A clinico-pathoanatomical study of multiple sclerosis diagnosis

Transcranial magnetic stimulation enhances the specificity of multiple sclerosis diagnostic criteria: a critical narrative review

Background

Multiple sclerosis (MS) is an immune-mediated neurodegenerative disease that involves attacks of inflammatory demyelination and axonal damage, with variable but continuous disability accumulation. Transcranial magnetic stimulation (TMS) is a noninvasive method to characterize conduction loss and axonal damage in the corticospinal tract. TMS as a technique provides indices of corticospinal tract function that may serve as putative MS biomarkers. To date, no reviews have directly addressed the diagnostic performance of TMS in MS. The authors aimed to conduct a critical narrative review on the diagnostic performance of TMS in MS.

Methods

The authors searched the Embase, PubMed, Scopus, and Web of Science databases for studies that reported the sensitivity and/or specificity of any reported TMS technique compared to established clinical MS diagnostic criteria. Studies were summarized and critically appraised for their quality and validity.

Results

Seventeen of 1,073 records were included for data extraction and critical appraisal. Markers of demyelination and axonal damage-most notably, central motor conduction time (CMCT)-were specific, but not sensitive, for MS. Thirteen (76%), two (12%), and two (12%) studies exhibited high, unclear, and low risk of bias, respectively. No study demonstrated validity for TMS techniques as diagnostic biomarkers in MS.

Conclusions

CMCT has the potential to: (1) enhance the specificity of clinical MS diagnostic criteria by "ruling in" true-positives, or (2) revise a diagnosis from relapsing to progressive forms of MS. However, there is presently insufficient high-quality evidence to recommend any TMS technique in the diagnostic algorithm for MS.

Multiple Sclerosis Diagnostic Delay and Misdiagnosis

Multiple sclerosis (MS) misdiagnosis in the form of an incorrect diagnosis of MS, as well as delayed diagnosis in patients who do have MS, both influence patient clinical outcomes. Contemporary studies have reported data on factors associated with these diagnostic challenges and their frequency. Expediting diagnosis in patients with MS and reducing MS misdiagnosis in patients who do not have MS may be aided by educational efforts surrounding early MS symptoms and proper application of MS diagnostic criteria. Emerging novel MS diagnostic biomarkers may aid early and accurate diagnosis of MS in the future.

Challenges in multiple sclerosis diagnosis: Misunderstanding and misapplication of the McDonald criteria

Objective:

To assess comprehension and application of the McDonald criteria.

Background:

Studies suggest that knowledge gaps for specific core elements of the McDonald criteria may contribute to multiple sclerosis (MS) misdiagnosis.

Methods:

Neurology residents (NR) and multiple sclerosis specialists (MSS) in North America completed a web-based survey.

Results:

A total of 160 participants were included: 72 NR and 88 MSS. Syndromes incorrectly identified as typical of MS included: complete transverse myelopathy (35% NR and 15% MSS), intractable vomiting/nausea/hiccoughs (20% NR and 5% MSS), and bilateral optic neuritis/unilateral optic neuritis with poor visual recovery (17% NR and 10% MSS). Periventricular magnetic resonance imaging (MRI) lesions were correctly identified by 39% NR and 52% MSS, and juxtacortical lesions were correctly identified by 28% NR and 53% MSS. The correct definition of “periventricular” was chosen by 38% NR and 61% MSS, and that of “juxtacortical” was chosen by 19% NR and 54% MSS. Regions incorrectly identified for MRI dissemination in space fulfillment included the optic nerve (31% NR and 26% MSS) and the subcortical white matter (11% NR and 18% MSS). The majority of participants assessed previous non-specific neurological symptoms without objective evidence of a central nervous system (CNS) lesion as sufficient for clinical dissemination in time.

Conclusion:

The McDonald criteria are often misunderstood and misapplied. Concerted educational efforts may prevent MS misdiagnosis.

