Preventing multiple sclerosis misdiagnosis using the “central vein sign”: A real-world study

•MS misdiagnosis is a common problem and often stems from MRI misinterpretation•The Central Vein Sign (CVS) is a novel MRI biomarker for MS•Patients with MS and patients previously misdiagnosed with MS were evaluated•Over 29% lesions with CVS distinguished those with MS from misdiagnosed patients•CVS identified 13/15 (87%) patients previously misdiagnosed with MS Background: Misdiagnosis of multiple sclerosis (MS) is common and often occurs due to misattribution of non-MS magnetic resonance imaging (MRI) lesions to MS demyelination. A recently developed MRI biomarker, the central vein sign (CVS), has demonstrated high specificity for MS lesions and may thus help prevent misdiagnosis. Objective: This study explores the potential “real world” diagnostic value of CVS by comparing CVS in patients with MS and patients previously misdiagnosed with MS. Methods: Fifteen patients with MS and 15 misdiagnosed with MS were prospectively recruited to undergo 3T brain MRI. T2-weighted fluid-attenuated inversion recovery (FLAIR) and T2*-weighted segmented echo-planar-imaging (T2*-EPI) were acquired. The generated FLAIR* images were analyzed by two independent raters. The percentage of lesions with CVS was calculated for each patient. Results: A CVS lesion threshold of 29% or higher resulted in high sensitivity (0.79) and specificity (0.88) for MS and correctly identified 87% of patients previously misdiagnosed with MS. Interrater reliability for CVS was high with a Cohen's kappa coefficient of 0.86. Conclusion: This study demonstrates the ability of CVS to differentiate between patients with MS and patients with an MS misdiagnosis resulting from standard MRI and clinical evaluation. Clinical application of CVS may reduce MS misdiagnosis.