Multiple sclerosis – white spots and red flags - part 1 - Making a diagnosis

Demyelinating disease is a common situation we encounter in neuroradiology, and properly diagnosing and tracking it using MRI is a key skill for neuroradiologists. Today, Dr. Michael Hoch gives the first part of a two part lecture on how to approach white matter abnormalities in the brain and use them towards making a diagnosis of multiple sclerosis.

Multiple sclerosis is a clinical diagnosis that depends on several possible presenting signs (such as depression, fatigue, vertigo, numbness or other neurological symptoms, bladder dysfunction, visual changes, or other phenomena including L'Hermitte's sign or Uhthoff's phenomenon) and other clinical sign (including tremor, decreased perception, hyperreflexia, and ataxia).

The imaging diagnosis of multiple sclerosis is based on the McDonald criteria, most recently revised in 2017. This requires dissemination in space, dissemination in time, and lack of an alternate explanation. You should evaluate different spaces for white matter abnormality, including the cortex, juxtacortical, subcortical and deep white matter, corpus callosum, and deep white matter, periventricular white matter. 

The locations of the lesions can provide a clue as to whether white matter lesions are more likely to be caused by demyelinating disease or other nonspecific insults, such as chronic microvascular ischemia. For instance, central lesions in the pons or lesions in the deep white matter are more nonspecific, while cortical/juxtacortical, periventricular, and anterior temporal lesions are more specific for multiple sclerosis.

The enhancement pattern is also a clue to whether a lesion might be demyelinating. Demyelinating lesions typically have an incomplete rim of enhancement, where the post-contrast enhancement has a broken circle type of appearance. Leptomeningeal enhancement can often be seen in patients with MS, although it is an alarm bell if patients don't have a known diagnosis, as it can represent other diseases such as leptomeningeal carcinomatosis.

Key take home points of this lecture include:

Multiple sclerosis is a clinical diagnosis, not an MRI diagnosis
White spot lesion location matters
Juxtacortical lesions must touch the cortex
Aggressively window the spine to look for cord lesions
Leptomeningeal enhancement is possible in multiple sclerosis

If you haven't already, please check out part 2, in which Dr. Hoch discusses potential mimics and pitfalls when assessing for demyelinating disease.

The level of this lecture is appropriate for radiology residents, radiology fellows, and trainees in other specialties who have an interest in imaging or treating patients with potential demyelinating diseases.

[k.m.slattery]

Thank you for addressing and explaining MS lesions. Is there a pattern/type difference for patients with Primary Progressive MS?

[puritanooj]

Few focal t2/flair hyperintensities seen in bilateral paritrigonal, frontal subcortical white matter. No diffusion restriction seen. (Meaning) Sir

[gularg-va]

Thanks a lot for such an informative video.i have one question: what does it mean agrresive window for cord lesions?

[kevinrichardson]

I suffered concussions and my MRI shows white matter and I get pressure headaches.

[ldjt]

What should someone do for themselves if they're diagnosed with ms? Do you have any favorite therapies or lifestyle strategies?

[ashleymiller]

I have non enhancing on both frontal lobes and then just found out non enhancing t2 hypertintense on Pons. My neurologist hasn’t been available since I got everything done. My left facial droop and right hand tremors I’ve had for many years but now I’m having numbness in 2 fingers. I don’t know if I should just give up trying to find out.

[slayqueen]

How to differentiate new lesion from old lesions in multiple sclerosis on mri? Is this how we find dissemination in time? Please clarify. Thankyou

[cozycatcorner]

Good I've been having odd intermittent symptoms for 2 years!!!! I'm 28 yo female. Now I'm experiencing unexplained weight loss down to 100 lbs, I get light headed, fatigue and sometimes my left arm goes numb and hurts and my legs hurt some. I had an MRI 1 year ago and the neurologist said my brain looked healthy and my spinal cord wasn't inflamed so no MS. It showed disc disease. To this day i still don't know why i have odd symptoms. I get off balance but I've never fallen i do have optic nerve damage in my eyes. I was born a preemie at 1 lb 2 oz so that could be a factor in my adulthood?

[basozkarim]

I only have 1 lesion on the Sri they think from migraine. but I almost have all the symptoms of systemic MS. what could it be?

[immane]

Excellent . Can you please share you protocol on 1.5 and 3 Tesla .TIA

[herbsmoked]

IMPRESSION:
There are multiple nonspecific white matter lesions which can be seen with
multiple etiologies including but not limited to demyelinating disease,
vasculitis, migraines, or small vessel ischemic changes which is unlikely given
patient's age.

[lisaann]

What does it mean along the the ventricles?