The lesions detected with MRI are pathologically nonspecific. More than half of people living with MS experience cognitive fog, or cog fog. Some of these diagnoses are easy to rule out with a simple blood test (e.g. During these episodes, active areas of inflammatory demyelination are sometimes visible on an MRI scan when contrast dye is used. With regard to the comparison of normal and pseudo-MS subjects, the exact same measures were found to have significantly changed as were found in the comparison of the normal and MS data sets. This form of MS is classified into stages of disease activity and remission, along with new MRI activity. Persamaan Antara Sclerosis Berbilang dan Sclerosis Sistemik 5. Here's what, Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. Characteristically, and by definition, multiple sclerosis is disseminated in space (i.e. 2010;257(1):63-71. You may be given earplugs or headphones during an MRI because the machine can be very loud. Each relapse eventually subsides (remits) with periods of partial or complete recovery that are called remissions. The most important point to take from this series is that many images can be compatible with MS. Thus, the differences depicted by the normal MTR data and the transformed normal MTR data (pseudo-MS data) are statistically similar to the differences exhibited by the normal MTR data and the MS MTR data. Several treatments can prevent 80% of new T2 lesions from developing in the brain. Tumefactive MS is a variant of Multiple Sclerosis. 15 per 100,000), with incidence gradually increasing with distance from the equator (e.g. 2010;31(6):983-9. Each lesion goes through three pathological stages: Plaques can occur anywhere in the central nervous system. Plaques are randomly distributed. Impaired vision (due to retrobulbar neuritis) is usually the first . Additionally, secondary progressive forms include stages during which the condition worsens on a more gradual basis, similar to primary progressive MS. 2000;21(6):1039-42. No abnormal findings on neurological exam. White Matter Diseases with Radiologic-Pathologic Correlation. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Using the N members of each set, S, the measures S1 to S4 were found. Mean MTR histograms for the normal volunteer group and the MS subject group. Given their differences in pathophysiology, proton MR spectroscopy may be able to distinguish . This normal-to-MS transform converts the set of normal MTR values into a set of MTR values typical of the MS data set. Dr Schiess added that ancillary testing, including blood work, CSF findings, optical coherence tomography (OCT), and evoked potentials can also facilitate diagnosis. A simple example can be illustrative as regards this technique: let the following list of numbers represent a mean parameter value from the set of normal data (1,2,2,1,1,2) and let the next list of numbers represent the mean value of this same parameter for the set of MS data (2,5,8,0,5,7). Initially, a mapfile was created for each subject by removing the skull and extradural tissues in the Mo volume from their first examination. 1991;157(5):1073-8. An MRI scan can determine with a great degree of certainty if a person is having a stroke or a multiple sclerosis flare-up, as stroke looks different than a multiple sclerosis lesion. Multiple sclerosis is believed to result from a cell-mediated autoimmune response against one's own myelin components, with loss of oligodendrocytes, with little or no axonal degeneration in the acute phase; however, in later stages, loss of oligodendrocytes results in axonal degeneration. Download Citation | On Jan 1, 2023, Amanda Frisosky Abuaf and others published Effectiveness of Ocrelizumab on Clinical and MRI Outcome Measures in Multiple Sclerosis across Caucasian and African . Copyright 2023 Haymarket Media, Inc. All Rights Reserved. AJNR Am J Neuroradiol. The presentation is usually between adolescence and the sixth decade, with a peak at approximately 35 years of age 12,19. The frequency with which you need repeat monitoring depends on the type of MS you have and on your treatment. Experts say initial symptoms can be difficult to determine. Nesbit G, Forbes G, Scheithauer B, Okazaki H, Rodriguez M. Multiple Sclerosis: Histopathologic and MR And/Or CT Correlation in 37 Cases at Biopsy and Three Cases at Autopsy. All rights reserved. Background and Objectives: Obesity aggravates disease severity in multiple sclerosis (MS). This study was reviewed and approved by the institutional review board at the National Institutes of Health. Enter multiple addresses on separate lines or separate them with commas. One potential problem is that the normal-to-MS transform was derived from the matching of the group mean histograms of the normal and MS subjects; therefore, an increase in histogram bin size will cause a decrease in transform resolution, which then decreases the resolution of the pseudo-MS data. Inaccurate MRI interpretation is the most common cause of incorrect diagnoses in patients with MS, underscoring the critical importance of the physicians familiarity with MS mimics.2 Taking a thorough medical history focused on questioning the patient about prior neurological episodes that might have been overlooked or dismissed by the patient remains crucial in any assessment for MS, said Nicoline Schiess MD, MPH, an assistant professor of neurology at Johns Hopkins University Multiple Sclerosis Center. 