Accuracy in Space and Time: Diagnosing Multiple Sclerosis

Accuracy in Space and Time:
Diagnosing Multiple Sclerosis
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Epidemiology
Multiple Sclerosis
• Multiple sclerosis is a chronic, unpredictable disease of the central nervous
system (the brain, optic nerves, and spinal cord)
• Affects more than 400,000 in the US and 2.1 million worldwide
• More than twice as common in women as in men
• Most people are diagnosed between the ages of 20 and 50, although
individuals as young as 2 and as old as 75 have developed it
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Typical symptoms
• Symptoms of MS are unpredictable and can vary from person to person,
and from time to time in the same person
• Symptoms may include partial or complete paralysis; difficulties with vision,
cognition, speech and elimination; fatigue; sensory changes; difficulty
walking; slurred speech; tremors; stiffness; bladder dysfunction
• Sometimes major symptoms disappear completely and a patient may
regain lost function
• In severe MS, people have symptoms on a permanent basis
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Clinical disease starts with a clinically
isolated syndrome
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Making the diagnosis of MS
can be challenging
Difficult diagnostic groups
• Monosymptomatic presentation
• Insidious neurologic progression (primary progressive MS)
• Explosive onset
• Vague symptoms
Delays in accurate diagnosis could mean loss of crucial time
in a disease with a limited treatment window.
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What’s the first step to effective treatment?
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Diagnostic principles
1. Dissemination in space (DIS)
2. Dissemination in time (DIT)
3. Rule out mimics
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Differential diagnosis
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Red flags for the misdiagnosis of MS
History and physical
• Normal neurologic examination
• Abnormality in a single location (no DIS)
• Progressive from onset (no DIT)
• Onset in childhood or over age 50
• Systemic disease present
• Prominent family history (consider genetic disease)
• Gray matter symptoms: dementia, seizures, aphasia
• Peripheral symptoms: neuropathy, fasciculations
• Acute hemiparesis
• Lack of typical symptoms (no optic neuritis, bladder problems, Lhermitte sign, etc)
• Prolonged benign course (eg, diagnosis made years ago with few findings now)
Tests
• Normal or atypical MRI
• Normal cerebrospinal fluid (CSF)
• Abnormal blood tests (though many are false positives)
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MRI mimics: Which is which?
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MRI alone is NOT specific for MS…
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Evolution of diagnostic criteria: Early history
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1965—Schumacher criteria
Clinically definite multiple sclerosis
1. Objective signs of dysfunction of the central nervous system;
symptoms not acceptable
2. Evidence of damage to 2 or more sites
3. Predominantly damage to the white matter
4a. Two or more episodes of at least 24 hours separated by at least
6 months
4b. Slow or stepwise progression over 6 months
5. Age of onset 10-50 years
6. Diagnosis by a neurologist; signs and symptoms cannot be explained by
other disease
No pathognomonic laboratory test for MS useful in selecting
cases has been discovered.
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1982—Poser criteria
Note: Paraclinical evidence defined as evoked potentials, CT or MRI; at least two oligoclonal bands, none in serum.
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McDonald criteria
*May include findings on neurological examination, visual evoked response in patients reporting prior visual disturbance, or MRI consistent
with demyelination in the implicated area of the CNS.
†Can
include historical events with symptoms and evolution characteristics of a prior inflammatory demyelinating event.
