From the Journals

Two MS diagnostic criteria found to have similar accuracy

 

Key clinical point: The 2016 Magnetic Resonance Imaging in Multiple Sclerosis (MAGNIMS) diagnostic criteria perform in a way similar to that of the 2010 McDonald criteria.

Major finding: The 2016 MAGNIMS criteria and 2010 McDonald criteria performed similarly for predicting clinically definite multiple sclerosis (a sensitivity of 91% and 93%, respectively, and a specificity of 33% and 32%).

Study details: A retrospective study of 368 patients with clinically isolated syndrome.

Disclosures: The study was funded by the U.K. MS Society, the National Institute for Health Research University College London Hospitals Biomedical Research Centre, and the Dutch MS Research Foundation. The study authors reported having numerous financial disclosures.

Source: Filippi M et al., Lancet Neurol. 2017 Dec 21. doi: 10.1016/S1474-4422(17)30469-6.

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MRI continues to be refined to predict MS

As multiple sclerosis diagnosis evolves, revisions to existing diagnostic criteria have increased sensitivity, which in turn has helped clinicians establish earlier diagnosis. In an editorial published online Dec. 21, 2017, in The Lancet Neurology (doi: 10.1016/S1474-4422(17)30459-3), Anne H. Cross, MD, and Robert N. Naismith, MD, point out that while the study by Dr. Filippi et al. showed that for both sets of MRI criteria sensitivity was greater than specificity for predicting clinically definite multiple sclerosis, the modest specificity is cause for concern. They cited one study (Neurology 2016;87:1393-9) that emphasized the importance of not misdiagnosing other CNS diseases as multiple sclerosis. “In that study at four academic medical centers, 110 people seen over a period of less than 1.5 years were found to have been misdiagnosed,” wrote Dr. Cross and Dr. Naismith, both with the department of neurology at Washington University, St. Louis. “[Seventy percent] of the 110 individuals had received disease-modifying therapy and 31% had unnecessary morbidity. Leading factors contributing to erroneous diagnosis in the study included overreliance on MRI abnormalities in patients with non-specific neurological symptoms.”

The authors noted that vascular and other diseases can cause MRI abnormalities that could meet the 2016 Magnetic Resonance Imaging in Multiple Sclerosis (MAGNIMS) recommendations or the 2010 and 2017 McDonald MRI criteria. For example, patients with monophasic inflammatory and infectious diseases might have gadolinium-enhancing lesions that meet the 2017 McDonald criteria for dissemination in time, which require only the simultaneous presence of gadolinium-enhancing and gadolinium-negative lesions in the proper locations. For patients with an atypical presentation who meet the 2010 and 2017 McDonald or 2016 MAGNIMS recommendations, they advise clinicians to weigh all of the observed imaging features (including the number of periventricular lesions, along with lesion size, shape, and location) to improve diagnostic specificity and help to limit misdiagnoses.

Dr. Cross has received consulting fees from AbbVie, Bayer, Biogen, EMD Serono, Genentech/Roche, Genzyme/Sanofi, Mallinckodt, Novartis, and Teva. Dr. Naismith has consulted for Acorda, Alkermes, Bayer, Biogen, EMD Serono, Genentech, Genzyme, Novartis, and Teva.


 

FROM THE LANCET NEUROLOGY

The 2016 Magnetic Resonance Imaging in Multiple Sclerosis (MAGNIMS) criteria showed accuracy similar to that of the 2010 McDonald criteria in predicting the development of clinically definite multiple sclerosis, a retrospective study found.

“Among the different modifications proposed, our results support removal of the distinction between symptomatic and asymptomatic lesions, which simplifies the clinical use of MRI criteria, and suggest that further consideration is given to increasing the number of lesions needed to define periventricular involvement from one to three, because this might slightly increase specificity,” wrote researchers led by Massimo Filippi, MD. The report was published Dec. 21, 2017, in The Lancet Neurology. “Further effort is still needed to improve cortical lesion assessment and more studies should be done to evaluate the effect of including optic nerve assessment as an additional DIS [dissemination in space] criterion.”

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In an effort to guide revisions of MS diagnostic criteria, Dr. Filippi and other members of the MAGNIMS network compared the performance of the 2010 McDonald and 2016 MAGNIMS criteria for MS in a cohort of 368 patients with clinically isolated syndrome (CIS) who were screened between June 16, 1995, and Jan. 27, 2017. They used a time-dependent receiver operating characteristic curve analysis to evaluate MRI criteria performance for DIS, DIT [dissemination in time], and DIS plus DIT. Changes to the DIS definition contained in the 2016 MAGNIMS criteria included removal of the distinction between symptomatic and asymptomatic lesions, increasing the number of lesions needed to define periventricular involvement to three, combining cortical and juxtacortical lesions, and inclusion of optic nerve evaluation. For DIT, removal of the distinction between symptomatic and asymptomatic lesions was suggested.

Dr. Filippi, of the neuroimaging research unit in the division of neuroscience at San Raffaele Scientific Institute at Vita-Salute San Raffaele University, Milan, and his coauthors at eight centers reported that of the 368 patients, 189 (51%) developed clinically definite MS at the last evaluation, which occurred at a median of 50 months. At 36 months, DIS alone showed high sensitivity in the 2010 McDonald and 2016 MAGNIMS criteria (91% vs. 93%, respectively), similar specificity (33% vs. 32%), and similar area under the curve values (AUC, 0.62 vs. 0.63). Inclusion of symptomatic lesions did not alter performance. The researchers also found that requiring three periventricular lesions reduced sensitivity to 85% and increased specificity to 40%, but did not affect AUC values (it stood at 0.63). When optic nerve evaluation was included, sensitivity was similar (92%), while specificity fell to 26% and AUC dropped to 0.59.

The 2016 MAGNIMS and 2010 McDonald criteria achieved similar sensitivity, specificity, and AUC values when compared on the performance of DIT criteria and DIS plus DIT criteria.

“For both sets of criteria, specificity was lower than that of previous studies that evaluated the diagnostic performance of the 2010 McDonald criteria,” the authors wrote. “Several factors could help explain our findings, including the different follow-up durations, the statistical methods (e.g., using a time-to-event analysis in our study), and the effect of treatment, which might have delayed or prevented the occurrence of the second attack during the study period.” They acknowledged certain limitations of the study, including its retrospective design and the fact that patients were recruited in highly specialized centers, which may have resulted in the selection of patients at higher risk of conversion to clinically definite multiple sclerosis.

The study was funded by the U.K. MS Society, the National Institute for Health Research University College London Hospitals Biomedical Research Centre, and the Dutch MS Research Foundation. The authors reported having numerous financial disclosures with the pharmaceutical industry.

SOURCE: Filippi M et al., Lancet Neurol. 2017 Dec 21. doi: 10.1016/S1474-4422(17)30469-6.

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