Aa
The McDonald Criteria
THE MCDONALD CRITERIA (revised 2005)
(The Myth of the 9 Lesions)
APPROACH TO THE DIAGNOSIS OF MS
First, you need to understand that MS always was, AND STILL IS, mainly a clinical diagnosis. The definition of “Clinical Diagnosis” is:
A diagnosis that can be made on the basis of the history and the physical exam alone. Yes, that means that in some cases, the diagnosis of MS can be made without using the MRI or other test at all. However, this is unusual, but it points out clearly the need for a thorough history and physical at the beginning of the diagnostic process. Many of the clues to the disease will already be there. In countries where MRIs are available, they are always obtained. And, in practice, the results of the MRI often overshadow the "clinical" findings from the patient's history and the neurological exam, especially if the MRI is negative or atypical. According the guidelines of diagnosis, this MRI would not have to be positive in order for the neurologist to be confident the person has MS. However, it takes a smart and very confident neurologist, usually an MS Specialist, to diagnose MS with a normal MRI. It does happen, though.
The categories of MS are also based solely on the patient's experience, that is, their history of symptoms, of resolution, and of accumulation of disability. The categories are discussed more fully in another Health Page (see "Categories of MS"). These are Relapsing Remitting MS (RRMS), Secondary Progressive MS (SPMS), Primary Progressive MS (PPMS), and Progressive Relapsing MS (PRMS). About 85% of people with MS will have the Relapsing Remitting form. For this reason, physicians begin looking a patient with suspected MS from the standpoint of attacks and remissions.
What is an Attack?
An attack (relapse, flair, exacerbation) of MS is the appearance of new neurological symptoms or the worsening of old neurological symptoms of the kind that are seen in MS. An attack may be documented from the report of the patient. In this case it is subjective. Or it may be observed by the doctor (as in descovering a new problem on the neuro exam), though usually it is a combination of the two. Anything problem observed by the doctor is said to be "objective." An attack must last at least 24 hours. An attack does not include a pseudoattack, which is the temporary worsening of symptoms that can occur elevation of the body's core temperature (as with fever or overheating). It also does not include single paroxysmal events (sudden jerks, brief loss of vision, single spasms of a muscle, a single bout of dizziness). If the single event occurs mutliple times over a period of more than 24 hours it would qualify as an attack. As noted above an attack often does include more than one symptom.
How Often Can Attacks Occur?
The time between attacks must be at least 30 days, during which the symptoms improve, resolve, or are stable in their intensity. So, a second attack must be at least 30 days from the day the first attack began to improve or stabilized. This period between attacks is called a remission. Clinically, a patient with RRMS is always either in an attack or in a remission.
THE IMPORTANCE OF THE HISTORY AND NEUROLOGIC EXAM
So you can see that the whole diagnostic process must begin with a thorough history from the patient of their symptoms, when they started, how they progressed, whether they improved and how much they improved, and whether they ever returned. It must look for a pattern of waxing and waning of symptoms, noting when new symptoms appeared. The physician must put together a timeline of the patient's complaints and symptoms looking for a pattern of "Relapse and Remission." The history should include the things that make symptoms worse or improve them, the pattern of symptoms severity with respect to time of day, level of exercise, temperature, and whether the symptoms became worse after things like infections, pregnancy, severe life stressors, or overexertion. It should be complete in other respects including non-neurological symptoms and events especially just preceding any attacks. The patient's Family History should be noted with respect to neurological illnesses, including MS, and for signs of MS Mimics in other members of the family. It is imperative that the neurologist pay close attention and devote time to hearing what the patient can offer. No patient should be comfortable with a doctor that does not take this time in one way or another.
The neurological exam is just as important! It should be a thorough exam, that takes a good amount of time. It should cover multiples tests in each part of the neurological system. It is a head to toe exam, and done well, can be exhausting. It should cover the multitude of tests of the face muscles and eye movements. There is also a thorough check of the major muscle groups through the body comparing one side to the other for symmetry. There should be checks for balance and coordination. There should be some testing of the sensation throughout the body using 2 or more tests of sharp/dull, soft touch, hot/cold, vibration, two-point discrimination and joint point-position sense. The doctor should observe the patient walking a good distance (more than the 4 steps across the exam room), walking on the toes and on the heels. Finally, several tendon reflexes should be checked and compared side to side.