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2010 McDonald MRI criteria:
Definition of attack
• A patient-reported or objectively observed event, current or historical, with
duration of at least 24 hours in the absence of fever or infection
• It should be supported by findings on neurological examination
• Reports of paroxysmal symptoms (historical or current) should consist of
multiple episodes occurring over not less than 24 hours
• Before a definite diagnosis of MS can be made, at least 1 attack must be
corroborated by
– Findings on neurological examination
– Visual evoked potential response in patients reporting prior
visual disturbance
– MRI consistent with demyelination in the area of the CNS implicated in
the historical report of neurological symptoms
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2010 McDonald MRI criteria:
Demonstration of DIS
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2010 McDonald MRI criteria:
Demonstration of DIT
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2010 McDonald criteria: PPMS
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CSF no longer part of
McDonald criteria for MS
• According to the 2001 and 2005 McDonald criteria:
– A positive CSF finding could be used to reduce the MRI requirements for
reaching DIS criteria (requiring only 2 or more MRI-detected lesions
consistent with MS if the CSF was positive)
• In 2010:
– Because imaging criteria for DIS and DIT were simplified, the panel
believed further liberalizing MRI requirements in CSF-positive patients
was not appropriate, and CSF was removed from the criteria for MS
– The panel reaffirmed that positive CSF findings can be important to
support the inflammatory demyelinating nature of the underlying
condition, to evaluate alternative diagnoses, and to predict CDMS
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MRI DIT
Review of McDonald updates
from 2001 to 2011
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McDonald criteria: Accuracy for
predicting future CDMS
1 year after patients presented with CIS, McDonald criteria (2001)
were applied:
• Sensitivity: 83%
• Specificity: 83%
• Positive predictive value: 75%
• Negative predictive value: 89%
Many more patients were identified by McDonald (2001) vs Poser
• Percentage of patients diagnosed with MS 1 year after initially presenting
with CIS was 48% using McDonald criteria vs 20% using Poser criteria
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Prognosis remains a major challenge
The most reliable prognostic factors are:
• Frequency and characteristics of relapses early in disease
• Occurrence of a progressive phase
Characteristics of disease onset associated with better prognosis
• Monosymptomatic
• Optic neuritis
• Complete recovery
• Long time interval between first and second relapse
• Lower number of relapses in initial years
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Risk factors associated with future disability
• Age at onset (≤40 vs >40 years)
• Symptoms at onset (isolated
sensory/cranial nerve vs motor or
motor + sensory)
• MRI status (Negative vs suspicious
vs suggestive)
• Interval between 1st and 2nd attack
(≥2.5 years vs <2.5 years)
• Attack frequency in 1st 2 years of
study (≤2 vs >2)
• Completeness of recovery from
initial attacks (Good vs poor)
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Future directions—MRI techniques
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Future directions—Potential biomarkers
• Genomics
– Human leukocyte antigen (HLA)
• Immune mediators
– Cytokines
– Chemokines
– Activation markers
– Adhesion molecules
• Pathogens
– Epstein-Barr
– Human herpesvirus 6
– MS-associated retrovirus
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References
Dalton CM, Brex PA, Miszkiel KA, et al. Application of the new McDonald criteria to patients with clinically isolated
syndromes suggestive of multiple sclerosis. Ann Neurol. 2002;52:47-53.
De Stefano N, Battaglini M, Stromillo ML, et al. Brain damage as detected by magnetization transfer imaging is less
pronounced in benign than in early relapsing multiple sclerosis. Brain. 2006;129:2008-2016.
Filippi M, Agosta F. Imaging biomarkers in multiple sclerosis. J Mag Res Imag. 2010;31:770-778.
Leary SM, Porter B, Thompson AJ. Multiple sclerosis: diagnosis and the management of acute relapses.
Postgrad Med J. 2005;81:302-308.
McDonald WI, Compston A, Edan G, et al. Recommended diagnostic criteria for multiple sclerosis: guidelines from the
international panel on the diagnosis of multiple sclerosis. Ann Neurol. 2001;50:121-127.
National Multiple Sclerosis Society. Just the facts. NMMS Web site. http://www.nationalmssociety.org/about-multiplesclerosis/index.aspx. Accessed June 5, 2011.
Polman CH, Reingold SC, Banwell B, et al. Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald
Criteria. Ann Neurol. 2011;69:292-302.
Polman CH, Reingold SC, Edan G, et al. Diagnostic criteria for multiple sclerosis: 2005 revisions to the “McDonald
Criteria.” Ann Neurol. 2005;58:840-846.
Poser CM, Brinar VV. Diagnostic criteria for multiple sclerosis: an historical review. Clin Neurol Neurosurg.
2004;106:147-158.
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References
Rolak LA, Fleming JO. The differential diagnosis of multiple sclerosis. The Neurologist. 2007;13:57-72.
Scott TF, Schramke CJ, Novero J, Chieffe C. Short-term prognosis in early relapsing-remitting multiple sclerosis.
Neurology. 2000;55:689-693.
Shaw C, Chapman C, Butzkueven H. How to diagnose multiple sclerosis and what are the pitfalls. Intern Med J.
2009;39:792-799.
Srinivasan R, Sailasuta N, Hurd R, et al. Evidence of elevated glutamate in multiple sclerosis using magnetic resonance
spectroscopy at 3 T. Brain. 2005;128:1016-1025.
Traboulsee A, Li DKB. Conventional MR imaging. Neuroimag Clin N Am. 2008;18:651-673.
Trapp BD, Ransohoff RM, Fisher E, Rudick RA. Neurodegeneration in multiple sclerosis: relationship to neurological
disability. Neuroscientist. 1999;5:48-57.
Villoslada P. Biomarkers for multiple sclerosis. Drug News Perspect. 2010;23:585-595.
Vukusic S, Confavreux C. Natural history of multiple sclerosis: risk factors and prognostic indicators. Curr Opin Neurol.
2007;20:269-274.
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