MS MRI Scans: Does Multiple Sclerosis Show Up on an MRI?

It’s natural to be worried if you have symptoms that suggest multiple sclerosis (MS). If you’re concerned about your symptoms and want an MRI scan to get answers or to rule out MS, we have all the information you need, from how doctors diagnose MS to how it shows up on MRI scans. 

What is multiple sclerosis?

Multiple sclerosis is a chronic (lifelong) autoimmune disorder affecting the central nervous system (the brain and spinal cord). It’s caused by the immune system attacking the myelin sheath, a protective covering of nerves in the central nervous system. 

The destruction of the myelin causes inflammation and damage to the central nervous system, resulting in disrupted signals along the nerve fibres or damage to the fibres themselves. This can cause a wide range of neurological symptoms, ranging from mild to severe. Symptoms also often depend on which part of the central nervous system has been affected. That’s why symptoms of MS can vary from person to person. 

MS is most commonly diagnosed in younger people in their 20s, 30s and 40s, although it can happen at any age. It’s more common in women than men and is one of the most common causes of disability in young adults.

Around 150,000 people in the UK have MS, and it can affect people from many ethnic backgrounds. There is currently no cure for MS, but doctors can treat and manage symptoms by using MRI scans to pinpoint old and new damage and see how active the condition is. 

Types of Multiple Sclerosis

There are three main types of multiple sclerosis: relapsing remitting MS, secondary progressive MS and primary progressive MS. They each affect people in different ways, and it may take time for your neurologist to diagnose which type you have. 

Relapsing Remitting Multiple Sclerosis

RRMS is the most common form of MS and is characterised by an active phase when your symptoms relapse (get worse), followed by periods of remission (when your symptoms get better). This form of the disease can progress into secondary progressive MS. 

Secondary Progressive Multiple Sclerosis

SPMS often follows RRMS and is characterised by a gradual worsening of symptoms, meaning that the disease has become progressive and you’re experiencing symptoms all the time. If you have SPMS, you may have periods of relapse when your symptoms are noticeably worse. 

Primary Progressive Multiple Sclerosis

PPMS is less common than RRMS and SPMS, and is characterised by a slow progression of worsening symptoms from the outset, with minimal periods of relapse or remission. 

Clinically Isolated Syndrome

CIS is a condition that can occur in clinically stable patients before MS develops, and is characterised by a short episode of symptoms lasting at least 24 hours. You may have one episode and never experience symptoms again, or it may develop into RRMS. 

Progressive Relapsing Multiple Sclerosis

PRMS is a rare type of MS characterised by a steady but gradual worsening of symptoms from the onset, with clear periods of relapse when your symptoms are noticeably worse.

What are common symptoms of MS?

The main symptoms of MS include:

• fatigue and weakness

• balance issues

• pins and needles, burning or numbness in the skin

• sensory loss, such as problems with smell and hearing

• vision problems, such as double vision, painful eye movements or loss of vision

• pain in the back and sometimes into the limbs

• problems with memory and thinking

• difficulty walking

• muscle stiffness and spasms (spasticity)

• bladder and bowel problems

• sexual problems

Less common symptoms include:

• speech disorders

• involuntary facial movements

• sleep disturbances

• vertigo

• swallowing difficulties

If your doctor thinks you may have MS, they’ll send you for tests with a specialist neurologist. There are diagnostic criteria a patient must meet to receive an MS diagnosis, which means performing multiple tests. There is no single test for MS. 

Causes of Multiple Sclerosis

MS is one of a few types of white matter diseases that affect the myelin sheath, a fatty substance that insulates nerve fibres, leading to multiple lesions and symptoms. 

It’s thought to result from an autoimmune process in which the immune system mistakenly attacks the body. As yet, doctors and scientists are unsure what causes this autoimmune attack, and clinical trials continue into the hypothesis that it could be caused by a virus or environmental toxin. 

