Ask the Experts: Diagnosis
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Q: Is it possible to have MS without having optic neuritis and with normal evoked potentials?
Q: I have nearly constant headaches and frequent facial numbness; sometimes I lose strength in my hands/wrists, have numbness in toes, can't bear weight in knees, feel extremely fatigued, or have trouble finding words. I've been diagnosed with palindromic rheumatism. I failed visual field test last month in right eye; passed longer test yesterday. An MRI in Nov. showed lesion on T11 left nerve sheath; diagnosed with perineural cyst. I have LLQ pain/neuralgia along dermatome distribution. How can you differentiate a perineural cyst from MS lesion?
A: It should be a fairly simple matter to distinguish an neural cyst from an MS lesion. Nerve sheath cysts would appear as a fluid filled space outside the central nervous system. This is in a location that would not be affected in multiple sclerosis.
Joshua Katz, MD
April 2013
Q: I was referred to a neurologist due to recurrent eye inflammation (uveitis) and vertigo. I have also had chronic pain issues, but RA, lupus, Lymes Disease, etc. have been ruled out. My MRI showed enlarged ventricles and bilateral hemispheric white matter foci of T2 hyperintensity involving subcortical and periventricular white matter. I'm 46 years old. I used to suffer from migraines, but it has been many years, and I'm wondering if the migraines could have caused this problem even though it has been so long since I've had them. They also did a LP, which was normal. Could this be MS or just left over from my history of migraines?
A: Uveitis is not a feature of Multiple Sclerosis, and the normal spinal fluid examination is also reassuring (assuming the fluid was examined with a view toward the consideration of MS). The T2 changes you describe are common in MS and in Migraine, and the presence many years after migraine attacks wane is common. A repeat MRI study with and without gadolinium enhancement (a magnetic dye) 4-6 months after the recent test may be useful in helping to distinguish between MS and other conditions. Given the concerns you raise, although the diagnosis of MS is unlikely based on your description, a second opinion at an MS center to be certain of the diagnosis of uveitis (vertigo is not a feature of that condition) seems reasonable. A discussion with your neurologist would be a good place to start.
Arthur Safran, MD
April 2013
Q: I have a family member who less than a year ago had 6 brain lesions. The next round of tests include: A spinal tap was clear, CT (all lesions healed), MRI (4 days ago, no active lesions), Is this typical for MS? Also portrays every possible symptom ever listed for MS from most common to least common but does not portray them always consistently. Do you have an idea of something else this could be? Is it possible this could be a mental issue? No diagnosis has been made yet.
A: There is no clear answer to this question, without knowing why a scan was ordered in the first place? Was that an MRI scan or a CT scan? MS lesions are rarely visible using a CT.
I can say this: In the early stages of MS, in some patients, there are few symptoms and even those are very short-lived. Nevertheless the MRI scans show activity. There is a protocol now, called Revised McDonald Criteria, which allows you to make a diagnosis of MS even with few or no symptoms if the MRI scans show the proper pattern.
If he does have early MS then there is an advantage to starting MS treatment. He would have to work with his neurologist to get that set up. If you need the names of MS neurologists, you can call the Society's Information and Resource line at 800-344-4867 and ask for the names of neurologists in your area.
David M. Dawson, MD
February 2013
Q: I am a 36 year old woman who was recently diagnosed with CIS. I started seeing neurologist after experiencing fleeting tingling sensation first in my legs and then all over my body. I also have dizziness. My brain MRI showed what he called lesions not typical for MS. Spine mri clean. EPA normal but LP had o bands. He suggested treatment. But had one more test done. Anticardiolipins which came back abnormal. Now I am being tested by a hematologist. I still only have tingling. And it has been with me for 2-1/2 months. Could this be something other than MS?
A: You may have a condition other than MS. Your presentation requires a thorough exploration of other possible diagnoses. Consultation with a hematologist as you are doing, and possibly a rheumatologist is a good idea.
Tanuja Chitnis M.D.
February 2013
Q: I'm 22 years old and I started experiencing tingling, numbness and pain in arms and legs about 14 months ago. It also seems like my arms and legs "fall asleep" a lot faster than they used to. My first brain MRI showed two lesions (one of them in the corpus callosum), spinal tap was negative, MRI of the spine was normal and all my blood test came back negative as well. Two months ago I had a check up MRI of my brain which only showed one brain lesion. My neurologist says it's not MS but he also doesn't know what it is. Could this still be MS even though all the testing was negative except for the brain lesion?
A: There are quite a few people in the world who have white spots in their brain, as you do, without any clinical sign that they have MS. It is not certain what they have or what should be done about it. Probably nothing. If they are followed, over the course of time many of them do turn out to develop MS judged by ordinary criteria. But some do not. And there are a few diseases that also produce white spots in the brain: One is B12 deficiency, and another is a disorder of the peripheral nerves (not the brain itself) that once in a while will be associated with a white spot or two. It's good news that one of the spots went away. It is rather like the people that have a positive blood test for infectious mono but have never had the disease.
In the MS clinic where I work, such patients are called "MS suspects." We do what your neurologist has done, repeat the scan periodically, watch for things to develop. I would continue to check in with him or her.
David M. Dawson, MD
January 2013
Q: I am a 27 male with no history of serious infections (only flu) or migraine or vascular disease or any metabolic problem. I did an MRI because I suddenly developed vertigo and tinnitus in one of ear, and then discovered that i have Periventricular White Matter Lesions (inactive with Gadolinium). my neurologist said i have MS because of that, and wanted to start treatment although i have no history of weakness, bladder problems or vision problems, and my neurological examination was clear, what does the lesions mean in this case?
A: This is an interesting and important question. To look at it scientifically you would have to read the most recent criteria for diagnosis of MS, put together by an international panel. They are described in an article in the Annals of Neurology, February 2011. Volume 69, pages 292 to 302. I think this is an open-access article---you don't need to be a subscriber. If you can't get it easily, try the local MS society.
Basically it will tell you need to have two kind of criteria---location, and time. Your scan sounds like MS in terms of location. But not time. You need to have more information about change in the scan over time---that is a new lesion more than 6 months later, or a new enhancing lesion. For all you know at this point, you could have had those lesions for 20 years. So I don't agree with a flat footed diagnosis of MS at this point in time. You should clarify this with your neurologist. Should you want to see an MS neurologist, please contact the Society's Information and resource line at 800-344-4867 and ask for the names of MS neurologists in your area.
David M. Dawson, MD
January 2013
Q: 10 years ago, I had an MRI because of neck pain. I had a herniated disk; however, the doctor also told me that I had some "gray areas" on my MRI that were consistent with someone who has MS. She did say that I didn't have many of these areas, though. Over the last few years, I have had weird symptoms such as vibrating feelings in my legs, brief HOT feelings in my thighs, numb sensations on my scalp, and more recently weakness in my extremities and shaking, particularly after over use of my muscles, especially my arms. Last spring, I had an episode where my legs went numb, I could barely walk, and almost passed out. I was rushed to the ER but they couldn't find anything wrong. Could it be that the MRI did in fact show MS, and it took this long to start exhibiting symptoms?
A: It is possible to have an MRI that shows findings of multiple sclerosis, years before developing symptoms of MS. In fact, there seem to be patients who have MS-like abnormalities on MRI that never develop symptoms. But it is less likely to see MRI abnormalities in the spinal cord that do not cause symptoms, because the spinal cord is such a delicate area. In your case, since you are having active symptoms, you should see a neurologist for a thorough evaluation, if you have not already done so. Should you need help locating an MS neurologist, please contact the Society's Information and Resource line at 800-344-4867, and ask for the names of MS neurologists in your area.
Joshua Katz, MD
January 2013
Q: I'm 25 male who was recently diagnosed with MS because I have white matter lesions (not active with contrast), but then they ruled out the diagnosis because CSF, bloodwork, Evoked potential, EMG & Nerve Conduction all came back normal. They told me i have alot of anxiety, and regardless of the white matter abnormality they diagnosed me with Generalized Anxiety Disorder (GAD). My symptoms are parasthesia, muscle spasm, tingling and numbness all in the leg. Can GAD mimic MS sensory and motor symptoms?
A: GAD would not be a reasonable explanation for white matter lesions on MRI- but they might not necessarily be from MS. Other conditions can also cause white matter lesions, including migraine. The important thing is whether your history of symptoms and neurologic exam suggest MS (or something else). Are you seeing a neurologist (preferably a specialist in MS)? Did you have MRI of the spinal cord in the neck or thorax? I think a second neurologic opinion might be helpful in this situation. Should you need the names of local MS Neurologists, please contact the Society's Information and Resource line at 800-344-4867.
Peter Riskind, MD., PhD
December 2012
Q: I am wondering if the timing of a spinal tap is important in the diagnosis of MS: will it show anything if someone has symptoms that are in remission?
A: The spinal tap may still show signs of MS even if someone is in remission.
Tanuja Chitnis M.D.
December 2012
Q: I was seeing an ENT for headaches. I was sent for an MRI of the head and it came back with 4+ lesions. My doctor immediately jumped to MS. I did four EEG tests and performed well in all except the left lower limb with some delays. MRI of my spine showed no lesions. My doctor was already talking treatment and now suggests a spinal tap. I am nervous to do so. My insurance wouldn't allow for a second opinion for up to 6 months. Any suggestions? I am a 26 year old female.
A: It is really hard to make a diagnosis of MS from the scans alone. There have been many reports of patients like yourself, where there is nothing to suggest MS as a diagnosis other than what is visible on an MRI scan.
