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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 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 test that can diagnose MS. Diagnosis must therefore be made on the basis of the patient’s medical history, report of symptoms, and neurological examination. Magnetic resonance imaging (MRI) is used to confirm a MS diagnosis. However, brain MRIs are normal in approximately 5% of patients with MS. A challenge in understanding MS is the observation that plaques can be "clinically silent." There is often no direct relationship between the number of lesions visualized on MRI and the severity of clinical symptoms.

Imaginis.com offers information on the use of MRI to detect the presence of MS plaques.

Be prepared to answer the following question.

True or False. CAT scans are just as good as MRI for diagnosing MS plaques.

A definitive diagnosis of MS requires both 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 white matter.
- Evidence that the plaques occurred at different points in time.

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

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 often 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.

Diseases That Can Mimic MS Signs and Symptoms
Infections	Lyme disease, syphilis, human immunodeficiency virus infection, human T-lymphotrophic virus type I
Inflammatory conditions	sarcoidosis, systemic lupus erythematosus
Microvascular disease	hypertension, diabetes mellitus, vasculitis, CADASIL
Genetic	leukodystrophy, hereditary myelopathy, mitochondrial disease
Compression of brain or spinal cord	cervical spondylosis, herniated disc, Chiari's malformation, tumor

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