7. In the below slideshow, Drs Lange, Melisaratos, and Schiess shared a collection of MRI findings from their clinical practice to illustrate a selection of MS mimics. In a study of 2 independent MS referral . Aided by a high-powered brain scanner and a 3D printer, NIH researchers peered inside the brains of hundreds of multiple sclerosis patients and found that dark rimmed spots representing ongoing, "smoldering" inflammation, called chronic active lesions, may be a hallmark of more aggressive and disabling forms of the disease. There's no single. I. Let mapfilej, Moj, and Msj represent the value of the mapfile, the Mo volume, and the Ms volume at voxel position j, where j goes from 1 to the total number of voxels in a volume. A complete list of these P values along with their direction of change is presented in the Table. Hyperintense lesions are bright or white. These types of lesions are new or getting bigger due to demyelination (damage to the myelin that covers certain nerves). There are rare cases where someone can have MS but their MRI will look clear. Thus, while no significant increase is found in the number of voxels representing lower MTR values, a significant increase is found in the percentage of the brain made up of these voxels. Demyelination occurs in discrete perivenular foci, termed plaques, which range in size from a few millimeters to a few centimeters 19. Multiple sclerosis (MS) is a common central nervous system (CNS) disease characterised pathologically by the development of multifocal inflammatory demyelinating white matter lesions. Pronin. Even on a single scan, some features are helpful in predicting relapsing-remitting vs progressive disease. (2006) ISBN: 9780071423663 -. Your use of this website constitutes acceptance of Haymarket Medias Privacy Policy and Terms & Conditions. Headache. Magnetization transfer is a technique that may be useful in characterizing the pathophysiological changes involved with multiple sclerosis (MS). This is because not all lesions in the CNS are due to MS, and not all people with MS have visible lesions. 2001;220(3):606-10. They may involve gray matter such as cerebral cortex, deep nuclei, and brainstem. The contrast MRI is used to look for areas of active inflammation. Being constipated isnt fun for anyone. MRI will show different things based on the type of MS involved. This finding is in contrast to the higher MTR values, in which a significant loss is found in both the number of voxels representing these values and the percentage of the brain made up of these voxels, and is consistent with the brain atrophy that has been observed in MS patients (21). But this experimental therapy may significantly reduce relapses and slow disease. Their presence indicates a risk of 82% in five years, while a normal brain MRI carries a predictive risk of between 6-24% at five years. The central vein sign and its clinical evaluation for the diagnosis of multiple sclerosis: A consensus statement from the North American Imaging in Multiple Sclerosis Cooperative. Use of the normal-to-MS transform may be informative in such a longitudinal study, since it provides a novel method of illustrating disease progression. Medicines and therapy can help control symptoms like muscle spasms and help you walk . Though the vast majority of MS patients have abnormalities on brain MRI, an estimated 5% of patients have normal imaging. The normalized parameters R5 to R8 were normalized by N, the number of brain voxels having an MTR value between 0.0 and 0.6. Nat Rev Neurol 2016; 12(12): 714-722. White matter lesions observed on brain MRI are usually characteristic and occur in specific areas including the corpus callosum and pons. The differences are that ALS causes symptoms like clumsiness and muscle cramps; and MS causes symptoms of vertigo, sexual dysfunction, and mood swings. Should initial serum anti-JCV testing be negative, it must be repeated, and, if suspicion of PML is still high, the current diagnostic Lumbar puncture findings in MS include a normal opening cerebrospinal fluid (CSF) pressure, fewer than 20 mononuclear cells, a normal or slightly elevated protein level, a negative CSF VDRL test, and negative tests for bacteria and fungi. Zalc B. Brain MRIs were blindly evaluated to determine if they satisfied Paty and/or Fazekas diagnostic criteria. So the best way to increase the odds that your MS progresses . Okuda D, Mowry E, Beheshtian A et al. This can make it especially difficult to exclude other potential diagnoses before MS can be diagnosed. You may be considered at high risk of MS if youve had CIS and an MRI scan shows MS-like lesions. The scan is a highly-sensitive, non-invasive way to view areas of damage in the central nervous system (CNS). This happens. These parameters simply find the mean and the range of each of the four count-based quadrants. 