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To examine cognitive and neurological changes and their relation to brain pathology in patients with multiple sclerosis during acute relapse.Thirteen patients with multiple sclerosis were examined with a battery of neuropsychological tests during acute relapse and six weeks later. Their performance was compared with the performance of 10 controls matched for age and premorbid IQ. Gadolinium (Gd) enhanced MRI was also performed in patients on both occasions.The patients with multiple sclerosis performed significantly worse than controls on most tests of attention and memory during acute relapse and in remission. At follow up there was a significant or trend of improvement in performance on some tests of attention for patients in whom the Gd enhanced lesion load had decreased. In this subgroup of patients, their improvement also correlated significantly with the reduction in acute lesion load.The findings suggest that certain neuropsychological deficits detected during an acute relapse may be reversible, particularly in patients who initially have mild cognitive impairment.(J Neurol Neurosurg Psychiatry 1998;64:529-532)Few attempts have been made to study cognitive changes in multiple sclerosis during acute relapse.Such studies present considerable methodological difficulties. There is anectodal evidence from a single case study that cognitive deficits can improve in parallel with neurological symptoms during remission.  In addition, our serial study in patients with frequent relapses and remissions provided evidence for the occurrence of "cognitively silent" new lesions which highlights the difficulties in studying the relation between short term fluctuations in cognition and brain pathology. Here we tried to document cognitive changes in a group of patients during the early stages of acute relapse and after remission in relation to neurological changes and MRI abnormalities.We also attempted to ascertain whether cognitive improvement was more likely in certain patient subgroups.