Application of the 2017 Revised McDonald Criteria for Multiple Sclerosis to Patients With a Typical Clinically Isolated Syndrome

Importance

In 2017, the International Panel on Diagnosis of Multiple Sclerosis revised the McDonald 2010 criteria for the diagnosis of multiple sclerosis (MS). The new criteria are easier to apply and could lead to more and earlier diagnoses. It is important to validate these criteria globally for their accuracy in clinical practice.

Objective

To evaluate the diagnostic accuracy of the 2017 criteria vs the 2010 criteria in prediction of clinically definite MS in patients with a typical clinically isolated syndrome (CIS).

Design, Setting and Patients

A total of 251 patients at Erasmus MC, Rotterdam, the Netherlands, in collaboration with several regional hospitals, fulfilled the inclusion criteria. Thirteen patients received another diagnosis early in the diagnostic process and therefore were excluded from the analyses. Nine patients with CIS declined to participate in the study. This left 229 patients who were included between March 2006 and August 2016 in this prospective CIS cohort. Patients underwent a baseline magnetic resonance imaging scan within 3 months after onset of symptoms and, if clinically required, a lumbar puncture was performed. Data were analyzed between December 2017 and January 2018.

Main Outcomes and Measures

Sensitivity, specificity, accuracy, and positive and negative predictive value were calculated after 1, 3, and 5 years for the 2017 vs the 2010 criteria.

Results

Among the 229 patients with CIS, 167 were women (73%), and the mean (SD) age was 33.5 (8.2) years. One hundred thirteen patients (49%) were diagnosed as having CDMS during a mean (SD) follow-up time of 65.3 (30.9) months. Sensitivity for the 2017 criteria was higher than for the 2010 criteria (68%; 95% CI, 57%-77% vs 36%; 95% CI, 27%-47%; P < .001), but specificity was lower (61%; 95% CI, 50%-71% vs 85%; 95% CI, 76%-92%; P < .001). Using the 2017 criteria, more MS diagnoses could be made at baseline (n = 97 [54%]; 95% CI, 47%-61% vs n = 46 [26%]; 95% CI, 20%-32%; P < .001). In the group with at least 5 years of follow-up, 33% of patients who were diagnosed as having MS using the 2017 criteria did not experience a second attack during follow-up vs 23% when using the 2010 criteria.

Conclusions and Relevance

The 2017 revised McDonald criteria are associated with greater sensitivity but less specificity for a second attack than the previous 2010 criteria. The tradeoff is that it leads to a higher number of MS diagnoses in patients with a less active disease course.

Moving from stigmatization toward competent interdisciplinary care of patients with functional neurological disorders: focus group interviews

PURPOSE

To explore facilitating and inhibiting factors in the inpatient care of patients with functional neurological disorders as experienced by interdisciplinary teams of healthcare professionals.

METHOD

Qualitative focus group interviews were conducted with 18 healthcare professionals of various professions. Data were analyzed using qualitative content analysis with inductive coding of data.

RESULTS

Two main categories were formulated: (a) Giving the diagnosis to patients - a moment of fragility and opportunities, and (b) Organization of care - ensuring the continuity and protecting patients' self-image. One overarching theme tied the two categories together: Establishing coherence in the inpatient trajectory - moving from stigmatization toward competent care. Coherence and steadiness in care was a prerequisite for transparency in goalsetting and for designating the responsibilities of individual healthcare professionals. Stigma and having clinical experience and knowledge of functional neurological disorders, as two counter-factors, influenced the extent to which this was achieved. Examples of facilitating factors for enhancing competent care were documentation of symptoms, effective ways of passing on clinical information, education, professional dialog, and organizational support.

DISCUSSION

To nurture competent care, guidelines, structured educational initiatives and other supportive actions should be promoted. We provide ideas for the next logical steps for clinical practice and research.IMPLICATIONS FOR REHABILITATIONClose collaboration between interdisciplinary healthcare professionals plays an important role for reaching optimal results in the rehabilitation of inpatients with functional neurological disorder.There is currently limited knowledge regarding the facilitating and inhibiting features encountered by interdisciplinary healthcare professionals in the provision of care for patients with a functional neurological disorder.The findings show that a working environment that endorses a skillful culture of practice and which facilitates actions to reduce problems that hamper effective teamwork needs to be promoted.Solutions that help to solve many obstacles encountered by the team of healthcare professionals in the care provision of patients with functional neurological disorders include open dialog regarding symptoms, diagnosis and treatment, effective ways of documenting and reporting symptoms, and availability of guidelines and supporting educational material.