Patients like yourself are in one category or another:
- Where the scan is really typical of MS---couldn't be anything else. In that situation, most of the patients will eventually develop MS. But you wait for treatment until there is evidence that MS has developed---either a change in the scans, or a clinical episode of some kind.
- Several spots on the scan which are not clearly due to MS. They could be, or maybe not. That's your situation. It is too soon to start treatment. And other tests, such as a spinal tap, or the electrical tests that you have had, are never going to settle the matter.
I think your doctor, in an effort to try to be sure he or she is doing the right thing, is over stepping. I'd do another scan in 6 months. If you want to wait until your insurance will cover it, then wait. And you would do well to go to one of the MS Society's approved MS clinics, where they will have a lot of experience with just this kind of decision.
David M. Dawson, MD
December 2012
Q: I am a 39 year old female. 6 months ago my right leg went numb, and was moving at an odd angle when I walked, and moving from the hip only, such that it was running into my left leg. That resolved by the next morning. Following that episode, I began to have numbness in my hands, arms and feet, muscle fasciculations all over, tingling all over, and fatigue. I have also developed blurry vision in my left eye. Symptoms were worse in the heat. Numbness is mostly better now; still get tingles and twitches, though now the twitches are most frequent in my left eye, and aren't as frequent as they were elsewhere. MRI in June was negative. OCT shows bilateral elongated discs and low normal RNFL thickness and macular volume. No LP done. Based on symptoms/MRI, does this seem like non-MS, or possibly an early attack that hasn't yet resulted in MRI-visible lesions?
A: "Your history does sound quite concerning for MS or a related disorder. Did you have MRI of the cervical spine (neck) as well as the brain? It's possible that the lesions are in the spinal cord at this point (besides the eyes). A lumbar puncture might be helpful. My main question is whether you are seeing a general neurologist or a neurologist that specializes in MS. It would probably be a good idea to see an MS specialist, especially since the initial Brain MRI was negative. A blood test for neuromyelitis optica (neuromyelitis optica-IG-g) should also be considered. If you need assistance locating an MS neurologist local to you, please call The National MS Society's Information and Resource line at 800-344-4867."
Peter Riskind, MD., PhD
December 2012
Q: In 2009 I had brain MRI and it stated " abnormal signal of T2 and Flair sequences at the white matter of the left frontal lobe without any clinical significance UBO. I then followed up with another MRI 2 years later that said Normal MRA Normal MRI everything normal. I later developed tingling in feet that turned out to be Tarsal Tunnel Synd, As a precaution we did a full cspine mri and another brain MRI with contrast. My question is if I had MS or any form CNS disorder disease would it have been spotted after so many MRIs?
A: With normal MRIs over a period of 2 years, MS is unlikely, but cannot be ruled out on that basis alone. You should discuss this with your neurologist.
James R. Lehrich, MD
November 2012
Q: My symptoms include abnormal nerve conduction study showing delayed responses in every tested area, pressure in head and ears, tremors in right leg, foggy head, fatigue, tingling in face, severe leg and foot cramps, upper and lower back pain. Head and back MRI's are all normal. Tremors present since 2007 Beginning with episodes after exercise. Other symptoms present for about a year but progressing. Neurologist says it is not MS. Could it be? What are other possible diagnosis.
A: Reduced nerve conduction time is not a feature of MS but are consistent with nerve damage or neuropathy. Many causes exist ranging from toxic exposure thru hereditary conditions. Tingling, cramps and tingling are commonly seen when a neuropathy is present. A discussion with your neurologist may help resolve your concerns.
Arthur Safran, MD
November 2012
Q: Is it possible to get MS at 66? I had 3 brief episodes of right leaning ataxia and no other syptoms. I pass Rhomberg test. My MRI report: "White matter abnormalites, although could be due to gliosis from aging. Consideration configuration concerning for MS." I see a neurologist soon and am aware I might have a spinal tap among other tests.
A: " It is still possible to develop the first symptoms of MS at age 66. However, MS is much less likely at this age, and alternative explanations (stroke, TIA, etc) are becoming increasingly more likely. You will need to have a thorough neurologic evaluation in order to uncover the cause."
Peter Riskind, MD., PhD
November 2012
Q: 2 years ago I had an MRI exposing multiple lesions suspicious for MS. My symptoms have largely abated but some remain, change, and rotate. Occasionally I have what feels like a resurgence, but nothing that rises to the level of what sent me for my first MRI. I've had regular MRIs since with no change. We are only doing brain and cervical spine. Should I be getting images of my whole spine? Spinal tap? Should I rest easy knowing that there are no new visible lesions?
A: Fixed lesions of MS can cause variable symptoms related to body temperature, exhaustion and other medications. The variations you describe are common in people with MS and do not require new lesions for explanation unless the worsening symptoms persist or cause new effects.
It would be hard to advise you about whether the sites examined by MRI are entirely appropriate or complete without knowing what the symptoms are and whether they are new or simply reflect a transient increase in old event.
Arthur Safran, MD
October 2012
Q: I am a 27 year old female. I experience extreme fatigue since a severe mono infection at age 14. Started experiencing numbness and tingling in my left hand and foot 4 years ago. Had also been diagnosed with Bell's Palsy, Interstitial Cystitis, thyroid problems... Dr ordered an MRI, which showed a focal cortical dysplasia, right posterior frontal region. (I have never had a seizure) The neurologist I saw at that time mentioned MS. I am now having extreme heat/tingling in my left foot and worsening brain fog. Dr. repeating MRI to compare to the first one. Wondering if MS has ever been tied to what they found on my first MRI?
A: No correlation is known between cortical dysplasia and MS but of course one condition does not exclude the other. Abnormalities in the spinal cord or brain could be responsible for your symptoms, or they could be the result of other medical conditions rather than MS. If the cause is still unknown after the follow up MRI's, a second opinion might be helpful.
Arthur Safran, MD
October 2012
Q: I am 49 yrs old and was put in hospital 2 years ago when my left leg went numb. I was tested for stroke and also ms. I had a spinal tap and cat scan they said the tests didn't show MS. I have previously been diagnosed with fibromyalgia which shares a lot of symptoms with ms. Is it possible to have ms without it showing on these tests?
A: It is possible to have MS without abnormalities in the tests you have mentioned. Much depends on what tests were done on the spinal fluid, whether your history suggests other remote demyelinating events (visual symptoms, weakness, bladder changes, among others). A CAT scan often does not demonstrate abnormalities very well as compared with an MRI study. It would seems helpful to consider the possibility of an MRI of the spine. It would seem reasonable to review the diagnosis with your neurologist, and if necessary request a second opinion.
Arthur Safran, MD
October 2012
Q: Hello, I am a 46 year old female. I have been having some health issues for about a year now which include intense sharp pain in my legs and hips. Pain in lower back and sometimes arms. My hands and feet are tingly and often go numb. I recently needed glasses for reading due to blurry vision. I have had an MRI of brain and neck w/wo contrast as well as a nerve study test and several blood test which all have come back normal. The neuerologist was looking for signs of MS . I haven't had a spinal tap . This was 2 months ago and the pain especially in my legs is so intense and has really changed the way I live my life. With these tests coming back normal is it still possible to have MS?
A: While it is certainly possible to have ms, given your symptoms, it is unlikely in the face of the normal MRI. Other possibilites include rheumatologic disorders, effects of medications, certain infectious conditions. Eyeglasses would not resolve the visual symptoms if they were MS related.
Arthur Safran, MD
October 2012
Q: I was diagnosed with MS in 2008. MRI of Brain showed 43 lesions and cervical spine MRI showed 3 lesions. I recently had a MRI of the cervical and lumbar spine which show numerous possible slipped discs but no lesions, not even the ones found previously. My question, can MS lesions resemble slipped discs to a Doctor?
A: The answer to the question posed, is---no, the distinction between a slipped disc and MS is pretty clear. Location for one thing, MS is in the central nervous system (brain or spinal cord) while a slipped disc is outside the nervous system in the bones and ligaments.
The additional question is related to the disappearance of the lesions. That is practically unheard of in MS. The lesions, once they have appeared, are usually there permanently, or at least most of them. So I wonder whether the diagnosis ought to be revised. There are acute demyellinating diseases---such as disseminated encephalomyelitits, which are one-shot deals. Once in while Lyme disease will cause quite a few lesions, although 43, plus lesions in the spinal cord, would be unusual for Lyme. I would get another opinion about the scans. One of the MS clinics might be helpful.
David M. Dawson, MD
September 2012
Q: I have had several episodes of severe muscle pain in legs arms and face(jaws)/spasms/tingling/headaches. always assumed it was the flu. 6 months ago I devoloped nausea, vertigo, confusion and memory issues with these episodes. Lab work only showed elevated triglycerides, and slightly elevated sed rate. MRI showed 6 lesions in my frontal lobe.EEG was normal. Im waiting to have an MRI of my cervical spine and EMG. Doctor says that the lesions (circular and all in the frontal lobe) are not consistant with where he has seen MS. Could I still have MS with lesions only in the frontal lobe?
A: Ms lesions can be limited to the frontal lobes in some stages of the condition, however your symptoms are not those expected in MS. It certainly seems reasonable to look further, as planned but it would be unusual and surprising that your symptoms as described would be related. I hope this is helpful..
