Beyond McDonald: updated perspectives on MRI diagnosis of multiple sclerosis

ABSTRACT

Introduction

Magnetic resonance imaging (MRI) is an essential paraclinical test to establish an accurate and early diagnosis of multiple sclerosis (MS), which is based on the application of the McDonald criteria.

Areas covered

The objective of this article is to analyze, based on publicly available database since the publication of the 2017 McDonald diagnostic criteria, the clinical impact of these criteria, to discuss the potential inclusion within these criteria of the optic nerve to demonstrate dissemination in space, and to guide the acquisition and interpretation of MRI scans for diagnostic purposes. Finally, the authors will review emerging MRI features that could improve the specificity of MRI in the diagnosis of MS and consequently minimize the misdiagnosis of this disease.

Expert opinion

Although the optic nerve has not been included as one of the topographies required to demonstrate demyelinating lesion disseminated in space in the 2017 McDonald criteria, new studies seem to show some improvement in the sensitivity of these criteria when this topography is considered. New radiological findings such as the central vein sign and iron rims, should be considered within the typical MRI features of this disease with the objective of minimizing MRI-based diagnostic errors.

KEYWORDS:

• Demyelination
• diagnosis
• mr imaging
• multiple sclerosis
• standardized examination

Article highlights

• The 2017 McDonald criteria allow an earlier diagnosis of multiple sclerosis, mainly due to the inclusion of oligoclonal bands in cerebrospinal fluid as an alternative to clinical or MRI demonstration of dissemination in time.

• Prospective studies are needed to analyse the impact of adding the anterior visual pathway as the fifth topography for demonstrating dissemination in space and the challenges associated with its implementation in clinical practice. This information would be extremely useful for considering the inclusion this additional topography in a future version of the McDonald criteria.

• MRI scans for diagnostic purposes must be obtained under optimal technical conditions using reasonable acquisition times and assessed by experts who have adequate knowledge of what constitutes a typical demyelinating lesion.

• All MRI examinations performed in patients with a potential or established diagnosis of multiple sclerosis require a written radiological report. This report should be accurate and clinically focused to properly assist with further patient management.

• New radiological findings that seem to be highly specific to multiple sclerosis, such as the central vein sign and iron rims, should be considered within the typical MRI features of this disease with the objective of minimizing MRI-based diagnostic errors.

Declaration of interest

A Rovira serves on scientific advisory boards for Novartis, Sanofi-Genzyme, Synthetic MR, Roche, Biogen, and OLEA Medical, and has received speaker honoraria from Bayer, Sanofi-Genzyme, Merck-Serono, Teva Pharmaceutical Industries Ltd, Novartis, Roche and Biogen. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.