1225331 tn?1333365769

Objective Clinical Lesion?

I was doing some leisurely reading :-)  of the Revised McDonal Criteria, and I was wondering what is exactly meant by the words, "objective clinical lesion"?  Does that just mean a T2 hyperintense lesion they see on an MRI in one of the hot spots for MS? Or does that mean a gadolinium enhancing lesion?  Or what?

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1453990 tn?1329231426
My understanding is that clinical lesions can be "evidence of a lesion" from a neurologic exam.  Any T2 hyperintense lesion less than about 40 days old will enhance on a T1 sequence after Gadolinium is administered.   GAD contrast does not make "unseen" lesions show up.  It just shows T2 lesions that still have a leaky blood brain barrier.  

Some of this explanation is in http://www.medhelp.org/health_pages/Multiple-Sclerosis/How-Can-a-Person-with-MS-Have-a-Negative-MRI/show/161?cid=36

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987762 tn?1331027953
I was reading on medscape, the 'Revised McDonald Criteria' March 2011 version and i actually think it is about making the MRI diagnostic side of dx MS easier. exert....

[  Previous iterations of the McDonald Criteria, as well as the latest revision, include recommendations on using MRI to demonstrate dissemination of disease in time and space. The revisions, Dr. Miller noted, are based largely on the work of the MAGNIMS (European Magnetic Resonance Imaging in MS) group that has shown benefits of using a simplified MRI scheme to demonstrate this. They state the following:

Dissemination in time can be demonstrated by a new T2 or gadolinium-enhancing lesion on a follow-up MRI, with reference to a baseline scan, regardless of when the baseline MRI was obtained. The earlier versions specified that the reference scan be performed at least 30 days after the initial clinical event; this is no longer a requirement.

Dissemination in space can be demonstrated with at least 1 T2 lesion in at least 2 of 4 areas of the central nervous system: periventricular, juxtacortical, infratentorial, or spinal cord. These lesions need not be gadolinium enhanced.

"This is a much simpler MRI schema to use," Dr. Miller said. "Now we have the possibility that a patient who presents with a CIS [clinically isolated syndrome] who has a brain MRI that shows both gadolinium-enhancing lesions and other T2-hyperintense lesions could be diagnosed at that point as having MS.

"In the previous iteration of the McDonald Criteria or its predecessor," he explained, "we always had to wait for new disease activity to occur; now the presumption is that when you have gadolinium-enhanced activity and other nonenhancing lesions that the nonenhancing lesions occurred sometime in the past and the gadolinium-enhancing lesions are occurring currently and so you meet dissemination in time."   ]


I still see possible problems with meeting this new criteria, 1. being clinical signs and no lesions evident on MRI 2. It requires the MRI to be done with and without contrast, which isn't always done. My first neuro went looking for MS didn't order it, the second neuro stated that 'gadolinium' was totally unnecessary so the presumption would be that he wouldn't order gadolinium either.

I still dont understand why it can't be even simpler, if a patient sx are evident on neuro testing and therefore consistent with having clinically evidence => lesions in 2 or more areas. The MRI is a modern tool that over rides neuro history, its become required to get the hard evidence, to prove the lesion(s) without doubt are there. Neuro tests have become clinical but not objective clinical, the MRI is required to provide the objective clinical evidence needed to meet the diagnostic criteria for MS.

Even with out gadolinium if the MRI shows 2 or more lesions in typical MS locations, coupled with the neuro testing and patient history, then that should meet the criteria of time and space. 2+ lesions = space and 2+ lesions = time, the odds of 2+ lesions forming at exactly the same time in different locations is statistically illogical.

According to the old criteria I should of been dx but didn't and with the new criteria nothing would of changed the outcome, my 'chronic' number of T2 lesions in the white matter and deep white matter still would not get me dx today, I need a second MRI to find the 'new' lesion. Seriously now, I already meet the space criteria but with only 1 MRI with out contrast the presumption is that all my T2 lesions happened at exactly the same time, now really what are the odds of that?

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1221035 tn?1301000508
My understanding is that an 'objective clinical lesion' is one seen by your neurologist during a neuro examination. For example; positive babinski, ataxia, hyperactive deep tendon reflexes, nystagmus, etc...
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1453990 tn?1329231426
The new 2010 Criteria still allows diagnosis by "Clinical Exam."  They have cleared up some of the issues with DIS and DIT using the MRI lesions as evidence.  They have also clarified the Dx  of PPMS.

The new criteria is available at: http://onlinelibrary.wiley.com/doi/10.1002/ana.22366/pdf

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1225331 tn?1333365769
I see that they can still make a diagnosis by "clinical exam," but I really wonder how many MS neuros out there actually do. I'd bet a lot of them still rely solely on the MRI scans, or at least put the majority of the weight there.  Which is double trouble if they choose not to prescribe the DMDs until their patients are officially Dxd.

Thanks everyone,
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