What should be the initial ER workup for a suspected multiple sclerosis (MS) exacerbation, including labs and imaging?

Initial Emergency Room Workup for Multiple Sclerosis Exacerbation

The initial emergency room workup for a suspected MS exacerbation should include brain and spinal cord MRI with and without contrast, along with basic laboratory tests to rule out alternative diagnoses and infection. 1, 2

Imaging Studies

Brain MRI

• Mandatory sequences 2:
  • Axial T1-weighted sequences (before and after contrast)
  • Axial T2-weighted and proton-density (or T2-FLAIR) sequences
  • Sagittal 2D or isotropic 3D T2-FLAIR sequences
  • Single dose (0.1 mmol/kg) gadolinium-based contrast with minimum 5-minute delay

Spinal Cord MRI

• Indicated for 2:

  • MS exacerbation with spinal cord symptoms
  • Inconclusive brain MRI findings
  • Strong clinical suspicion despite negative brain MRI
  • Primary progressive MS

• Required sequences 2:

  • Sagittal dual-echo (proton-density and T2-weighted) conventional/fast spin-echo
  • Sagittal STIR (alternative to proton-density-weighted)
  • Sagittal contrast-enhanced T1-weighted spin-echo (if T2 lesions present)
  • Optional: Axial T2-weighted fast spin-echo and contrast-enhanced T1-weighted spin-echo

Laboratory Studies

Basic Labs

• Complete blood count (CBC)
• Comprehensive metabolic panel (CMP)
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP)
• Urinalysis (to rule out infection as trigger)

Additional Testing (as indicated)

• Lumbar puncture - Consider when:
  • Diagnosis is uncertain
  • Alternative diagnoses need to be excluded
  • Brain MRI findings are equivocal or minimal 2, 1
  • Look for:
    • Oligoclonal bands
    • Elevated IgG index
    • Normal cell count and protein levels

Diagnostic Approach

1. Confirm true exacerbation:

   • Symptoms lasting at least 24 hours 2
   • New or worsening neurological symptoms
   • No better explanation (infection, metabolic disturbance)

2. Evaluate for alternative diagnoses:

   • Rule out infection (particularly UTI, which can trigger pseudo-exacerbations)
   • Consider vascular events, especially in patients >50 years or with vascular risk factors 2
   • Evaluate for metabolic disturbances

3. Document objective evidence:

   • Obtain objective clinical signs of new neurological deficits
   • Compare with baseline neurological status (if available)

Important Considerations

• MRI should be performed on systems with minimum field strength of 1.5T 2
• Spinal cord MRI is technically more challenging than brain imaging but provides valuable diagnostic information 2
• Standardized image acquisition between baseline and follow-up is crucial to establish dissemination in time 2
• Contrast enhancement in MS lesions is typically transient (2-8 weeks, usually 4 weeks) 2

Common Pitfalls to Avoid

1. Missing alternative diagnoses:

   • Not all neurological deterioration in MS patients is due to MS exacerbation
   • Always consider infection, which can cause pseudo-exacerbations

2. Inadequate imaging:

   • Using only brain MRI when spinal symptoms are present
   • Omitting contrast, which is essential to identify active lesions

3. Overreliance on historical symptoms:

   • Clinical evidence depends primarily on objectively determined clinical signs 2
   • Historical accounts of symptoms may lead to suspicion but are insufficient for diagnosis

4. Failure to document baseline:

   • Not establishing the patient's baseline neurological status makes it difficult to determine if changes represent new disease activity

By following this structured approach to the initial ER workup for MS exacerbation, clinicians can accurately diagnose true exacerbations, rule out alternative diagnoses, and guide appropriate treatment decisions to improve patient outcomes.