Multiple sclerosis diagnostic study of choice: Difference between revisions

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== Overview ==
== Overview ==
There is no single diagnostic study of choice for the diagnosis of multiple sclerosis, but multiple sclerosis can be diagnosed based on [[History and Physical examination|clinical presentation]], [[MRI]] findings, and [[CSF analysis]]. Sequence of diagnostic studies are [[History and Physical examination|history and physical examination]], [[imaging]], and [[CSF analysis]]. The findings are [[cerebral]] plaques which are [[demyelinating]] areas on [[Magnetic resonance imaging|MRI]] and an elevated concentration of [[CSF]] [[oligoclonal bands]]. The diagnostic criteria for multiple sclerosis is [[McDonald criteria]].


== Diagnostic Study of Choice ==
== Diagnostic Study of Choice ==
Line 8: Line 9:
=== 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.<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>
There is no single diagnostic study of choice for the diagnosis of multiple sclerosis, but multiple sclerosis can be diagnosed based on [[History and Physical examination|clinical presentation]], [[MRI]] findings, and [[CSF analysis]].
 
 
 
[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:
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 multiple sclerosis, the [[CSF analysis]] 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 multiple sclerosis, the [[Magnetic resonance imaging|MRI]] is the most sensitive test for [[Diagnosis-related group|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] ====
 
<small> [Name of test with higher sensitivity and specificity] is the preferred investigation based on the sensitivity and specificity</small>


===== Diagnostic results =====
===== Diagnostic results =====
The following finding(s) on performing [investigation name] is(are) confirmatory for [disease name]:
The following findings are confirmatory for multiple sclerosis:
*[[cerebral]] plaques which are [[demyelinating]] areas.<ref name="pmid9445407">{{cite journal |vauthors=Trapp BD, Peterson J, Ransohoff RM, Rudick R, Mörk S, Bö L |title=Axonal transection in the lesions of multiple sclerosis |journal=N. Engl. J. Med. |volume=338 |issue=5 |pages=278–85 |date=January 1998 |pmid=9445407 |doi=10.1056/NEJM199801293380502 |url=}}</ref>
*[[Cerebral]] plaques which are [[demyelinating]] areas on [[MRI contrast agent|MRI]].<ref name="pmid9445407">{{cite journal |vauthors=Trapp BD, Peterson J, Ransohoff RM, Rudick R, Mörk S, Bö L |title=Axonal transection in the lesions of multiple sclerosis |journal=N. Engl. J. Med. |volume=338 |issue=5 |pages=278–85 |date=January 1998 |pmid=9445407 |doi=10.1056/NEJM199801293380502 |url=}}</ref>
* An elevated concentration of [[CSF]] [[oligoclonal bands]] is [[diagnostic]] of multiple sclerosis and can be seen in more than 95% of these 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><ref name="pmid23431079">{{cite journal |vauthors=Dobson R, Ramagopalan S, Davis A, Giovannoni G |title=Cerebrospinal fluid oligoclonal bands in multiple sclerosis and clinically isolated syndromes: a meta-analysis of prevalence, prognosis and effect of latitude |journal=J. Neurol. Neurosurg. Psychiatry |volume=84 |issue=8 |pages=909–14 |date=August 2013 |pmid=23431079 |doi=10.1136/jnnp-2012-304695 |url=}}</ref><ref name="pmid2245296">{{cite journal |vauthors=McLean BN, Luxton RW, Thompson EJ |title=A study of immunoglobulin G in the cerebrospinal fluid of 1007 patients with suspected neurological disease using isoelectric focusing and the Log IgG-Index. A comparison and diagnostic applications |journal=Brain |volume=113 ( Pt 5) |issue= |pages=1269–89 |date=October 1990 |pmid=2245296 |doi= |url=}}</ref>  
* An elevated concentration of [[CSF]] [[oligoclonal bands]].<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><ref name="pmid23431079">{{cite journal |vauthors=Dobson R, Ramagopalan S, Davis A, Giovannoni G |title=Cerebrospinal fluid oligoclonal bands in multiple sclerosis and clinically isolated syndromes: a meta-analysis of prevalence, prognosis and effect of latitude |journal=J. Neurol. Neurosurg. Psychiatry |volume=84 |issue=8 |pages=909–14 |date=August 2013 |pmid=23431079 |doi=10.1136/jnnp-2012-304695 |url=}}</ref><ref name="pmid2245296">{{cite journal |vauthors=McLean BN, Luxton RW, Thompson EJ |title=A study of immunoglobulin G in the cerebrospinal fluid of 1007 patients with suspected neurological disease using isoelectric focusing and the Log IgG-Index. A comparison and diagnostic applications |journal=Brain |volume=113 ( Pt 5) |issue= |pages=1269–89 |date=October 1990 |pmid=2245296 |doi= |url=}}</ref>  


===== Sequence of Diagnostic Studies =====
===== Sequence of Diagnostic Studies =====
* History and physical examination
* [[History and Physical examination|History and physical examination]]
* Imaging
* [[Imaging]]
* CSF analysis
* [[CSF analysis]]


