What is the role of imaging in the diagnosis of multiple sclerosis (MS)?

Updated: Mar 27, 2019
  • Author: James A Wilson, MD, MSc, FRCPC; Chief Editor: James G Smirniotopoulos, MD  more...
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Radiologically, MRI has revolutionized the investigation, diagnosis, and even the treatment of MS. Usually, MRI is the only imaging modality needed for imaging patients with MS, and it far surpasses all other tests with respect to its positive predictive value. [1, 2, 3]

(See the images below.)

Sagittal T1-weighted MRI depicts multiple hypointe Sagittal T1-weighted MRI depicts multiple hypointense lesions in the corpus callosum; this finding is characteristic of multiple sclerosis.
Coronal fluid-attenuated inversion recovery (FLAIR Coronal fluid-attenuated inversion recovery (FLAIR) MRI in a patient with multiple sclerosis demonstrates periventricular high–signal intensity lesions, which exhibit a typical distribution for multiple sclerosis. FLAIR MRI is a highly sensitive sequence for lesion detection, particularly supratentorially.
Axial T2-weighted MRI in a patient with multiple s Axial T2-weighted MRI in a patient with multiple sclerosis demonstrates numerous white matter plaques in a callosal and pericallosal white matter distribution.
Axial diffusion-weighted MRI in a patient with mul Axial diffusion-weighted MRI in a patient with multiple sclerosis shows several hyperintense lesions, a feature of inflammatory disease activity.

One of the limitations of using MRI in patients with MS is the discordance occurring between lesion location and the clinical presentation. In addition, depending on the number and location of findings, MRI can vary greatly in terms of sensitivity and specificity in the diagnosis of MS. This is especially true of primary progressive MS, which may not show the classic discrete lesions of relapsing-remitting MS.

A clinician may be presented with an MRI report that notes nonspecific white matter lesions compatible with MS. Imaging findings need to be described in detail and, preferably, referenced to one of the published set of diagnostic criteria. [4, 5] Finally, the specific patient's neurologic history and clinical findings must be correlated with the imaging findings to establish an accurate diagnosis. [6]

Plain radiographic studies have no positive predictive value in the diagnosis of multiple sclerosis, but occasionally, plain radiographs may be used to exclude mechanical bony lesions. Angiography also has a limited role in the diagnosis and management of MS, but when central nervous system (CNS) vasculitis is considered in a patient with undifferentiated findings, angiography may occasionally be considered.

Cerebrospinal fluid (CSF) analysis for oligoclonal banding or immunoglobulin G (IgG) levels is no longer routine in the investigation of MS, although this test may be of use when MRI is unavailable or MRI findings are nondiagnostic. [7]

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