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Abstract
Objective To evaluate the prevalence of prior inflammatory events in patients consulting for a first inflammatory neurological event and improve early diagnosis of multiple sclerosis.
Methods During the initial visit, the neurologist gave patients a self-administered questionnaire containing 72 questions regarding previous symptoms lasting >24 h. During the follow-up visit, the neurologist validated the symptoms and collected information about the current attack.
Results The cohort included 178 patients (74% women, mean age (SD) 33.7 (10.1) years). The main reason for the initial visit was visual disturbance and sensory troubles in limbs. Mean (SD) global Expanded Disability Status Scale score was 1.4 (1.1), 46% of brains MRIs were positive according to Barkhof–Tintoré criteria, 41% had abnormal white blood cell count in cerebrospinal fluid and 71% had immunoglobin G oligoclonal bands. Prior symptoms suggestive of demyelination were reported by 79 patients (44%), validated by the neurologist for 70% (55 patients) and identified only by the neurologist in four patients. Sequelae were observed in 14 patients with validated prior symptoms (26%). The self-administered questionnaire showed an overall sensitivity of 93% and specificity of 80% for identifying patients with prior symptoms suggestive of demyelination.
Conclusion A patient-administered questionnaire subsequently validated by the neurologist demonstrated that 33% of patients consulting for a first demyelinating event had prior symptoms suggestive of central nervous system demyelination that had gone unnoticed, and almost 70% had either sequelae of prior demyelination or McDonald criteria for dissemination in space. Such a questionnaire could be a useful tool for earlier diagnosis of multiple sclerosis.
- Multiple sclerosis (41)
- clinical trial observational study (23)
- all demyelinating disease (CNS) (40)
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In multiple sclerosis (MS), the notion of first attack is still vague. Before the clinical event that leads to consultation in a hospital's neurology department, there are often pre-existing symptoms suggestive of MS such as fatigue, limb weakness, blurred vision, paraesthesias, vertigo and urinary disturbances.1 These initial symptoms correspond to the clinically isolated syndrome. In the study Optic Neuritis Treatment Trial,2 3 antecedents such as those described above (mostly paraesthesia) were identified in 45 of 149 (30%) patients who had abnormal cerebral MRI and 12 of 202 (5.9%) patients with normal MRI. For all patients, whatever the MRI result, presence of such an antecedent was a risk factor for developing clinically definite MS within 5 years. Furthermore, according to McDonald's new criteria for MS diagnosis,4 5 patients who presented at the first attack with sequelae of a pre-existing symptom suggestive of a demyelinating event (ie, lasting at least for 24 h) can be considered as having MS, as can patients who have had two attacks in addition to clinical evidence of one lesion and criteria for dissemination in space, which is demonstrated by MRI or at least 2T2 lesions and a positive cerebrospinal fluid (CSF). Therefore, the primary objective of the present study was to evaluate the prevalence of patients presenting with antecedents suggestive of demyelinating event(s) that went unnoticed among patients consulting or hospitalised in a neurology department for a first inflammatory demyelinating event and to initiate the development of a specific screening questionnaire to accurately identify these suggestive antecedents.
Methods
Patients
Patients included in the study were male and female adults who had been hospitalised or seen in the neurology outpatient clinics for a first inflammatory neurological event.
