Diagnosing MS

Diagnostic Criteria in MS and an Interview with Dr. Craig Smith
By Laurie Long

You've had strange symptoms for years - burning sensations, tingling sensations, clumsiness, fatigue, cognitive difficulties and more. You went to your doctor, and eventually to a neurologist. Your own research into the matter suggested MS. Your doctors agreed that it was a possibility. Your neurologist sent you to have an MRI, and the MRI came back negative. Based on this, your neuro said you didn't have MS. Several years later, you finally got another MRI due to your continuing symptoms. This one came back positive. Together with your clinical history, exam and other tests, you were diagnosed with MS.

So what happened? Why did it take so many years before a clear diagnosis could be made?

The answer to that lies in the range and variety of MS symptoms, and the difficulty in narrowing down a diagnosis from the numerous possibilities. The guidelines for a diagnosis of MS have evolved over the years to include new testing techniques, such as the MRI, for earlier and more accurate diagnosis. There is no question that the use of Magnetic Resonance Imaging to detect brain and spinal lesions indicative of MS has greatly increased the accuracy of diagnosis. The problems lie in the fact that not every MRI is of equal quality, and not every doctor or neurologist has sufficient experience with MS to recognize a case with borderline indicators.

Because MRIs have been of such tremendous use in the detection of MS, many doctors and general neurologists have relied heavily on MRI results as a basis for their diagnoses. While this practice poses no problems where the MRI shows obvious MS lesions, it raises questions in cases where the MRI is negative and other diagnostic measures must be used to facilitate an accurate diagnosis.

Diagnostic Criteria History

The first set of diagnostic criteria for MS were the Schumacher criteria, developed in 1965.They have been the basis of all subsequent criteria. The Schumacher criteria relied largely on a neurological examination by the doctor and symptom history. If a sufficient number of abnormalities in the Central Nervous System (CNS) were detected, and these abnormalities and symptoms were recurring or progressing over time, and also indicated that more than one area of the CNS was involved, then a diagnosis of MS could be put forward. At the time the criteria were developed, MRIs and many of the other testing procedures had not yet been developed.

MRIs arrived on the scene in 1977, and by 1983 a new set of criteria called the Poser criteria were developed for use in clinical trials involving MS. The Poser criteria were much more specific than the earlier Schumacher criteria, and recognized the usefulness of MRI scans and spinal taps in the detection of brain and spinal lesions. The criteria helped doctors to focus their search and increased the chances of accurate diagnosis.

For twenty years the medical community relied on the Poser criteria for MS diagnosis, but the criteria were insufficient for the new classes of clinical trials, and did not reflect the advances in technology for MS detection. New criteria called the McDonald criteria were developed and published in 2001.These criteria further honed the requirements for MS diagnosis and gave the MRI scan a much larger role in MS detection, along with Visual Evoked Potentials (VEP) testing and Cerebrospinal Fluid (CSF) testing through spinal taps. Gadolinium-enhanced MRIs were specified because Gadolinium enhancing specifically targets new (inflammatory) lesions in the CNS.

Although the McDonald criteria has recommended the use of Gadolinium-enhanced MRIs to detect new lesions, many of the MRIs given to detect cases of possible MS are not Gad-enhanced. Moreover, the science of the MRI is still evolving. The Consortium of MS Centers has recommended standardizations for MRIs, and hopes to institute those standards in the MS centers affiliated with the Consortium within a year. Even with standardization of MRIs, however, expert MRI technicians and MS specialist neurologists are necessary to detect some cases of MS. Often in the case of a negative MRI where MS is suspected, further tests such as spinal taps (to study any abnormalities in the CSF) and VEP tests are ordered. An MS specialist neurologist can use the clinical and para-clinical evidence to diagnose even when the MRI evidence is lacking.

Dr Craig Smith, director of the Swedish Medical Center MS Center in Seattle, has written an article clarifying the new McDonald criteria and has seen hundreds of MS patients over his career. Dr. Smith explains, "You do not have to have an abnormal MRI to be diagnosed with MS. Someone who has optic neuritis and a spinal cord event may have MS under the international criteria, but you may not see it on the MRI. The MRI is just one way to look at objective lesions."

