Incidental Lesions Suggesting Multiple Sclerosis

Purpose of Review: Neurologists are frequently asked to consult on patients with incidentally observed anomalies on brain MRI that may be suggestive of multiple sclerosis (MS). The identification of such findings has important clinical management implications. This review provides an overview and practical clinical approach options for clinicians. Recent Findings: An increase in the number of brain MRI studies performed annually is expected to result in detection of a corresponding greater number of unanticipated anomalies. A disproportionate number of patients referred to neurologists for this reason have punctate subcortical T2 hyperintensities that appear nonspecific in origin rather than having imaging features concerning for MS. However, in some instances, the MRI characteristics appear to be typical for demyelination. When these features are observed, efforts should be pursued to identify an accurate explanation for the preclinical findings through rigorous clinical evaluation, paraclinical testing, and utilization of longitudinal imaging. Summary: The identification of subjects with incidental T2 hyperintensities highly suggestive of MS is important for patient counseling and management. Continued neurologic evaluations and reassessment of the original clinical impression are recommended to ensure accurate interpretation of the available data.