MRI is valuable in the diagnosis of multiple sclerosis
In investigating the diagnostic utility of MRI in cases of suspected
multiple sclerosis (MS), Whiting et al have evaluated imaging findings
reported in many different studies – mainly whether or not there are any
lesions present on a brain scan1. This approach does not reflect the real
life situation where neurologists use a more detailed interpretation of
MRI abnormalities in the context of the clinical findings to come up with
a diagnosis. Clinicians deal with many different clinical settings that
make the diagnosis of MS more or less likely and also have to consider the
differential diagnosis. An early and reliable diagnosis facilitates best
management and alleviates anxiety due to diagnostic uncertainty. While the
diagnosis of MS is based primarily on clinical manifestations, it is often
helpfully - and sometimes crucially - supported by laboratory
investigations. When used appropriately, MRI – and sometimes CSF and
neurophysiological (evoked potentials) examination - improves diagnostic
accuracy and helps exclude or identify other important conditions2.
Appropriate use of MRI in cases of suspected MS involves more than
determining whether or not there is a lesion in the brain and if so how
many. There are numerous causes of white matter lesions and the correct
use of brain imaging to improve specificity in suspected MS will take in
to account lesion location (Barkhof-Tintore criteria for dissemination in
space3,4), lesion activity (gadolinium enhancement) and the appearance of
new lesions (dissemination in time, a mandatory requirement in making the
diagnosis of MS3). The currently accepted brain MRI criterion for
dissemination in space3 has a higher specificity than 3 lesions per se for
MS versus other neurological diseases5. Detection by MRI of the
characteristic spinal cord lesions of MS is of particular diagnostic
value6, and because a cord syndrome is the presenting feature of ~50% of
MS patients, imaging of this region is often needed to exclude an
alternative treatable disorder such as spinal cord compression.
Whiting et al have underestimated the contribution that MRI makes in
the diagnosis and differential diagnosis of MS, and might encourage some
clinicians to avoid using this investigation when required. Failure to do
so will generate errors of diagnosis and will also delay making the
diagnosis of MS in people who have the disease.
1. Whiting P, Harbord R, Main C, et al (2006). Accuracy of magnetic
resonance imaging for the diagnosis of multiple sclerosis: systematic
review. BMJ online
2. Miller DH, McDonald WI, Smith K (2005). The diagnosis of multiple
sclerosis. In: McAlpine’s Multiple sclerosis 4th edition, Ed: A Compston,
Elsevier, London, pp 347-388.
3. Polman CH, Reingold SC, Edan G, et al (2005). Diagnostic criteria
for multiple sclerosis: 2005 revisions to the "McDonald Criteria". Ann
Neurol 58:840-6
4. Korteweg T, Tintore M, Uitdehaag B, et al (2006). MRI criteria
for dissemination in space in patients with clinically isolated syndromes:
a multicentre follow-up study. Lancet Neurol 5:221-7
5. Nielsen JM, Korteweg T, Barkhof F, et al (2005). Overdiagnosis of
multiple sclerosis and magnetic resonance imaging criteria. Ann Neurol
58:781-3.
6. Bot JC, Barkhof F, Lycklama G, et al (2002). Differentiation of
multiple sclerosis from other inflammatory disorders and cerebrovascular
disease: value of spinal MR imaging. Radiology 223:46-56.
We are members of the Steering Committee of MAGNIMS, a European
Network on Magnetic Resonance in Multiple Sclerosis
Competing interests:
None declared
Competing interests:
No competing interests
05 April 2006
David H Miller
Professor of Clinical Neurology
Frederik Barkhof, Franz Fazekas, Massimo Filippi, Ludwig D Kappos, Xavier Montalban, Jacqueline Palace, Chris H Polman, Marco Rovaris, Alex Rovira, Nicola de Stefano, Alan J Thompson, and Tarek Yousry.
Institute of Neurology, University College London, London WC1N 3BG, UK
Rapid Response:
MRI is valuable in the diagnosis of multiple sclerosis
In investigating the diagnostic utility of MRI in cases of suspected
multiple sclerosis (MS), Whiting et al have evaluated imaging findings
reported in many different studies – mainly whether or not there are any
lesions present on a brain scan1. This approach does not reflect the real
life situation where neurologists use a more detailed interpretation of
MRI abnormalities in the context of the clinical findings to come up with
a diagnosis. Clinicians deal with many different clinical settings that
make the diagnosis of MS more or less likely and also have to consider the
differential diagnosis. An early and reliable diagnosis facilitates best
management and alleviates anxiety due to diagnostic uncertainty. While the
diagnosis of MS is based primarily on clinical manifestations, it is often
helpfully - and sometimes crucially - supported by laboratory
investigations. When used appropriately, MRI – and sometimes CSF and
neurophysiological (evoked potentials) examination - improves diagnostic
accuracy and helps exclude or identify other important conditions2.
Appropriate use of MRI in cases of suspected MS involves more than
determining whether or not there is a lesion in the brain and if so how
many. There are numerous causes of white matter lesions and the correct
use of brain imaging to improve specificity in suspected MS will take in
to account lesion location (Barkhof-Tintore criteria for dissemination in
space3,4), lesion activity (gadolinium enhancement) and the appearance of
new lesions (dissemination in time, a mandatory requirement in making the
diagnosis of MS3). The currently accepted brain MRI criterion for
dissemination in space3 has a higher specificity than 3 lesions per se for
MS versus other neurological diseases5. Detection by MRI of the
characteristic spinal cord lesions of MS is of particular diagnostic
value6, and because a cord syndrome is the presenting feature of ~50% of
MS patients, imaging of this region is often needed to exclude an
alternative treatable disorder such as spinal cord compression.
Whiting et al have underestimated the contribution that MRI makes in
the diagnosis and differential diagnosis of MS, and might encourage some
clinicians to avoid using this investigation when required. Failure to do
so will generate errors of diagnosis and will also delay making the
diagnosis of MS in people who have the disease.
1. Whiting P, Harbord R, Main C, et al (2006). Accuracy of magnetic
resonance imaging for the diagnosis of multiple sclerosis: systematic
review. BMJ online
2. Miller DH, McDonald WI, Smith K (2005). The diagnosis of multiple
sclerosis. In: McAlpine’s Multiple sclerosis 4th edition, Ed: A Compston,
Elsevier, London, pp 347-388.
3. Polman CH, Reingold SC, Edan G, et al (2005). Diagnostic criteria
for multiple sclerosis: 2005 revisions to the "McDonald Criteria". Ann
Neurol 58:840-6
4. Korteweg T, Tintore M, Uitdehaag B, et al (2006). MRI criteria
for dissemination in space in patients with clinically isolated syndromes:
a multicentre follow-up study. Lancet Neurol 5:221-7
5. Nielsen JM, Korteweg T, Barkhof F, et al (2005). Overdiagnosis of
multiple sclerosis and magnetic resonance imaging criteria. Ann Neurol
58:781-3.
6. Bot JC, Barkhof F, Lycklama G, et al (2002). Differentiation of
multiple sclerosis from other inflammatory disorders and cerebrovascular
disease: value of spinal MR imaging. Radiology 223:46-56.
We are members of the Steering Committee of MAGNIMS, a European
Network on Magnetic Resonance in Multiple Sclerosis
Competing interests:
None declared
Competing interests: No competing interests