1260255 tn?1288654564

Health Page Update- Revised McDonald Criteria?

Lulu, Shell and JJ:

I’m going to request that the Health Pages be updated with the revised McDonald Criteria and the rationale behind adopting it.

Based on many of the posts I read, it appears that many doctors/neurologists are not using the new criteria. My understanding of the revisions is that it is supposed to rely less on repeat MRI’s and more on clinical evidence and patient history. I think of Quix, who used to get rather animated about “lesion counting” before making a diagnosis.

I feel that in my particular case, neurologists have completely dismissed “clinical lesions” which I interpret to be abnormal results on a neurological exam, such as Babinski’s sign, repeated assymetrical clonus and dysmetria with the heel knee-shin tests. These would all seem to point to cerebellar dysfunction, yet no lesions appear on the MRI.
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198419 tn?1360242356
Sure - no problem. It's been needing to be done ;)

But, the old still carrys much weight. You'll see in the year-by-year comparison Health Page. i.e., One year they may make new recommendation in the area of DIT, and the very year after, not much of a mention.  It's the primary reason I broke them out.

The new recommendations seem to have given more flexibility in dx'ing, but there still has to be certainty of the disease process.  That leaves a fair amount of discretion for the neuro, i.e., for more evidence, or time and space, etc.  It's that important to get it right since dx dictates proper treatment.

Thanks much for the reminder - I'll get it added to the comparison.
Helpful - 0
987762 tn?1331027953
Your absolutely right the newest version needs to be included, I thought it had been lol I didn't even notice it wasnt, so thank you for pointing it out! We did talk about the changes on the forum, I found it by doing the 'search this community' option, typing in Mcdonald Criteria 2010. In that discussion it mentions a few places where you can find it, I pulled this explanation, its worth reading the entire thing, it disects the changes etc, a big big read but very interesting.

see http://onlinelibrary.wiley.com/doi/10.1002/ana.22366/pdf

[If the Criteria are fulfilled and there is no better explanation for the clinical presentation, the diagnosis is ‘‘MS’’; if suspicious, but
the Criteria are not completely met, the diagnosis is ‘‘possible MS’’; if another diagnosis arises during the evaluation that better
explains the clinical presentation, then the diagnosis is ‘‘not MS.’’

a)An attack (relapse; exacerbation) is defined as patient-reported or objectively observed events typical of an acute inflammatory
demyelinating event in the CNS, current or historical, with duration of at least 24 hours, in the absence of fever or infection. It
should be documented by contemporaneous neurological examination, but some historical events with symptoms and evolution
characteristic for MS, but for which no objective neurological findings are documented, can provide reasonable evidence of a prior
demyelinating event.

Reports of paroxysmal symptoms (historical or current) should, however, 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, or MRI consistent with demyelination in the area of the CNS implicated in the historical report of neurological symptoms.

b)Clinical diagnosis based on objective clinical findings for 2 attacks is most secure. Reasonable historical evidence for 1 past attack,
in the absence of documented objective neurological findings, can include historical events with symptoms and evolution characteristics
for a prior inflammatory demyelinating event; at least 1 attack, however, must be supported by objective findings.

c)No additional tests are required. However, it is desirable that any diagnosis of MS be made with access to imaging based on these
Criteria. If imaging or other tests (for instance, CSF) are undertaken and are negative, extreme caution needs to be taken before making a diagnosis of MS, and alternative diagnoses must be considered. There must be no better explanation for the clinical presentation, and objective evidence must be present to support a diagnosis of MS.

d)Gadolinium-enhancing lesions are not required; symptomatic lesions are excluded from consideration in subjects with brainstem or spinal cord syndromes.]

Are you saying you do not have 'any' visible MRI lesions, zero lesions showing up anywhere at all and no other diagnostic tests suggestive of MS eg EVP, ON etc but the dr's have dx 'clinical signs of lesions' (Babinski’s sign, assymetrical clonus, dysmetria) ? If you are, even though i'm not 100% sure but i think table 4, the very first option would cover that scenario.

"2 attacks; objective clinical evidence of 2 lesions or objective clinical evidence of 1 lesion with reasonable historical evidence of a prior attack"

I dont think there would be many dr's out there that would dx with out other diagnostic evidence. In the explanationary part, option (c) could potentially take away the option of dx with out MRI evidence because of "it is desirable that any diagnosis of MS be made with access to imaging based on these Criteria" Which could easily be interpreded as MRI evidence is the prefered 'objective clinical evidence' needed for dx, even though the patients clinically dx signs are suppose to be the most relivant 'objective clinical evidence'.

Quite frustrating but not sure there is much you can do, these are the only choices i see you have 1) wait for MRI evidence to show its self.  2) get another opinion with an old style MS neuro. 3) continue to seek a "better explanation for the clinical presentation" if you haven't already.

Helpful - 0
1475492 tn?1332884167
The key is they are seeking specific areas of attack separated by 30 days.

The lesions can't be just located in one area --- they have to attack two specific MS areas for their to be a diagnosis. That's what makes this process so frustrating.

This is part of the revised criteria.

"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.
Helpful - 0
987762 tn?1331027953
Hmmm i've just had a look at your MRI's and it does appear that you also have 'other' objective clinical evidence of 2> attacks and lesions, so its basically 'all' evidence of, is being dismissed for some reason or other. Did you get any explanation for your clinical signs and or MRI brain lesions, anything at all?

Helpful - 0
572651 tn?1530999357
I keep thinking that someday soon there will be a brand new set of criteria and the Macdonald will be done.    but that's just me - I think diagnosing MS is so much more than a chart.
Helpful - 0
572651 tn?1530999357
and by the way, anyone can do a health page - in fact we would love to see some new topics up there.
Helpful - 0
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