Arthur Safran, MD
August 2012
Q: I have had a sound phosphene, some light phosphenes on lateral eye movement (altho I am myopic), and in dark, also some spasticity of legs/ muscle fatigue, intention tremor, and vertigo/ dizziness for some time, intermittent. Severe spastic colon/bladder for years. First cousin with MS. Also poor temperature regulation in body. Long hx intermittent fatigue of muscles of mastication/swallowing. Severe autoimmune thyroiditis. How specific is this for MS?
A: Your symptoms are not specific for MS, but it is a possibility. You should be evaluated by a neurologist.
James R. Lehrich, MD
August 2012
Q: I've been diagnosed with "silent MS' in 2010 because i have lesions in the brain but no symptoms, by the end of 2011, symptoms started as numbness, spasm and paresthesia in the leg only, my neurologist told me it's probable MS because im not meeting the criteria, the lesions are inactive, the question is how could I have symptoms in the leg while the spinal is clear, with only few lesions in the frontal and parietal lobe? Do I really have ms in this case? I also have Meniere's disease which was the reason I did MRI.
A: MS lesions may be very small and if located in a critical region can causes symptoms even if not seen in an MRI. In addition, at some point in the course of the illness, MS can progress by scarring without new lesion formation. It would be helpful to repeated the MRI with gadolinium (if not done at the time) and then do another in 4-6 months to be more certain. An alternative would be to consider evoked response testing to find hidden functional abnormalities which might mimic Meniere's disease. There is not enough information given in your question, and if concerns persist, a second opinion at an MS center might be useful. I hope this material is helpful to you.
Arthur Safran, MD
August 2012
Q: I am a 26 year old female with symptoms including numbness in both hands and feet which seems to be related to sleeping. For example if I sleep on my left side, the symptoms are worse on that side. I have occasional trouble swallowing, muscle spasms in my back and neck (2 episodes), some blurred vision. I had MRIs -brain, cervical, and thoracic, all were found completely normal. The neurologist diagnosed me with carpal tunnel since I have had pain in my wrists but I am still quite worried. Would my next step be to have a spinal tap? Would I be risking a better prognosis if I waited 6 months and had more tests done? Would waiting give more definitive results?
A: You need to ask your own neurologist about this. The symptoms you describe are not highly suggestive of MS, and the normal MRIs should be reassuring.
James R. Lehrich, MD
August 2012
Q: I'm a 22 y.o. male who's been experiencing neurological symptoms for the past 9 months including constant stiffness in the right leg, visible body-wide fasciculations (esp. in calves), and intermittent tingling in the right hand and foot. I've had two negative MRI sets (Brain, C-Spine, T-Spine) with and w/o contrast & a negative EVP, one set at symptom onset and the other 6 months later (normal exams too). Second opinion with MS specialist agreed with my neuro. The symptoms have continued, should I continue to fear MS/PPMS in particular?
A: Response: Your symptoms could be due to a neuromuscular condition. You should check with your neurologist whether an EMG-nerve conduction test is required. The presence of negative MRIs supports that this is not MS.
Tanuja Chitnis M.D.
July 2012
Q: If I have no lesions on my brain, but healed (lesions) on my spine is it definitely MS? Both sides of my body were numb and tingly, not just one. I had a lumbar puncture. Will this be "normal" if I do not have MS? Can you have healed lesions on spine and NOT have MS? Can you have healed lesions on spine and it be benign MS?
A: Your description suggests that you may have transverse myelitis. That condition can develop without recurrance and not all cases go on to become MS. There is some disagreement among neurologists about whether a isolated bout ot TM (transverse myelitis) should be treat with the usual disease modifying agents used in ms. There is evidence to suggest that these agents delay or may even prevent the evolution of TM to MS. Even without treatment the spinal disorder can stabilize and not recur. I hope this is helpful to you.
Arthur Safran, MD
July 2012
Q: I’m 47 year old female. Ive been having muscle pain since i was 17. Recently, Ive been waking up to pain in my legs. I wake up as though I’ve run a marathon. My muscles are heavy, they feel like they are in constant spasm. walking is becoming difficult especially burning in my upper thigh areas. I’m exhausted when i wake up but by noon it gets worse. I have a hard time remembering things and following conversations. My MRI came back negative. Will a spinal tap definitely show me what’s wrong? Can you tell me what tests i should be getting or if this even sounds like MS ? I have 5 cousins with MS and my daughter and sister have the same symptoms I’m describing to you now. Thank you
A: Your condition is complex but has more of the quality of a neuromuscular disorder than MS. I doubt that a spinal tap will resolve the situation.
Given your family history, it seems to me that a consultation at a major medical center with a neurologist who specializes in neuromuscular disorders would be a prudent step. I hope this is helpful to you.
Arthur Safran, MD
July 2012
Q: I am a 56 yr old woman in 2007 had a mri showed 20+ lesions,2008 multiple areas of high signal in periventricular & subcortiical mild to moderate white matter disease.2009 multiple areas para periventricular white matter some abut ventricular system.most lesions measure 2 and 5-6mm slightly more confluent white matter posterior to occipital horns lateral ventricles bilaterally 11mm & 9mm.2012lesions in periventricular white matter¢rum semiovale,corpus callosum & pericallosal region dawson fingers appearance lesions temporal lobes. Csf normal. Have gait, balance,muscle spasms, pain bowel inconst pins and needles dizziness, small fiber neuropathy. Dr says no MS due to normal CSF. I've had this for 6 yrs. MRI gets worse everytime. Do I have MS??
A: Your description sounds like MS, but in order to make a full diagnosis, the neurologist would have to know what the full clinical picture is like, including results of the neurologic exam, and medical history. There is nothing definitive about the CSF if it's negative. You might still have MS. You need to follow up with your neurologist.
Linda Y. Buchwald, MD
July 2012
Q: My boyfriend has been sick since October when he returned to Germany from Africa. The doctors tested for everything and were sure he had MS. They say he has all the symptoms but the tests were negative. He has tremors, occasional paralysis, feels unbalanced and many more issues. They're stumped. What else can they test for?
A: Sorry that your boyfriend is ill. Since he travelled abroad, he needs to see a tropical disease specialist. There are odd viruses and other infections that you can acquire in Africa and only a specialist would be fully informed about these. He could have chronic fatigue syndrome which sometimes starts abruptly. MS is still possible although practically everybody with MS has evidence of it on MRI scans,if they did complete scans of head and cervical spine.
It may be a long and difficult process to get this all sorted out. Best of luck
David M. Dawson, MD
February 2012
Q: I'm a 42 yo female with neuro symptoms for last 21 months. Started with left eye pain/spasm and left pinky/ring finger numbness. MRI/LP/EMG negative 9 mos ago. Aside from 1 small flair on T2 in subcortical white matter. No optic neuritis. Progressed to constant vibrating/buzzing hands/feet. Tremor in hands, esp in morning. Feels like electricity running thru extremities. Neck ache, weight loss, fatigue. Brain fog. Muscles quivering. ANA was weakly positive but additional rheum work up negative. Lyme negative. Could this still be ms. Where to go from here?
A: As you point out, the diagnosis is not clear. Your symptoms are not typically those seen in MS and other tests and examinations do appear appropriate. It would seem reasonable to talk with your neurologist about a second opinion at a medical center.
I hope this is helpful to you.
Arthur Safran, MD
July 2012
Q: 3 months ago I started getting constant migraines. Followed by muscle weakness and numbness on right side of my body and left side of my face. They did an MRI which said possible early demyelination? Since then I had a repeat of same symptoms but when I took Imitrex the frontal lobe pain went away but not the pain at the base of my skull. Neuro did a cervical MRI which was normal. Also I did interferon 10 yrs ago for hepc. Could that affect these results? Also both occurrences started with my period, should I go see someone else?
A: Migraine causes MRI changes which can mimic those of Multiple Sclerosis and your description suggests that diagnosis. There is a form of migraine (hemiplegic migraine) which can cause the kind of symptoms you describe.
If you do in fact have hemiplegic migraine the use of imitrex can be associated with complications. It would seem to be reasonable to review this possibility with your neurologist, and if concerns remain to consider a second opinion possibly at an MS center.
I hope this is helpful.
Arthur Safran, MD
July 2012
Q: I am 26 years old female and a medical student. I suddenly had ptosis in my left eye and myocolonic movement in left side of my face after my first night shift at the hospital , the symptoms lasted for 2 weeks and were treated after I took clonazepam. My neurologist assured me that I had a normal MRI and also the 6 month follow up MRI was normal.
2 years after that, with a huge stress, I had a sudden episode of reduced sharpness of vision (with no eye pain) in my left eye.
My new MRI report says: There are a few preventricular and pericallosal hyperintensitis in both centrum semiovale. there is typical involvement of corpus callosum and both frontotemporal lobe subcortical white matter. infratentorial involvement is present in the pons and right brachium pontis as well as right side of the medulla. Is it really the "MS"? are there any chances that its just due to stress? I work a lot and I have lots of stress as a doctor in night shifts.
A: Other conditions can produce the MRI you describe, including migraine. The diagnosis of MS is possible but the criteria for diagnosis are not met based on the symptoms you describe. Another MRI with contrast enhancement should be considered in 3-6 months to help determine activity, and more importantly the original MRI should be physically compared to the current one. Techniques, and interpretive skills vary widely. It would also be important to know if you experienced a viral illness associated with any change in level of alertness or confusion. Finally, a visual evoked response (VER) seems warranted to determine if in fact there is any optic nerve involvement.
I hope this is helpful. If doubt remains other tests can be considered and a second opinion at an MS center may be useful.
