Abstract

That radiological features highly suggestive of multiple sclerosis (MS) can be observed prior to the first acute demyelinating episode or even prior to the development of an insidious neurological symptom that evolves progressively may be viewed as being controversial amongst specialists in neuroimmunology. If the treatment of incidentally identified MS radiological features in subjects without a history of clinical symptoms typical for CNS demyelination influence clinical outcomes, a transformation in our approach to care would be expected. The growth of scientific knowledge pertaining to subjects with radiologically isolated syndrome (RIS) has increased significantly in recent years. Yet, even when MRI features appear to be classic for CNS demyelination with high-signal abnormalities observed within the supratentorial and infratentorial regions along with the spinal cord, the proper treatment approach is unclear. Other risk factors for clinical conversion have also been identified including age, presence of unique oligoclonal bands within the CNS, and gadolinium enhancement on subsequent MRI studies. Despite the recent identification of additional risk factors for disease evolution, treatment within this group remains controversial. Can early treatment interventions reduce future disability outcomes? Is the cost of treating RIS subjects economically sound? Do the benefits clearly outweigh the risks? This presentation aims to address the challenge of treating RIS subjects in the context of key themes in favor and in opposition of treatment. The rationale for early treatment, the unpredictability of CNS demyelinating disease, advances in imaging technology and emergence of artificial intelligence platforms for better disease characterization, the current irreversibility of demyelinating events, and early markers for neurodegeneration will be discussed. Soon-to-be released data will be revealed from two large, multi-center, randomized, double-blinded trials focused on the impact of approved oral disease modifying therapies in extending the time to a first clinical event. The reported findings will be meaningful in moving beyond conjecture by providing data relevant to the topic of this presentation and the impact of treatment in this group.