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Review Article
The early diagnosis and treatments in multiple sclerosis
So Young Huh
Kosin Medical Journal 2017;32(2):151-163.
Published online: January 19, 2017
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Department of Neurology, College of Medicine, Kosin University, Busan, Korea

Corresponding Author: So Young Huh, Department of Neurology, College of Medicine, Kosin University, 262, Gamcheon-ro, Seo-gu, Busan 49267, Korea Tel: +82-51-990-6461 Fax: +82-51-990-3077 E-mail:
• Received: April 6, 2017   • Accepted: April 19, 2017

Copyright © 2017 Kosin University School of Medicine Proceedings

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • Multiple sclerosis (MS) is a chronic inflammatory demyelinating disorder of the central nervous system that leads to neurological disability. The diagnosis of MS relies on the MRI criteria, which can demonstrate dissemination in space and time. Exclusion of other demyelinating mimics is essential because there are no specific biomarker for MS and MRI criteria are still have imperfect. There is incremental improvements in MS treatment option that have contributed to the delay of disease progression. The early initiation of DMT may ameliorate the neurological disability. In this review, we discusses the new diagnostic MS criteria and summarize the evidences supporting the early treatment in the course of MS.
Fig. 1.
Example of lesion for multiple sclerosis MRI Criteria of dissemination in space (A) periventricular lesions; (B) juxtacortical lesions; (C) infratentorial lesions; (D) spinal cord lesion; (E) optic nerve lesion. Gadolinium-enhancing lesion in T1 gadolinium weighted image; (F) are visible in the patient with MS.
Table 1.
CIS clinical features and likelihood of signaling an MS diagnosis4
CIS features typically seen in MS Less common CIS features which may be seen in MS Atypical CIS features not expected in MS
Optic nerve
Unilateral optic neuritis
Pain on eye movement
Partial and mainly central visual blurring
Normal disc or mild disc swelling
Bilateral simultaneous optic neuritis
No pain
No light perception
Moderate to severe disc swellingwithno hemorrhages
Uveitis (mild, posterior)
Progressive optic neuropathy
Severe, continuous orbital pain
Persistent complete loss of vision
Neuroretinitis (optic disc swelling with
macular star)
Uveitis (severe, anterior)
Brain stem/cerebellum
Bilateral internuclear ophthalmoplegia
Ataxia and multidirectional nystagmus
Sixth nerve palsy
Facial numbness
Unilateral internuclear
ophthalmoplegia, facial palsy, facial
One-and-a-half syndrome
Trigeminal neuralgia
Paroxysmal tonic spasms
Complete external ophthalmoplegia;
verticalgaze palsies
Vascular territory syndrome, e.g., lateramedullary
Third nerve palsy
Progressive trigeminal sensory neuropathy
Focal dystonia, torticollis
Spinal cord
Partial myelopathy
Lhermitte’s symptom
Deafferented hand
Urinary urgency, incontinence, erectile
Progressive spastic paraplegia
Complete transverse myelitis
Radiculopathy, areflexia
Segmental loss of pain andtemperature sensation
Partial Brown-Sequard syndrome
(sparing posterior columns)
Faecal incontinence
Progressive spastic paraplegia
Anterior spinal artery territory lesion
(sparing posterior columns only)
Cauda equina syndrome
Sharp sensory level to all modalities
andlocalized spinal pain
Complete Brown-Sequard syndrome
Acute urinary retention
Progressive sensory ataxia (posterior
Cerebral hemispheres
Mild subcortical cognitive impairment
Encephalopathy (obtundation, confusion, drowsiness)
Cortical blindness
Table 2.
2010 McDonald criteria and 2016 MAGNIMS Diagnosis criteria8
2010 McDonald criteria 2016 MAGNIMS criteria
in space
≥2 of 4 characteristic location
≥1 periventricular lesion
≥1 juxtacortical lesion
≥1 asymptomatic brainstem lesion
≥1 asymptomatic spinal cord lesion
≥2 of 5 characteristic location
≥3 periventricular lesion
≥1 cortical/juxtacortical lesion
≥1 brainstem lesion
≥1 spinal cord lesion
≥1 optic nerve lesion
*If a patient has a brainstem or spinal cord syndrome, or optic neuritis, the symptomatic lesion
(or lesions) are not excluded from the criteria and
contribute to the lesion count.
†This combined terminology indicates the involve- ment of the white matter next to the cortex,
the involvement of the cortex, or both, thereby
