Diagnosing Multiple Sclerosis

To make a diagnosis of MS, the physician must:

• Find evidence of damage in at least two separate areas of the central nervous system (CNS), which includes the brain, spinal cord and optic nerves; AND
• Find evidence that the damage occurred at least one month apart; AND
• Rule out all other possible diagnoses.

In 2001, the International Panel on the Diagnosis of Multiple Sclerosis updated the criteria to include specific guidelines for using magnetic resonance imaging (MRI), visual evoked potentials (VEP), and cerebrospinal fluid analysis to speed the diagnostic process.

These tests can be used to look for a second area of damage in a person who has experienced only one attack, also called a relapse or an exacerbation, of MS-like symptoms, referred to as a clinically isolated syndrome (CIS). A person with CIS may or may not go on to develop MS.

The criteria, referred to as the Revised McDonald Criteria, were further revised in 2005 and again in 2010 to make the process easier and more efficient.

Blood tests

While there is no definitive blood test for MS, blood tests can rule out other conditions that cause symptoms similar to those of MS, including Lyme disease, a group of diseases known as collagen-vascular diseases, certain rare hereditary disorders and acquired immune deficiency syndrome (AIDS).

Cerebrospinal fluid analysis

Analysis of the cerebrospinal fluid, which is sampled by a spinal tap, detects the levels of certain immune system proteins and the presence of oligoclonal bands. These bands, which indicate an immune response within the CNS, are found in the spinal fluid of about 90 to 95 percent of people with MS. But because they are present in other diseases as well, oligoclonal bands cannot be relied on as positive proof of MS.

Medical history and neurologic exam

The physician takes a careful history to identify any past or present symptoms that might be caused by MS and to gather information about birthplace, family history, and places traveled that might provide further clues. The physician also performs a variety of tests to evaluate mental, emotional, and language functions, movement, and coordination, balance, vision, and the other four senses.

In many instances, the person’s medical history and neurologic exam provide enough evidence to meet the diagnostic criteria. Other tests are used to confirm the diagnosis or provide additional evidence, if necessary.

MRI

MRI is the best imaging technology for detecting the presence of MS plaques or lesions in different parts of the CNS. It can also differentiate old lesions from those that are new or active.

The diagnosis of MS cannot be made solely on the basis of MRI because there are other diseases that cause lesions in the CNS that look like those caused by MS. And even people without any disease, particularly the elderly, can have spots on the brain that are similar to those seen in MS.

Although MRI is a very useful diagnostic tool, a normal MRI of the brain does not rule out the possibility of MS. About 5% of people who are confirmed to have MS do not initially have brain lesions evidenced by MRI. However, the longer a person goes without brain or spinal cord lesions on MRI, the more important it becomes to look for other possible diagnoses.

Visual evoked potential (VEP)

Evoked potential (EP) tests are recordings of the nervous system’s electrical response to the stimulation of specific sensory pathways (e.g., visual, auditory, general sensory). Because damage to myelin (demyelination) results in a slowing of response time, EPs can sometimes provide evidence of scarring along nerve pathways that does not show up during the neurologic exam. Visual evoked potentials are considered the most useful for confirming the MS diagnosis.

• Demyelination in the central nervous system: Although MS is the most common, other conditions can damage myelin in the CNS, including viral infections, side effects from high exposure to certain toxic substances, severe vitamin B12 deficiency, autoimmune conditions that lead to inflammation of blood vessels, and some rare hereditary disorders.
• Demyelination in the peripheral nervous system: Demyelination of the peripheral nervous system occurs in Guillain-Barré syndrome. After some injuries, the myelin sheath in the peripheral nervous system regenerates, bringing recovery of function.

Some demyelinating conditions are self-limiting, while others may be progressive. Careful and sometimes repetitive examinations may be needed to establish an exact diagnosis among the possible causes of neurologic symptoms.