Global Approaches to the Management of Relapsing Multiple Sclerosis - Episode 1
Fred Lublin, MD: Hello, and welcome to this NeurologyLive® Peer Exchange titled, “Global Approaches to the Management of Relapsing Multiple Sclerosis.” I’m Dr Fred Lublin from the Corinne Goldsmith Dickinson Center for Multiple Sclerosis at the Mount Sinai Medical Center in New York. Joining me today in this virtual discussion are my colleagues: Dr Wallace Brownlee, from the National Hospital for Neurology and Neurosurgery in London; Dr Patricia K. Coyle, from Stony Brook Neurosciences Institute in Stony Brook, New York; and Dr Sven Meuth from the University of Münster, Germany. Today, we’re going to discuss a number of topics pertaining to the diagnosis and treatment of multiple sclerosis [MS], offering a global perspective. Let’s get started on our first topic.
The diagnosis of multiple sclerosis has, for the last almost 20 years, been dependent on something called the McDonald Criteria. This is a set of guidelines that were first published in 2001, named after the chairman of the group that first put these out, Ian McDonald, who came from Dr Brownlee’s Institution of the National Hospital for Neurology and Neurosurgery. After coming out in 2001, they were modified in 2005, in 2010, and then the last time, in 2017. Each time, they’ve become more and more evidence-based, and each time, they have improved upon the accuracy and produced some simplicity in terms of acquiring these criteria. Wallace, why don’t you start out and talk to us about the 2017 revisions?
Wallace Brownlee, MBChB, PhD, FRACP: Thanks, Fred. Some of the key changes that came in the 2017 revisions to the McDonald Criteria were changes in the requirements for dissemination in space, and some new sites were added for dissemination in space, including the inclusion of cortical lesions. And more importantly and what has had a bigger impact on my practice is the inclusion of symptomatic lesions in dissemination in space. In patients with transverse myelitis, we can now count spinal cord lesions on MRI, in our MRI criteria for making the diagnosis of MS. The other key change for me was the addition of oligoclonal bands. If patients have unmatched IgG [immunoglobulin G] oligoclonal bands present intrathecally in the CSF [cerebrospinal fluid], this can be used as a substitute for either clinical or MRI evidence of dissemination in time within the diagnostic criteria.
Fred Lublin, MD: Patricia, you’re rather critical of the 2001 criteria. As they’ve evolved, have you become happier with them?
Patricia K. Coyle, MD: I am now a fan, Fred. The 2017 diagnostic criteria are very crisp, very clear. We should be promoting their use on a regular basis. That’s not really being done in the United States. I like that they clarified that these are supposed to be applied to very crisp neurologic syndromes, not foggy brain, not pins and needles, not joint pain, muscle pain, but the optic neuritis, the transverse myelitis, the isolated brainstem syndrome. They clarified that periventricular lesions should abut the ventricles because people were calling things periventricular lesions that were not, and juxtacortical lesions should abut the cortex. And I like that they pushed imaging the spinal cord. We at Stony Brook Neurosciences Institute do the entire spinal cord routinely. They also enhanced the value of spinal fluid. We routinely do CSF on everybody. So I am a big fan of these revised diagnostic criteria.
Sven Meuth, MD, PhD: May I add something for Germany? You all might know that we have a history when it comes to spinal tapping. We’ve liked it forever, so we are very happy that it is now included in this new criteria, but I learned that in the United States, you are not doing it on a regular basis. Is this correct?
Fred Lublin, MD: It’s rather variable. For example, as Dr Coyle said, she’s long been a proponent of spinal fluid analysis in the diagnosis of multiple sclerosis. Other centers, not so much, including ours at the Corinne Goldsmith Dickinson Center for Multiple Sclerosis at the Mount Sinai Medical Center, but I must say that, since the 2017 criteria came out, we’re doing more spinal taps. It’s been a useful addition to the criteria, even though it breaks the concept of dissemination in time, which has been around so long that I miss it in terms of the uniqueness of multiple sclerosis, but it’s been an important change. I did want to highlight something Patricia said, and say it again: the criteria are really for the typical first episodes, first clinically isolated syndromes of partial myelitis, brain stem cerebellum inflammatory lesions, and optic neuritis. That’s what they were tested in for their accuracy. Other vaguer neurologic symptoms don’t necessarily hold up. Another important point I want to make that I’d like you to comment on is that that the McDonald Criteria are for diagnosing multiple sclerosis, not differentially diagnosing multiple sclerosis.
Wallace Brownlee, MBChB, PhD, FRACP: That’s absolutely right, Fred, and the application of these criteria, how they perform in clinical settings, is entirely dependent on what the pretest probability of MS is. If you’re evaluating someone with nonspecific neurologic symptoms like Patricia described, then these criteria shouldn’t be applied. There’s still a key role for the clinical neurologists in taking a history, undertaking a neurological examination, and confirming that the person has symptoms that are suggestive of MS, and at the same time, being vigilant for other conditions that may mimic multiple sclerosis.
Patricia K. Coyle, MD: Fred, that’s really a key point, that everything rides on having ruled out other possibilities for the syndrome: creating the differential diagnosis, evaluating the patient, and that’s why we would argue for a very robust laboratory work-up.