Differential Diagnosis of MS - How Likely is Microvascular Ischemic Disease for A 35 Year Old?

Here is My Question:
Differential Diagnosis of MS - How Likely is Microvascular Ischemic Disease for A 35 Year Old?

My latest MRI report stated: 11 foci of hypertensity (FLAIR) predominately in the subcortical white matter of the cerebrum bilaterally. Of course it goes on to state that nothing abnormal was found on other sequences...

The list of differential diagnosis included migraines, demyelinating disease, vasculitis and microvascular ischemic disease. 

I’ve never had a migraine (ruled out by neuro) and don’t have primary or secondary vasculitis (ruled out by rheumatology twice). My MS Specialist felt my symptoms suggested Multiple Sclerosis. 

My question is: How likely is microvascular ischemic disease in a patient who is 35 and has no risk factors? No family history of strokes, no personal history of diabetes, normal (to low) blood pressure, normal lab work (for almost anything you can imagine to rule out MS), low stress lifestyle, etc. 

​The MRI report also mentioned that this amount of hyperintensities is not atypical of a patient of my age. I was under the impression that 1 lesion per decade was at the upper limit of normal until the 60’s, then these changes begin to become apparent. 

Answer:
In general, microvascular changes in 35 year olds with no risk factors are rare, but can happen. Sometimes family history contributes, sometimes the changes are not microvascular changes but enlarged perivascular spaces. The key is the interpretation and getting another neurologist or neuroradiologist to review controversial MRIs (ie second opinions) is often a good idea.
 
Benjamin M. Greenberg, MD, MHS
Vice Chair of Translational Research and Strategic Initiatives
Cain Denius Scholar of Mobility Disorders
Distinguished Teaching Professor
Department of Neurology and Neurotherapeutics
Department of Pediatrics
UT Southwestern Medical Center
Dallas, Texas