “The number of new active and new inactive lesions which are present in the currently displayed scan”
Julia
Nicholas
