Subscribe or Manage Preferences
VBCN - November 2016 Volume 3, No 3 - Multiple Sclerosis
Chase Doyle

Despite improvements in radiographic diagnostic techniques, including magnetic resonance imaging (MRI), the misdiagnosis of multiple sclerosis (MS) is a common problem that can lead to treatment-related and psychosocial morbidity.

“Today, MRI is the best biomarker we have, but the specificity is not 100%. Even in the hands of experts who develop these criteria, you can only distinguish MS from other criteria 87% of the time among experienced researchers using formal criteria—and that’s actually high,” said John R. Corboy, MD, FAAN, Co-Director, Rocky Mountain Multiple Sclerosis Center, University of Colorado, Aurora, at the 2016 American Academy of Neurology meeting.

“In real-world practice, however, this formal MRI criteria is not in general use,” he added.

Common Conditions Misdiag­nosed as Multiple Sclerosis

A number of conditions can be misdiagnosed as MS, including migraine alone or in combination with other diagnoses, fibromyalgia, nonspecific or nonlocalizing neurologic symptoms with abnormal MRI results, conversion or psychogenic disorder, and neuromyelitis optica spectrum disorder.

The diagnostic potential of MRI has advantages and pitfalls, Dr Corboy explained. “We’re living in the era of effective therapy,” he said. “We can start highly effective therapy that we think has a significant opportunity to limit the likelihood of developing disability over time.”

“On the flip side, however, there’s fear that if you miss a diagnosis—or don’t diagnose fast enough—you’ll be contacted by a lawyer,” he added.

There can also be inducement on the part of physicians in the form of money for in-office infusions. “Ultimately, regardless of the motivations, if there’s misdiagnosis and there’s treatment, there is mistreatment,” said Dr Corboy.

How Diagnostic Mistakes Are Made

According to Dr Corboy, misdiagnosing MS can be attributed to several factors, including:

  • Lack of correlation of symptoms and signs
  • Desire and/or demand to “make a diagnosis”
  • Unwillingness to say, “I don’t know,” and reassess over time
  • Overreliance on MRI, because:
    • Many are read by general radiologists
    • Many are not read by a treating neurologist
    • Calling subcortical lesions “periventricular.”
Given the dramatic, “almost logarithmic” rise in prices of MS medications in the past 10 to 12 years, misdiagnosis can also be a costly mistake.

Furthermore, significant harm can befall patients who are mistreated. For example, one patient with relapsing-remitting MS died from progressive multifocal leukoencephalopathy after receiving natalizumab (Tysabri) and interferon beta-1a as part of a clinical trial, Dr Corboy reported.

“You’re not only treating the wrong disease, but you’re exposing those patients to potentially expensive and/or potentially deadly medications,” Dr Corboy emphasized.

One study of patients misdiagnosed with MS showed that 70% of them had received disease-modifying therapies, and >30% had suffered a significant level of morbidity. Furthermore, >50% of the patients had been misdiagnosed for a “prolonged period of time,” suggesting that “once someone gets misdiagnosed with MS, it becomes very difficult to ‘un-ring that bell,’” said Dr Corboy.

Improving Multiple Sclerosis Diagnosis

According to Dr Corboy, improving the diagnostic accuracy of MS starts with the following measures:

  • Adhering to diagnostic criteria
  • Keeping an open mind for alternative diagnoses
  • Knowing the MRI features that give the greatest specificity
  • Assessing the brain and spine
  • Personally reading the MRIs
  • Obtaining help if needed
  • Enhancing education of neurologists, primary care physicians, and radiologists
  • Making MS an affirmative diagnosis, not a default diagnosis
  • Developing better biomarkers in blood, cerebral spinal fluid, or MRI.
“The development of better biomarkers will have a substantial impact on clinicians’ ability to make the diagnosis more accurate. For example, the detection of the central vessel sign using FLAIR [fluid attenuated inversion recovery] on 3T MRI may be helpful for the differentiation of MS from migraine,” Dr Corboy concluded.

Related Items
Can Some Patients with Multiple Sclerosis Stop Treatment?
Caroline Helwick
Web Exclusives: Value-Based Care - September 2017 published on August 30, 2017 in Multiple Sclerosis
Oral Ozanimod: A Safer Sphingosine-1-Phosphate Receptor Modulator?
Caroline Helwick
Web Exclusives: Value-Based Care - June 2017 published on June 26, 2017 in Multiple Sclerosis
Vitamin D Supplementation Shows Benefits in Multiple Sclerosis, but Questions Remain
Caroline Helwick
Web Exclusives: Value-Based Care - April 2017 published on March 31, 2017 in Multiple Sclerosis
Simvastatin plus Vitamin D May Prevent Headaches in Adults with Migraines
Chase Doyle
VBCN - November 2016 Volume 3, No 3 published on November 22, 2016 in Migraine Update
Alemtuzumab Reduces Disability in Patients with Active Relapsing-Remitting Multiple Sclerosis
Laura Morgan
VBCN - November 2016 Volume 3, No 3 published on November 22, 2016 in Multiple Sclerosis
Reducing the Cost and Improving the Care of Patients with Multiple Sclerosis
Laura Morgan
VBCN - November 2016 Volume 3, No 3 published on November 22, 2016 in Multiple Sclerosis
Stem-Cell Therapy Reverses Disability in Multiple Sclerosis
Laura Morgan
VBCN - November 2016 Volume 3, No 3 published on November 22, 2016 in Multiple Sclerosis
Brain–Computer Interfaces Breaking New Ground in Patients with Neurologic Disability
Chase Doyle
VBCN - November 2016 Volume 3, No 3 published on November 22, 2016 in Brain Technology
Idalopirdine Improves Cognition in Patients with Moderate Alzheimer’s Disease
Chase Doyle
VBCN - November 2016 Volume 3, No 3 published on November 22, 2016 in Alzheimer’s Disease/Dementia
Pro and Con: Do Cognitive-Enhancing Activities Prevent Dementia?
Chase Doyle
VBCN - November 2016 Volume 3, No 3 published on November 22, 2016 in Alzheimer’s Disease/Dementia
Last modified: November 30, 2016
  • American Health & Drug Benefits
  • Lynx CME
  • Value-Based Care in Myeloma
  • Value-Based Cancer Care
  • Value-Based Care in Rheumatology