Multiple sclerosis: a few questions and answers
Nitin K. Sethi, MD
Assistant Professor of Neurology
New York-Presbyterian Hospital
Weill Cornell Medical Center
New York, NY 10065
Topics:Test for MS
MRI shows I possess at least 5 criteria under the Macdonald criteria for ms, but my symptoms are entirely random and neurologist doesn’t think it fits with ms. How common is this?
You ask a good question. The McDonald criteria (named after the lead author) are diagnostic criteria for MS and have been revised in the recent past. Basically these are criteria which aid in improving the diagnostic certainty of MS. Let me attempt to make these criteria simple. Well basically there are 3 situations:
1. Clinically definite MS–(the diagnosis of MS is confirmed, there is no doubt!!)
2. Clinically probable MS–(patient likely has MS, though the diagnosis is not confirmed)
3. Clinically possible MS-(it is possible the patient may have MS though other diagnoses cannot be ruled out).
Now Tami, you will agree that for clinically probable and clinically possible MS further testing is needed to either rule in or rule out MS as the diagnosis. Before I go further, I want to emphasizethat first and foremost, a definitive diagnosis of MS can be made just clinically without any other imaging studies like MRI or the need for invasive tests like lumbar puncture (spinal tap). How you may ask? _Well if by history you have had two attacks suggestive of MS which are disseminated in time and space, then a definitive diagnosis of MS can be made. No further testing is needed (_I wrote about this at length in my previous interview with Merely Me and you may like to refer to it).
But coming back to patients who fall in either the clinically probable or clinically possible MS categories. How does one go about confirming the diagnosis of MS in these patients? In these patients, the results of tests such as MRI of the brain and spinal cord, the spinal fluid (CSF) results and other tests such as visual and somatosensory evoked potentials aid in establishing or ruling out the diagnosis of MS.
Well that brings us to your question and the use of MRI to aid in the diagnosis of MS. The McDonald criteria lays down some recommendations with respect to the MRI. Basically how many lesions (we call them plaques) should be there and in which location. Do they enhance with contrast and if they do how many of the lesions enhance? As you can see it gets quite complicated and there are numerous patients who fall in the grey zone meaning not quite meeting all the McDonald criteria. My personal experience is that if you follow these patients for a sufficient length of time, the diagnosis becomes clear by itself (either they have a new attack or new lesions appear on the MRI).
2. Does the MRI to rule out MS have to be done with contrast?
I have a history of B12 defiecency, however, as my level improved to normal my symptoms didn’t and in fact worsen. My body feels at times like it’s just not communicating well ( I just do not know how else to describe it). My legs get weak and wobbly, I have a lot of aching in them especially at night. I have a positive Romberg (I’ll fall to the left every time). Clumsiness, extreme fatigue, parasthesias in all extremeties that comes and goes, numbness (mostly to the left side and it comes in patches again will come and go, will also get it in my toes and occasionally in my fingers and hand. I have lots of constipation and urinary frequency with these attacks also. My family doctor says all signs point to MS and ordered MRI and neurologist consult. MRI without contrast came back normal, it was of brain, neck, and spine. I do not see neuro for another month. I feel glad, although baffled by what the heck could be happening to me. Also, on a note, if I have even a half a glass of wine, it makes symptoms worse! The MRI’s were quite expensive, and I’d hate to think they couldn’t rule out MS and didn’t do everything possible at the time I was in there like the contrast if that was needed to totally rule out.
sorry to hear that you are passing through such a rough time. I shall not attempt to make a diagnosis here since I truly believe that unless you have the patient in front of you and can examine and take a history in person, attempting a diagnosis shall be a disservice and shall only confuse you further. Read my earlier interview with Merely Me where in I talk about MS as the great mimicker. Many diseases can resemble MS in its clinical presentation and vice-versa (a case in point is vitamin B12 deficiency causing neurological symptoms). Vitamin B12 deficiency causes demyelination of the tracts in the spinal cord (we call this sub-acute combined degeneration of the spinal cord). This presents with many symptoms similar to the ones you describe. Your treating doctor and the neurologist whom you consult shall be the best in determining what plagues you.
Let me answer this in another way. The MRI to rule out MS should ideally be done with contrast. As I stated earlier contrast enhancement (meaning if some lesions enhance with contrast) gives some indication about disease activity (is the disease active? is the lesion new? ).
3. Does MS always cause paralysis?
It’s necessary that RRMS turns into SPMS and Does MS always cause paralysis?
No MS does not always cause paralysis. Paralysis or rather paraparesis (weakness of both the legs) is most common if the MS involves the spinal cord (in the spinal cord all the tracts descending from the brain are in close proximity and hence even a small MS lesion can cause profound weakness of both the legs and problems with bladder and bowel control).
Not all patients who have relapsing remitting MS (RRMS) shall progress to secondary progressive MS (SPMS). That said and done, it has been seen that if you follow MS patients for a long period of time most of them do develop neurological deficits (meaning they do not revert completely back to normal after an attack of MS).
4. Do MS patients always have lesions on an MRI?
Let me answer this in this way. If a patient has clinically definite MS, more than likely they shall have lesions (plaques) on the MRI of the brain or spinal cord. It is patients who have a clinically isolated syndrome (CIS) (you can read more about that in my previous interview with Merely Me) who may have a normal MRI but yet go on to develop MS in the future.
5. I have had numb feet for 2-3 weeks. Should I call my doctor?
I have had numb feet and depression for 2-3 weeks. I also have weak legs, but only for a short time and same with eye problems. SHould I call my doctor?
There can be many causes to explain your symptomatology. Bringing your complaints to the attention of your PMD, shall be the reasonable first step.
6. Genetics and MS
My name is Elizabeth and I have a 2nd cousin and a great aunt who both have MS. My cousin is currently dying from it and my aunt has the late onset and has good controll of her MS. I am 5 months pregnant and there has been many questions going around about how MS affects the family and who, geneticly, MS can come from? What side of the family does it affect and can it affect any generation? Both my aunt and cousin are on my fathers side of the family and so far they are the only ones that have been diagnosed. Are there test that can be done to see if MS is in my genes or even in me?
You ask a good question and I wish I could give you a good answer. Unfortunately the genetics of MS are still be well elucidated. We do know there is a genetic component to the disease and certain HLA have been linked to MS. Yet the transmission is still not clear. To my knowledge none of the genetic tests are standardized Let me explain that. Even if we were able to determine that you have some genes that predispose you to MS, we do not know how to act on that information. Would you develop MS just because you have the genes? If yes at what age? And so on. The current thinking is that MS occurs due to a complex interaction between genetic and environmental factors.