Arthur Safran, MD
June 2012
Q: What are the benefits of a lumbar puncture for a person who has the diagnosis, inactive Radiologically Isolated Syndrome (2010), remains to have no clinical findings or events, had a stable MRI/MRA of the brain (9 months ago), with no MS-related findings on a cervical and thoracic MRI/MRA, and no blood tests findings beyond anemia? Can a lumbar puncture diagnose MS in this situation? If I have MS and am asymptomatic, would the test even present positive during a potential remission?
A: I cannot see value in a lumbar puncture in the situation you describe unless there is some question about the diagnosis. There are some studies looking at MS markers in various body fluids but if a lumbar puncture is done for that purpose it should be described as such.
I hope this is helpful in your review.
Arthur Safran, MD
June 2012
Q: About two and a half years ago at age 31, I was very stressed at work and felt "dizzy" for about two days. The MRI came back with a spot in my white matter and my neurological exam was negative and my neuroligist said that the spot on the MRI was non-specific and did not look like an MS lesion based on the location,but the neurologist suggested I have a lumbar puncture... the lumbar puncture showed two oligoclonal bands. ... So here I am at almost 34 with no new symptoms and two repeat MRIs approximately 8 months apart that show the spot is unchanged. Can generally healthy people have two O-bands? Does the presence of O-bands put me at increased risk of developing MS?
A: 2 oligoclonal bands are not necessarily significant, especially without changes in MRI, symptoms, or neurological examination. You should continue regular follow-up with your neurologist.
James R. Lehrich, MD
May 2012
Q: I'm a 48yo female recently diagnosed with Relapsing MS. I've had MRI's of the Brain, Cervical and Thoracic spines. All tests indicate Relapsing MS. Is it necessary to also have a spinal tap or are the MRI's along with other testing sufficient to dx Relapsing MS?
A: The diagnosis of relapsing multiple sclerosis can often be confirmed using the clinical history and neurological examination in conjunction with the MRI studies. There is often no need to examine the spinal fluid, and this is not required to establish a diagnosis. However, if the history or the MRIs are not typical and there is any question about the diagnosis, a spinal tap can yield important information which could help confirm a diagnosis.
Ellen Lathi, MD
May 2012
Q: I am a 54 year old female. Had MRI with contrast it came back positive.... I experience left leg severe foot drop and also fatigue. I had a lumbar puncture and it came back negative. Can I have MS with a Negative lumbar puncture?
A: The answer is yes. The clinical picture and MRI findings suggest at least clinically isolated syndrome. We would need more information, in order to make a more specific diagnosis. A negative lumbar puncture or spinal fluid results does not exclude MS.
Linda Y. Buchwald, MD
May 2012
Q: I have fibromyalgia(but not MS) with pain being more apparent on the left side of my body. [I’ve experienced burning sensations and stiff muscles, and now muscle spasms over the past 18 months]. All my test (blood, nerve, muscle and evoked potentials) come back normal except for three small sub-cortial white matter lesions in my frontal lobe. Question: Would a spinal tap be beneficial? What percentage of MS diagnosis show up in the spinal tap when all other tests appear negative?
A: Your symptoms do not suggest MS, although presentations can be atypical. Cerebral Spinal Fluid testing is rarely positive if MRI lesions are not seen, and the variability in duration and location of your symptoms would suggest a relatively large number of sites in the brain and spinal cord were the cause found to be MS. Fibromyalgia is assoicated with MRI lesions in the brain, and waxing and waning moveable sensory symptoms.
Of course other causes may be present, since fibromyalgia does not exdclude the presence of another condition.
If you and/or your neurologist are uncomfortable with the diagnosis, a second opinion at an MS center might be helpful.
Arthur Safran, MD
April 2012
Q: 65 years old. For the past four months I have been experiencing numbness, pins-and-needles and/or burning in left arm and leg, and sometimes in right leg. For past year, left leg weakness, occasional slight bladder incontinence and loss of balance. Recently had a few visual-spatial disturbances and right-sided ear clicking which have resolved. Always feel worse in hot weather. Neuro exam was positive for mild left-sided weakness, tandem gait, Romberg sign and hyperactive reflexes. Open MRI of brain w/o contrast showed only "few tiny punctate foci in subcortical, periventricular white matter, probably small vessell disease." Cervical MRI showed degenerative arthritis. Negative carotid doppler. Normal BP. Normal blood tests. Neurologist is unsure of dx. at this time. Is it possible to have MS at my age?
A: The short answer is yes, it is possible to develop symptoms related to MS at age 65. It is however unusual to have the symptoms you describe (which suggest a possible problem in the cervical spinal cord) caused by MS with the MRI findings you have presented.
Given the circumstances another neurologic opinion may be wise, along with other tests which might include an MRI made with a contrast agent (gadolinium) which might disclose further information.
I hope this is helpful.
Arthur Safran, MD
April 2012
Q: January 10th I had a possible stroke... headache, left side paralysis, memory loss. CT and MRI came back clean and they marked it up to stress. Follow up with my family dr. said I had a probable RIND stroke and he put me on Diltiazem. Feb 17th my fiance noticed the left side of my body was twitching, followed by a headache and another stroke again left side paralysis, memory loss and speech impaired. Tremors and eye jumping is increasing and getting worse, it even wakes up my fiance. Again MRA clean, still waiting on EEG results. Dr. said my Estrogen is low- but I have not symptoms. His theory is give me estrogen and it will stop headaches which will stop strokes. I have several symptoms of MS, but have not been diagnosed with MS. Family Dr. said if I had MS he would see in on MRI, but everything we read says MS is hard to diagnois. My doctors said it's easy. Should we still push for answers and not go with the estrogen theory? Also I had estrogen shot 24 hours ago... stil having headache and tremors.
A: You raise several complex issues. Without more information it is difficult to suggest a reasonable diagnosis but your description raises the possibility of a condition called hemiplegic migraine, which might respond unfavorably to hormonal treatment.
I would urge you to seek a neurologic opinion. The epsodes you describe are not likely to be MS.
I hope this is helptul to you.
Arthur Safran, MD
April 2012
Q: My husband had vertigo and headaches 7 yrs ago and they suspected MS but it was not proven. Now, he has optic neuritis with a banding sensation around his foot and leg, plus the vertigo, ringing in his ears. His brain MRI still shows the spots with a few new ones. His spinal MRI remains negative. No doctor wants to say definite MS. Why is there a reluctance to make the MS diagnosis? What are the chances that all these symptoms are from other causes but coincidentally point to MS?
A: You are dealing with some old fashioned ideas here. It used to be—that the MD would wait on making the diagnosis of MS until there was no doubt. No more. There are treatments now that can prevent a person from getting worse, and one of them should be started earlier rather than later, to gain the advantage of early control of the disease.
Judging from the symptoms you report, it is at least a 50:50 bet that your husband has MS.
The best course is probably to call the MS Society at 1800-244-4867 and find an MS clinic near you. They will be the right people to take the correct action.
David M. Dawson, MD
February 2012
Q: I'm a 22 year old female and 4 months ago I started experiencing tingling in both of my arms and legs. They found out that I had a mild vitamin D deficiency and put me on 50000 IU vitamin D2. 3 months ago I had an MRI done which showed 2 brain lesions with only one of them being suspicious for MS. My neurologist also did a spinal tap and an MRI of my neck/spine and everything came back completely normal. I also have a history of migraines with aura but at the time where my symptoms started I had no problems with migraines until they just recently started getting worse again. My neurologist says he doesn't think it's MS since it's unlikely that all four extremities are involved and since the tingling starts most of the time at night when I sit/lay down. All he wants to do is a check up MRI of my brain in 11 months but I'm wondering if this could still be MS? Could my symptoms be related to the migraines?
A: There are several responses to your questions:
- Vitamin D deficiency would not account for your symptoms
- Migraine can cause MRI abnormalities in the brain which persists long after migrainous episodes stop.
- Tingling in all 4 limbs related to positional change suggests the possibility of a problem in the spinal cord
- The normal spinal fluid examination makes MS unlikely (assuming the proper tests were carried out on the fluid in a reliable laboratory)
- At the time of the next MRI your neurologist might also consider including images of the spinal cord
- If symptoms persist and the tests are normal, a second opinion at an MS center might be considered with your neurologist.
I hope this is helpful.
Arthur Safran, MD
April 2012
Q: A year and a half ago I had a MRI of the BRain to r/o MS because of my identical twin having MS, it showed a lesion. Six months later I had another one and it showed six lesions. I just recently had a third MRI (anther six months) and the lesions are gone. Meanwhile I have been having MS symptoms since the first I thought the chances were really slim for a set of identical twins to both have MS. My neurologist wants me to have a spinal tap done due to being perplexed as to why the brain lesions have improved. Could it still be MS? Or could I have some sort of infection that went undiagnosed? I'm curious as to what a spinal tap will show, or what she could be looking for with me having a spinal tap. Is this something you would recommend as well? Should I have the spinal tap?
A: Unfortunately there is an increased incidence of MS in twins, more so for identical twins. It is common for MS lesions to "disappear" in an MRI. The actual lesion remains but the surrounding tissue swelling which the most prominent of the MRI changes resolves over months leaving scars which are much smaller and harder to detect. The symptoms relate more to the location of the ms lesion than its size and many non-eloquent areas of the brain may be involved causing no clinical symptoms.
