Nicholas

In 2007, a 38-year-old male experiences right hemisensory syndrome  involving the face and minor involvement of the left hand and forearm. Further examination reveals impaired dexterity and fine motor skills of the right hand [right hand (motor)]. Magnetic resonance imaging (or MRI) reveals multiple non-enhancing (inactive) lesions in the brain

A diagnosis of Relapsing Remitting Multiple Sclerosis is made and an injectable disease modifying therapy (or DMT) commenced.

Therapy is ceased due to injection fatigue and depression after 6 months, and the patient elects to remain on no therapy. The patient represents in 2010 with subacute weakness of left upper and lower limbs and distal sensory disturbance of both feet. 

Examination reveals lower limb proximal pyramidal weakness and hyperreflexia. MRI reveals 2 new inactive lesions in the brain, but the patient declines to receive DMT.

3D Scan 1 (January 2011)

The patient experiences new right facial and hemi-tongue numbness and generalised fatigue resolving spontaneously over 3 months.  

MRI reveals an enlarged posterior periventricular lesion, but imaging is otherwise unchanged. The patient continues working full-time.   Oral DMT is commenced in the context of a clinical trial.

EDSS = 0.0 “The Expanded Disability Status Scale (EDSS) is a method of quantifying disability in MS and monitoring changes in the level of disability over time”)

PBVC = -3.28% “The patient’s percent brain volume change (PBVC) since the RRMS diagnosis has decreased by 3.28%”]

3D Scan 3 (April 2014) 

The patient reports prominent fatigue and a tendency, which has developed insidiously, to catch the toes of his right foot while walking. He has minor bladder urgency 

Examination reveals minor weakness of the hip flexion and the patient's disability has increased from EDSS 2 to 3.

Despite these clinical symptoms MRI reveals only a small inactive frontal white matter lesion that was not definitively identified on the prior scan. 

Furthermore, the patient begins to experience poor concentration and forgetfulness at work. A baseline cognition assessment is performed using the Symbol Digit Modality Test (or SDMT)

EDSS = 3.0 “The Expanded Disability Status Scale (EDSS) is a method of quantifying disability in MS and monitoring changes in the level of disability over time”

PBVC = -5.27% “The patient’s percent brain volume change (PBVC) since the RRMS diagnosis has decreased by 5.27%”

SDMT (z score) = 1.0 “The Symbol Digit Modality Test (SDMT) is an assessment of cognitive processing speed where a higher z score reflects better cognitive potential”

3D Scan 4 (November 2014) 

Despite being clinically stable with no new MRI lesions the patient continues to experience reduced work performance and has difficulty multitasking. He ceases DMT due to intolerance and is switched to a new oral agent.

EDSS = 3.0 “The Expanded Disability Status Scale (EDSS) is a method of quantifying disability in MS and monitoring changes in the level of disability over time”

PBVC = -6.14% “The patient’s percent brain volume change (PBVC) since the RRMS diagnosis has decreased by 6.14%”

SDMT (z score) = 1.0 “The Symbol Digit Modality Test (SDMT) is an assessment of cognitive processing speed where a higher z score reflects better cognitive potential”

3D Scan 5 (May 2015) 

The patient is clinically stable with no new MRI lesions. Nevertheless, the patient reduces their workload from 5 to 4 days per week.

EDSS = 3.0 “The Expanded Disability Status Scale (EDSS) is a method of quantifying disability in MS and monitoring changes in the level of disability over time”

PBVC = -5.66% “The patient’s percent brain volume change (PBVC) since the RRMS diagnosis has decreased by 5.66%”

SDMT (z score) = 0.95 “The Symbol Digit Modality Test (SDMT) is an assessment of cognitive processing speed where a higher z score reflects better cognitive potential”

3D Scan 6 (May 2016) 

The patient’s right foot drop becomes more pronounced and he is unable to stand on his right heel. He also experiences mild weakness of hip flexion, ankle dorsiflexion and the upper limb. Walking is now restricted to about 500m, and he reports worsening urinary urgency.

Despite no new MRI lesions, the patient's EDSS climbs to 4. Similarly, the patient's SDMT score continues to decline.

EDSS = 4.0 = “The Expanded Disability Status Scale (EDSS) is a method of quantifying disability in MS and monitoring changes in the level of disability over time”

PBVC = -6.72% “The patient’s percent brain volume change (PBVC) since the RRMS diagnosis has decreased by 6.72%”

SDMT (z score) = 0.80 “The Symbol Digit Modality Test (SDMT) is an assessment of cognitive processing speed where a higher z score reflects better cognitive potential”

3D Scan 7 (August 2017) 

The patient's annualised percent brain volume change since their last scan is negative 2.2%, with his total brain volume down by 9.4% since diagnosis. This atrophy is mirrored by a 47% increase in ventricular volume.

The patient’s SDMT score has decreased further and his workload is reduced from 4 to 3 and a half days per week.

EDSS = 4.0 “The Expanded Disability Status Scale (EDSS) is a method of quantifying disability in MS and monitoring changes in the level of disability over time”

PBVC = -9.46% “The patient’s percent brain volume change (PBVC) since the RRMS diagnosis has decreased by 9.46%”

SDMT (z score) = 0.65 “The Symbol Digit Modality Test (SDMT) is an assessment of cognitive processing speed where a higher z score reflects better cognitive potential”

3D Scan 8 (August 2018) 

Despite the absence of new MRI brain lesions in the past 4 years the patient has accumulated an 11% percent brain volume loss since diagnosis. Similarly, even though the patient has not experienced a relapse since 2013, he reports ongoing fatigue and his walking distance has reduced to 300m unaided. The EDSS has increased from 2 to 4.5. 

The patient’s confirmed disability progression independent of relapse supports a diagnosis of Secondary Progressive Multiple Sclerosis at this time.

EDSS = 4.5 “The Expanded Disability Status Scale (EDSS) is a method of quantifying disability in MS and monitoring changes in the level of disability over time”

PBVC = -11.01% “The patient’s percent brain volume change (PBVC) since the RRMS diagnosis has decreased by 11.01%”

SDMT (z score) = 0.45 “The Symbol Digit Modality Test (SDMT) is an assessment of cognitive processing speed where a higher z score reflects better cognitive potential”