Diagnostic Criteria, Classification and Treatment Goals in Multiple Sclerosis: The Chronicles of Time and Space

Multiple sclerosis (MS) is one of the most diverse human diseases. Since its first description by Charcot in the nineteenth century, the diagnostic criteria, clinical course classification, and treatment goals for MS have been constantly revised and updated to improve diagnostic accuracy, physician communication, and clinical trial design. These changes have improved the clinical outcomes and quality of life for patients with the disease. Recent technological and research breakthroughs will almost certainly further change how we diagnose, classify, and treat MS in the future. In this review, we summarize the key events in the history of MS, explain the reasoning behind the current criteria for MS diagnosis, classification, and treatment, and provide suggestions for further improvements that will keep enhancing the clinical practice of MS.

The contemporary spectrum of multiple sclerosis misdiagnosis: A multicenter study

OBJECTIVE

To characterize patients misdiagnosed with multiple sclerosis (MS).

METHODS

Neurologists at 4 academic MS centers submitted data on patients determined to have been misdiagnosed with MS.

RESULTS

Of 110 misdiagnosed patients, 51 (46%) were classified as "definite" and 59 (54%) "probable" misdiagnoses according to study definitions. Alternate diagnoses included migraine alone or in combination with other diagnoses 24 (22%), fibromyalgia 16 (15%), nonspecific or nonlocalizing neurologic symptoms with abnormal MRI 13 (12%), conversion or psychogenic disorders 12 (11%), and neuromyelitis optica spectrum disorder 7 (6%). Duration of misdiagnosis was 10 years or longer in 36 (33%) and an earlier opportunity to make a correct diagnosis was identified for 79 patients (72%). Seventy-seven (70%) received disease-modifying therapy and 34 (31%) experienced unnecessary morbidity because of misdiagnosis. Four (4%) participated in a research study of an MS therapy. Leading factors contributing to misdiagnosis were consideration of symptoms atypical for demyelinating disease, lack of corroborative objective evidence of a CNS lesion as satisfying criteria for MS attacks, and overreliance on MRI abnormalities in patients with nonspecific neurologic symptoms.

CONCLUSIONS

Misdiagnosis of MS leads to unnecessary and potentially harmful risks to patients. Misinterpretation and misapplication of MS clinical and radiographic diagnostic criteria are important contemporary contributors to misdiagnosis.

Differential diagnosis of Mendelian and mitochondrial disorders in patients with suspected multiple sclerosis

Several single gene disorders share clinical and radiologic characteristics with multiple sclerosis and have the potential to be overlooked in the differential diagnostic evaluation of both adult and paediatric patients with multiple sclerosis. This group includes lysosomal storage disorders, various mitochondrial diseases, other neurometabolic disorders, and several other miscellaneous disorders. Recognition of a single-gene disorder as causal for a patient's 'multiple sclerosis-like' phenotype is critically important for accurate direction of patient management, and evokes broader genetic counselling implications for affected families. Here we review single gene disorders that have the potential to mimic multiple sclerosis, provide an overview of clinical and investigational characteristics of each disorder, and present guidelines for when clinicians should suspect an underlying heritable disorder that requires diagnostic confirmation in a patient with a definite or probable diagnosis of multiple sclerosis.