The lumbar puncture may show chemical abnormalties which would tend to confirm an MS diagnosis, or even possible suggest another disorder. It appears to be a reasonable suggestion. Another option would be to have yet another MRI in 4-6 months along with an contrast injection to determine if another lesion has developed. I hope this is helpful to you.
Arthur Safran, MD
March 2012
Q: My wife was recently tested for T3, T4 thyroid issues, but recently receives test results that were inconclusive for any particular condition. 2 years ago, a week after our second daughter's birth she suffered from a visual migraine and resulting scotomata which has left her eyesight cloudy since. About 3 months ago she had another visual migraine and since then has had general weakness, tremors in her legs and hand (they don't actually move just feel shaky) heart palpitations, low blood pressure but high resting heart rate, lightheadedness. Her doctor hasn't recommended an MRI, but after pathophysiology (I'm a older nontraditional premed student) I feel like the tremors she is experiencing might be symptoms of MS. Would this be a fair assumption? Thank you!
A: The short answer is probably no, the symptoms do not sound like MS. Much depends on the reasons for making the diagnosis of visual migraine. That condition is not usually mistaken for MS given the history, onset, residua and opthalmologic testing results.. If you and your wife are uncertain, consider asking your neurologist about another opinion at an MS center, or with a neuropthalmologist.
I hope this is helpful.
Arthur Safran, MD
February 2012
Q: I have Chronic Lyme Disease, (diagnosed by a Doctor). The symptoms are similar to MS. I was tested positive for Lyme, could I possibly also have MS? I've had trouble for many years, tested negative on spinal tap twice in my life but just in December 2010 they found I had Lyme for some time. Was treated with Doxy and IV-Ceftin. Dr.told me I'd be difficult to treat and cure and she was right. I still was walking with a cane after treatments. I get shooting pain in mostly both legs when I complete a mile walk, anything more is too difficult. Legs tend to give way at unexpected moments. Vision has been getting more blurry. I have a large numb spot in middle of back for several years and gives me pain at times. Was diagnosed with neuropathy. Often times my right side of my face tingles. There's so many other little symptoms. Right foot has gone numb from walking also. Your thoughts would be helpful,thanks.
A: While MS cannot be excluded, your history is not typical for that condition, nor is neuropathy usually manifested by a numb region in the center of the back. It is quite unusual for spinal fluid testing for be normal in MS ( assuming the correct laboratory studies were done for that condition). Chronic Lyme disease is difficult to treat even if the causitive organisim had been eliminated by antibiotics.
The visual symptoms are of concern, unless related to fatigue or medication, or a refractive error. Referral to a neurologist is certainly a reasonable next step to help further sort out the features of your condition and correlate them with your examination. I hope this is helpful.
Arthur Safran, MD
February 2012
Q: I am a 28 year old white female and for the past three weeks, I have been experiencing new symptoms. These had included poor balance (first one I noticed), ingling/numbness, dizziness, painful muscle cramps, eye pain, constricted feeling in my chest, muscle twitches and severe weakness in my legs that cause my knees to give out, making it extremely hard to walk or stand. My general doctor had an MRI done but said that was completely normal. Could this really be MS even if it doesn't show up on the MRI?
A: This is a tough situation. I would start with the information that MRI studies of the brain are positive---show areas of MS inflammation--- in more than 95% of patients. Therefore one would have to consider alternative diagnoses: Lyme disease, fibromyalgia, lupus, being several choices. There are tests for many of these conditions..
But there still is a chance that you have MS. You might want to talk to your doctor about the following ideas: repeat the head MRI in a month, include the spinal cord in the next round of tests, and make sure that the scan that was done was extra good quality (sometimes they do just a screening scan without a great deal of detail).
Did anyone check to see if your neurological exam is OK? In the old days people used to do a spinal tap, to look for high gamma globulin, often found in MS patients. That has been given up as a test. You are going to have to rely on the MRI for certainty of diagnosis.
David M. Dawson, MD
February 2012
Q: For 2.5 yrs I have been suffering with severe headaches,numbness optic neuritsis,visison problems,temors as wells as numness and stroke like symptoms. I have seen neumerous neurologists and had MRI done where they found lesions. Ive been on topamax, immentrex, treximet, as well as other meds that have not helped. I am currently on 900mg of neurontin for my temors and have just has my 2nd spinal tap. Yet no one will confirm MS and by spinal fluid tested neg for Lymes but my ANA tes came back positive. But the double dna strand test came back neg. Any idea what I am suffering from?
A: "Unfortunately it is not possible to make a diagnosis of a complicted neurologic problem without having seen and examined you and without reviewing the MRI's and all of the lab test results. Sometimes it is very difficult to reach a diagnosis even after doing a very comprehensive evaluation, and the physician may need to see you multiple times over a long period before the dignosis is clear.
Your best chance of getting the right diagnosis is to be seen in a specialized multiple sclerosis- or clinical neuroimmunology- center. If you feel you are not progressing toward a diagnosis and treatment plan, it is entirely legitimate to request a second opinion."
For assistance in locating an MS Neurologist in your area, please contact the Society's Information and Referral Line at 800-344-4867.
Peter Riskind, MD., PhD
January 2012
Q: I'm a 33year old female experiencing numbness, tingling, and weakness to my right side of body (affecting my right arm and leg, as well as the right side of my face and tongue). I've had a spinal tap, MRI, CT-scan, and various labwork. My MRI did come back with one lesion and my neurologist said that the spinal fluid came back with 3 "markers" indicating positive. I also had a positive ANA result. My CT was clear. Lupus and possible arthritis were ruled out by urine and blood samples. Would you agree with my neurologist's opinion of an MS diagnosis?
A: The diagnosis is probably correct but in the absence of additional lesions and a history of more than one attack the criteria for a definite diagnosis seem not to be completely met. Ordinarily another MRI done with an intravenous contrast agent would be considered in several months to be more certain.. Did the MRI include a study of your spinal cord? Do you have any cardiac problems? Is your vision or your bladder affected? How positive was the ANA test (measured by titration) which ANA test and confirmatory tests were done?
All in all, a second opinion at an MS center would be something to consider. If you need to find a local MS Specialist or MS Center in your area, please call the National MS Society’s Information and referral line at 800-344-4867, and ask for a referral in your area.
I hope this is helpful.
Arthur Safran, MD
December 2011
Q: I had an episode of optic neuritis while in college in 1987, that resolved completely. Months later I had numbness in one of my arms that lasted on-and-off for about a week. It was treated with daily at home cervical traction. Other than these occurrences and discovering last year that I have/had serious iron-deficiency anemia, I am very healthy and very active. As a result of a routine info gathering discussion with a new doctor in 2003 I had an MRI done due to the optic neuritis history. The MRI showed plaques in typical ms areas and I was then diagnosed with MS. I do not have ANY episodes and haven't had anything unusual since the '87 and '88 incidents. Is it possible I do not have ms? I really don't feel like I do. Thanks!
A: I would start out with congratulations. Whatever you have is leaving you alone and not hassling you. Then we come to definition. You have a scan that looks like MS, and had two relapses. I say you have MS. But—there is a sub-category of MS, known as benign MS, affects about 10% of all the MS people—that would be what you have, I assume.
Then we come to the decision about whether you should start treatment. You could find some MS experts who would say, the risk of further relapses is small, but it isn't zero, and you should be treated with one of the long term medications. I don't think so. I would recommend an MRI every couple of years—if that is quiet, then just continue to monitor, with an occasional MRI if there are any doubts.
Of course you'll need to be taking iron supplements.
David M. Dawson, MD
December 2011
Q: I am a 38 year old female who had numbness on left side of body with extreme pressure in the back of my head for ~2 days, 3 months later optic neuritis in right eye and 3 months after that experienced feeling of "bugs" moving in my forearms and legs which lasted ~5 days. LP had 1 oband, 3 sets of MRI (brain & spine) were all negative (no lesions). EVP showed delay in right eye. Lyme disease negative. IgG levels low. I've been seeing an MS specialist but she says she needs to do more tests. Could this be something else? Or is it possible to have MS and no lesions on brain or spine at this time?
A: It is possible to have MS with negative MRI's - about 5% do (old figure- maybe less today with better technology.) If it is MS, there is a better prognosis with early MRI of the brain being negative. I don't know what other tests were done, so it is difficult to comment. It is possible to have another inflammatory disorder or systemic(medical) disease. One would want to know what your objective findings were at or after the time of symptoms in consideration of an MS diagnosis.
Linda Y. Buchwald, MD
October 2011
Q: I was diagnosed with MS 17yrs ago. MRI had 2 lesions, spinal tap came back with 3 bands and had optic neuritis at time of diagnosis. I was recently hospitalized with pain in left arm like a bp cuff was around upper arm and shock like symptoms in the left chest area. All Cardiac workup was normal. Had an MRI done and it shows as normal study. Does this mean I was misdiagnosed with MS all those years ago? I did take Copaxone for 3 years.
A: From your description of your symptoms and laboratory findings 17 years ago, it appears likely that you do have MS. Your current symptoms have not been explained so far, but this does not mean the original diagnosis was incorrect. We do not have enough information to comment on your recent and previous brain MRIs. An MRI of your cervical spinal cord might be helpful.
