Diagnosis and management of multiple sclerosis

Abstract

A handful of patience is worth more than a bushel of brains — Dutch proverb Controversy exists concerning almost every aspect of the diagnosis and management of multiple sclerosis (MS), the most common nontraumatic cause of neurologic disability in young adults. Although authoritative guidelines for diagnosis, such as those of the McDonald Committee, are available, a high rate of false positive attribution of MS has been observed in clinical practice.1 On the other hand, data from the North American Research Committee on Multiple Sclerosis registry demonstrate that the ascertainment time (from first symptom to diagnosis) is currently very brief, indicating that false negative attribution of MS is rare or transient.2 Currently, overdiagnosis in suspected MS is the most common diagnostic error and has been ascribed to uncritical reliance on MRI and hasty workup.1,3 Management of MS is controversial, both in terms of the general role of disease-modifying treatment (DMT) and the merits of specific DMTs. A recent “Controversies in Neurology” in the Archives of Neurology featured opposing reviews by MS specialists either favoring or questioning universal institution of DMT once MS or a MS-like clinically isolated syndrome is diagnosed.4,5 Experts on both sides of this dispute agree with the authoritative Cochrane reviewers …