Dr Smith also adds, "When there has not been a clear diagnosis - where (the patient) has gone to a doctor and been frustrated - they probably just ought to be seen in an MS center. If you have cancer, you're not generally treated by a general practitioner but by an oncologist. If you have MS, you probably ought not to be treated by a general neurologist but by one who treats MS."

Dr. Smith recommends keeping track of your symptoms in a diary or journal that you can show your neurologist or use to refresh your memory. Dr. Smith also strongly encourages patients to bring a family member, spouse or significant other with them to their appointment, "as a listener and also as a historian."

Dr Smith is not alone is his recommendation to seek an MS specialist when searching for a diagnosis where MS is suspected. The National MS Society states, "a diagnosis of MS remains a partly subjective process best made by an expert who is familiar with MS", and the report of the Consensus Panel on the New International Panel Guidelines for Diagnosis of MS declares that, "diagnosis ultimately depends on a physician (preferably a neurologist) skilled and knowledgeable in the diagnosis and management of patients with MS".

Read Dr. Smith's paper on the McDonald Criteria.

Clinical, magnetic resonance imaging, cerebrospinal fluid and electrophysiological characteristics of the earliest multiple sclerosis

Was this information helpful? Then please consider making a donation. We are a small, independent nonprofit agency and are dependent on donations from our supporters. Thank you from all the staff at the MSA.

References and Bibliography

Craig Smith, MD, MS's New Challenge: The McDonald Criteria, June 2002.

Robert M. Herndon, MD, Patricia Coyle, MD, Thomas J. Murray, MD, Jerry Wolinsky, MD, Report of the Consensus Panel on the New International Panel Guidelines for Diagnosis of MS, International Journal of MS Care 2002;4:170-173.

McDonald et al., Recommended diagnostic criteria for multiple sclerosis: Guidelines from the International Panel on the Diagnosis of Multiple Sclerosis. Annals of Neurology, April 2, 2001.

National MS Society Research/Clinical Update, International Panel Revises Diagnostic Criteria for MS, May 4, 2001.

Veronica Rose, New Criteria Aids in Multiple Sclerosis Diagnosis From Single Clinical Episode of Demyelination, http://www.docguide.com, 7/29/2002.

Annals of Neurology, Vol 52, Issue 1, 2002, pp 47-53. Application of the new McDonald criteria to patients with clinically isolated syndromes suggestive of multiple sclerosis.

Mark S. Freedman, MD, Normal MRI and MS Diagnosis, Medscape Neurology and Neurosurgery 4(2), 2002

All About MS, Diagnostic Criteria for Multiple Sclerosis, http://www.mult-sclerosis.org, 9/22/2002

Shahid Riaz, MD and William Nowack, MD, Diagnostic Problems in MS - Overreliance on Neuroimaging, Southern Medical Journal, Vol 91, No. 3, March 1998

CNN.com, Study: MRI brain scans help predict MS, New England Journal of Medicine, 1/17/2002

Priscillia Ann Taylor, MN, CGRN, Diagnosing Multiple Sclerosis, Clinician Reviews 9(7): 72, 1999, Clinicians Publishing Group and Williams & Wilkins

Steven L. Galetta, MD, University of Pennsylvania School of Medicine, Getting a Head Start on MS Treatment, Healthology.com 8/8/2002

FirstGov for Seniors, NIH Licenses New MRI Technology That Produces Detailed Images of Nerves, Other Soft Tissues, July 2002

Jerry Wolinski, MD, Fred Lublin, MD, Randall Schapiro, MD,MRI Parameters:How Much Should They Influence Treatment Decisions and the Management of MS Patients? Point Counterpoint Bulletin, May 7, 2002

Jack P. Antel, MD, The Delicate Task of Diagnosing Multiple Sclerosis, Emergency Medicine, Nov. 1983.