James R. Lehrich, MD
October 2011
Q: I am a 29 yr old female with intermittent symptoms mainly over the last two years but the first symptom started 5 years ago. The first symptoms to appear were pins/needles and numbness(lef side mainly), double vision, dizziness, off balnace at times. In the past 6 mos I have had de-sensitivity in touch, temp., severe fatigue and weakness, stuttering, trouble "finding" words, knees have gone out twice, brain fog. I had a MRI 1.5 yrs ago and another one yesterday(without contrast) that came back normal. I did have an EEG that showed slowing in the left temporal lobe. I am frustrated because I feel horrible and yet no one can tell me what is wrong. What tests should I try now? or should I just drop it? Should I have a MRI done of my full spine or spinal tap?=
A: Your symptoms are complex and could be caused by several different conditions. It is quite rare to have a normal MRI after this period of time coupled with your medical history if MS is present.. I would suggest a visit to an MS center where an evaluation to look for MS as well as other conditions could be made.
It is not clear to me that a spinal MRI and/or a spinal tap are warrented but after a full review of your history, laboratory tests and examination one of these tests might be appropriate.
Finally, MRI interpretation skills vary in different settings, and if you choose to visit an MS center you should bring all of youor medical records, including the actual MRI with you.
I hope this is helpful.
Arthur Safran, MD
October 2011
Q: I am a 53 year old woman. About five months ago I began having a burning sensation on my right forearm near my elbow. It feels like a severe sunburn when touched. I have seen a neurologist and just received my MRI results. He said that I had several white scars on my frontal lobe probably due to migraines. I do have frequent headaches, but most can be handled with ibuprofen. The burning sensation has diminished. The doctor wants me to call him if anything changes. The doctor assures me that the white scars are not MS. Do you think he is correct?
A: Yes, I agree with his conclusions. Small white spots like this have very little significance. Migraine is a perfectly reasonable explanation. In MS, the spots are larger, located in different areas, and nowadays, with modern techniques, can be recognized for what they are. I wonder if the problem in your arm was a damaged nerve under the skin. In any case, I think your neurologist is on the right track.
David M. Dawson, MD
October 2011
Q: I am a 35 year old female that was diagnosed with MS about 3 months ago after many blood tests, a MRI with and without contrast that showed lesions and a LP positive with 1 oligoclonal band. I just received results from my 6 month MRI that showed no changes. I sit possible I was misdiagnosed and do not have MS or is it common to show no changes in 6 months?
A: It is quite common to show no new lesion development 6 months after the diagnosis has been made, and implies a low activity of the condition, possible related to treatment. When a person has a single bout of a neurologic condition, and the diagnosis of MS is not clear, it is common to repeat an MRI in 6 months to be more certain of the presence of MS. This is done to confirm that the condition has a relapsing component. There is not enough information in your note to be certain that is the case. If the diagnosis is secure, the absence of change is a good sign. If the diagnosis is not certain, the absence of new lesions at this point continues the uncertainty. There are very few conditions with oligoclonal banding in the spinal fluid and abnormal MRI's which are not MS. A careful history and physical examination should usually permit a diagnosis given the test results you describe.
If uncertainty persists, a second opinion at an MS center may be helpful.
Arthur Safran, MD
October 2011
Q: For several years I have been having nerve pain, muscle twitching, muscle weakness, eye pain with loss of vision etc. trigeminal neuralgia I have had several MRIs that have shown multiple "lesions" in the white matter with new lesions on successive scans, the radiologists reports swing from age related changes to possible MS. In January I had something happen to me that made me temporarily unable to move that slowly dissipated. My muscles have not regained the tone or strength they had formerly. Doctors keep saying that since my LP was negative for o bands and I can walk then I don't have MS. Now I finally got an eye exam and it shows some loss of optic nerve thickness but still I am told I am just getting old. I am 53 now but I was in my late 20s when this began. Is there a reason Dr.’s don't want to diagnose ms. I have been dealing with this so long and the pain is getting so bad i don't know how long I can handle it.
A: It is difficult to be clear about the proper diagnosis because much more detail is needed which can best be elicited at a face to face review and examinationi.
The symptoms and conditions you describe, if they do indeed include trigeminal neuralgia, epsisodic weakness, and progressive MRI changes are consistent with MS and although spinal fluid bands are found in the vast majority of cases, no single test can either prove of disprove the presence of the disorder. There are in fact several other conditions which might account for the problems.
In this circumstance, a visit to an MS center for another opinion seems a reasonable next step.
I hope this is helpful to you.
Arthur Safran, MD
September 2011
Q: I'm a 30 year old female. In March 2011 I had an episode of blurry vision that lasted about 10 mins then 2 days later I got a massive headache that started in my neck and moved up the back of my head. I went to the general practitioner and he said migraines. Well after about two weeks of headache and on and off of blurry vision I became normal then June 2011 again it happened again, so I went to the ophthalmologist, who didn't find any vision problems or optic neuritis. I met with a neurologist- he did a physical exam and said it was normal, including my optic nerve, and suggested further testing. I decided to have the MRI and lab worked ordered but found out I'm pregnant so could not have testing done I’m just so confused and scared I still have like spots in my vision every now and then bad neck pain so I think after I have the baby I should go have an MRI done I just don’t know what to do I need help please.
A: Your episodes have the usual characteristics of migraine and not MS. An MRI might even be misleading because migraineurs often have "UBO's" known as unidentified bright objects which can be confused with MS. If your current opthalmologic and neurologic examinations are normal, if you have no past history of optic neuritis (the episodes you describe at not typical of that condition), of limb weakness or paralysis lasting more than 24 hours, of double vision, sensory loss, incontinence (all lasting more than 24 hours) I would follow the advice of your treating neurologist.
If you remain concerned, a second opinion is certainly reasonable, but again your symptoms, age, and hormonal situation are all consistent with migraine and do not suggest MS. I hope this is helpful to you.
Arthur Safran, MD
September 2011
Q: I have had MS for three years now and a few days ago I woke up with a splitting pain in my neck. Then later the next day my left arm went numb and eventually felt like it was 'asleep', and now I can barely use it. Are there treatment options available and is it even MS related?
A: Sudden pain like this is not common in MS, and I would wonder if this is a herniated cervical disc instead. You will need to see a neurologist, and no doubt will need to have an MRI scan that shows the cervical region. This is especially true if the pain travels down the arm—you mention numbness of the arm, but not traveling pain. If the scan shows a new MS lesion then you will probably need to have a course of intravenous steroids. For acute flare-ups of MS—if that is what is going on—steroids are very effective.
We hope that you are taking one of the long term MS drugs—such as interferon, glatirimir, or one of the new ones.
David M. Dawson, MD
October 2011
Q: I have been having tingling and numbness in both hands and both feet for about 3 weeks. An MRI showed "five punctate gliotic foci involving the deep white matter of the frontal lobes. One lesion involving the left pericallosal white matter does demonstrate perpendicular orientation."
There was no enhancement following the administration of contrast. The MRI of spine was unremarkable. Also, a spinal tap showed no myelin protein or oligolonal bands. What are the chances this could still be ms? Is it possible that the tests were performed too early after the onset of symptoms? Thanks!
A: Your symptoms and the MRI findings suggest that you have an illness involving the central nervous system; MS could certainly still be the cause, although it is key that other possible explanations are also considered. The spinal tap results are NOT absolutely definitive- it is still possible that you have MS.
My suggestion is that you see a neurologist with experience in MS.Usually a detailed history and neurologic examination are extremely helpful in situations such as yours.
Peter Riskind, MD., PhD
October 2011
Q: I'm a 34 year old female who presented with new onset hypertension being 140's/90's to 150's/100's. I started having severe headaches and numbness to my right foot about a year ago. About a month or two ago, I started having blurry vision and seeing spots and one night my right eye went dark. I didn't lose total vision. The Doctor ordered an MRI which said: Few tiny flair hyperintensities due to microangiopathy in the white matter. Likely causes demyelinization diseases (ms or lyme disease) Less likely causes, migraines, vasculitis, or Adem... and Mild thickening of mucosa in ethmoid sinuses. My headaches are extremely severe with extreme eye pressure. Any thoughts?
A: [You] do not have to worry about having MS. These small bright spots on MRI scans can be a source of confusion. But in this case they are small, and aren't located in the correct areas to be MS spots. People with migraine have them, and especially people with high blood pressure (an issue in this case). The spots probably are the result of leakage of a tiny amount of fluid from blood vessels, which can happen with hypertension. I know the reading from the radiologist differs from my version but I respectfully disagree.
- The problem with the eye---temporary loss of vision--needs an explanation.
- An eye doctor can measure the pressure in the eye, to exclude glaucoma.
- There should be a sonogram or flow study in the carotid artery on that side.
- And the retina itself should be looked at by an eye doctor. The high blood pressure should be investigated further as you are quite young to have a blood pressure at that level.
David M. Dawson, MD
September 2011
Q: I am a 48 year old female who has in the last 4 months been experiencing most of the symptoms of MS. I have at least one of these symptoms bothering me everyday. I had an MRI and the neurologist said that it was normal and there was no reason to see him again. I am still having symptoms with no reason for them. My mother had MS. I also have Crohn's Disease. Should I stop worrying about the lack of interest on my neurologist's part or should I insist on further testing and if so, which test should I insist upon?
A: The conclusion that you presently don't have MS should not be construed as your neurologists "lack of interest". M.S. is often not easy to diagnose, as evidenced by the accepted diagnostic categories of: (1.) Possible; (2.) Probable; (3.) Definite. The tools for diagnosis include: (1) The story; (2) The neurologic examination; (3) The MRI; (4) Examination of the spinal fluid; and(5) Visual Evoked Potentials
Each of these tools vary in their sensitivity and specificity Most sensitive is the MRI. Most specific, is oftentimes the story. A normal MRI does not absolutely rule out MS, but it is unlikely if normal. A 1st degree relative with MS is a concern, there being a +/- ten fold greater likelihood. The symptoms you have noted in your question are very non-specific, could have other causes including their being caused by Crohn's disease.
