Multiple Sclerosis Diagnostic Approach and Treatment

Initial Diagnostic Workup

Brain and spinal cord MRI with T2-weighted, T2-FLAIR, and gadolinium-enhanced T1-weighted sequences should be included in the diagnostic workup, according to the National Multiple Sclerosis Society and as recommended by Nature Reviews Neurology 1
Baseline MRI should be performed with a minimum 1.5T field strength, slice thickness ≤3mm, and in-plane resolution 1×1mm, as suggested by Nature Reviews Neurology 1
Lumbar puncture for oligoclonal bands, cell count, and protein should be performed, as recommended by Praxis Medical Insights: Practical Summaries of Clinical Guidelines 2
Cognitive assessment using the Symbol Digit Modalities Test (SDMT) should be used as a baseline, according to Praxis Medical Insights: Practical Summaries of Clinical Guidelines 3
Pre-treatment screening should include liver function, bone marrow, viral profiles, glomerular filtration rate, lung function, cardiac assessment (ECG, echocardiography), and dental check-up, as recommended by Nature Reviews Neurology 4

Autologous haematopoietic stem cell transplantation (AHSCT) is recommended for relapsing MS refractory to high-efficacy DMT, as suggested by Nature Reviews Neurology 5, 6
AHSCT conditioning regimens, such as Cyclophosphamide + ATG or BEAM + ATG, should be used, according to Nature Reviews Neurology 4
AHSCT is highly effective at stopping inflammation and MRI activity, as reported by Nature Reviews Neurology 6

Follow-up MRI should be performed every 3-12 months, depending on patient characteristics, as recommended by Nature Reviews Neurology 1
High-risk patients should undergo MRI every 3-4 months, according to Nature Reviews Neurology and Praxis Medical Insights: Practical Summaries of Clinical Guidelines 1, 2
Standard monitoring should include MRI every 6 months in the first year, then annually if stable, as suggested by Nature Reviews Neurology and Praxis Medical Insights: Practical Summaries of Clinical Guidelines 1, 7
Diffusion-weighted imaging should be included for PML monitoring in high-risk patients, according to Nature Reviews Neurology 1
Cognitive assessment (SDMT) should be performed every 6 months, as recommended by Praxis Medical Insights: Practical Summaries of Clinical Guidelines 3

Liver function tests should be performed regularly in patients on interferon therapy, as recommended by the Journal of the American Academy of Dermatology 8
JC virus antibody testing should be performed before initiation and every 6 months in patients on natalizumab, according to Praxis Medical Insights: Practical Summaries of Clinical Guidelines 3
Brain MRI should be performed every 3-4 months if treatment duration is ≥18 months in patients on natalizumab, as recommended by Praxis Medical Insights: Practical Summaries of Clinical Guidelines 3

DMT withdrawal should not be unnecessarily prolonged, as it increases the risk of MS relapse, according to Nature Reviews Neurology 4
MRI protocols should be consistent to facilitate serial comparison, as recommended by Praxis Medical Insights: Practical Summaries of Clinical Guidelines 2
Clinical assessment should not be ignored in favor of imaging alone, according to Praxis Medical Insights: Practical Summaries of Clinical Guidelines 2
Disease progression and treatment complications should be distinguished, as recommended by Praxis Medical Insights: Practical Summaries of Clinical Guidelines 2
The carryover effects of long-acting lymphodepleting agents (alemtuzumab) should not be underestimated before AHSCT, according to Nature Reviews Neurology 4

Suboptimal response to treatment should be identified by new relapses, new or enlarging T2 lesions on MRI, gadolinium-enhancing lesions, or sustained EDSS progression, as recommended by Nature Reviews Neurology 1
Treatment should be adjusted by switching to a higher efficacy DMT or considering AHSCT if already on high-efficacy therapy, according to Nature Reviews Neurology 5, 6