Multiple sclerosis diagnostic study of choice: Difference between revisions

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Revision as of 15:06, 18 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D.

Overview

Diagnostic Study of Choice

Study of choice

Before MRI becomes a common imaging technique for diagnosis MS, clinical presentation was the only tool. Nowadays, new diagnostic criteria (mcDonald criteria) are focusing on MRI finding in addition to clinical presentation of patients.^[1] MRI can show lesions better than CTscan. We can find typical white matter lesion in most of the MS patients. These findings alone can’t confirm the diagnosis since there are so many conditions mimicing MS imaging especially ischemic lesions in patients more than 50 years old.^[2]

[Name of the investigation] is the gold standard test for the diagnosis of [disease name].

OR

The following result of [gold standard test] is confirmatory of [disease name]:

[Result 1]
[Result 2]

OR

[Name of the investigation] must be performed when:

The patient presents with [symptom/sign 1], [symptom/sign 2], and [symptom/sign 3].
A [name of test] is positive for [sign 1], [sign 2], and [sign 3] in the patient.

OR

[Name of the investigation] is the gold standard test for the diagnosis of [disease name].

OR

The diagnostic study of choice for [disease name] is [name of the investigation].

OR

There is no single diagnostic study of choice for the diagnosis of [disease name].

OR

There is no single diagnostic study of choice for the diagnosis of [disease name], but [disease name] can be diagnosed based on [name of the investigation 1] and [name of the investigation 2].

OR

[Disease name] is primarily diagnosed based on the clinical presentation.

OR

Investigations:

Among the patients who present with clinical signs of [disease name], the [investigation name] is the most specific test for the diagnosis.
Among the patients who present with clinical signs of [disease name], the [investigation name] is the most sensitive test for diagnosis.
Among the patients who present with clinical signs of [disease name], the [investigation name] is the most efficient test for diagnosis.

The comparison of various diagnostic studies for [disease name]

Test	Sensitivity	Specificity
Test 1	...%	...%
Test 2	...%	...%

[Name of test with higher sensitivity and specificity] is the preferred investigation based on the sensitivity and specificity

Diagnostic results

The following finding(s) on performing [investigation name] is(are) confirmatory for [disease name]:

[Finding 1]
[Finding 2]

Sequence of Diagnostic Studies

History and physical examination
Imaging
CSF analysis

Name of Diagnostic Criteria

McDonald criteria

2 or more attacks (relapses)
2 or more objective clinical lesions

None; clinical evidence will suffice (additional evidence desirable but must be consistent with MS)

* 2 or more attacks

* 1 objective clinical lesion

Dissemination in space, demonstrated by:

MRI
Further clinical attack involving different site.

New criteria: Dissemination in Space (DIS) can be demonstrated by the presence of 1 or more T2 lesions in at least 2 of 4 of the following areas of the CNS: Periventricular, Juxtacortical, Infratentorial, or Spinal Cord.

* 1 attack

* 2 or more objective clinical lesions

Dissemination in time (DIT), demonstrated by:

MRI
Second clinical attack

New criteria: No longer a need to have separate MRIs run; Dissemination in time, demonstrated by: Simultaneous presence of asymptomatic gadolinium-enhancing

and nonenhancing lesions at any time; or A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, irrespective of its timing with reference to a baseline scan; or Await a second clinical attack. [This allows for quicker diagnosis without sacrificing specificity, while improving sensitivity.]

* 1 attack

* 1 objective clinical lesion

(clinically isolated syndrome)

New criteria: Dissemination in space and time, demonstrated by:

For DIS: 1 or more T2 lesion in at least 2 of 4 MS-typical regions of the CNS (periventricular, juxtacortical, infratentorial, or spinal cord); or Await a second clinical attack implicating a different CNS site; and For DIT: Simultaneous presence of asymptomatic gadolinium-enhancing and nonenhancing lesions at any time; or A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, irrespective of its timing with reference to a baseline scan; or Await a second clinical attack.

Insidious neurological progression

suggestive of MS

(primary progressive MS)

New criteria: One year of disease progression (retrospectively or prospectively determined) and

two or three of the following:

1. Evidence for DIS in the brain based on 1 or more T2 lesions in the MS-characteristic (periventricular, juxtacortical, or infratentorial) regions

2. Evidence for DIS in the spinal cord based on 2 or more T2 lesions in the cord

It is recommended that you include the criteria in a table. Make sure you always cite the source of the content and whether the table has been adapted from another source.