I would suggest that "further testing" is to continue sharing your concerns with your neurologist and to trust in their ability to bring some certainty as to their cause. Hopefully, it won't be MS.
Richard Toran, MD
September 2011
Q: It is my understanding that on an MRI white spots from MS and migraines look different. Can you explain the difference? Are their "classic" MS-looking spots and typical migraine-looking spots?
A: The distribution in the brain is different. Often there is a difference in size and shape. The MRI alone is not sufficient to either establish or disprove the diagnosis.
Arthur Safran, MD
September 2011
Q: I recently had an MRI showing chronic demyelination based on subcortical white matter focus of T2 and FLAIR hypersensitivity. It goes on to say that DWI, ADC, and EADC sequences demonstrate mild increased diffusivity. The MRI was performed due to an increase in migraines. I have had migraines, short term memory loss (I teach and tell my students I have a swiss cheese memory), depression, difficulty reacting to new circumstances-processing information and probably some more things I am unsure of. I did not know to ask the neurologist about MS or if these findings show evidence of the lesions associated with MS. I am due to have nerve testing in my wrists as I also believe I have undiagnosed carpal tunnel.
Do these results seem indicative of MS and what should I be asking my neurologist during the next visit? They just put me on Topamax to increase the myelin production (or that was my understanding).
A: The MRI findings you describe are quite typical of migraine. While MS cannot be excluded the description does not suggest its presence. You should ask your physician for further information and an inquiry made as to whether you history or examination suggest MS. I hope this information is useful to you.
Arthur Safran, MD
September 2011
Q: I am a 34 yo woman who has had two separate episodes of tremors in my right hand, along with numbness and pins and needles in both arms and left leg. I have become terribly fatigued, cognitive difficulties, have trouble urinating, blurred vision and vertigo. My mother and grandmother have autoimmune problems. My neuro exam was normal, as was a nerve conduction study on my right hand. I was sent to a neurologist by my PCP and he sent me to an MRI, which was normal. He told me to reduce my stress and prescribed Ativan. The MRI, however, was a .7t open MRI, which I've heard is not sufficient to detect ms lesions. What should I do next? Thanks!
A: While it is true that the open .7 tesla MRI is not the most sensitive for finding MS lesions, you could certainly have a significant neurological illness even if an optimal brain MRI was normal and your exam was "normal". It would be worthwhile to get a second opinion, ideally with a neurologist that sees MS and related illnesses.
Peter Riskind, MD., PhD
August 2011
Q: Is it possible to have MS without having optic neuritis and with normal evoked potentials?
A: The short answer is yes. Optic neuritis is not required to be present for a person to have MS. Evoked potentials are almost invariably abnormal in optic neuritis but may be normal in MS. It depends on where the lesions are.
Hope this is helpful.
Arthur Safran, MD
April 2010
Q: I was diagnosed with Lupus 14 years ago. My ANA (blood test for Lupus) levels have been normal for years. For several years doctors have been bringing up the MS diagnosis. I have not pursued this for multiple reasons, but have had episodes of temporary visual impairment in one of my eyes, numbness, extreme dizziness, my clumsiness, etc. Is it possible to have both? Is it possible to be misdiagnosed? Is it possible to have had a positive ANA at one point and is there a correlation with MS?
A:
- It is possible to have both
- Positive ANA tests are not rare in MS
- It is sometimes very difficult to distinguish these conditions as both can cause MRI and spinal fluid changes which may be similar in nature
- Sometimes more sophisticated testing can be helpful in attempting to separate the conditions. In this circumstance, an evaluation at a major medical center with expertise in both rheumatology and in MS may be helpful.
- You might consider asking your neurologist to suggest another point of view and to help you select a site.
Arthur Safran, MD
March 2010
A: Atypical MS is a condition which does not satisfy all the criteria to make the diagnosis, or has a course or clinical or laboratory features which are not generally identified with MS.
Arthur Safran, MD
February 2010
Q: I have had MS for 18 years. Most of the lesions are on my brain. Is there any technology to tell how long a lesion takes to form? If I can back date my lesions 5 years, I may be able to qualify for VA disabity.
A: There is no reliable way to date lesions that old. On the other hand, if there are any medical records which suggest relevant symptoms or any testimony by friends, or colleagues, it may serve just as well as a contemporaneous MRI.
Arthur Safran, MD
December 2009
Q: Hi I have MS, but also someone I know thinks she has it. She has been having a really hard time walking and has optic neuritis. But the MRI did not show any lesions. Can you have MS without any lesions showing up on your MRI?
A: If you mean MS without lesions seen in an MRI yes, although rare. If you mean MS without lesions present in the brain or spinal cord, the answer is no. The condition is defined by the presence of MS plaques.
Arthur Safran, MD
October 2009
Q: I would like to know if an open MRI can detect MS? I had a broken leg at the time of my MRI and couldn't do a regular one, I was told it would be able to detect. I had one MRI in a closed setting which was negative. 6 months later, I had another MRC in an open setting, also negative. I still have symptoms should I ask for another MRI in a closed setting? Thank you.
A: Much depends on the technique used in the MRI test, and the part of the brain, or spinal cord being scanned. Without a clearer indication of the reasons MS is suspected, it would be difficult to decide about whether to recommend another study.
There are other ways to make the diagnosis, although if proper technique is used, and the proper areas examined, the yield exceeds 90%. I hope this is helpful. Given your concerns, a second opinion in an MS center might be helpful.
Arthur Safran, MD
June 2009
Q: I was diagnosed with MS over 5 years ago and have had no symptoms. Right before the diagnosis, I had been having severe headaches for months and was rushed to emergency one day because I was having a hard time breathing. My blood pressure was very very high and probably had been for quite some time, which explains the headaches. Because of the prolonged high blood pressure I have damage to my kidneys and my heart and was diagnosed with hypertension. I then went to an opthamologist because my vision was blurry. He ordered an MRI and I was immediately diagnosed by a neurologist as having MS based on the MRI test results. Is it possible that the hypertension could have caused my eye blurriness and lesions to show up on my MRI? I was under the impression that MS could not be diagnosed so quickly. That other things had to be ruled out first. So I asked the Dr. about this and he said that based on the MRI results he was sure that I have MS.
A: It is difficult to rely on a single MRI to make a definite diagnosis of MS. At times migraine alone can cause changes in the brain which mimic it. Given the circumstances you describe, it might be useful to consider a second opinion from an additional neurologist or a Multiple Sclerosis Center. You might ask you doctor to recommend a colleague or a center. If that is not comfortable or successful, the MS society maintains a list of neurologists with a particular interest in the condition.
Arthur Safran, MD
March 2009
Q: I have had MS for 30 years - relapsing/remitting. I've lost two family members to chronic/progressive and two of us remain. What do I tell my daughters in their 30s who are now exhibiting neurologic symptoms? I know where I stand (I may have MS, but MS doesn't have ME!!), but how about my children and their children?
A: I'm sorry to hear about you family losses. It's tough when there is that kind of bad news looking at everybody.
In general, the effect of heredity in causing MS is less than it is in truly hereditary diseases, like hemophilia or Huntington's disease. In MS, you have to have the heredity, plus some other outside factor. No one knows what that is. Possibly it is a virus, and it may be a different virus in different people. The virus of infectious mono is probably the relevant virus in some people. So your daughters may or may not run into the outside factor.
In general, there is a 1 per 1,000 risk of having MS for any person in New England. For the daughter of an MSer, the risk is about 1 in 50. (If you had an identical twin, that twin would have a risk of 1 in 3.)
If your daughters have gotten to their 30's without MS, that by itself is good news.
It is pretty clear that if they have typical MS symptoms they should have an MRI and find out if they have the disease. Everybody knows by now that early treatment is very important.
Good luck to you, and to your daughters.
David M. Dawson, MD
March 2009
Q: My wife is 58 years old. A year and a half ago she was diagnosed with Breast Cancer. She had a mastectomy and radiation, plus four reconstruction surgeries. Sometime during the past year, she developed double vision and fatigue. MRI ruled out brain cancer, but show lesions on the brain. Two doctors suggested MS. A spinal tap was negative for MS, and we were referred to a neurologist MS specialist.
He said my wife does not have MS because of where the lesions are located. In reading your other responses you state that there are other things that mimic the symptoms of MS. Can you tell me what those are and what tests we need to be looking to conduct?
A: There are many causes of double vision. Any imbalance of the eye muscles will cause that symptom. If it is getting worse it is important to follow through diagnostically, but if there is no worsening then it may not be too important.
MS is not the first diagnosis that comes to mind.
Most likely the MRI scan showed some white spots in areas of the brain that are not typical of MS. Therefore the neurologist that your wife has seen, did not reach the conclusion that MS was part of the picture. As a guess, some form of vascular disease---even including migraine--would be more likely. If that is the case, then follow-up MRI scans months later would be the usual approach.
The double vision could be evaluated by a neuro-ophthalmologist. That would probably require a visit to a large medical center since a specialist of that type isn't available everywhere.
