Diagnosing Multiple Sclerosis

MS often offically begins with a history of fluxuating, hard to describe, and seemingly minor, strange symptoms that family and friends dismiss or discount; they resolve without treatment, but continue to return.

Many of its signs could be attributed to a number of different medical conditions and there is neither sign nor test that proves MS. So a time may elapse with a prolonged diagnostic procedural requirement, before MS is confirmed or mentioned. Rolling Eyes Smiley

On the other hand a diagnosis of MS may be much quicker, with a clearly abnormal Neurologic Examination, classic symptoms (e.g. RetroBulbar Neuritis, Paraparesis), and a medically documented chronology of attacks.                                                           Free counter and web stats

    MS Diagnostic Criteria
      The Neurologist requires clinical evidence (the Neurologic Examination) that your Neurologic deficits:
      1. Indicate involvement of at least TWO different areas (Functional Systems) of the CNS:
      2. With documented Neurologic Signs occurring at TWO separate and distinct time periods:
      3. ALL other possible causes must have been eliminated
        (Poser Criteria).
      1. Poser, C.M.; Paty, D.W.; McDonald, W.I.; Scheinberg, L.; Ebers. G.C.; eds.
        "The Diagnosis Of Multiple Sclerosis" New York: Thieme-Stratton Inc.; 1984

      2. Poser CM, Paty DW, Scheinberg L, et al.
        "New Diagnostic Criteria For Multiple Sclerosis: Guidelines For Research Protocols"
        Ann Neurol 1983;13:227-231
 These diagnostic requirements were updated in Ann Neurol 2001 Jul;50(1):121-7, to the McDonald Criteria and they have recently been revised to the Newest McDonald Criteria (11/30/2005).

Multiple Sclerosis remains a clinically determined diagnosis of exclusion that is based on the findings of the Neurologic Examination. Additional supporting paraclinical evidence (MRI, EVP, and LP) is not always necessary, but is often useful. Jaded Smiley

There are NO tests which are specific for MS, and NO single test is 100% conclusive. Conventional MRIs only image some lesions (Macroscopic ones), which are NonSpecific as to cause and do NOT fully account for MS damage.

Therefore, several tests and procedures are needed to eliminate ALL other possible causes and firmly establish a diagnosis of MS. They include the following:
  • Diagnostic Categories
  • Medical History
  • Neurologic Examination
    		•
  • Evoked Potentials
  • Magnetic Resonance Imaging
  • Lumbar Puncture (Spinal Tap)
    		•

    Medical History
    The physician will take a complete medical history, which will include your past record of Signs and Symptoms, as well as the current status of your health. The type of symptoms, their onset and pattern may suggest MS, and will largely determine your case; but a full Neurologic Examination and additional diagnostic tests will be needed to confirm the diagnosis.

    Neurologic Examination
    The Neurologist will test for abnormal responses (Signs) in Nerve Pathways, to document the presence of Neural deficits that may explain your symptoms.

    However, a Neurologic Examination cannot determine the precise cause, rather it medically documents the existence of a Neurologic deficit and provides the required clinical evidence for diagnosing MS. Therefore, all other possible causes that can produce similar MS Signs, must first be investigated and eliminated. Frown
    Common MS Signs from Motor Systems in:
    Cerebellum
    Asthenia, Ataxia, Diplopia, Dizziness, Dysarthria, Dysmetria, Dysphagia, Dysphonia, Fatigability, Hypotonia, InterNuclear Ophthalmoplegia, Nystagmus, Oscillopsia, Scanning Speech, Tremor

    		 Or   Spinal Cord (CorticoSpinal Tract)
    Babinski's Sign, Bladder Dysfunction, Clonus, Fatigue, Heat Sensitivity, L'hermitte's Sign, Paralysis, Romberg's Sign, Spasticity, Transverse Myelitis, MS Hug, Trigeminal Neuralgia
    Evoked Potential Tests (EVPs)
    When DeMyelination or Sclerosis (scarring) occurs, the Conduction of messages along the Nerves (Axons) is slowed or interrupted. Evoked Potentials measure the time required by the Brain, to receive and process nerve messages (Nerve Conduction Velocity).

    This is done by placing small electrodes on the head, which monitor Brain waves, in response to Visual or Auditory (Hearing). While Sensory stimuli are recorded from electrical inputs applied to, either the legs and feet or hands and wrists.

