Wednesday, 11 July 2018

MRI: A land of confusion?

When patients present with typical clinical and radiological features, MS is not difficult to recognize. However, things are not always what they seem to be at first glance!

To date, MRI is the most commonly used test to look for findings that support a diagnosis of MS or suggest a different condition. In fact, the International Panel on Diagnosis of MS (2017 McDonald criteria) recommended that brain MRI should be obtained in all patients being considered for a diagnosis of this demyelinating disease. No doubt, MRI is invaluable when it is effectively used and correctly interpreted. Despite most clinicians are very familiar with the radiological features of MS, MRI abnormalities associated with other disorders can be easily mistaken for this condition. That said, neurologists must show vigilance for radiological “red flags” to prompt consideration for diagnoses other than MS before committing a patient to unnecessary long-term treatments.

Can you spot the 'clues' that mimics left behind to correctly differentiate them from genuine MS? There’s one way to find out. We dare you to take this challenge: Which one is MS?

** Reproduced and modified from Geraldes et al (1), Aliaga et al (2) and Siva (3).

When the MRI findings are so similar, it can be very challenging indeed! MRI scan D and MRI scan H are from patients with MS. Lets take a better look at the MRI mimics of MS: 

We hope you enjoyed the challenge. It is good to know these imaging tips when clinical evidence supporting a diagnosis of MS is insufficient. Let us know what other mimics would you like to add to the table above? 

Additional comment: Yes, H is from an MSer! It is paramount to recognize MS mimics but critical not to miss the MS chameleons: MSers with an atypical radiological presentation resembling other disease processes. Tumefactive demyelinating lesions in MS can be difficult to differentiate from tumours. In this case, open ring enhancement is more likely to be due to demyelination than the presence of a neoplasm or infection.

  1. Geraldes R, et al. The current role of MRI in differentiating multiple sclerosis from its imaging mimics. Nat Rev Neurol 2018;14(4):213.
  2. Aliaga ES, et al. MRI mimics of multiple sclerosis. Handb Clin Neurol 2014;122:291-316.
  3. Chen JJ, et al. MRI differential diagnosis of suspected multiple sclerosis. Clin Radiol 2016;71(9):815-27.
  4. Siva A. Common Clinical and Imaging Conditions Misdiagnosed as Multiple Sclerosis: A Current Approach to the Differential Diagnosis of Multiple Sclerosis. Neurol Clin 2018;36(1):69-117.


  1. What about the central vein sign? it seems to best differentiate MS from mimics, although standardization is needed. Why not work on that? The ground is mature enough and the gain within this decade!

  2. Thanks for the post! Really informative!

    I have seen two cases recently of PPMS patients who were later diagnosed with Neurosarcoidosis. The one had Sarcoidosis already but the other had positive Xray many years after the initiation of nervous symptoms. Little is known about this disease.
    And what about anti-MOG? Is the MRI similar to the NMOSD?

  3. I assume all neurologists are fully trained to correctly interpret MRI scans and to recognize these other diseases that mimic MS? I certainly hope so because patients totally rely on their expert advice when trying to choose a DMT that could potentially cause harm long-term.


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