There are, however, certain risk factors that may slightly increase your risk of developing MS and MS lesions:

• Being female

• Being aged between 20 and 50

• Being a smoker or an ex-smoker

• Having had the Epstein-Barr virus, the virus that causes glandular fever

There may also be a genetic cause; if you have a parent or sibling with the condition, you might be at high risk of also having it. 

Prognosis and Treatment

Currently, there’s no cure for MS, and getting an MS diagnosis is understandably difficult. There are treatments that can make the symptoms more manageable and slow the progression of the disease. 

Treatment options include medications to reduce swelling around your nerves, muscle relaxants to reduce stiffness and spasms and medicines to help you manage pain and vision problems. Severe symptoms may be helped by plasma exchange to remove harmful antibodies and by monoclonal antibody treatment to reduce relapses. 

You’ll also be supported with physiotherapy, fatigue-reduction techniques, cognitive behavioural therapy to support your mental health and mobility aids to help with day-to-day living and getting about.

Diagnosing Multiple Sclerosis

1. Medical History Assessment - You’ll be asked a series of questions about your symptoms, how long you’ve had them and if they sometimes feel better or worse. Your neurologist will also check your movement, balance, coordination and vision. 

2. Neurological Examination - They’ll then check your reflexes and eye movements and ask you about any numbness, tingling and sensitivity to touch and vibration. 

3. MRI Scan Of Brain And Spinal Cord - You’ll be sent for an MRI scan of the brain and spinal cord using gadolinium contrast enhancement, which will help to identify MS lesions. 

4. Optical Coherence Tomography - You may also undergo an OCT test, a type of imaging used to assess the health of the retina and optic nerves within the eyes, which can be affected by MS. 

5. Lumbar Puncture - A small sample of cerebrospinal fluid from your spinal cord is taken using a long, thin needle. This is analysed for the presence of proteins called oligoclonal bands and kappa-free light chains, key markers of MS. 

6. Visual Evoked Potential Tests - You may also undergo a series of tests that assess electrical activity in the brain when certain nerves are stimulated. 

7. Blood Tests To Rule Out Other Conditions - You’re also likely to have blood tests to help rule out an infection or another condition that may be causing your symptoms. 

8. Application of McDonald Criteria for Diagnosis Confirmation - Your doctor will collate all your results and either diagnose or rule out MS using the McDonald Criteria, a set of specialised guidelines that help diagnose the condition more quickly. 

Does MS show up on MRI?

Yes, doctors can identify MS using an MRI scan. MRI images can spot MS-related abnormalities, including lesions, damage and inflammation in the central nervous system. MRI scans can also track the condition’s activity and progression.

When looking for multiple sclerosis, doctors will look at two main types of images:

• T2-weighted or FLAIR scans: these show the total damage caused by MS

• T1-weighted scans with gadolinium contrast: these show older damage and new, active damage by using a special dye

How an MRI scan detects Multiple Sclerosis

An MRI creates detailed images of the brain and spinal cord and highlights active lesions on the nerves and basal ganglia (structures deep within the brain responsible for movement and cognition), which appear as bright white spots on a dark background. MRI scans also highlight juxtacortical lesions, MS lesions that affect the cerebral cortex, and paramagnetic rim lesions that indicate chronic inflammation and ongoing damage. 

Often, doctors also perform an MRI scan with a contrast agent, or dye, injected into a vein in the arm. This is called a gadolinium-enhanced MRI and highlights older or inactive disease as darker spots alongside the brighter spots of enhancing lesions and active disease. Gadolinium enhancement also highlights inflammation resulting from a breakdown of the blood-brain barrier, an early indicator of the disease. 

This combination allows doctors to determine the pattern of the disease and lesion load, the total number of active lesions.

What does MS look like on MRI images? 

How MS shows up depends on the type of MRI scan you have:

A T2-weighted or FLAIR scan shows MS as bright, white spots (lesions) on a black background. It shows areas where the myelin has been damaged and helps doctors determine whether MS is affecting the brain or spinal cord.

