b'diagnosis of RRMS in a person presenting MS is radiographic isolated syndrome. Thesewith CIS. If a CIS patient has evidence of are brain MRI changes typical for MS in theboth acute and older areas of demyelination absenceofsymptoms. Thissituationmayon MRI, this satisfies the requirement for arise if a person has an MRI as part of andissemination of neurological events in both evaluation for headaches or a concussion.time and space and establishes an MS diagnosis. When the person with an RIS is followed overThe presence of even one brain MRI lesion time,many willgoontohavetypicalMStypical for demyelination in the person with symptoms and an MS diagnosis later in life.a CIS puts them into a higher risk group for Earlier, we discussed the acute treatmentMS. In some situations, a CSF examination of a CIS with steroids, IVIG, or plasmamay be pursued. If a person has evidence of exchange. We also need to consider long-termoligoclonal bands in their spinal uid, this will treatment to prevent future attacks. If a personalso put them into a high-risk group for is in a high-risk group for the developmentdeveloping MS. Oligoclonal bands are anti- of MS or meets the McDonald Criteria for anbodies produced in the spinal uid and are MS diagnosis after a CIS, we should considercommonly seen in MS. starting an MS disease-modifying therapy.Symptoms and PrecursorsResearchhasbeenconsistentinshowingWhile brain MRI and the CSF examination that the sooner we start therapy, the moreare the main factors that determine the risk of likely we are to prevent disability in theMS after CIS, we can also look at the presenting future. symptoms. How CIS presents clinically may Wevecomealong waysincethedaysgive us some clues as to whether there is a when a person presenting with their firsthigherriskforthedevelopmentofMS.In demyelinating attack was told to go hometransversemyelitis,mildersymptoms(i.e. and call if it happens again. We have betternumbness without weakness) are associated diagnostictools,abetterunderstandingwith a higher risk for the future development about the insidious nature of MS and betterof MS. If optic neuritis is present in one eye treatment options. I know we all look forwardvs. both eyes, this is linked to a higher risk for to the day when we can stop MS in its tracksthe development of MS100 percent of the time. While wetypicallythinkofRRMSasbeginning with the rst attack or CIS we knowMS likely begins even earlier. Recent studieshave shown that years before an MS diagnosis,people with MS visit their primary care doctorsmorefrequentlythanpeoplewithoutMS.These visits are usually for nonspecic issueslike fatigue or mood changes. So, there appearsto be some type of clinical precursor that occursin people with MS even before their rst bigattack. Another possible early manifestation of37 msfocusmagazine.org'