Diagnosis is it time for an update?

Caucheteux N, Maarouf A, Genevray M, Leray E, Deschamps R, Chaunu MP, Daelman L, Ferré JC, Gout O, Pelletier J, Pierot L, Edan G, Tourbah A. Criteria improving multiple sclerosis diagnosis at the first MRI. J Neurol. 2015 Feb [Epub ahead of print]

The introduction of the McDonald criteria has enabled earlier diagnosis of multiple sclerosis (MS). However, even with the 2010 revised criteria, nearly 50 % of patients remain classified as “possible MS” following the first MRI. The present study aimed to demonstrate that time to MS diagnosis could be shorter than 2010 revised criteria, and established after a single early MRI in most patients with the association of the symptomatic lesion and at least one suggestive asymptomatic lesion. We also evaluated the short-term predictive capacity of an individual suggestive lesion on disease activity. We analyzed initial MRI results from 146 patients with MS from a multicenter retrospective study. Visualization of the symptomatic lesion was used as a primary criterion. Secondary criteria included one suggestive lesion (SL) aspect or topography on MRI, or one non-specific lesion associated with positive CSF. The proposed criteria led to a positive diagnosis of MS in 100 % of cases, from information available from the time of the first MRI for 145 patients (99.3 %). At least one SL was observed for 143 patients (97.9 %), and positive CSF for the 3 others. Compared to the McDonald criteria, the proposed criteria had 100 % sensitivity, with a significantly shorter mean time to reach a positive diagnosis. Furthermore, the simultaneous presence of corpus callosum, temporal horn, and ovoid lesions was associated with radiological or clinical activity after a year of follow-up. The proposed diagnostic criteria are easy to apply, have a good sensitivity, and allow an earlier diagnosis than the 2010 McDonald criteria. Nevertheless, prospective studies are needed to establish specificity and to confirm these findings.

Many years ago there was no rush to give a diagnosis of MS, because there was nothing to give treatment-wise. However this has now changed and there are options available at least for our non-UK Neuros who have no problem treating during clinically isolated syndrome.Therefore, there is an advantage to detect and diagnose MS as quickly as possible. Diagnosis used to be clinical with disease in “time” and “space”  according to the Poser criteria. Then we put MRI into the mix and this is capable of spotting lesions in time and space with one scan. We had the MacDonald criteria and then the Barkhof criteria which brought imaging into diagnostic criteria. 

This study suggests a further modification and can spot MS after one scan because the Old MacDonald criteria are not so much E-I-E-I-O but they miss a lot, so the diagnosis may not be certain. Maybe it possible to be 100% certain off finding MS by these criteria and cut the time to diagnosis. Will these catch on? and who gets to name the criteria?

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  • Limbo is a hard place to be and a more rapid diagnosis can only be a good thing, psychologically and from a treatment perspective.
    In lesion numbers and location I met the McDonald criteria on my first scan but no contrast was used so a diagnosis of CIS was given. I was however able to get on Beta Interferon and I know that’s quite unusual here in the UK.
    I’ve been stable since but asked for another MRI which has come back with a new lesion so definite CDMS. If I hadn’t asked for a repeat MRI I’d still be undiagnosed. As it is I now meet the eligibility criteria for higher efficiency DMT’s.
    I feel lucky to be ahead of the game so to speak and glad I pushed for what I’ve had.

  • There are still things which can be done with "probable MS" that can no longer be done once the label of "MS" sticks. For example, in the U.S. we can still apply for long term care insurance. One we have MS, such care insurance gets drastically harder to obtain.

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