Cerebrospinal fluid analysis

The cerebrospinal fluid (CSF) is a bodily fluid, which is both easily accessible and the most proximate to the pathological alterations of multiple sclerosis (MS). Consequently, the analysis of this fluid provides an important window into the pathological underpinnings of this disease. For example, for years, it has been known that the CSF of MS patients contains oligoclonal gamma immunoglobulins (IgG), which are synthesized within the central nervous system and presumably relate to the immune dysfunction, which is characteristically found in MS. This insight has lead to the introduction of highly-effective anti-B-cell therapies into the field of MS therapeutics. Moreover, the presence of an oligoclonal IgG response in the CSF, although not specific for MS, is a very sensitive finding and, as a result, its presence can be quite helpful for establishing an MS diagnosis in the right clinical context. In addition, this finding has predictive value. Thus, patients without a definite diagnosis who have CSF IgG bands are significantly more likely to develop definite MS compared to those patients without such a banding pattern. Other biological molecules can also be found in the CSF including neurofiliment, myelin basic protein (MBP), glial fibrillary acidic protein (GFAP), tau, neuronal cell adhesion molecule (NCAM), and the growth associated protein (GAP-43). However, the value of measuring these (and other) CSF constituents for both diagnostic and prognostic purposes and for following response to therapy is still to be determined.

Diagnosis of multiple sclerosis

This chapter will serve as a guide for the diagnosis of multiple sclerosis (MS). Primary aims include a review of both the common and atypical clinical manifestations of MS, a detailed discussion of the alternative diagnoses which can mimic MS, as well as a review of the current established diagnostic criteria and a history of their development. It will also review the distinct disease courses and MS variants. The goal of the chapter is to facilitate the diagnostic process for clinicians so that they may expedite early diagnosis and treatment in an effort to alter disease outcomes and ultimately improve patients' quality of life.

Multiple sclerosis: a practical overview for clinicians

Multiple sclerosis (MS) is the commonest disabling neurological condition to afflict young adults and therefore has a high social burden. Over several decades, there has been a considerable progress in the understanding of the disease pathogenesis as well as in the clinical management of MS patients. The emphasis in managing MS patients has shifted to multidisciplinary teams working in specialist groups. A review of the literature was conducted using MedLine to identify recent advances in MS. The current consensus is that MS is an autoimmune disease triggered by environmental agents acting in genetically susceptible people. Based on that concept, new methods of immune intervention procedures have been introduced into clinical practice. Licensed first-line disease-modifying therapies reduce the MS attack or relapse rate by a third and delaying short-term disease progression. More effective therapies have emerged; however, these are associated with increased risks. New clinical and pathological insights are making us question the aetiology and pathogenesis of MS. The recognition of pathological heterogeneity has raised the question of whether MS is a single disease entity or a syndrome. Recent evidence suggests that the pathological subtype may predict therapeutic response to specific therapies. A new novel auto-antibody has defined a subset of neuromyelitis optica or Devic's disease as being distinct from MS. This is an attractive concept that is not widely accepted. The observation that MS progresses despite immunosuppressive therapy suggests that MS may be a neurodegenerative disease with overlapping immune activation possibly in response to the release of central nervous system auto-antigens. The development of neuroprotective therapies for MS is required to prevent the devastating effects of long-term disability as a result of progressive disease.

Wallenberg syndrome caused by multiple sclerosis mimicking stroke

We describe a patient presenting with the rapid onset of incomplete Wallenberg syndrome (WS) as the initial clinical manifestation of multiple sclerosis (MS). This patient was initially diagnosed with acute ischaemic lateral medullary syndrome, but further assessment led to the diagnosis of definite MS. Our report aims to highlight the importance of awareness of MS as a cause of WS, as well as the potential misdiagnosis of MS as stroke.

Neuroepidemiology: Fundamental Considerations

This chapter provides a review of essential concepts, including an overview of the nervous system and methods for diagnosing neurologic disease. Knowledge of the unique characteristics of the nervous system is essential to the design and conduct of studies of neurologic diseases. The chapter provides an overview of epidemiologic study design, emphasizing aspects that are particularly important in the investigation of neurologic disease. These sections emphasize the importance of defining the research question, choosing the study population, and defining study outcomes. A particular focus is the unique methodological considerations for studying neurological conditions.

