What are the clinical indicators of multiple sclerosis (MS) in a patient?

From the Guidelines

When suspecting multiple sclerosis (MS) in a patient, look for a combination of neurological symptoms that come and go, affecting different parts of the nervous system, and order an MRI of the brain and spinal cord to support the clinical diagnosis and rule out other disorders, as recommended by the 2010 McDonald criteria 1. The diagnosis of MS is based on the detection of lesions within the CNS that demonstrate dissemination in space (DIS) and dissemination in time (DIT), and the diagnostic criteria require exclusion of alternative diagnoses that can mimic MS either clinically or radiologically. Key symptoms to look for include vision problems, sensory disturbances, motor symptoms, fatigue, and cognitive changes.

• The hallmark of MS is dissemination in time and space—symptoms occurring in different locations in the central nervous system at different times.
• MRI findings can replace certain clinical criteria in a substantial proportion of patients, and the 2010 McDonald criteria increased the sensitivity of the criteria and simplified the features of both DIS and DIT.
• Cerebrospinal fluid analysis may show oligoclonal bands and elevated IgG index, and visual evoked potentials can detect slowed nerve conduction even in patients without visual symptoms.
• The diagnosis of primary progressive MS (PPMS) can be challenging, particularly in patients with normal brain MRI and inconclusive spinal cord findings, and paraclinical support of the PPMS diagnosis can be based solely on brain and spinal cord MRI findings 1.
• Early diagnosis is crucial as disease-modifying therapies are most effective when started early in the disease course, and the 2010 McDonald criteria have substantially improved the diagnostic process in relapsing–remitting MS (RRMS) 1.

From the Research

Diagnostic Criteria for Multiple Sclerosis

To diagnose multiple sclerosis (MS), several factors should be considered, including:

• A combination of signs and symptoms, such as sensory disturbances, motor weakness, impaired gait, incoordination, optic neuritis, and Lhermitte sign 2
• Radiographic findings, such as magnetic resonance imaging (MRI) T2 lesions 3, 4, 5
• Laboratory findings, such as cerebrospinal fluid-specific oligoclonal bands 3, 4, 5
• Application of the 2017 McDonald Criteria 3, 2

Clinical Characteristics of Multiple Sclerosis

Patients with MS may exhibit various clinical characteristics, including:

• Predominant afferent symptoms, such as sensory disturbances 4
• Less frequent predominant cerebellar and efferent symptoms, such as ataxia and weakness 4
• Optic neuritis, which can be detected using visual evoked potentials (VEPs) 6, 4, 5
• Brainstem syndromes, such as internuclear ophthalmoplegia 3

Diagnostic Tools for Multiple Sclerosis

Several diagnostic tools can be used to diagnose MS, including:

• MRI, which can detect lesions in the central nervous system 3, 4, 5
• Evoked potentials, such as VEPs, brain-stem auditory evoked potentials, and somatosensory evoked potentials 6, 4, 5
• Cerebrospinal fluid analysis, which can detect oligoclonal bands and elevated cell counts 3, 4, 5

Importance of Early Diagnosis and Treatment

Early diagnosis and treatment of MS are crucial to slow disease progression and disability 3, 2, 4. Disease-modifying therapies, such as interferons, glatiramer acetate, and monoclonal antibodies, can reduce clinical relapses and MRI lesions 3. A multidisciplinary team approach, including physical and occupational therapists, speech and language therapists, mental health professionals, pharmacists, dietitians, neurologists, and family physicians, is essential for managing MS patients 2.