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MRI can help or hinder treatment of MS (CMSC 2015)

A presentation at the 2015 Annual Meeting of the Consortium of Multiple Sclerosis Centers highlighted common MRI-related issues that can lead to misdiagnosis and suboptimal disease management. The conference was held May 27–30 in Indianapolis

“Having white spots on your brain MRI does not mean that you have MS, and MS is not just having spots,” said Jill Conway, MD, of the Carolinas HealthCare System in Charlotte, NC. “There are lots of causes for white spots on MRI, including headaches, small vessel ischemic disease and changes due to aging, diabetes and high cholesterol.”

However, certain characteristics of lesions are particularly suggestive of MS, including ovoid appearance and periventricular location, though the cerebellum is frequently involved, she said. Sagittal FLAIR imaging is useful for detecting Dawson’s fingers, which are elongated lesions that rise perpendicularly from the ventricles and often involve the corpus callosum.

The list of differential diagnoses for MS is lengthy, and the financial and psychosocial consequences that come with an MS diagnosis are substantial. Thus, it’s incumbent upon the clinician to weigh MRI findings alongside patients’ symptoms, history, physical exam, and test results such as oligoclonal bands in cerebrospinal fluid, Dr. Conway noted.

Recent research supports the role of MRI in misdiagnoses. A 2012 survey of MS specialists found that 95 percent had strongly disagreed with one or more patients’ MS diagnosis in the previous year. Roughly 80 percent of these respondents suspected small vessel ischemic disease as an alternative diagnosis, and nearly one-third suspected fibromyalgia. These findings suggest an overreliance on MRI criteria or improper interpretation, the authors noted.[1]

In her experience, Dr. Conway said she’s found that if an MRI was performed for complaints like headaches or widespread pain suggestive of fibromyalgia, or to assess damage following a car accident or other trauma, it’s less likely to be useful in uncovering MS.

In patients with established MS, regular surveillance with MRI is important, she said. She recommended an MRI six months after a medication change to assess how it’s working, citing a 2009 Italian study of patients who were taking interferon beta. After a year of therapy, those with no new lesions had 5 percent risk of worsening disability over four years of follow-up, but with three or more new lesions, their risk jumped to 83 percent.[2]

Though some clinicians question the expense of MRI, imaging represents a fraction of the cost of a year of disease modifying therapy, Dr. Conway noted. Continuing a treatment that’s ineffective for a particular patient also creates risk of disease progression, she said. “It’s easier to prevent than repair. The best way to manage MS is to prevent [exacerbations] from happening.”

Solomon AJ, Klein EP. “Undiagnosing” multiple sclerosis: the challenge of misdiagnosis in MS. Neurology. 2012; 78(24): 1986–91.

Prosperini L, Gallo V. One-year MRI scan predicts clinical response to interferon beta in multiple sclerosis. Eur J Neurol. 2009; 16(11): 1202–9.

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About the Editors

  • Prof Timothy Vartanian

    Timothy Vartanian, Professor at the Brain and Mind Research Institute and the Department of Neurology, Weill Cornell Medical College, Cornell...
  • Dr Claire S. Riley

    Claire S. Riley, MD is an assistant attending neurologist and assistant professor of neurology in the Neurological Institute, Columbia University,...
  • Dr Rebecca Farber

    Rebecca Farber, MD is an attending neurologist and assistant professor of neurology at the Neurological Institute, Columbia University, in New...

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Multiple Sclerosis and Related Disorders, September 2015, Vol 4 Issue 5