David M. Dawson, MD
February 2009
Q: Two years ago my Dad was diagnosed with MS. He is 72. He has had some hip and knee issues in the past but nothing that would have given us this conclusion. When my Dad had his MRI two lesions were found on his brain supporting the diagnosis. Within the last two years, he has lost most of his mobility in his legs but there has not been as great an impact on other parts of his body. He has been taking Copaxone but without much success. As I have been doing research I have noticed an increase in cases of elderly onset MS. However, given his age is it possible that he has been misdiagnosed. We are due for a second opinion in late February. Are there anything other suggestions I can request that the doctors to look for that may rule out a MS diagnosis in someone his age?
A: When MS begins in older men, it usually follows a progressive course and is likely not responsive to the standard disease modifying agents. There certainly are other possible causes for this kind of problem including vascular disorders, and spinal cord disorders since the description of the MRI you provided certainly does not make the diagnosis of MS definite. I think you are wise to ask for a second opinion and hope there turns out to be a condition which is more likely to respond to treatment.
Arthur Safran, MD
February 2009
Q: I was tested for MS 7 years ago. I received a negative MRI and a negative spinal fluid test. At the time of testing I was having symptoms that consisted of my legs feeling numb and I was also told I had hyperactive reflexes. I recently saw another neurologist because of headaches and he has started more testing for MS. A recent MRI was also negative. I do occasionally have some tingling on my left thigh and my left hand but I have no other symptoms. This neurologist also said that I have hyperactive reflexes. I am now 34. Is it possible to have MS after negative MRIs and a negative spinal fluid test?
A: It is possible but unlikely. The most recent symptoms are vague and could reflect a number of different processes. Even an earlier single sensory episode (numbness, tingling,etc.) with two negative MRI's 7 yrs apart would be unlikely to convert to clinically definite MS and if same were to happen a course of benign sensory disease would be more likely than an aggressive one.
Linda Y. Buchwald, MD
January 2009
Q: I am 51 years old. In January 2008, my left eye started twitching and six weeks later my right eye. They are very painful at times which the doctor informed me that it might be muscles contractions from the twitching. I was taking Reglan and was told to stop at that time. Upon distcontinuing Reglan, I began having twitching in my hands and legs. I was diagnosed with tardive dyskinesia, and prescribed Xanax .025 twice a day.The Xanax has helped wonderfully with the twitching. I have now experieced insomnia and episodes of crying and ringing in my ears. I had a MRI in April which was clear. On November 18, 2008, the left side of my face and left arm and hand went numb, and this symptom continues to come and go. Three weeks later, my right leg started to tingle.
My doctor is sending me for another MRI to check for MS. Do you think I need to worry about this being MS? I have also had celiac sprue and was told my thyroid was being attacked by celiac. Could this be why I am having these symptoms? I did look into Xanax and it does cause numbness and tingling. I am very confused and scared I need some advice.
A: Your doctor is correct to suspect the possibility of multiple sclerosis, but your features are quite atypical. Reglan might have been related to your initial twitching movements but should not be the cause of ringing in the ears or asymmetric numbness. Xanax should not cause asymmetric numbness.
There are some conditions which cause both neurologic and intestinal symptoms, and depending on the results of the MRI scan (which should generally be done both with and without contrast injection) and include both the spinal cord and brain, more testing may well be necessary. At some point, an evaluation by a neurologist would seem reasonable. There is insufficient information to date to make a diagnosis. I hope this is helpful.
Arthur Safran, MD
December 2008
Q: I'm a 49 year old woman, and Over the last year Ive experienced loss of sensation to my left foot, my vision has severely declined escpecially in one eye, my memory is becoming a real concern, and when I get overheated I begin to shake in my hands, along with other varying concerns, I have seen a neurologist who has sent me for an MRI on both the brain and spine, as she said that MS was a possibility; the report is as as follows: Several small subcortical white matter hyperintensities within both frontal lobes consistent with small post ischaemic gliotic foci secondary to small vessel disease..also at the t1 level. There is a lesion of low signal on t1 and high signal on t2 involving the vertebrae. As I'm not seeing her for awhile as she is away, could you tell me if MS is a possibility?
A: Your history and the MRI findings certainly are consistent with multiple sclerosis. I suspect the T1 and T2 lesions you describe are in the spinal cord rather than in the vertebrae but I would have to review the actual films. There should be another neurologist on call for you if your doctor is away for any period of time, who may have access to your actual records and be able to give you a better answer. There are certainly other possibilities as well.
Arthur Safran, MD
November 2008
Q: My daughter-in-law was been told she has brain lesions in Feb 2008. She has had a spinal tap (clear) and another MRI done Oct 2008 and the lesions are the same. Her neurologist will be doing some further visual and memory testing and wants to start treating her for MS. He says she is a "possible MS".
She is also seeing a Rheumatologist for fibromyalgia. She was on steriods for years with colitis (colon removed 12 years ago). She has 3 bulging dics in her neck and arthritis in her neck. Headaches, numbness in her right arm (occasionally),always tired - sleeps all the time (currently unemployed), aches and pains (back mainly). Is it possible she has both diseases?
A: It is certainly possible she may have more than one condition, but brain lesions seen in an MRI are not usually confused between these diagnoses. It would be important to define what clinical symptoms she has which led to the MRI study. Fatigue is common to both. The spinal fluid may be quite normal in appearance in MS (clear) but immunologic testing of the fluid is usually abnormal in MS. Given your description I would suggest you ask your neurologist for suggestions about a second opinion at an MS center for confirmation. A review of the MRI's may also be quite helpful in making a distinction.
If you choose to ask for another opinion it would be very important to bring along all the records and MRI studies.
Arthur Safran, MD
November 2008
Q: I am 23 years old, and have no history in family of MS. I had no medical conditions until returning from service in Iraq in December, 2005. I developed severe respiratory problems, dizziness, headaches, lightheadedness, blind spots, fatigue, tremor in my hands. Recently I had an LP that came back positive for Oligoclonal Bands. All MRIs have been completely unremarkable, so was chest Xray. I also have a circadian rhythm sleep disorder being treated with Melatonin. Could any of these symptoms be related to MS?
A: Multiple sclerosis is a clinical diagnosis that is supported by laboratory testing, including brain and spinal cord MRI, spinal fluid exam, and sometimes visual evoked responses (VER). Some of the symptoms you describe can be seen in MS, but none of them are specific for that diagnosis. MRI studies are nearly always abnormal in patients with MS, partcularly in the face of numerous symptoms and abnormalities on neurological examination. Although an MRI can initially be negative, this is unusual. Another set of MRIs after an interval of 3-6 months may be appropriate. The presence of oligoclonal bands in the spinal fluid is also a common feature in MS, although these can be seen in other disorders as well, including other inflammatory or autoimmune disorders, and the presence of bands does not make a diagnosis of MS without the appropriate clinical history or MRI findings! I would follow-up with your neurologist and address or re-address these questions. Best of luck with finding the correct diagnosis and treatment!
Ellen Lathi, MD
August 2008
Q: I have had a history of trigeminal neuralgia for the past 12 years. For the past two years, I have had many falls, numbness, tingling, visual decline (although common problem on mom's side), and overall nerve problems. I went to a neurologist for 1/2 hr visit and had basic neurological exam, but he said I didn't have MS. I have two cousins who have MS. I trust the neurologist but feel that the diagnosis was really quick. There were 3 attempts at open MRI, but I am extremely claustrophobic. Do you think I should ask for referral from my primary for a visit to an actual MS clinic?
A: Your letter suggests that a referral to a neurologist would be a reasonable next step. There is not enough information here to make a firm diagnosis, but the symptoms you describe could be related to MS.
Arthur Safran, MD
March 2008
Q: I have recently had an MRI done that shows 15 white spots. I had a sudden onset of slurred speech, numbness and weakness on my left side. My doctor is concerned because the numbness, weakness, and speech problems have improved some but have not gone away. They are testing me for a number of things including MS, was wondering what your thoughts on it may be.
A: Multiple Sclerosis is certainly a possibility and this may be the first clinical episode, or a so-called Clinically Isolated Syndrome (CIS) event. Before the firm diagnosis can be made, there are other conditions which can mimic MS and your doctor is correct in considering other possible causes.
Arthur Safran, MD
March 2008
Q: AT 31 I was diagnosed with Trigeminal Neuralga two months later I came done with Bell's Palsy which left me paralyzed for 6 months and with residual paralysis. At 38 I had an episode where my head and face became tingling like going to the dentist this time on the left they told me it was Bell's Palsy again. At 39 soon to be 40 in the last 2 months I have the same episodes tingling in the face, heaviness in my head bilateral and pain in my neck and shoulders especially in the left arm. They once again have put me back on steriods and anti-viral medication. The have conducted two MRI s one on 2006 and one in 2007. The one in 2006 showed increases activity in the gray matter compared to the one in 1999 which could be the beginnings of MS. The head MRI in 2007 showed no chang e and the Spinal was clear, Is this really BElls' Palsy Like this? Help
A: MS cannot be excluded on the basis of information supplied. It is true that the early development of Tic Dolereaux can be associated with multiple sclerosis but there is not enough information here to make the diagnosis clear, and other causes are possible, which could include a connective tissue disorder.
You might ask your neurologist about other tests, including evoked potentials and spinal fluid examination and test for a connective tissue disorder, and about the nature of the MRI techniques used, and whether a gadolinium dye injection was made at each event. Grey matter involvement is common in MS but not usually seen in the MRI.
In the end, the diagnosis based on the material provided is not clear. If you continue to be uncertain after discussing the situation with your doctor, a second opinion might be helpful.
Arthur Safran, MD
February 2008