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MS Diagnosis

Patients with MS may experience symptoms for months to years before they are correctly diagnosed and begin treatment. MS is characterized by an unusual variety of signs and symptoms, many of them subjective in nature.

Common Signs & Symptoms of MS include:

Signs	Symptoms
Action tremor Slurred speech Decreased perception of pain, vibration, or proprioception Decreased strength Hyperreflexia, spasticity, Babinski's sign Impaired balance & coordination Impaired visual acuity Nystagmus	Depression Dizziness or vertigo Fatigue Heat sensitivity Lhermitte's sign (electrical sensation down the spine on neck flexion) Numbness, tingling, pain Bladder dysfunction Visual impairment (monocular or diplopia) Weakness

There is no single definitive test to diagnose MS. Diagnosis is made by clinical and paraclinical evidence

Clinical

HIstory
- Gender, age, race
- Signs & symptoms: fatigue, weakness, spasticity, balance problems, incontinence problems, numbness, vision loss, tremors, heat sensitivity and depression etc.
- Chronology of symptoms
- Trauma, illness, allergies, familial neurological disorders, surgeries, habitat experience, medication history, chemical and substance experience
Physical
- Rule out signs of physical trauma
- Neurological exam:
  - Babinski's reflex
  - gait abnormalities
  - tremor
  - Eye exam retina and optic disc
Rule out other likely diseases
- Post Infectious Encephalomyelitis - demyelinating disease resulting in gait, mentation, incontinence disorders.
- Primary CNS Vasculitis - headache, confusion
- Lyme Disease - multiple intermittent CNS symptoms: fatigue, weakness, numbness, cognitive
- Systemic Lupus Erythematosus - optic abnormalities, transverse myelitis, encephalopathy
- Tropical Spastic Paraparesis - progressive spastic paraparesis
- Behcet Syndrome - quadriparesis, pseudobulbar palsy, cranial neuropathy, cerebellar ataxia
- etc.

Paraclinical

MRI Evidence
- Use of Fluid-Attenuated Inversion Recovery (Flair) MRI technology
- Evidence of plaques or lesions in two distinct areas of the CNS (Disemmination by space).
- Evidence that the plaques occurred at different points in time (Disemmination by time).

Gadolinium contrast in conjunction with MRI can reveal blood brain barrier permeability characteristic of active disease
Exclusion of all other reasonable explanations for the presence of plaques in the CNS.

Evoked Potential Tests
- Visual Evoked Potentials - used to detect optic neuritis
- Brain Stem Auditory Evoked Potentials - detects demylenating lesions in the brainstem which cause delays in the transmission of sounds.
- Somatosensory Evoked Potentials - electrical stimulus to wrists or ankles detects transmission defects from periphery to CNS
Spinal Fluid Analysis
- myelin protein components
- IgG index is abnormal in 90% of MS patients

MRI is the imaging procedure of choice for confirming a clinical diangosis of MS and monitoring disease progression in the brain and spinal cord. The Consortium of Multiple Sclerosis Centers (CMSC) revised MRI protocol and guidelines in 2015, recommend using higher-resolution three-dimensional (3D) imaging over two-dimensional (2D) imaging. MRI shows brain abnormalities in 90-95% of MS patients and spinal cord lesions in up to 75%, especially in elderly (Luzzio C., & Chawla, 2023)

2017 McDonald Criteria for the Diagnosis of Multiple Sclerosis
Prerequisites →		Elimination of more likely diagnoses Demonstration of lesions in the central nervous system disemminated in time (DIT) and disemminated in space (DIS).
MS Diagnostic Criteria for a person who has experienced a typical MS attack/CIS at onset
Clinical Presentation		Data Still Needed for MS Diagnosis
Attacks (DIT) 2 or more	Lesions (DIS) 1 newer lesion and 1 older lesion in another location	Evidence of (DIS) and evidence of (DIT) have been met.
OR
2 or more	1 lesion associated with prior attack in different location
Clinical Presentation		Additional Data Still Needed for MS Diagnosis
Attacks 2 or more	Lesions Evidence of 1 lesion Plus→	DIS data -1 or more MS-typical MRI T2 lesions in 2 or more areas of CNS: periventricular, cortical, juxtacortical, infratentorial or spinal cord
Clinical Presentation		Additional Data Still Needed for MS Diagnosis
Attacks 1 attack	Lesions Evidence of 2 or more lesions	DIT shown by one of these criteria: - Additional clinical attack - Simultaneous presence of both enhancing and non-enhancing MS typical MRI lesions, or new T2 or enhancing MRI lesion compared to baseline scan (without regard to timing of baseline scan) - CSF oligoclonal bands
Attacks 1 attack	Lesions Evidence of 1 lesion	DIS shown by one of these criteria: - Additional attack implicating different CNS site - 1 or more MS-typical T2 lesions in 2 or more areas of CNS: periventricular, cortical, juxtacortical, infratentorial or spinal cord AND DIT shown by one of these criteria: - additional clinical attack - Simultaneous presence of both enhancing and non-enhancing MStypical MRI lesions, or new T2 or enhancing MRI lesion compared to baseline scan (without regard to timing of baseline scan) - CSF oligoclonal bands
MS Diagnostic Criteria for a person who has steady progression of disease since onset
1 year of disease progression		DIS shown by at least two of these criteria: - 1 or more MS-typical MRI T2 lesions (periventricular, cortical, juxtacortical or infratentorial) - 2 or more MRI T2 spinal cord lesions - CSF oligoclonal bands
Adapted from source: Thompson AJ, Banwell BL, Barkhof F, et al. (2017) Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol 2018; 17: 162–173

Imaginis.com http://www.imaginis.com/multiple-sclerosis/multiple-sclerosis-ms-resource-center

Instant Feedback:
Laboratory and radiological tests are used to confirm the diagnosis of MS.

Because there is no single diagnostic test specific for MS, and time between attacks can range from months to years, obtaining a diagnosis of MS can be a long and challenging process. In addition, symptoms differ among patients and are often subjective. Healthcare providers often minimized or dismissed patient concerns.

Some individuals may have minor symptoms and others may experience major, ongoing problems with symptom progression. MS symptoms may occur at the beginning of the disease process, resolve, and never recur, or they may reoccur throughout the individual’s lifetime. Symptom severity can vary as well in the same patient or within a group of patients.

Some patients express anger or grief when informed of the diagnosis. Others may express relief that they finally know the cause of their symptoms and can begin treatment. Healthcare professionals can assist patients and families by educating them about the array of potential symptoms and how MS may affect them. Patients also need current information regarding MS management, research toward a cure, and new drug treatments information.

Instant Feedback:

Diagnosing MS can be a long process due to variations in the presentation and duration of signs and symptoms.

The National Multiple Sclerosis Society web site provides an excellent MS resource.

References

Christopher Luzzio, M. (2023, June 30). Multiple sclerosis. Practice Essentials, Background, Pathophysiology. https://emedicine.medscape.com/article/1146199-overview?form=fpf

Thompson AJ, Banwell BL, Barkhof F, et al. (2017) Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol 2018; 17: 162–173

MS Diagnosis

2017 McDonald Criteria for the Diagnosis of Multiple Sclerosis