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Using the 2024 McDonald Criteria revisions, around 30% of patients with atypical clinical symptoms or radiological-only presentation meet MS diagnostic criteria.

Using the 2024 McDonald Criteria revisions, around 30% of participants with atypical clinical symptoms or radiological-only presentation meet diagnostic criteria for multiple sclerosis (MS). These findings resulted from a cross-sectional analysis of data from participants of the CAVS-MS study and could alter treatment recommendations for these patients.

The revised 2024 McDonald Criteria for MS are the first to allow the diagnosis in people with incidental imaging findings suggestive of demyelinating disease and certain other clinical presentations not specific to MS.¹ Requirements in the 2024 criteria are MRI evidence of dissemination in space (DIS) together with either dissemination in time (DIT), 6 or more lesions with the central vein sign (Select-6 CVS), or the presence of cerebrospinal fluid–specific immunoglobulin synthesis.

In a cross-sectional analysis, Alexandra Scharf, a medical student at Case Western Reserve University School of Medicine, Cleveland, Ohio, and colleagues at Cleveland Clinic, Cleveland, Ohio, used baseline data from 420 participants enrolled in the CAVS-MS study. They applied the revised criteria for MS diagnosis to people with atypical and radiological-only presentations. They determined the prevalence of DIT and DIS and evaluated the contribution of intrathecal antibody synthesis, DIT, and Select-6 CVS in determining MS.

Of the 420 participants, 166 had atypical onset, and 25 had a radiological-only presentation. Of this combined subset of 191 participants, 44 (23%) met DIS-only criteria, and 7 (4%) met DIT and DIS criteria. Of the 44 participants meeting DIS-only criteria, 19 (43%) were Select-6 positive, 15 (34%) had oligoclonal bands (OCB), and 5 (11%) were Select-6 and OCB positive. In all, 36 of 191 participants (19%) with atypical presentations or radiological-only presentations met the 2024 McDonald Criteria for MS. Of these 36, 7 met DIS and DIT criteria (6 atypical, 1 radiological-only), and 29 met DIS-only criteria (22 atypical and 7 radiological-only).

Ms. Scharf concluded that a substantial proportion of participants with radiological-only presentation (32%) and atypical onset (28%) met the 2024 McDonald Criteria for MS. She noted that CVS is among the most useful para-clinical tools to confirm MS in people with atypical onset or radiological-only presentation. She added that these findings have implications for treatment, since early initiation of disease-modifying therapy improves outcomes.

Medical writing support was provided by Michiel Tent.
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