Multiple Sclerosis

This chapter provides information on the epidemiology of multiple sclerosis (MS), the most common disabling neurological disease in young adults. It describes the clinical and pathologic features of MS and how these features pose challenges for clinical diagnosis and case definition criteria. Information is provided regarding the descriptive epidemiology of MS, including studies of incidence, prevalence, and temporal trends in MS frequency. Also included is a discussion of the interesting geographical features of the MS distribution, including MS disease clusters, the latitude gradient in disease risk, and migrant studies of individuals who move from high-risk to low-risk regions. Other sections of the chapter cover evidence regarding the infectious etiology of MS, including the important role that Epstein-Barr virus appears to play in disease susceptibility. The role of lifestyle factors is receiving increasing emphasis in MS epidemiologic studies, and evidence is summarized regarding the potential role of cigarette smoking, diet, and hormonal factors.

Glioma and multiple sclerosis: case report

We report a case of a 44-years-old woman with relapsing-remitting and secondarily progressive form of multiple sclerosis (MS) since aged 24 years, who developed an anaplastic astrocytoma. The neurological manifestations of the tumor were misinterpreted as resulting from MS. Sequential MRI examination and seizures raised the possibility of another nature of her symptoms, besides MS. Her initial good response to high doses corticosteroids led to the initial assumption her symptoms were only exclusively due to the demyelinating process. She underwent craniotomy with radical excision of the lesion. Pathological examination disclosed anaplastic astrocytoma. Other cases of coincidental MS and primary CNS tumors are reviewed, as well as their possible relation.

Clinical demographics of multiplex families with multiple sclerosis. Multiple Sclerosis Genetics Group

The demographic and clinical characteristics of 89 multiplex families whose affected members meet proposed diagnostic criteria for multiple sclerosis (MS) genetic research are described and compared with 425 sporadic cases of MS and other published collections of MS multiplex families. The proportion of affected multiplex family members who experienced gradual progression of disability from onset (primary progressive MS) is lower than reported by other investigators. Different phenotypes of MS may reflect genetic heterogeneity that may partially explain inconsistencies in the results of genetic linkage studies. Clinical details of affected multiplex family members must be described so that comparisons of genetic results across studies can be properly interpreted.

The diagnosis of multiple sclerosis

The process of diagnosing multiple sclerosis (MS) is much like that of analyzing evidence in a courtroom; they both rely on reason, judgement, and experience, rather than on any formal set of diagnostic criteria. The history, physical examination, and laboratory tests all have limitations and pitfalls that make MS one of the most difficult diseases to diagnose.

Genetic disorders that masquerade as multiple sclerosis

There are many genetic disorders that have signs and symptoms suggestive of multiple sclerosis and that may easily be overlooked in the evaluation of both adult and pediatric multiple sclerosis patients. The recognition of a genetic disorder as the cause of a patient's "multiple sclerosis" phenotype has important implications not only for the patient, but often also for others in the patient's family who may be at risk for the same disease. We present here a review of single gene disorders that can masquerade as multiple sclerosis. For each disorder, the major clinical and biochemical characteristics are discussed, together with the appropriate testing to screen for and confirm the diagnosis. In addition, guidelines are presented for when to suspect an underlying genetic condition in a patient with a diagnosis of definite or probable multiple sclerosis. The great variety of genetic disorders that can masquerade as multiple sclerosis and the many implications of a genetic diagnosis underscore the importance of recognizing genocopies of multiple sclerosis.

Making a diagnosis in patients with an isolated spinal cord syndrome

In this study, a retrospective comparison was made between 40 patients with an isolated spinal cord syndrome in whom an ultimate diagnosis of multiple sclerosis was made and 40 patients with a spinal cord syndrome due to other diseases. The results of the study indicate which anamnestic items and laboratory findings at the time of presentation can provide additional support for making a diagnosis in the individual patient with myelopathy without clinical evidence of supraspinal lesions.

A clinical patho-anatomical study of clinically silent multiple sclerosis

This is the first study on the frequency, size, number, and location of plaques in clinically silent MS. Among the present 18 patients in whom MS was unexpectedly diagnosed at autopsy, it had been clinically silent in 13. An estimate of the prevalence of silent MS is about 25% of that diagnosed in vivo. In the silent group, the MS plaques were located mainly in the periventricular areas, and this may explain the silent nature of the disease.