21. Radiology. 10. Scans can let healthcare professionals know when. Trigeminal neuralgia, sometimes called tic douloureux, is a type of nerve (neuropathic) pain in the side of the face and can be a symptom of multiple sclerosis. In other instances patients present with the first plaque. All other parameters were set according to manufacturer's specifications. CSF total protein, white cell count, and angiotensin . For this analysis, a histogram, referred to as histo[ ], contained 100 bins, with each bin representing an MTR range of .006 (0.6/100). 1 Because there is no single highly specific biomarker for MS, misdiagnosiswhen a patient without MS receives an incorrect diagnosis of MSis unfortunately common. Allan Ropper, Joshua Klein, Martin Samuels. The normal-to-MS transform was created through the matching of the mean MTR histograms of the normal data (labeled N 15) and the MS data (labeled MS 18). Multiple sclerosis symptoms can be both visible, like changes in speech or difficulty with coordination, and invisible, such as fatigue or a dysfunctional bladder. 2001;22(2):292-3. Studies (i.e., science) show that early use of higher efficacy DMTs lead to less disability over time. Finally, to provide a single illustrative technique for describing the differences between these two groups, a transform relating the set of normal subjects to the set of MS subjects was created through the matching of each group's mean MTR histogram. The same set of 17 measures were found to be significantly different when comparing the normal and pseudo-MS data. Multiple sclerosis. This transform will be referred to as a normal-to-MS transform. 6. Chong A, Chandra R, Chuah K, Roberts E, Stuckey S. Proton Density MRI Increases Detection of Cervical Spinal Cord Multiple Sclerosis Lesions Compared with T2-Weighted Fast Spin-Echo. It requires the doctors to really eliminate a lot of other potential diseases and it takes a doctor who's had significant experience with the disease. In addition to the potential for disease progression resulting in progressive neurological impairment, a number of specific complications need to be considered. We want you to take advantage of everything Neurology Advisor has to offer. The disease manifestation and its severity are due to a complex interplay between genetic predisposition and environmental triggers (Muoz-Culla et al., 2013).It has a strong bias towards the female sex and a predilection for certain races. If you have symptoms of MS, your doctor may order an MRI scan of your brain and spinal cord. Thus, the five normal subjects were converted into five pseudo-MS subjects. Rather than intense bouts of inflammatory demyelination, progressive forms of MS involve a steady progression of damage. 17. MRI imaging of the brain provides the objective support needed to endorse the diagnosis, though it is only one of many tools that help guide the diagnostic process, according to Dale J. Lange, MD, and Darius P. Melisaratos, MD, of Hospital for Special Surgery (HSS) in New York. These include 20,21: Multiple sclerosis was first defined by Jean-Martin Charcot(1825-1893), French neurologist, in 1868 27. The application of DTI in Multiple Sclerosis (MS) has yielded noteworthy results. AJR Am J Roentgenol. We provide a unique illustration of these . While this work has been based on each subject's mean value of each of the 30 measures, a longitudinal study of each of these measures over time would be a promising area for future work. If you have upper motor neuron lesions, you have damage to certain nerve cells that help you move. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. For classic (Charcot type) MS, the differential can be divided into intracranial and spinal involvement. Multiple sclerosis has a fascinating geographic distribution: it is rarely found in equatorial regions (e.g. "Although uncommon, at the beginning of the disease, MRI in a patient with multiple sclerosis can be normal," says Resham Mendi, MD, a renowned expert in the field of medical imaging, and the medical director of Bright Light Medical Imaging. Your doctor will explain the procedure to you in detail, but if you have questions, be sure to ask them. By multiplying the first set by 3, one can arrive at a set of pseudo-MS data containing the same mean as the MS data; that is, (3,6,6,3,3,6). A group's mean histogram is a histogram created using all of that group's MTR data. A number of clinical variants are recognized, each with specific imaging findings and clinical presentation. Since five normal subjects had an average of 4.2 studies each, 21 MTR volumes were transformed in the creation of the five pseudo-MS subjects. 2 Address reprint requests to John Ostuni, PhD, National Institutes of Health, Building 10, Room B1N256, 10 Center Dr, MSC 1074, Bethesda, MD 20892. Meyer-Schwickerath R, et al. Check for errors and try again. 2007;244(3):823-31. The digital press . In order to confirm the diagnosis of MS, your healthcare provider must be able to rule out other possible diagnoses that could explain the symptoms you are experiencing.. What Causes Multiple Sclerosis Back Pain? However, in many cases, the white matter lesions as isolated observations are nonspecific and could be due to MS or another cause, explained Drs Lange and Melisaratos. Each distinct attack is called a relapse. 5. They are typically ovoid in shape and perivenular in distribution. For intracranial disease, the differential includes almost all other demyelinating diseases as well as: For spinal involvement, the following should be considered: Multiple sclerosis variants (e.g. It uses a powerful magnetic field and radio waves to transmit information to a computer, which then translates the information into cross-sectional pictures. Ge Y, Grossman R, Udupa J, Babb J, Nyl L, Kolson D. Brain Atrophy in Relapsing-Remitting Multiple Sclerosis: Fractional Volumetric Analysis of Gray Matter and White Matter. To further understand this reduction, it is informative to examine the normalized quadrant counts, c1n, c2n, c3n, and c4n. One other important area of future work would be the use of this type of transform to allow pooling of MTR data. If they do, keep in mind that this is a painless, noninvasive test that can tell your doctor a lot about whether you have MS and, if you do, what kind you have. what is scattered subcortical hyperintensities involving both cerebral hemispheres which may relate demyelinating/ischemic change Believe radiologist or neurologist? They may suggest that you get an MRI scan. Once the histogram was created, the following measures were calculated: Typical normal MTR histogram shows the parameters H1 through H5. Features that may be present include: MRI has revolutionised the diagnosis and surveillance of patients with MS. Not only can an MRI confirm the diagnosis (see McDonald diagnostic criteria for multiple sclerosis), but follow-up scans can assess response to treatment and help determine the disease pattern. In this report, the difference between MS and normal subject groups with respect to these global MTR values was explored through the use of 30 different measures. This data structure is basically a one-dimensional array in which each array element represents a specific MTR range. Multiple sclerosis (MS) is a chronic degenerative disease of the CNS characterized by demyelination and axonal degeneration in the brain and spinal cord, which are caused by an immune-mediated inflammatory process.The prevalence of MS is higher among women and people in temperate regions such as Europe and North America. lesions occur at different times). Sarbu N, Shih R, Jones R, Horkayne-Szakaly I, Oleaga L, Smirniotopoulos J. Incidental MRI Anomalies Suggestive of Multiple Sclerosis: The Radiologically Isolated Syndrome. P values associated with the comparison of the measures shown with respect to normal and MS subjects (filled bars) and with respect to normal subjects and pseudo-MS subjects (open bars). After registration, each Mo-Ms pair was used to create a new volume whose voxel values were equal to their MTR at that location. Rigidity; sustained dystonia. tumefactive MS) are discussed separately. A and B, Normal-to-MS transform. Many of the lesions may not be causing obvious symptoms. About 95% patients with clinically definitive MS have an abnormal MRI, but MRI is not a definitive investigation as up to 4% normal healthy individuals can have periventricular lesions that cannot be distinguished from MS. White matter lesions can also be found in other conditions, including ischemic and age related changes. Many of the typical MS symptoms are also seen in other disorders ranging from Lyme disease and stroke to neuromyelitis optica, a disorder of the optic nerves and spinal cord. Background: Relapses in multiple sclerosis (MS) patients are usually defined as subacute clinical symptoms that last for at least 24 h. To validate a clinical relapse on magnetic resonance imaging (MRI), an anatomically fitting lesion with gadolinium enhancement in the central nervous system (CNS) would be mandatory. Informed consent was obtained for each normal volunteer and MS