Diagnosis and Symptoms
The symptoms of MS are unpredictable and variable. While one individual may present or experience one symptom, a second may experience many, and a third may experience a completely different panel of symptoms than the second. As a result, clinicians must comprehensively evaluate symptoms and initiate individualized therapy accordingly.1
The most common symptoms of MS include:1,2
- Sexual dysfunction
- Mood changes/depression
- Cognitive changes
- Walking difficulty
- Vision abnormalities
- Bladder/bowel dysfunction
At this time, there is no single diagnostic test that confirms multiple sclerosis. While there are accepted diagnostic criteria for MS, this system is imperfect. Since establishing diagnosis can be difficult, neurologists specializing in MS are often essential for confirming diagnosis and working with the patient to begin a path of treatment.1,2
Types of MS include:
- Clinically-isolated syndrome.
- Primary progressive.
- Secondary progressive.
Accurate diagnosis is based on medical history and neurological exam. A necessary skill for neurologists is that of asking proper questions that will comprehensively assess signs and symptoms and correctly identify problems that may help direct the neurologist. The differential diagnosis for MS includes blood vessel inflammation, strokes, certain vitamin deficiencies, genetic disorders, neoplasms (cancers) and brain infection, and stress-related disorders may also lead to MS misdiagnosis.
Testing often used for MS diagnosis includes:
- Spinal tap
- Lumbar puncture
- Evoked potential tests
- Blood tests
General criteria for MS diagnosis include:
- Age of onset between 20 and 60
- Signs and symptoms indicating CNS disease
- Evidence of two or more lesions on MRI of brain and spinal cord
- Objective evidence of disease on examination
- An episode of MS symptoms and changes on MRI
- No other explanation
Diagnostic criteria for MS include clinical and laboratory/imaging tests that focus on demonstrating dissemination of lesions in space (DIS) and dissemination in time (DIT). As mentioned above, diagnosis can be made on clinical grounds alone, though MRI and other testing are usually performed to support the diagnosis. In terms of diagnosis, the McDonald Criteria which were developed and revised over the past decade have resulted in earlier MS diagnosis with a high degree of both sensitivity and specificity.1,2
Notably, in the 2017 McDonald criteria revision, the panel set forth that in patients with a typical clinically isolated syndrome and clinical or MRI demonstration of dissemination in space, presence of CSF-specific oligoclonal bands allows a diagnosis of MS.3 Additionally, symptomatic lesions can be used to demonstrate dissemination in space or time in patients with supratentorial, infratentorial, or spinal cord syndrome. Also, cortical lesions can be used to demonstrate dissemination in space. These represent notable updates from the 2010 criteria.
To review the McDonald Criteria, please visit the following links:
Informing the patient of MS is a significant part of management, and clinicians need to be aware of several tips that will help make it easier for the patient. These include:
- Give diagnosis in person, not over the telephone.
- Suggest patient bring a family member or friend.
- Realize that patients are only going to process a small amount of what you tell them.
- Emphasize key positive points.
- Allow time for initial questions.
- Provide resources.
- Schedule follow-up to answer questions and discuss treatment.
Please also see the “Additional Reading” and “Resources” for additional information on diagnosis.
- National Multiple Sclerosis Society. Symptoms and Diagnosis. Available at: http://www.nationalmssociety.org/Symptoms-Diagnosis.
- National Institute of Neurological Disorders and Stroke. Multiple Sclerosis: Hope Through Research. Available at: http://www.ninds.nih.gov/disorders/multiple_sclerosis/detail_multiple_sclerosis.htm.
- Thompson A, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol. 2018;17(2):162-73.