A T1-weighted scan with gadolinium contrast shows older damage as darker spots and new and active damage as bright white spots. This allows doctors to see how active the disease is, which helps them plan your treatment more effectively. 

Multiple sclerosis MRI vs normal

In a person without MS, the MRI scan would show the brain or spinal cord as generally uniform in colour, with no bright spots or darker areas indicating damage, inflammation or activity. 

Early MS MRI

If you’ve just started having symptoms, you may be wondering, does early MS show up on MRI? Yes, early multiple sclerosis can show up on an MRI. 

On T2-weighted and FLAIR scans, early MS appears as small bright spots in the brain and spinal cord, indicating early damage to the protective covering of nerve fibres. 

On T1-weighted scans with gadolinium contrast, bright spots may appear after a special dye is injected, showing areas of active inflammation and ongoing damage.

Spotting these changes early on an MRI helps doctors diagnose early-stage multiple sclerosis sooner. This is crucial because it allows for earlier treatment, which can slow the disease's progress. 

Does MS always show up on MRI? Can MS be missed on MRI?

It’s possible for an MRI scan to miss MS in the very early stages of the disease. This might be because the lesions are too small or too few to be picked up by the MRI or because they are in an area that is hard to image.

It’s also possible that the quality of the scanning machine will affect the results. It’s also possible for MS to be missed if the magnetic fields are not strong enough, the technician doesn’t use the correct imaging techniques, or the radiologist cannot definitively interpret the images as showing signs of MS.

Can a CT scan detect MS?

CT scans are not typically used to diagnose MS.

Although a CT scan can detect abnormalities in the brain, it’s not sensitive enough to detect the damage caused by MS. It doesn't show the small, detailed lesions that an MRI can. MRI is much better at seeing the brain and spinal cord soft tissues, which are essential for spotting MS. 

Differential Diagnosis

There are some medical conditions that cause similar symptoms to MS, that are either diagnosed or ruled out during tests for MS. These include vitamin B12 deficiency, nerve damage, Lyme disease, lupus, Sjögren disease, neuromyelitis optica spectrum disorder and progressive multifocal leukoencephalopathy. 

Why an MRI Scan is a Good Option

An MRI machine is the gold standard in the diagnosis of multiple sclerosis. It can detect spinal cord lesions and active lesions of the cervical cord (the uppermost part of the spinal cord, located in the neck) in both early and progressive disease. 

An MRI scan is used alongside blood tests and tests on the cerebrospinal fluid (the fluid surrounding the spinal cord). However, an MRI scan is the only way for doctors to see MS activity and active lesions.

Which MS scan to choose?

MRIs provide the most detailed and accurate imaging of MS. Don’t worry if you’re still not sure whether a private MRI scan is best for you, or what the difference is between an MRI and CT scan of the brain.

All Scan.com bookings include two clinical consultations. One happens before the scan to ensure your clinician recommends the best scan for you in light of your symptoms. The second consultation takes place after the scan, where your clinician will clearly explain the results and the next steps. 

Sources:

Feng, Y, et al. (2019). A self-adaptive network for multiple sclerosis lesion segmentation from multi-contrast mri with various imaging sequences. https://ieeexplore.ieee.org/document/8759522/

How is MS diagnosed? (N.D.) https://www.mssociety.org.uk/about-ms/diagnosis/the-tests-for-ms

MRI and MS: 7 things you need to know. (2017). https://www.mssociety.org.uk/research/latest-research/research-blog/mri-and-ms-7-things-you-need-know

Multiple sclerosis. (2022). https://www.nhs.uk/conditions/multiple-sclerosis/

Multiple Sclerosis. (2023).https://www.ninds.nih.gov/

Multiple sclerosis in adults: management. (2022). https://www.nice.org.uk/guidance/ng220/chapter/Recommendations#diagnosing-multiple-sclerosis

What is MS? (2021). https://www.mssociety.org.uk/sites/default/files/2021-04/What%20is%20MS%20Mar%202021%20%28web%29_0.pdf