Questions about optic neuritis and multiple sclerosis

Here is My Question:
Thank you, Healthcare Journey Doctors, for all the help you are giving. You are providing a great resource for which many are grateful.

I'd like to ask about hyperintensities in a patient over 40 with a history of optic neuritis: a) if optic neuritis occurs with nonspecific hyperintensities, is the risk of MS raised and by how much? Or is this just if the hyperintensities occur in MS specific areas?; b) in such a situation is a mild increase in nonspecific hyperintensities between mris in any way significant?; c) how likely is it the optic neuritis and nonspecific hyperintensities would have different pathologies?; d) how would you recommend treating such a patient? Is treatment by a neurologist advised? What about symptom treatment? Is it recommended to treat nonspecific symptoms of MS (eg fatigue) with meds in such a patient or should the patient look for answers elsewhere?

Answer:
These are excellent but complicated questions about optic neuritis and an abnormal MRI brain with white matter hyperintensities.
​
In general, having one WM lesion that looks like a demyelinating lesion (based on shape, size and location) increases the risk of developing MS over the next 5 years to about 75-80%
Having no WM lesions in the setting of optic neuritis is associated with a lower (25%) risk of developing MS in the next 5 years.

Most MS specialists recommend treating patients with WM lesions and a history of optic neuritis with one of the approved immunomodulatory drugs for MS (for example, an interferon, glaitramer acetate, or one of the oral medication for MS).

In patients with no WM lesions, most neurologists would not recommend treatment.
Regarding "non specific" WM lesions, the significance of these findings are not clear in patients without a diagnosis of MS yet.  One has to take in to consideration other diseases that might cause non specific WM lesions, such as diabetes mellitus, hypertension, heart disease, migraine headaches, prior traumatic brain injury, etc.  
​
I would not recommend treatment of non-specific symptoms such as fatigue without first seeing a general physician (primary care doctor) to rule out other potential causes of "fatigue" (such as hypothyroidism, vitamin B12 deficiency, etc.).

Benjamin Osborne, MD
Associate Professor
Departments of Neurology and Ophthalmology
Georgetown University Hospital