During the neurological exam the doctor is looking for "clinical lesions." A clinical lesion is an abnormality on the exam that is objective evidence that there is damage in the nervous system. Examples of "clinical lesions" are 1) hyperactive reflexes which signal damage in the spinal cord, 2) problems with the muscles that move the eyes indicating a problem in the brainstem, 3) spasticity, usually also from the spinal cord, 4) positive Babinksi or Hoffman's test, and 7) paleness of the optic disc at the back of the eye. These are just a few of many dozens that can occur.
Please note that the word "lesion" is used in two different ways throught discussions of MS. There are "clinical lesions" as described above. These are areas of the CNS that must be damaged in order to cause the problems seen in the body. There are also "MRI lesions" which are the abnormalities "seen" on the MRI images. The two are not always the same. One can have a clinical lesion that does not show up on the MRI. There can also be white spots on the MRI that don't appear to have a symptom associated with them. For clarification of this point please see the Health Page "Lesions vs. Symptoms."
So, it becomes clear that the neurologist must listen to and exam the patient carefully at some point early in the diagnostic process before making any judgment on the diagnosis. The first clues about whether this is MS, a mimic or something else will come from this process. Be wary of the neurologist who skips these steps.
Quix
(The Myth of the 9 Lesions)
APPROACH TO THE DIAGNOSIS OF MS
First, you need to understand that MS always was, AND STILL IS, mainly a clinical diagnosis. The definition of “Clinical Diagnosis” is:
A diagnosis that can be made on the basis of the history and the physical exam alone. Yes, that means that in some cases, the diagnosis of MS can be made without using the MRI or other test at all. However, this is unusual, but it points out clearly the need for a thorough history and physical at the beginning of the diagnostic process. Many of the clues to the disease will already be there. In countries where MRIs are available, they are always obtained. And, in practice, the results of the MRI often overshadow the "clinical" findings from the patient's history and the neurological exam, especially if the MRI is negative or atypical. According the guidelines of diagnosis, this MRI would not have to be positive in order for the neurologist to be confident the person has MS. However, it takes a smart and very confident neurologist, usually an MS Specialist, to diagnose MS with a normal MRI. It does happen, though.
The categories of MS are also based solely on the patient's experience, that is, their history of symptoms, of resolution, and of accumulation of disability. The categories are discussed more fully in another Health Page (see "Categories of MS"). These are Relapsing Remitting MS (RRMS), Secondary Progressive MS (SPMS), Primary Progressive MS (PPMS), and Progressive Relapsing MS (PRMS). About 85% of people with MS will have the Relapsing Remitting form. For this reason, physicians begin looking a patient with suspected MS from the standpoint of attacks and remissions.
What is an Attack?
An attack (relapse, flair, exacerbation) of MS is the appearance of new neurological symptoms or the worsening of old neurological symptoms of the kind that are seen in MS. An attack may be documented from the report of the patient. In this case it is subjective. Or it may be observed by the doctor (as in descovering a new problem on the neuro exam), though usually it is a combination of the two. Anything problem observed by the doctor is said to be "objective." An attack must last at least 24 hours. An attack does not include a pseudoattack, which is the temporary worsening of symptoms that can occur elevation of the body's core temperature (as with fever or overheating). It also does not include single paroxysmal events (sudden jerks, brief loss of vision, single spasms of a muscle, a single bout of dizziness). If the single event occurs mutliple times over a period of more than 24 hours it would qualify as an attack. As noted above an attack often does include more than one symptom.
How Often Can Attacks Occur?
The time between attacks must be at least 30 days, during which the symptoms improve, resolve, or are stable in their intensity. So, a second attack must be at least 30 days from the day the first attack began to improve or stabilized. This period between attacks is called a remission. Clinically, a patient with RRMS is always either in an attack or in a remission.
THE IMPORTANCE OF THE HISTORY AND NEUROLOGIC EXAM
So you can see that the whole diagnostic process must begin with a thorough history from the patient of their symptoms, when they started, how they progressed, whether they improved and how much they improved, and whether they ever returned. It must look for a pattern of waxing and waning of symptoms, noting when new symptoms appeared. The physician must put together a timeline of the patient's complaints and symptoms looking for a pattern of "Relapse and Remission." The history should include the things that make symptoms worse or improve them, the pattern of symptoms severity with respect to time of day, level of exercise, temperature, and whether the symptoms became worse after things like infections, pregnancy, severe life stressors, or overexertion. It should be complete in other respects including non-neurological symptoms and events especially just preceding any attacks. The patient's Family History should be noted with respect to neurological illnesses, including MS, and for signs of MS Mimics in other members of the family. It is imperative that the neurologist pay close attention and devote time to hearing what the patient can offer. No patient should be comfortable with a doctor that does not take this time in one way or another.
