Recognising a possible presentation of multiple sclerosis (MS)

A summary of NICE guidance is presented below (1):

Recognising multiple sclerosis

Be aware that people with multiple sclerosis (MS) may present with a wide range of symptoms affecting different parts of the body. The most common are:

• loss or reduction of vision in 1 eye with painful eye movements
• double vision
• ascending sensory disturbance and/or weakness
• altered sensation or pain travelling down the back and sometimes into the limbs when bending the neck forwards (Lhermitte's sign)
• progressive difficulties with balance and gait

Be aware that usually people with MS present with neurological symptoms or signs as described above, and

• are often aged under 50 and
• may have a history of previous neurological symptoms and
• have symptoms that have evolved over more than 24 hours and
• have symptoms that may persist over several days or weeks and then improve and
• do not have fever or infection

Do not routinely suspect MS if a person's main symptoms are fatigue, depression, dizziness or vague sensory phenomena, unless they have a history or evidence of focal neurological symptoms or signs

Initial assessment

• before referring a person suspected of having MS to a neurologist, confirm that this is a neurological episode by taking a history, undertaking a physical examination and excluding alternative, more common diagnoses

Referral and diagnosis

• Refer people suspected of having MS for diagnosis by a consultant neurologist or a specialist under their supervision. Contact the consultant neurologist directly if you think a person needs to be seen urgently

Diagnosis

• diagnose MS using a combination of history, examination, MRI and laboratory findings, and by following the 2017 revised McDonald criteria. This should include:
  • assessing that symptoms are consistent with an inflammatory demyelinating process; for example, headache is not suggestive of MS
  • excluding alternative diagnoses (targeted laboratory tests may be indicated if the history, examination or MRI findings are atypical)
  • establishing that lesions on MRI scans have developed at different times and are in different anatomical locations for a diagnosis of relapsing-remitting MS
  • looking for cerebrospinal fluid-specific oligoclonal bands if there is no clinical or radiological evidence of lesions developing at different times
  • establishing progressive neurological deterioration over 1 year or more for a diagnosis of primary progressive MS
• If the McDonald criteria are not met but MS is suspected or the person has confirmed clinically isolated syndrome (see the 2017 McDonald criteria for a definition of clinically isolated syndrome):
  • plan a review to reassess the possibility of MS. Discuss the timing of this and future reviews with the person (for example, annually)
  • provide information and ensure that the person knows who to contact for advice if they develop further neurological symptoms or if current symptoms worsen

Do not diagnose MS on the basis of MRI findings alone

For complete details then consult NICE (June 2022).Multiple sclerosis in adults: management

Reference:

1. NICE (June 2022).Multiple sclerosis in adults: management
2. Thompson AJ, Banwell BL, Barkhof F et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria