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MS Diagnosis Text Overview of Video

Dr Suzi Claflin and Professor Bruce Taylor

Suzi: In this video, we’re going to talk about the process of diagnosing someone with Multiple Sclerosis. So Bruce, when do people usually get diagnosed with Multiple Sclerosis?

Bruce: Most people get diagnosed with Multiple Sclerosis in their 30s and 40s, but it can occur at any age, from very young children right up into people in their 70s or 80s.

Suzi: Why is the process of being diagnosed sometimes confusing or can take quite a while?

Bruce: Well the reason for that is that we don’t have a specific test which tells us that someone has MS. We rely on history and examination, particularly when we need to define the person has had two attacks or areas of damage within the spine, brain or optic nerves which are separate from each other. And we need to show that there have also been two attacks, which means that we show over time, so separated by at least a month. And that’s what we call dissemination in time. So, someone’s got to have one attack and 30 days or more later have a second attack. And those attacks can be years apart.

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Sometimes people would have one attack, have no evidence of anything for many, many years and then have a second attack. And that can mean the diagnosis can be many, many years after the first event. And then once people have had events or an event which is suggestive of MS, we then can do further testing which is to aid the diagnosis, because there’s no specific test which can tell you that someone’s got MS. And the second thing it does is it rules out other possibilities which can mimic MS.

Suzi: And there is something called “clinically isolated syndrome”?

Bruce: Yes.

Suzi: Tell me more about that.

Bruce: That’s a single attack. A lot of people will present with their first attack of MS, being an attack in the optic nerve, for instance, which causes optic neuritis, and that may be the only thing they’ve got, and they may only have no other findings at all, and nothing on their investigations. And then you have to wait and watch and see. And it may be 20, 30 years or never that they go on and have a second attack, or it might be 30 days. And then that defines as MS. And that’s why it can take a long time after a first attack.

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Suzi: What tests do you use to aid the diagnosis?

Bruce: The first thing, which is standard, is the history and examination. We do a very careful history and examination of the person to make sure that - sometimes we can find evidence that they’ve had an attack that they’re not even aware of. And on history, an event which was labelled as something else may make us thing ‘hang on a sec, that was the first attack of MS, this person has now had a second attack, they’ve got MS.’ Then we can use testing such as magnetic resonance imaging, visual evoked potentials and lumbar punctures to aid in our diagnosis.

Suzi: Tell me more about MRI or magnetic resonance imaging.

Bruce: Magnetic resonance imaging is a test which is done. It’s a painless test which uses a magnetic field which measures the amount of water within a tissue. The difference between an area that is inflamed and an area that’s not inflamed is that there is more water in that area and therefore it produces a different signal on the MRI.

Suzi: When someone takes an MRI, what happens?

Bruce: Well, it’s very simple. It’s painless, but it requires the person to lie down very flat and very still. Their head goes into a large machine or, if they’re imaging the spine, the whole of the

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upper body goes into the machine. It’s quite a narrow tunnel and they often have a guard on over their face to hold their head steady, and therefore it can be quite claustrophobic, and a number of people can’t have it done because of claustrophobia. You also can’t have it done if you’ve got any metal in your body which is magnetic. So, if someone has got a pacemaker or they’ve had metal in their eye or have had a shotgun pellet under their skin - it’s one of many things that we see - they can’t have it because the metal will be attracted towards the machine and can cause damage. But in general, people with MS get very familiar with MRI scanners and tolerate them extremely well.

Suzi: And they produce images like the one that we’re looking at here?

Bruce: Yes, that’s exactly correct - which is usually a detailed picture of a section of the brain. This is what we call a sagittal section, which means it goes from the front to the back. And, in

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fact, here we can see part of the eyeball. And this is the back of the brain which is called the cerebella. Now, these dark areas are the normal spaces in the brain which are called the ventricles. And we can see around the ventricles in this person. They’ve got these white lesions which are suggestive of MS, but they’re not diagnostic. There are a number of other things that can have this appearance. And therefore people often say an MRI diagnoses MS, but it doesn’t, it supports the diagnosis of MS.

Suzi: And with an MRI, why would you use contrast?

Bruce: Well, contrast tells you how active a lesion is. Many of these lesions, for instance - so I would imagine this bright little white one here and these ones here, are most likely to be scars. They’re not likely to be an active lesion. But it’s possible that these ones which are a little bit more fluffy, here and here, may actually be new lesions. And that’s one of the things that is important, that we like to show - are there new lesions? And that means that we can say that there are two lesions here. This one may be old and this one may be new - which allows us to make that dissemination in time diagnosis on a scan. So sometimes we use contract when we first see people with MS, as it tells us whether their lesions are active. And if we’re worried about progression or change in MS, we’ll use contrast as well to show us whether there’s new lesions appearing. The other thing we can do is, we can see over time, if we do serial MRI scans, we can see how things change.