The neurological exam is just as important! It should be a thorough exam, that takes a good amount of time. It should cover multiples tests in each part of the neurological system. It is a head to toe exam, and done well, can be exhausting. It should cover the multitude of tests of the face muscles and eye movements. There is also a thorough check of the major muscle groups through the body comparing one side to the other for symmetry. There should be checks for balance and coordination. There should be some testing of the sensation throughout the body using 2 or more tests of sharp/dull, soft touch, hot/cold, vibration, two-point discrimination and joint point-position sense. The doctor should observe the patient walking a good distance (more than the 4 steps across the exam room), walking on the toes and on the heels. Finally, several tendon reflexes should be checked and compared side to side.
During the neurological exam the doctor is looking for "clinical lesions." A clinical lesion is an abnormality on the exam that is objective evidence that there is damage in the nervous system. Examples of "clinical lesions" are 1) hyperactive reflexes which signal damage in the spinal cord, 2) problems with the muscles that move the eyes indicating a problem in the brainstem, 3) spasticity, usually also from the spinal cord, 4) positive Babinksi or Hoffman's test, and 7) paleness of the optic disc at the back of the eye. These are just a few of many dozens that can occur.
Please note that the word "lesion" is used in two different ways throught discussions of MS. There are "clinical lesions" as described above. These are areas of the CNS that must be damaged in order to cause the problems seen in the body. There are also "MRI lesions" which are the abnormalities "seen" on the MRI images. The two are not always the same. One can have a clinical lesion that does not show up on the MRI. There can also be white spots on the MRI that don't appear to have a symptom associated with them. For clarification of this point please see the Health Page "Lesions vs. Symptoms."
So, it becomes clear that the neurologist must listen to and exam the patient carefully at some point early in the diagnostic process before making any judgment on the diagnosis. The first clues about whether this is MS, a mimic or something else will come from this process. Be wary of the neurologist who skips these steps.
Quix
Thank you for laying this out in laymen terms. As much as you possibly can. With all the if, ands, and buts, its a wonder anyone gets dx.
I just wanted to let you know you are so appreciated here. I know it is exhausting and very time consuming to put all this together. It shows what a selfless person you truly are. Taking time for others to understand this diease.
BRAVO TO YOU!!!
I just wanted to let you know you are so appreciated here. I know it is exhausting and very time consuming to put all this together. It shows what a selfless person you truly are. Taking time for others to understand this diease.
BRAVO TO YOU!!!
No, I'm afraid you have not struck gold. :( The description juxtacortical refers to crossing a thin boundary not lying between the white and gray matter. There is not "in between".Sorry. You're stuck with sub-cortical, in the white matter.
To say that they are in the juxtacortical position, the radiologist actually has to say it.
Thanks for the kudos. Yes, this was very hard to distill, and I see that I have more work to do on it. There is just so much info and so many specific definitions. Some of the definitions here are used only here and are different from common usage. Alas...
Tammy, sorry I didn't see your point. Yes, neurologists will have a different take on the Criteria often if they are putting more weight on one area than another.
We know there are strict "lesion counters."
We know there are nurrows that think EVERYONE has to have 9 lesions
We know there are docs that look at someone with several clear attacks and accumulation of disability and will accept less than the full MRI criteria (mine for instance).
We know that there are nurrows that think a positive LP is mandatory. I really wonder where they see that in the Criteria. (Actually I know they get it from mis-interpreting studies done AFTER the Criteria were published).
To all: Please note here or PM me where my descriptions are not understandable. I want this in GOOD form before it graduates to HP status.
Thanks all,
Quix
To say that they are in the juxtacortical position, the radiologist actually has to say it.
Thanks for the kudos. Yes, this was very hard to distill, and I see that I have more work to do on it. There is just so much info and so many specific definitions. Some of the definitions here are used only here and are different from common usage. Alas...
Tammy, sorry I didn't see your point. Yes, neurologists will have a different take on the Criteria often if they are putting more weight on one area than another.
We know there are strict "lesion counters."
We know there are nurrows that think EVERYONE has to have 9 lesions
We know there are docs that look at someone with several clear attacks and accumulation of disability and will accept less than the full MRI criteria (mine for instance).
We know that there are nurrows that think a positive LP is mandatory. I really wonder where they see that in the Criteria. (Actually I know they get it from mis-interpreting studies done AFTER the Criteria were published).
To all: Please note here or PM me where my descriptions are not understandable. I want this in GOOD form before it graduates to HP status.