expanding the term juxtacortical lesion.
in time
- Simultaneous presence of asymptomatic Gd-en-
hancing and non-enhancing lesion at any time
- A new T2 and/or Gd-enhancing lesion on follow-up MRI irrespective of timing of baseline
- Simultaneous presence of asymptomatic Gd-en-
hancing and non-enhancing lesion at any time
- A new T2 and/or Gd-enhancing lesion on follow-up MRI irrespective of timing of baseline
- Clinical symptoms should be associated with
radiologically isolated syndrome
Table 3.
Clinical and MRI major red flags suggestive of alternative diagnosis to multiple sclerosis4
Red flag Type Examples of alternative diagnosis
Bone lesions Clinical Histiocytosis; Erdheim Chester disease
Lung involvement Clinical Sarcoidosis; Lymphomatoid granulomatosis
Multiple cranial neuropathies or pol-yradiculopathy Clinical Chronic meningitis, including sarcoidosis and tuberculosis; Lyme disease
Peripheral neuropathy Clinical B12 deficiency; adrenoleukodystrophy; metachromatic leukodystrophy, Lyme disease
Tendon xanthomas Clinical Cerebrotendinous xanthomatosis
Cerebral venous sinus thrombosis MRI Behçet’s disease; vasculitis; chronic meningitis, antiphospholipid or anticardiolipin antibody syndromes
Cardiac disease Clinical Multiple cerebral infarcts; brain abscesses with endocarditis or right to left cardiac shunting
Myopathy Clinical Mitochondrial encephalomyopathy (e.g.,MELAS); Sjögren’s syndrome
Cortical infarcts MRI Embolic disease; thrombotic thrombocytopenic purpura; vasculitis
Hemorrhages/ microhemorrhages MRI Amyloid angiopathy; Moya Moya disease; CADASIL; vasculitis
Meningeal enhancemen MRI Chronic meningitis; sarcoidosis; lymphomatosis; CNS vasculitis
Extrapyramidal features Clinical Whipple’s disease; multisystem atrophy; Wilson’s disease
Livedo reticularis Clinical Antiphospholipid antibody syndrome; systemic lupus erythematosus; Sneddon’s syndrome
Retinopathy Clinical Mitochondrial encephalomyopathy; Susac, and other vasculitides (retinal infarction); neuronal ceroid lipofuscinosis
Calcifications on CT scans MRI Cysticercosis; toxoplasmosis, mitochondrial disorders
Diabetes insipidus Clinical Sarcoidosis; histiocytosis
Increase serum lactate level Clinical Mitochondrial disease
Selective involvement of the anterior temporal and inferior frontal lobe MRI CADASIL
Hematological manifestations Clinical Thrombotic thrombocytopenic purpura; vitamin B12 deficiency; Wilson’s disease (hemolytic anemia); copper deficiency
Lacunar infarcts MRI Hypertensive ischemic disease; CADASIL; Susac syndrome
Persistent Gd-enhancement and continued enlargement of lesions MRI Lymphoma; glioma; vasculitis; sarcoidosis
Mucosal ulcers Clinical Behçet’s disease
Myorhythmia Clinical Whipple’s disease
Hypothalamic disturbance Clinical Sarcoidosis; neuromyelitis optica; histiocytosis
Recurrent spontaneous abortion or thrombotic events Clinical Antiphospholipid antibody syndrome; thrombotic thrombocytopenic purpura; metastatic cancer with hypercoagulable state
Simultaneous enhancement of all lesions MRI Vasculitis; lymphoma; sarcoidosis
Rash Clinical Systemic lupus erythematosus; T-cell lymphoma; Lyme disease, Fabry disease
T2-hyperintensity in the dentate nuclei MRI Cerebrotendinous xanthomatosis
Arthritis, polyarthalgias, myalgias Clinical Systemic lupus erythematosus; Lyme disease; fibromyalgia
Amyotrophy Clinical Amyotrophic lateral sclerosis; syringomyelia; polyradiculpathy
Headache or meningismus Clinical Venous sinus thrombosis; chronic meningitis; lymphoma or glioma, vasculitis, systemic lupus erythematosus
T1-hyperintensity of the pulvinar MRI Fabry disease; hepatic encephalopathy; manganese toxicity
Persistently monofocal manifestations Clinical Structural lesion (e.g., Chiari malformation); cerebal neoplasm
Large and infiltrating brainstem lesions MRI Behçet’s disease; pontine glioma
Predominance of lesions at the cortical/subcortical junction MRI Embolic infarction; vasculitis; progressive multifocal leukoencephalopathy

CADASIL; cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, MELAS; mitochondrial myopathy, encephalopathy, lactic acidosis, stroke-like episodes syndrome

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        The early diagnosis and treatments in multiple sclerosis
        Kosin Med J. 2017;32(2):151-163.   Published online January 19, 2017
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