Ask the Experts: Diagnosis
Email your questions to "Ask the Experts!"
Q: Is it possible to have MS without having optic neuritis and with normal evoked potentials?
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
March 2009
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