[Disease name] is primarily diagnosed based on clinical presentation. There are no established criteria for the diagnosis of [disease name].

OR

There is no single diagnostic study of choice for [disease name], though [disease name] may be diagnosed based on [name of criteria] established by [...].

OR

The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].

OR

The diagnosis of [disease name] is based on the [criteria name] criteria, which includes [criterion 1], [criterion 2], and [criterion 3].

OR

[Disease name] may be diagnosed at any time if one or more of the following criteria are met:

Criteria 1
Criteria 2
Criteria 3

OR

IF there are clear, established diagnostic criteria

The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].

OR

The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].

OR

The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].

OR

References

↑ McDonald WI, Compston A, Edan G, Goodkin D, Hartung HP, Lublin FD, McFarland HF, Paty DW, Polman CH, Reingold SC, Sandberg-Wollheim M, Sibley W, Thompson A, van den Noort S, Weinshenker BY, Wolinsky JS (July 2001). "Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis". Ann. Neurol. 50 (1): 121–7. PMID 11456302.
↑ Offenbacher H, Fazekas F, Schmidt R, Freidl W, Flooh E, Payer F, Lechner H (May 1993). "Assessment of MRI criteria for a diagnosis of MS". Neurology. 43 (5): 905–9. PMID 8274173.

Template:WH Template:WS

[pmid11456302-1] McDonald WI, Compston A, Edan G, Goodkin D, Hartung HP, Lublin FD, McFarland HF, Paty DW, Polman CH, Reingold SC, Sandberg-Wollheim M, Sibley W, Thompson A, van den Noort S, Weinshenker BY, Wolinsky JS (July 2001). "Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis". Ann. Neurol. 50 (1): 121–7. PMID 11456302.

[pmid8274173-2] Offenbacher H, Fazekas F, Schmidt R, Freidl W, Flooh E, Payer F, Lechner H (May 1993). "Assessment of MRI criteria for a diagnosis of MS". Neurology. 43 (5): 905–9. PMID 8274173.

[1]

[2]

