I have one enhanding lesion in the brain stem...

Here is My Question:
I am the 41 year old who asked about risk of PML with Tecfidera. Thank you for your extensive response. You were correct on most of the assumptions. I should have included that there was one enhancing lesion which was the one in the brain stem. Does knowing this now change anything in the response you provided? As an FYI I have increased my Vitamin D3 which went from 19 to 37.1 in two months. 

Answer:
Thank you for the added information.

The presence of an enhancing lesion, if all other lesions are consistent with MS and the brainstem lesion does reveal iron on gradient echo imaging (a capillary telangiectasia), is consistent with a diagnosis of MS. Based on your features, nothing else would change in my comments. If there were multiple enhancing lesion I would be inclined to start a DMT now. Without multiple enhancing lesions, you have the option of monitoring with frequent MRI. Some people do the repeat MRI imaging every 6 months for the monitoring. This is reasonable and cost effective. Afterall, disease modifying therapies cost up about  $60,000 per year.

The most important thing is to make sure the radiologist performed gradient echo imaging to exclude a capillary telangiectasia. Otherwise, these normal brainstem lesions (basically a birth mark in the brain) look just like an active MS lesion.

Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Director of Hillcrest Neurology
Professor of Clinical Neurosciences
University of California San Diego