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MS – PIRA Concept — SCE Neurology MCQ

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HardMultiple Sclerosis & CNS InflammationMS – PIRA ConceptSCE Neurology

A 45-year-old woman presents with a 2-year history of gradually worsening fatigue and cognitive slowing. She was diagnosed with RRMS 10 years ago and has been on interferon beta-1a for 8 years with no clinical relapses. However, annual MRI shows slowly enlarging T2 lesions and new brain atrophy without gadolinium enhancement. What does this imaging pattern most likely represent?

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Correct answer: D — Progression independent of relapse activity (PIRA)

Progression independent of relapse activity (PIRA) describes disability worsening in MS that occurs without clinical relapses, now recognised as the dominant driver of disability accumulation even in relapsing MS. Imaging features include slowly expanding lesions (SELs), new T2 lesions without enhancement, and progressive brain atrophy. This concept has shifted the understanding of MS progression and supports early high-efficacy treatment. A: The imaging shows progression, not stability. C: Pseudoprogression relates to treatment-related imaging changes (e.g., post-radiation). D: Interferon does not cause progressive lesion enlargement. E: The rate of atrophy exceeds normal ageing.

Reference: ABN MS Guidelines (2022); Lublin et al. MS Phenotype Revision (2014)