Thanks all,
Quix
Ohhhhhh....I wasn't really looking for any answers when I posted that....It was just more or less just to add in a totally different scenario...
I think it's fascinating to see (read) what different stages a lot of us Limbo landers are in and I just wanted to add my 2 cents. :)
My question was more of the hypothetical type.....
It's also extremely interesting to me the difference of opinions in Neuro's as far as following the McDonald criteria....It seems no 2 Neuro's are the same....
Have a great day! :)
Tammy
I think it's fascinating to see (read) what different stages a lot of us Limbo landers are in and I just wanted to add my 2 cents. :)
My question was more of the hypothetical type.....
It's also extremely interesting to me the difference of opinions in Neuro's as far as following the McDonald criteria....It seems no 2 Neuro's are the same....
Have a great day! :)
Tammy
this is what my mri results said....
There are two nonspecific foci of increased signal seen on FLAIR in the left cerebral hemispheres both of which are in the left frontal lobe and subcortical WHITE MATTER measuring approximately 3.3 to 3.8 mm.
Impression:
NO evidence for acute ischemia
There are two nonspecific foci of signal withing the WHITE MATTER in the left frontal lobe in the subcortical region. this is nonspecific but atypical for demyelinating lesions these can be seen with migraine headaches and chronic vessel ischemic change.
OK, so I'm understanding... lol
this is what my mri said. (above) sooooo my understanding is that mine are actually in the juxtacortical area because he stated they were in the white matter,,, and not between...
Do I have it?????? Have I struck gold??????? am I a genius??????? lolol
(Joke again)
one more question,, probably stupid but here goes..... Is the cerebral hemispheres and the cerebellum same thing??? oy!!!!!!!!!!!!!!!!!
I hope you start feeling better Quix I'm sure your exhausted you've worked so hard on this and Quix it is amazing to me. You are helping sooooooooooo many people and even though you are not actually working in the clinic, Quix your working your guts out on here, It is sooooooo appreciated and needed. Your a very Wonderful/Selfless/kind person.
Prayers to you
Ray
There are two nonspecific foci of increased signal seen on FLAIR in the left cerebral hemispheres both of which are in the left frontal lobe and subcortical WHITE MATTER measuring approximately 3.3 to 3.8 mm.
Impression:
NO evidence for acute ischemia
There are two nonspecific foci of signal withing the WHITE MATTER in the left frontal lobe in the subcortical region. this is nonspecific but atypical for demyelinating lesions these can be seen with migraine headaches and chronic vessel ischemic change.
OK, so I'm understanding... lol
this is what my mri said. (above) sooooo my understanding is that mine are actually in the juxtacortical area because he stated they were in the white matter,,, and not between...
Do I have it?????? Have I struck gold??????? am I a genius??????? lolol
(Joke again)
one more question,, probably stupid but here goes..... Is the cerebral hemispheres and the cerebellum same thing??? oy!!!!!!!!!!!!!!!!!
I hope you start feeling better Quix I'm sure your exhausted you've worked so hard on this and Quix it is amazing to me. You are helping sooooooooooo many people and even though you are not actually working in the clinic, Quix your working your guts out on here, It is sooooooo appreciated and needed. Your a very Wonderful/Selfless/kind person.
Prayers to you
Ray
Hi, Tam-Tam,
I can answer questions in general about how these criteria can be applied, but I don't think it is a good idea to try to apply them to people's situations. I don't have all the facts and well...., I'm just uncomfortable doing it.
Is that okay?
Quix
I can answer questions in general about how these criteria can be applied, but I don't think it is a good idea to try to apply them to people's situations. I don't have all the facts and well...., I'm just uncomfortable doing it.
Is that okay?
Quix
OK, so I have a totally different scenario...Mine! :)
I have lesions up the......um...wazoo, and only 1 documented 'attack', with several "subjective" symptoms...(some still left over from end of March attack)
BUT....the majority of my Neurological exam was normal.....The only 2 things I had back in December were slow corneal reflex in right eye, and I bombed the heel-toe test...(Sorry, I don't know the technical term for that one)
What does this mean for me? I go to the MS Clinic in 10 days!!!
Tammy
I have lesions up the......um...wazoo, and only 1 documented 'attack', with several "subjective" symptoms...(some still left over from end of March attack)
BUT....the majority of my Neurological exam was normal.....The only 2 things I had back in December were slow corneal reflex in right eye, and I bombed the heel-toe test...(Sorry, I don't know the technical term for that one)
What does this mean for me? I go to the MS Clinic in 10 days!!!
Tammy
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