    Normally, the Brain's reaction to such stimuli is almost instantaneous. DeMyelination or a Lesion in the Nerve Pathway cause a conduction delay and the response time will be much slower (Longer Latency Time) than normal.

    Evoked Potentials are most useful in the diagnosis of MS; because they can confirm the presence of a suspected Lesion not shown on MRI, and can identify the existence of an UnSuspected Lesion (Clinically Silent) that has not produced any symptoms. EPs are not invasive or painful and do not require a hospital stay.

    Magnetic Resonance Imaging (MRI)
    The MRI scanner takes detailed pictures of the Brain and Spinal Cord, showing areas of Sclerosis (Lesion, Plaque), when they are larger than 2mm (Macroscopic Lesions).

    Scans can NOT show Microscopic Lesions, as they are too small for current imaging resolutions; but are included in your Lesion Load and Atrophy totals. These early smaller lesions are better documented, by EVP testing, which are equally valid in meeting a Laboratory Supported Definite Multiple Sclerosis diagnosis.

    While this is the only test in which some Multiple Sclerosis Lesions can be seen, it cannot be regarded as conclusive; because, all lesions do not register on MRI scans and many other diseases can produce identical MRI images.

    MRI shows the size, quantity and distribution of Lesions larger than 2mm, and together with supporting evidence from your other diagnostic tests, Medical History, and Neurologic Examination, may be a positive finding that confirms the MS diagnosis.

    It also provides an objective measure (Para-Clinical Evidence) of MS lesion activity in the Brain and Spinal Cord.

    However, Conventional MRI (T1 and T2 images) are NonSpecific (cause unknown), have little relation to MS progression, and insufficiently correlation with disability.

    Magnetization Transfer and Proton MR Spectroscopy are two imaging techniques that better correlate with MS activity. They are not yet widely used, but newer more specific imaging protocols are presently being formulated.

      Abnormal MRI scans are found in
    • 96% with a definite diagnosis of MS
    • 70% with a diagnosis of probable MS
    • 30%-50% with possible MS

    Lumbar Puncture (Spinal Tap)
    In this test, CerebroSpinal Fluid (the fluid which flows around the Brain and Spinal Cord) is tested for the presence of OligoClonal Bands (AntiBodies), and fragments of Myelin Basic Protein.

    Intrathecal production of Ig G can occur with MS, but is also found with other Neurologic conditions. A positive finding is most common in Progressive MS, while it is usually negative in Relapsing MS, unless you are having or recently had an Exacerbation.

    The CSF is taken from the Spinal Cord by inserting a needle into the Spinal Canal and withdrawing a small amount of fluid. A local anesthetic is given to numb the skin and while it is uncomfortable, it is not too painful.

    A Spinal Tap, does require you to lay flat for a number of hours after the test (many experience very painful headaches when standing or sitting). You may require an overnight stay in a hospital, subsequently, a short period of recuperation may be required. This test may indicate MS but is NOT in itself conclusive.

    The diagnosis of MS is not always clear cut. The initial symptoms may be transitory, vague and confusing to both you and the doctor.

    Invisible and/or subjective symptoms are often difficult to communicate to doctors, who often do not believe what they cannot see (If I don't see it, you do not have it.) and too often dismiss people as being neurotic. Rolling Eyes Smiley

    Your doctor may not have even told you that MS was suspected; because, he or she may want to see at least two distinct episodes with symptoms that are separated, by at least one month and lasting for at least 24 hours (Poser Criteria). This medical criteria must be met before a confirmed diagnosis, of Multiple Sclerosis can be reached.

    A good relationship with your Neurologist and family physician is essential. If you do not have a good relationship, by all means, take the time to locate one (Good Doc's List) you do have confidence in. MS may have times of crisis and require specialized medical knowledge, but it is a disease that must be lived and managed every day.

    This goal can only be accomplished, if you and your physican trust and have confidence in each other. The time of diagnosis is stressful, not only for MSers, but also for your whole family, friends, and carers.

    They should also be fully informed of your diagnosis, prognosis, treatment management plan, and the lifestyle adjustments - necessitated by MS. Receiving the diagnosis of MS can be a shock, your physician and local MS Society are vital resources, for you and your family.

    Allow for the demands Multiple Sclerosis requires; in time, you can sucessfully manage your MS and achieve a fullfilling life. This may surprise you; but, MSers can and do have productive, very complete lives.     Big Grin

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