The 1990s have seen significant progress in both the diagnosis and management of multiple sclerosis (MS). The widespread use of magnetic resonance imaging (MRI) has enabled an earlier and more accurate diagnosis in many instances. An increasing range of effective strategies for symptom management have evolved as has the widespread introduction of partially effective disease modifying therapies. This chapter summarizes current approaches to diagnosis and management. As MS remains a disabling disease of unknown cause, the chapter concludes with a brief discussion of potential future therapeutic strategies.

Diagnosis

General requirements

The diagnosis of MS is based primarily on clinical features, but in the presence of a characteristic clinical picture, there is a number of laboratory investigations that are very helpful in supporting the diagnosis. The most widely used diagnostic criteria of recent decades have been those of Schumacher et al. (1965) and Poser et al. (1983). These have emphasized the requirement for there to be a history of multiple episodes separated in time, and signs on examination of multiple lesions affecting different parts of the central nervous system (CNS) white matter. Both sets of criteria have applied categories of definite, probable and possible MS, based largely on the completeness for the evidence for dissemination in time and space. An age range at diagnosis of 10–59 years is suggested, although rarely presentation will be seen at a younger or older age. There must be no better explanation for the clinical presentation. The Poser criteria added the results of laboratory investigations to increase diagnostic certainty. Thus, the presence of oligoclonal IgG bands in the cerebrospinal fluid (CSF) but not serum (indicating intrathecal production) could upgrade the diagnosis from clinically probable to laboratory supported definite MS. The presence of clinically silent lesions on MRI or evoked potential testing could be used, along with clinical signs of a single CNS lesion, to satisfy the criterion of dissemination in space.

The Poser criteria were formulated in 1982, when experience with MRI was limited. A new set of criteria incorporating the progress of the last two decades has been recommended by an International Panel in 2001 (McDonald et al., 2001; Tables 99.2–99.4). They represent a considerable simplification in the diagnostic classification. The outcome of a diagnostic evaluation is now ‘MS’, ‘possible MS’, or not MS.