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This is the earliest MRI in this series and this is the latest one. And as you can see, from exactly the same section, this person has gone on and developed many, many, many new lesions. They’ve also changed, their brain has changed in its structure. We can see that the ventricles are getting bigger, which means there’s been atrophy, or brain atrophy, and loss of neurons or neurodegeneration, which makes the brain shrink. So we can use the MRI not only to diagnose. If we did this scan and then we repeated it and it showed new lesions, that’s suggestive of new attacks and makes us able to make that diagnosis.

Suzi: And then visual evoked potentials?

Bruce: Well, visual evoked potentials are a very interesting test because it’s one way we can look dynamically at how the brain works. And what we do is we sit the person in front of a checkerboard very much like this one. And then we put some electrodes on the back of their head, over their occipital head region, and then what we want to know is when you change the colour, so that the black squares go white and the white

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squares go black when you’re looking at that, it sets off an electric current in your retina, then that electric current travels through your optic nerve, all the way back to your occipital cortex where you register vision. And we can measure a little potential at the back of the brain. We know when the checkerboard changed and then we figure out how long it takes to get to the back of the brain. And because MS slows that rate of progression of that electrical impulse, we can tell whether there has been damage to the nervous system in the optic pathway. And it can be very useful in people who have had one attack and have got no evidence of any other change. We can show that slowing and we can then say they must have had an attack in their optic pathways, and therefore we can be more confident about making the diagnosis of MS. Again, it’s a painless, easy test to do.

Suzi: What about lumbar puncture?

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Bruce: What we’re looking at here on the screen is four vials of spinal fluid or cerebrospinal fluid or CSF which, as you can see is crystal clear. And that’s the fluid that bathes the brain and the spinal cord. And we sometimes, and quite often now, do a lumbar puncture when we’re diagnosing people with MS. Many people have heard of lumbar punctures and often they’re regarded as being a painful, nasty test to have. And that’s generally developed because when people used to have lumbar punctures, it was done because they had things such as encephalitis or meningitis where, in fact, the coatings of the brain and the spinal cord were inflamed, and it could hurt and it could be quite painful. But in lumbar puncture done for the diagnosis of Multiple Sclerosis, it’s actually generally a very easy test to do. We insert a very fine needle between two of the lumbar vertebrae below the level of the spinal cord and we take off some of this fluid that bathes the brain and the spinal cord. And that fluid is very useful. Firstly, it allows us to look for inflammation in the brain and spinal cord, which is native to the brain and spinal cord, and that’s what we call oligoclonal bands, and we compare those to the banding or the immunoglobulins in the blood or the plasma and we compare them. We’re looking for ones that are only present in the brain and spinal cord. And that tells us that there’s generational inflammatory activity within the brain and spinal cord and is highly suggestive of MS, but it’s not diagnostic. And it also allows us to make sure that there’s no other cause for inflammation in the brain and spinal cord. Because, in general, people with MS have CSF that looks like this. There should be no evidence of inflammation, as in lots of cells in their CSF; there should be no blood; there should be nothing else to suggest an infection. And it can be very useful in that respect.

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Suzi: So, you’re looking for signs that the immune system is acting in the way that we think that it typically does when you have MS, when you’re looking at the spinal fluid?

Bruce: Yes. We’re trying to confirm that there is, in fact, intrathecal, or within the spinal fluid, production of immunoglobulin which is only produced in there and not produced in the periphery. Now, that’s really important because that tells you that the immune process is affecting the brain and the spinal cord. It’s very important in that respect.

Suzi: As we’d expect if someone was experiencing MS?

Bruce: Yes. Now, the other thing we use a lumbar puncture for is that if those oligoclonal bands are present with our new diagnostic criteria in someone who has had the clinically isolated syndrome, if they’ve got a typical MRI and they’ve got oligoclonal band, we can make that diagnosis of MS earlier, which is very important for the person who has got the disease.

Suzi: So, you don’t necessarily have to wait for the confirmation of that second event?

Bruce: No, we don’t anymore. We can do that in two ways now. One is by the MRI, and the second way is by the CSF. So we can shorten that time, which was in the 70s and 80s - you know, average time from onset to diagnosis was somewhere around

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two years. We now hope that we can reduce down that time significantly.

Suzi: We’ve talked about four major types of tests or examinations. We have a history, the magnetic resonance imaging, visual evoked potentials and lumbar puncture. So once a diagnosis is made, what then? What do you typically recommend?

Bruce:Well, what we typically recommend is, first of all, we need to know what type of MS the person has. If they’ve got MS which comes on in attacks or relapsing and remitting MS, we would strongly recommend that nearly everyone, at that stage, should strongly consider being treated because there’s good evidence that if we treat it early, we can reduce the rate of brain volume loss, we can improve outcomes for people, we can keep them in work and give them hopefully a normal life. If they’ve got progressive onset MS, the treatment options are less. But the point of the diagnosis is the point where you start talking about the person’s therapeutic journey; what they need to do to help themselves; what they need to do about treatment; what are the factors that they can modify, which we’ll talk about later on in the course, that may allow them to improve their chances of having a good outcome.

Suzi: In this video, we talked about the process of being diagnosed with Multiple Sclerosis. Later on in the course, we’ll talk about the impact of diagnosis and how to get support after diagnosis.