Treatment Approach for MS with Non-Enhancing Lesions
Key Clinical Interpretation
- Non-enhancing lesions on T2-weighted sequences still represent active MS disease, as enhancement occurs primarily during acute inflammatory phases lasting only weeks 1, 2, 3
- The appearance of two new lesions between May 2023 and October 2025 demonstrates ongoing disease activity 4, 5
- In relapsing-remitting MS, only a small percentage of new lesions fail to enhance, and these are invariably small—but they still count as disease progression 1, 2
Recommended Treatment Algorithm
- First follow-up MRI at 3-6 months after initiating DMT to assess treatment response 6
- Subsequent MRIs every 6 months for the first 1-2 years given documented disease activity 6
- Use consistent MRI protocols with T2-weighted sequences and gadolinium enhancement to allow accurate comparison 4, 1, 2
Critical Pitfalls to Avoid
- Delaying treatment due to lack of gadolinium enhancement 1, 2, 3
- Inconsistent MRI protocols between scans 4, 6
- Underestimating the significance of small lesions 1, 2