	Diagnosing MS Diagnostic Criteria in MS and an Interview with Dr. Craig Smith By Laurie Long You've had strange symptoms for years - burning sensations, tingling sensations, clumsiness, fatigue, cognitive difficulties and more. You went to your doctor, and eventually to a neurologist. Your own research into the matter suggested MS. Your doctors agreed that it was a possibility. Your neurologist sent you to have an MRI, and the MRI came back negative. Based on this, your neuro said you didn't have MS. Several years later, you finally got another MRI due to your continuing symptoms. This one came back positive. Together with your clinical history, exam and other tests, you were diagnosed with MS. So what happened? Why did it take so many years before a clear diagnosis could be made? The answer to that lies in the range and variety of MS symptoms, and the difficulty in narrowing down a diagnosis from the numerous possibilities. The guidelines for a diagnosis of MS have evolved over the years to include new testing techniques, such as the MRI, for earlier and more accurate diagnosis. There is no question that the use of Magnetic Resonance Imaging to detect brain and spinal lesions indicative of MS has greatly increased the accuracy of diagnosis. The problems lie in the fact that not every MRI is of equal quality, and not every doctor or neurologist has sufficient experience with MS to recognize a case with borderline indicators. Because MRIs have been of such tremendous use in the detection of MS, many doctors and general neurologists have relied heavily on MRI results as a basis for their diagnoses. While this practice poses no problems where the MRI shows obvious MS lesions, it raises questions in cases where the MRI is negative and other diagnostic measures must be used to facilitate an accurate diagnosis. Diagnostic Criteria History The first set of diagnostic criteria for MS were the Schumacher criteria, developed in 1965.They have been the basis of all subsequent criteria. The Schumacher criteria relied largely on a neurological examination by the doctor and symptom history. If a sufficient number of abnormalities in the Central Nervous System (CNS) were detected, and these abnormalities and symptoms were recurring or progressing over time, and also indicated that more than one area of the CNS was involved, then a diagnosis of MS could be put forward. At the time the criteria were developed, MRIs and many of the other testing procedures had not yet been developed. MRIs arrived on the scene in 1977, and by 1983 a new set of criteria called the Poser criteria were developed for use in clinical trials involving MS. The Poser criteria were much more specific than the earlier Schumacher criteria, and recognized the usefulness of MRI scans and spinal taps in the detection of brain and spinal lesions. The criteria helped doctors to focus their search and increased the chances of accurate diagnosis. For twenty years the medical community relied on the Poser criteria for MS diagnosis, but the criteria were insufficient for the new classes of clinical trials, and did not reflect the advances in technology for MS detection. New criteria called the McDonald criteria were developed and published in 2001.These criteria further honed the requirements for MS diagnosis and gave the MRI scan a much larger role in MS detection, along with Visual Evoked Potentials (VEP) testing and Cerebrospinal Fluid (CSF) testing through spinal taps. Gadolinium-enhanced MRIs were specified because Gadolinium enhancing specifically targets new (inflammatory) lesions in the CNS. Although the McDonald criteria has recommended the use of Gadolinium-enhanced MRIs to detect new lesions, many of the MRIs given to detect cases of possible MS are not Gad-enhanced. Moreover, the science of the MRI is still evolving. The Consortium of MS Centers has recommended standardizations for MRIs, and hopes to institute those standards in the MS centers affiliated with the Consortium within a year. Even with standardization of MRIs, however, expert MRI technicians and MS specialist neurologists are necessary to detect some cases of MS. Often in the case of a negative MRI where MS is suspected, further tests such as spinal taps (to study any abnormalities in the CSF) and VEP tests are ordered. An MS specialist