Radiologically isolated syndrome: managing the preclinical phase of MS
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This episode of the Practical Neurology Podcast explores radiologically isolated syndrome (RIS), a condition where MRI findings consistent with multiple sclerosis (MS) are discovered incidentally in patients with no clinical symptoms. Host Amy Ross-Russell interviews Audrey Reynolds, a neurology specialist registrar from Dublin, who details the diagnostic challenges, evolving criteria, and management strategies for RIS. The discussion covers key radiological features—such as periventricular lesions, Dawson's fingers, juxtacortical and infratentorial lesions, gadolinium enhancement, and advanced markers like central vein signs and paramagnetic rim lesions—that help differentiate demyelination from small vessel disease. The new McDonald criteria are highlighted as a pivotal shift toward biological diagnosis, allowing earlier intervention in high-risk RIS patients with multiple risk factors like spinal cord lesions, oligoclonal bands, or positive central vein signs. Reynolds emphasizes the importance of multidisciplinary collaboration with radiologists, careful patient communication, and risk stratification to guide decisions on disease-modifying therapy. The episode also touches on controversial topics like the use of anti-TNF agents in RIS patients, the potential role of biomarkers such as neurofilament light chain and OCT, and the evolving debate around early treatment in preclinical MS. Key takeaways include: 1) RIS is a preclinical phase of MS, with about 50% converting to clinical MS within 10 years; 2) Advanced MRI markers like central vein signs and paramagnetic rim lesions significantly increase diagnostic specificity; 3) The new McDonald criteria enable earlier MS diagnosis in high-risk RIS patients, justifying early treatment; 4) Risk stratification using factors like oligoclonal bands, spinal lesions, and gadolinium enhancement is critical for management decisions; 5) Biomarkers such as neurofilament light chain and OCT may soon supplement MRI in monitoring RIS progression. The overall tone is cautiously optimistic, reflecting growing confidence in early intervention and improved diagnostic precision.
RIS is a preclinical phase of MS, with approximately 50% of patients developing clinical MS within 10 years.
Advanced MRI markers like central vein signs and paramagnetic rim lesions significantly improve diagnostic accuracy for MS.
The new McDonald criteria allow earlier diagnosis of MS in high-risk RIS patients, enabling timely initiation of disease-modifying therapy.
Risk stratification using oligoclonal bands, spinal cord lesions, and gadolinium enhancement helps identify patients who benefit most from early treatment.
Biomarkers such as neurofilament light chain and OCT may soon play a role in monitoring RIS progression and guiding intervention.
Introduction and Guest Introduction
Amy Ross-Russell introduces the April 2026 Editor's Choice podcast and welcomes Audrey Reynolds, a neurology specialist registrar from Dublin, who is an expert in multiple sclerosis research.
Defining Radiologically Isolated Syndrome (RIS)
Audrey Reynolds defines RIS as the incidental discovery of MRI findings consistent with demyelination in a patient with no clinical symptoms of MS, emphasizing the importance of excluding clinical relapses and neurological deficits.
Historical Context and Diagnostic Evolution
The episode traces the evolution of RIS diagnosis from the 2009 description to the current McDonald criteria, highlighting how MRI has become central to MS diagnosis and the challenges of identifying true preclinical cases.
Radiological Features of Demyelination
Detailed discussion on distinguishing demyelinating lesions from small vessel disease using features like ovoid shape, periventricular location, Dawson's fingers, juxtacortical lesions, and spinal cord involvement.
Advanced MRI Markers: Central Vein and Paramagnetic Rim Signs
“If a large proportion of the lesions have a central vein, that's more consistent with demyelination.”
“If you have four risk factors, you have a 90% risk of conversion at two years.”
“It's not all RIS patients, it's those who we know are much higher risk of developing MS that it's reasonable to then offer them disease modifying therapy.”
“If a large proportion of the lesions have a central vein, that's more consistent with demyelination.”
Host
Guest
multiple sclerosis
other
radiologically isolated syndrome
other
audrey reynolds
person
amy ross-russell
person
practical neurology podcast
media
mcdonald criteria
other
central vein sign
other
oligoclonal bands
other
paramagnetic rim lesion
other
teriflunomide
product
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