Does a patient with a history of Multiple Sclerosis (MS) presenting with left facial, arm, and leg changes in sensation and a questionable new upper C2 lesion on brain MRI require treatment prior to cervical spine MRI results?

Treatment Decision for MS Patient with New Sensory Symptoms and Questionable C2 Lesion

Direct Recommendation

Yes, this patient requires immediate treatment with high-dose intravenous corticosteroids for an acute MS relapse without waiting for cervical spine MRI results. 1

Clinical Reasoning

Evidence of Active Relapse

• The patient presents with new neurological symptoms (left facial, arm, and leg sensory changes) representing a clinical relapse, which is the primary indication for acute treatment. 1, 2
• A questionable new C2 lesion on brain MRI further supports active disease, though the clinical presentation alone justifies treatment. 2
• The cervical spine MRI is pending but should not delay treatment initiation, as clinical relapses require prompt intervention to minimize permanent disability. 1

Standard Acute Relapse Treatment Protocol

Administer methylprednisolone 1000 mg IV daily for 3-5 days, which can be initiated immediately based on clinical presentation. 1

• The FDA-approved regimen for acute MS exacerbations is 160 mg daily for one week followed by 64 mg every other day for one month, though higher pulse-dose regimens (1000 mg daily for 3-5 days) are more commonly used in current practice. 1
• Treatment should begin within days of symptom onset to maximize recovery potential. 1

Role of Pending Cervical Spine MRI

• Cervical spine MRI has limited value for routine disease monitoring and should not delay treatment of a clinical relapse. 3
• Spinal cord imaging is less sensitive than brain MRI for detecting disease activity and is primarily indicated for unexplained spinal cord symptoms, not for confirming treatment decisions in the setting of clear clinical relapse. 3
• The frequency of asymptomatic cervical spine lesions ranges from 4.8% to 12.1%, but their presence or absence does not change acute management. 4

Critical Pitfalls to Avoid

• Do not delay corticosteroid treatment while awaiting additional imaging studies when clinical relapse is evident. 1, 2
• Do not assume all new symptoms require MRI confirmation before treatment—clinical judgment based on history and examination is paramount. 2
• Avoid undertreating relapses, as early aggressive treatment may reduce long-term disability accumulation. 1

Post-Treatment Monitoring Strategy

• Complete the cervical spine MRI to establish baseline disease burden and assess for dissemination in space, which informs long-term prognosis and treatment escalation decisions. 3
• Perform follow-up brain and cervical spine MRI at 3-6 months after treatment to assess for new lesion development, which would indicate ongoing disease activity requiring disease-modifying therapy adjustment. 3, 5
• If the patient is not currently on disease-modifying therapy or is on lower-efficacy treatment, this relapse warrants consideration of treatment initiation or escalation. 3

Long-Term Disease-Modifying Therapy Considerations

• The presence of a new clinical relapse with corresponding MRI findings indicates active disease requiring optimization of disease-modifying therapy. 3
• If already on treatment, evaluate for breakthrough disease activity using criteria such as one or more relapses with at least one contrast-enhancing lesion or two new T2 lesions, which would suggest suboptimal treatment response. 3
• Higher-efficacy therapies should be considered for patients demonstrating breakthrough activity on current treatment. 6