neurologist can use the clinical and para-clinical evidence to diagnose even when the MRI evidence is lacking. Dr Craig Smith, director of the Swedish Medical Center MS Center in Seattle, has written an article clarifying the new McDonald criteria and has seen hundreds of MS patients over his career. Dr. Smith explains, "You do not have to have an abnormal MRI to be diagnosed with MS. Someone who has optic neuritis and a spinal cord event may have MS under the international criteria, but you may not see it on the MRI. The MRI is just one way to look at objective lesions." Dr Smith also adds, "When there has not been a clear diagnosis - where (the patient) has gone to a doctor and been frustrated - they probably just ought to be seen in an MS center. If you have cancer, you're not generally treated by a general practitioner but by an oncologist. If you have MS, you probably ought not to be treated by a general neurologist but by one who treats MS." Dr. Smith recommends keeping track of your symptoms in a diary or journal that you can show your neurologist or use to refresh your memory. Dr. Smith also strongly encourages patients to bring a family member, spouse or significant other with them to their appointment, "as a listener and also as a historian." Dr Smith is not alone is his recommendation to seek an MS specialist when searching for a diagnosis where MS is suspected. The National MS Society states, "a diagnosis of MS remains a partly subjective process best made by an expert who is familiar with MS", and the report of the Consensus Panel on the New International Panel Guidelines for Diagnosis of MS declares that, "diagnosis ultimately depends on a physician (preferably a neurologist) skilled and knowledgeable in the diagnosis and management of patients with MS". Read Dr. Smith's paper on the McDonald Criteria. Clinical, magnetic resonance imaging, cerebrospinal fluid and electrophysiological characteristics of the earliest multiple sclerosis Was this information helpful? Then please consider making a donation. We are a small, independent nonprofit agency and are dependent on donations from our supporters. Thank you from all the staff at the MSA. References and Bibliography Craig Smith, MD, MS's New Challenge: The McDonald Criteria, June 2002. Robert M. Herndon, MD, Patricia Coyle, MD, Thomas J. Murray, MD, Jerry Wolinsky, MD, Report of the Consensus Panel on the New International Panel Guidelines for Diagnosis of MS, International Journal of MS Care 2002;4:170-173. McDonald et al., Recommended diagnostic criteria for multiple sclerosis: Guidelines from the International Panel on the Diagnosis of Multiple Sclerosis. Annals of Neurology, April 2, 2001. National MS Society Research/Clinical Update, International Panel Revises Diagnostic Criteria for MS, May 4, 2001. Veronica Rose, New Criteria Aids in Multiple Sclerosis Diagnosis From Single Clinical Episode of Demyelination, http://www.docguide.com, 7/29/2002. Annals of Neurology, Vol 52, Issue 1, 2002, pp 47-53. Application of the new McDonald criteria to patients with clinically isolated syndromes suggestive of multiple sclerosis. Mark S. Freedman, MD, Normal MRI and MS Diagnosis, Medscape Neurology and Neurosurgery 4(2), 2002 All About MS, Diagnostic Criteria for Multiple Sclerosis, http://www.mult-sclerosis.org, 9/22/2002 Shahid Riaz, MD and William Nowack, MD, Diagnostic Problems in MS - Overreliance on Neuroimaging, Southern Medical Journal, Vol 91, No. 3, March 1998 CNN.com, Study: MRI brain scans help predict MS, New England Journal of Medicine, 1/17/2002 Priscillia Ann Taylor, MN, CGRN, Diagnosing Multiple Sclerosis, Clinician Reviews 9(7): 72, 1999, Clinicians Publishing Group and Williams & Wilkins Steven L. Galetta, MD, University of Pennsylvania School of Medicine, Getting a Head Start on MS Treatment, Healthology.com 8/8/2002 FirstGov for Seniors, NIH Licenses New MRI Technology That Produces Detailed Images of Nerves, Other Soft Tissues, July 2002 Jerry Wolinski, MD, Fred Lublin, MD, Randall Schapiro, MD,MRI Parameters:How Much Should They Influence Treatment Decisions and the Management of MS Patients? Point Counterpoint Bulletin, May 7, 2002 Jack P. Antel, MD, The Delicate Task of Diagnosing Multiple Sclerosis, Emergency Medicine, Nov. 1983.
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