@@ Line 9: / Line 9: @@
 * Before [[MRI]] becomes a common imaging technique for [[diagnosis]] [[MS]], clinical presentation was the only tool. Nowadays, new [[diagnostic criteria]] ([[mcDonald criteria]]) are focusing on [[MRI]] finding in addition to clinical presentation of patients.<ref name="pmid11456302">{{cite journal |vauthors=McDonald WI, Compston A, Edan G, Goodkin D, Hartung HP, Lublin FD, McFarland HF, Paty DW, Polman CH, Reingold SC, Sandberg-Wollheim M, Sibley W, Thompson A, van den Noort S, Weinshenker BY, Wolinsky JS |title=Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis |journal=Ann. Neurol. |volume=50 |issue=1 |pages=121–7 |date=July 2001 |pmid=11456302 |doi= |url=}}</ref>  MRI can show lesions better than CTscan. We can find typical white matter lesion in most of the MS patients. These findings alone can’t confirm the diagnosis since there are so many conditions mimicing MS imaging especially ischemic lesions in patients more than 50 years old.<ref name="pmid8274173">{{cite journal |vauthors=Offenbacher H, Fazekas F, Schmidt R, Freidl W, Flooh E, Payer F, Lechner H |title=Assessment of MRI criteria for a diagnosis of MS |journal=Neurology |volume=43 |issue=5 |pages=905–9 |date=May 1993 |pmid=8274173 |doi= |url=}}</ref>
@@ Line 86: / Line 85: @@
 {|
-! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Subtypes
+! colspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |McDonald criteria
-! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Explanation
 |-
-! style="background: #DCDCDC; text-align: center;" |Acute Motor Axonal Neuropathy (AMAN)
+! style="background: #DCDCDC; text-align: center;" |
+* 2 or more attacks (relapses)
+* 2 or more objective clinical lesions
 | style="background: #F5F5F5;" |
-* The most common type (85-90%).
+* None; clinical evidence will suffice (additional evidence desirable but must be consistent with MS)
-* Prior infection can trigger it.
-* [[Autoimmune disorder]].
-* The target is [[schwann cell]] surface membrane or the [[myelin]].
-* Causes [[demyelination]].
-* In electrodiagnostic tests we can see slowing of nerve conduction.
-* In pathology we can see [[Lymphocyte|lymphocytic]] infiltration of peripheral nerves and [[macrophage]] invasion of [[myelin sheath]] and [[Schwann cell|schwann cells]].
 |-
-! style="background: #DCDCDC; text-align: center;" |Acute Motor Axonal Neuropathy (AMAN)
+! style="background: #DCDCDC; text-align: center;" |* 2 or more attacks
-| style="background: #F5F5F5;" |
+<nowiki>*</nowiki> 1 objective clinical lesion
-* It’s common among Chinese and Japanese people.
+| style="background: #F5F5F5;" |Dissemination in space, demonstrated by:
-* It can be triggered by C. jejuni.
+* MRI
-* It is associated with anti[[ganglioside]] [[antibodies]].
+* Further clinical attack involving different site.
-* [[Autoimmunity|Autoimmune]] disorder.
+'''New criteria:''' Dissemination in Space (DIS) can be demonstrated by the presence of 1 or more T2 lesions in at least 2 of 4 of the following areas of the CNS: Periventricular, Juxtacortical, Infratentorial, or Spinal Cord.
-* Target is [[Axon|axonal]] membrane.
+|-
-* Causes [[Axon|axonal]] degeneration in [[Motor neuron|motor neurons]].
+! style="background: #DCDCDC; text-align: center;" |* 1 attack
-* In electrodiagnostic study we can see reduction of compound muscle [[action potential]].
+<nowiki>*</nowiki> 2 or more objective clinical lesions
+| style="background: #F5F5F5;" |Dissemination in time (DIT), demonstrated by:
+* MRI
+* Second clinical attack
+'''New criteria:''' No longer a need to have separate MRIs run; Dissemination in time, demonstrated by: Simultaneous presence of asymptomatic gadolinium-enhancing
+and nonenhancing lesions at any time; or A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, irrespective of its timing with reference to a baseline scan; or Await a second clinical attack. [This allows for quicker diagnosis without sacrificing specificity, while improving sensitivity.]
 |-
-! style="background: #DCDCDC; text-align: center;" |Acute motor and sensory axonal neuropathy
+! style="background: #DCDCDC; text-align: center;" |* 1 attack
-| style="background: #F5F5F5;" |
+<nowiki>*</nowiki> 1 objective clinical lesion
-* The incidence rate is under 10%.
-* Causes [[Axon|axonal]] [[degeneration]].
+(clinically isolated syndrome)
-* It is similar with [[Acute motor axonal neuropathy|AMAN]] but involves both motor and sensory [[Axon|axons]].
+| style="background: #F5F5F5;" |'''New criteria:''' Dissemination in space and time, demonstrated by:
+For DIS: 1 or more T2 lesion in at least 2 of 4 MS-typical regions of the CNS (periventricular, juxtacortical, infratentorial, or spinal cord); or Await a second clinical attack implicating a different CNS site; and For DIT: Simultaneous presence of asymptomatic gadolinium-enhancing and nonenhancing lesions at any time; or A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, irrespective of its timing with reference to a baseline scan; or Await a second clinical attack.
+*
 |-
-! style="background: #DCDCDC; text-align: center;" |Miller Fisher syndrome
+!Insidious neurological progression
-| style="background: #F5F5F5;" |
+suggestive of MS
-* Causes a clinical triad: [[ophthalmoplegia]], [[ataxia]] and [[areflexia]].
-* Associated with [[ganglioside]] GQ1b [[antibody]].
+(primary progressive MS)
-|}
+!'''New criteria:''' One year of disease progression (retrospectively or prospectively determined) and
+two or three of the following:
+. Evidence for DIS in the brain based on 1 or more T2 lesions in the MS-characteristic (periventricular, juxtacortical, or infratentorial) regions
+. Evidence for DIS in the spinal cord based on 2 or more T2 lesions in the cord
+|}
 '''It is recommended that you include the criteria in a table. Make sure you always cite the source of the content and whether the table has been adapted from another source.'''