patient. Analyzing the visible changes in the brain and spinal cord may help assess current treatment and future options. A mapfile or image mask is simply a set of images that describe which voxel locations need to be analyzed and which voxel locations should be ignored in the analysis of a subject's brain. Steroids, disease-modifying therapies, and autologous hematopoietic stem cell transplantation are all used. Owing to its ability to depict the pathologic features of multiple sclerosis (MS) in exquisite detail, conventional magnetic resonance (MR) imaging has become an established tool in the diagnosis of this disease and in monitoring its evolution. Interestingly, the change in all four of these parameters can be explained by the loss of voxels with MTR values in the range (0.300.60) without regard for the gain of voxels with lower MTR values. There is no cure for either disease. Reference article, Radiopaedia.org (Accessed on 18 Jan 2023) https://doi.org/10.53347/rID-1700, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":1700,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/multiple-sclerosis/questions/2512?lang=us"}, Case 12: extensive brainstem and cerebellar involvment, Schilder type (diffuse cerebral sclerosis), neuromyelitis optica spectrum disorder (Devic disease), McDonald diagnostic criteria for multiple sclerosis, progressive multifocal leukoencephalopathy (PML), acute inflammatory demyelinating polyradiculoneuropathy (AIDP), acute motor-sensory axonal neuropathy (AMSAN), chronic inflammatory demyelinating polyneuropathy (CIDP), acute disseminated encephalomyelitis (ADEM), acute hemorrhagic encephalomyelitis (AHEM), longitudinally extensive spinal cord lesion (LESCL), megalencephalic leukoencephalopathy with subcortical cysts, hypomyelination with atrophy of the basal ganglia and cerebellum (H-ABC), leukoencephalopathy with brainstem and spinal cord involvement and lactate elevation, hypomyelination with brainstem and spinal cord involvement and leg spasticity, cathepsin A-related arteriopathy with strokes and leukoencephalopathy (CARASAL), leukoencephalopathy with calcifications and cysts, pontine autosomal dominant microangiopathy with leukoencephalopathy (PADMAL), retinal vasculopathy with cerebral leukoencephalopathy and systemic manifestations (RVCL-S), adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP), leukoencephalopathy due to autosomal recessive mutations in the mitochondrial alanyl-transfer RNA (tRNA) synthetase gene (AARS2-L), globoid cell leukodystrophy (Krabbe disease), adult-onset autosomal dominant leukodystrophy, cystic leukoencephalopathy without megalencephaly, classic multiple sclerosis (Charcot type), a strong association with HLA-DR15 (formerly covered by HLA-DR2)class II has been identified, patients exhibit periodic symptoms with complete recovery (early on), approximately 85% of patients with relapsing-remitting MS eventually enter a secondary progressive phase, defined by a progressive accumulation of disability for >12 months from disease onset, which can be determined prospectively or retrospectively, patients do not have remissions, with neurological deterioration being relentless, incorporates the previously described "progressive-relapsing"phenotype, defined as patients who remain functionally active for over 15 years, and thus is only a retrospective diagnosis, plaques can be homogeneously hypoattenuating, brain atrophy may be evident in long-standing chronic MS, some plaques may show contrast enhancement in the active phase, ideally performed as a 3D volumetric scan (1 mm isotropic), or, T1: 3D inversion recovery prepared gradient echo, lesions are typically iso- to hypointense (, hyperintense lesions are associated with brain atrophy and advancing disease, acute lesions often have surrounding edema, when these propagate centrifugally along the medullary venules and are arranged perpendicular to the lateral ventricles in a triangular configuration (extending radially outward - best seen on parasagittal images), they are termed, FLAIR is more sensitive than T2 in the detection of juxtacortical and periventricular plaques, while T2 is more sensitive to infratentorial lesions, enhancement is often incomplete around the periphery (, active plaques may demonstrate high or low ADC (increased or decreased diffusion), PD images are better at detecting cervical spinal cord MS lesions especially when T2W images fail to demonstrate these lesions, a sequence that suppresses both CSF and white matter signal and offers better delineation of the plaques, interferon beta: inhibition of T-lymphocyte proliferation, glatiramer acetate (Copaxone): immunomodulation, teriflunomide (Aubagio): reduces both T-cell and B-cell activation and proliferation, dimethyl fumarate (Tecfidera) and diroximel fumarate (Vumerity): immunomodulation, fingolimod (Gilenya), siponimod (Mayzent) and ozanimod (Zeposia): prevents lymphocyte migration out of lymph nodes and into CNS, natalizumab (Tysabri): inhibits binding of lymphocytes to endothelium, cladribine (Mavenclad): purine analog that targets lymphocytes, ocrelizumab (Ocrevus) and ofatumumab (Kesimpta): anti-CD20 monoclonal antibodies, alemtuzumab (Lemtrada): immunomodulation of T-cell and B-cell function, mitoxantrone (Novantrone): reduces T-cell and B-cell proliferation and reduces T-cell activation, particularly in patients treated with natalizumab with positive JC virus serology, a complication of cessation of natalizumab or treatment for natalizumab-related PML with plasma exchange or immunoabsorption, rarely lymphoma appears to arise from previously identified demyelinating lesions. This destruction is called demyelination . They include: This article concerns itself primarily with classic (Charcot type) multiple sclerosis. AJNR Am J Neuroradiol. While the MTR values used to derive the simple statistics, the range statistics, and the order statistics are basically unlimited in resolution, this is not true of the histogram parameters, which are derived using binned MTR values. SWI uses a fully flow compensated, long echo, gradient recalled echo (GRE) pulse sequence to acquire images. Multiple sclerosis (MS) is a chronic disease of your central nervous system (CNS). Thus, it allows one to examine the number of MTR values falling within specific ranges for all of that group's data. Using a Wilcoxon rank sum test, the normal and MS data are not significantly different (P = .0592), whereas the normal and the pseudo-MS sets are significantly different (P = .0277). For every MTR value examined, the bin representing that value is incremented by 1. As for the exact effect of different bin sizes on the found histogram parameters, this has not yet been investigated. The accurate diagnosis of multiple sclerosis (MS) typically presents several challenges: There is no definitive test for the disease, and symptoms vary widely between patients. Cog Fog: How to Deal with This Frequent MS Symptom, Christina Applegate and MS: The Early Warning Signs She Says She Missed, 7 Remedies for Constipation with Multiple Sclerosis (MS), Understanding Symptoms of Multiple Sclerosis (MS), The Possibility of Multiple Sclerosis Prevention. Sometimes the nerve fibers that send messages (axons) are also damaged. For most people with multiple sclerosis who are affected by temperature changes, a cool climate may be better. Next, all normal MTR data were put through this transform to create pseudo-MS MTR data. 2009;72(9):800-5. 1998;121 ( Pt 1)(1):3-24. In addition, after a software or hardware upgrade, previously acquired data must be analyzed separately from any newly acquired data, thus limiting statistical analysis. AJNR Am J Neuroradiol. MS is an inflammatory disorder in which infection-fighting white blood cells enter the nervous system and cause injury. AJNR Am J Neuroradiol. Close more info about Differentiating Multiple Sclerosis Mimics on MRI. Christina Applegate says she didn't recognize early symptoms of multiple sclerosis. Whenever clinical or MRI signs suggestive of PML are encountered, natalizumab should be immediately stopped. On MRI it presents as a large intra-parenchymal lesion with usually less mass effect than would be expected for its size. The Criteria for a Diagnosis of MS. To make a diagnosis of MS, the physician must: Find evidence of damage in at least two separate areas of the central nervous system (CNS), which includes the brain, spinal cord and optic nerves; AND. The measures that were significantly different with respect to these two groups were discovered. Early dementia. These results confirm some of the previous findings of van Buchem et al (13, 14); that is, that the MTR mean and peak significantly decrease in MS patients as compared with normal control patients. These scars, or lesions, consist mostly of dead nerve cells, whose axons have been denuded of the myelin sheaths that normally protect them and permit the conduction of nerve impulses. The only way to tell is to determine if there are co-existing abnormalities in other parts of the brain and this must be incorporated within the context of the clinical condition, they said. Multiple Sclerosis Reference Diagnosing Multiple Sclerosis With MRI Written by WebMD Editorial Contributors Medically Reviewed by Christopher Melinosky, MD on March 06, 2021 Widespread. (2018). Brain Hemodynamic Changes Associated with Chronic Cerebrospinal Venous Insufficiency Are Not Specific to Multiple Sclerosis and Do Not Increase Its Severity. Examples of common clinical features include 23,24: A number of patterns of longitudinal disease have been described 11,12: As is evident from this list, there is overlap, and in some cases, patients can drift from one pattern to another (e.g.