'Time is brain' also in multiple sclerosis.

The review by Goodin and Bates in this issue 1 on treating multiple sclerosis (MS) when it might first be heralding is indeed timely for a number of reasons. First, virtually all of the first line current disease modifying drugs (interferon beta and glatiramer acetate) have now been shown to be effective at the stage called 'CIS' or the first 'clinically isolated syndrome' in reducing the chance of developing a relapse (either clinical or new MRI lesions), although we await word from the nearly completed REFLEX study, which is testing interferon beta-1a 44 mcg three times vs. once weekly. Secondly, these first line agents have been with us for nearly two decades and have failed to demonstrate any significant long-term side effects, with nothing new appearing when used in a CIS population. Thirdly, these same drugs are demonstrating even greater efficacy in recent populations compared with the effects shown in the pivotal studies justifying their approval, 2 an effect that many would suggest is due to starting them earlier in the course of disease, which is in turn due to our improved ability to accurately diagnose MS much earlier. Fourthly, although patients presenting with a CIS syndrome might indeed have a disease other than MS, there are now refined diagnostic algorithms for the work up of such patients to insure that there is ''no better explanation'' than demyelination due to MS. 3 Lastly, the recent BENEFIT data caught us all by surprise by showing that early initiation of interferon beta-1b to CIS patients delayed disease progression (as measured by the expanded disability status scale (EDSS)) at 3 years compared to a placebo group – a time delay for the group that amounted to a mere 1.33 year head start. 4 Could that short time delay really make that much a difference? What is that telling us about the early period following presentation of disease? Our stroke colleagues have recognized for years that time is their enemy when it comes to the presentation of the first symptoms of stroke and the implementation of therapy. In fact, even though transient ischaemic attacks (TIAs) were thought to represent minor reversible ischemic events, advanced imaging indicate clear areas of damage. 4,5 Key to the management of stroke is the early implementation of therapy aimed at preventing recurrence, which in many cases can be as imminent as the first 24 hours following a TIA. 6 …