=== McDonald criteria  ===
=== McDonald criteria  ===
<ref name="pmid30658260">{{cite journal |vauthors=Gobbin F, Zanoni M, Marangi A, Orlandi R, Crestani L, Benedetti MD, Gajofatto A |title=2017 McDonald criteria for multiple sclerosis: Earlier diagnosis with reduced specificity? |journal=Mult Scler Relat Disord |volume=29 |issue= |pages=23–25 |date=January 2019 |pmid=30658260 |doi=10.1016/j.msard.2019.01.008 |url=}}</ref><ref name="pmid114563022">{{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>
The [[diagnostic criteria]] for multiple sclerosis is [[McDonald criteria]].<ref name="pmid30658260">{{cite journal |vauthors=Gobbin F, Zanoni M, Marangi A, Orlandi R, Crestani L, Benedetti MD, Gajofatto A |title=2017 McDonald criteria for multiple sclerosis: Earlier diagnosis with reduced specificity? |journal=Mult Scler Relat Disord |volume=29 |issue= |pages=23–25 |date=January 2019 |pmid=30658260 |doi=10.1016/j.msard.2019.01.008 |url=}}</ref><ref name="pmid114563022">{{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>
{|
{|
|-
|-
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* 2 or more objective clinical lesions
* 2 or more objective clinical lesions
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* None; clinical evidence will suffice (additional evidence desirable but must be consistent with MS)
* None; [[clinical]] evidence will suffice (additional evidence desirable but must be consistent with MS)
|-
|-
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
Line 85: Line 43:
* 1 objective clinical lesion
* 1 objective clinical lesion
| style="background: #F5F5F5; padding: 5px;" |Dissemination in space, demonstrated by:  
| style="background: #F5F5F5; padding: 5px;" |Dissemination in space, demonstrated by:  
* MRI  
* [[MRI]]
* Further clinical attack involving different site  
* Further clinical attack involving different site  
* 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
* 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]]
'''New criteria:''' Dissemination in Space (DIS) can be demonstrated by the .
'''New criteria:''' Dissemination in Space (DIS) can be demonstrated by the .
|-
|-
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* 2 or more objective clinical lesions
* 2 or more objective clinical lesions
| style="background: #F5F5F5; padding: 5px;" |Dissemination in time (DIT), demonstrated by:
| style="background: #F5F5F5; padding: 5px;" |Dissemination in time (DIT), demonstrated by:
* MRI  
* [[MRI contrast agent|MRI]]
* Second clinical attack  
* 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
'''New criteria:''' No longer a need to have separate [[MRI|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.]
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; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
Line 106: Line 64:
* 1 objective clinical lesion (clinically isolated syndrome)  
* 1 objective clinical lesion (clinically isolated syndrome)  
| style="background: #F5F5F5; padding: 5px;" |'''New criteria:''' Dissemination in space and time, demonstrated by:
| style="background: #F5F5F5; padding: 5px;" |'''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.
* 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 non-enhancing [[Lesion|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; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
* Insidious neurological progression suggestive of MS (primary progressive MS)
* Insidious [[neurological]] progression suggestive of MS (primary progressive MS)
| style="background: #F5F5F5; padding: 5px;" |'''New criteria:''' One year of disease progression (retrospectively or prospectively determined) and two or three of the following:
| style="background: #F5F5F5; padding: 5px;" |'''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 [[brain]] based on 1 or more T2 [[Lesion|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  
* Evidence for DIS in the spinal cord based on 2 or more T2 [[lesions]] in the cord  
|}
|}


Latest revision as of 23:09, 8 January 2021

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

Overview

There is no single diagnostic study of choice for the diagnosis of multiple sclerosis, but multiple sclerosis can be diagnosed based on clinical presentation, MRI findings, and CSF analysis. Sequence of diagnostic studies are history and physical examination, imaging, and CSF analysis. The findings are cerebral plaques which are demyelinating areas on MRI and an elevated concentration of CSF oligoclonal bands. The diagnostic criteria for multiple sclerosis is McDonald criteria.

Diagnostic Study of Choice

Study of choice

There is no single diagnostic study of choice for the diagnosis of multiple sclerosis, but multiple sclerosis can be diagnosed based on clinical presentation, MRI findings, and CSF analysis.

Investigations:

  • Among the patients who present with clinical signs of multiple sclerosis, the CSF analysis is the most specific test for the diagnosis.
  • Among the patients who present with clinical signs of multiple sclerosis, the MRI is the most sensitive test for diagnosis.
Diagnostic results

The following findings are confirmatory for multiple sclerosis:

Sequence of Diagnostic Studies

McDonald criteria

The diagnostic criteria for multiple sclerosis is McDonald criteria.[5][6]

Clinical presentation Additional Data Needed
  • 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
  • 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

New criteria: Dissemination in Space (DIS) can be demonstrated by the .

  • 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 non-enhancing 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:
  • 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

References

  1. ↑ Trapp BD, Peterson J, Ransohoff RM, Rudick R, Mörk S, Bö L (January 1998). "Axonal transection in the lesions of multiple sclerosis". N. Engl. J. Med. 338 (5): 278–85. doi:10.1056/NEJM199801293380502. PMID 9445407.
  2. ↑ 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.
  3. ↑ Dobson R, Ramagopalan S, Davis A, Giovannoni G (August 2013). "Cerebrospinal fluid oligoclonal bands in multiple sclerosis and clinically isolated syndromes: a meta-analysis of prevalence, prognosis and effect of latitude". J. Neurol. Neurosurg. Psychiatry. 84 (8): 909–14. doi:10.1136/jnnp-2012-304695. PMID 23431079.
  4. ↑ McLean BN, Luxton RW, Thompson EJ (October 1990). "A study of immunoglobulin G in the cerebrospinal fluid of 1007 patients with suspected neurological disease using isoelectric focusing and the Log IgG-Index. A comparison and diagnostic applications". Brain. 113 ( Pt 5): 1269–89. PMID 2245296.
  5. ↑ Gobbin F, Zanoni M, Marangi A, Orlandi R, Crestani L, Benedetti MD, Gajofatto A (January 2019). "2017 McDonald criteria for multiple sclerosis: Earlier diagnosis with reduced specificity?". Mult Scler Relat Disord. 29: 23–25. doi:10.1016/j.msard.2019.01.008. PMID 30658260.
  6. ↑ 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.

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