Study design
This was a prospective, multicentre, observational pilot study, conducted in 14 French reference hospital neurology departments specialising in MS. The objective was to collect data on neurological antecedents in patients hospitalised for a first demyelinating event (ie, clinically isolated syndrome) as well as data on environmental factors and family history that could affect the management and evolution of the disease (see online table 1—PEDIAS questionnaire). Patients were included in the study after being informed about the study by the neurologist. At the initial visit, the neurologist gave a self-administered questionnaire to patients about antecedents suggestive of a first demyelinating event. Patients were invited to fill out the questionnaire at home and to return it at the next planned visit. Questions were about demographic data (age, sex, marital status), sociogeographic characteristics (occupation, educational level, residence area) and neurologically relevant medical and family history. In particular, the patient had to describe all previous symptoms lasting >24 h that could be related to a central nervous system (CNS) demyelination: fatigue, visual disturbance (diplopia, blurred vision and ocular pain), sensations (tingling, burning, numbness, electrical shock in one or several limbs), clumsiness (hand clumsiness, impaired walking and limb muscle weakness), bladder problems (urinary urgency or retention), loss of balance, vertigo, hearing disturbance and facial paralysis. During the normal follow-up visit (usually 1–2 months after the initial visit), the patient returned the completed questionnaire to the neurologist, who then reviewed it with the patient. The neurologist then completed part of the questionnaire, indicating onset of the current attack, supposed localisation of the neurological lesion, Expanded Disability Status Scale score,6 and signs and symptoms attesting to the antecedents reported by the patient. The neurologist also reported all available results of complementary tests concerning this current attack, including brain MRI, Barkhof–Tintoré criteria7 8 evaluation and lumbar puncture. All brain MRI was performed on 1.5-T scanner and immunoglobin G oligoclonal bands were detected by isoelectric focussing.
Statistical methods
Descriptive statistics were performed for all patients or events, and for selected subgroups. For quantitative variables, the total number, mean, SD, median, quartiles and range were calculated. For qualitative data, the total number, percentages and 95% confidence interval were calculated. Comparisons between groups (χ2, Fisher and Wilcoxon tests) and correlations were performed considering α risk at level 5%. An analysis of sensitivity and specificity was performed on the questionnaire.
Result
Population description
A total of 178 patients were included: 131 women (74%) and 47 men (26%). Mean (SD) age at baseline was 33.7 (10.1) years, with a range of 15–60 years. A family history of MS was reported by 11% of the patients. Most patients (72%) were referred by a specialist, usually an ophthalmologist, neurologist or emergency department physician. The median time between the first episode and the patient's initial visit was 29 days (range, 0–686 days). According to the neurologist, the affected area of the CNS was the optical nerve (in 33% of cases), spinal cord (37.5%), brainstem (12.5%) or brain (11%). Six per cent of patients presented with two different affected sites. Mean Expanded Disability Status Scale score was 1.4 (1.1).
Brain MRI results
MRI was performed for 99% of the patients and with gadolinium infusion for 94% of patients. The mean delay from onset was 27 (24) days (range, 0–87 days). MRI was abnormal in 87% of cases and 46% were positive according to Barkhof–Tintoré criteria (presenting with at least three of the four criteria).
Lumbar puncture—cerebrospinal fluid (CSF) test
Lumbar puncture was performed for 87.5% of the patients. The mean white blood cell (WBC) count was 7 cells/mm3 (range 0–100). Immunoglobin G oligoclonal bands were present in 71% of patients.
Prior symptoms suggestive of demyelination
A total of 139 prior symptoms suggestive of demyelination were reported by 79 patients (44%), and at least one of these suggestive symptoms was validated by the neurologist for 55 patients (70%) (figure 1). In addition, neurologists identified 12 prior symptoms in 10 patients that had not been reported by the patients. Therefore, neurologists identified 59 patients (33%) with at least one prior symptom suggestive of demyelination: 36 patients presented with a single event and 23 patients presented with several events, usually two or three. The mean time period between the first suggestive symptom and the first demyelinating event leading to a neurology department consult was 46 months (range, 1–202 months). The most frequent events were tingling sensations (9.6% of all patients), visual disturbances (6.2%) and muscular weakness in one or several limbs (6.2%). Partial numbness, impaired walking and loss of balance were each suggestive of prior CNS demyelination for nine patients (5.1%). Six to eight patients presented with electrical shock sensation (Lhermitte's sign), diplopia, fatigue or urinary urgency. Most demyelinating events led to consultation with a general practitioner or a specialist (or both, for 26 patients), but no further investigation had been performed to diagnose CNS demyelination. In summary, in terms of identifying patients with at least one prior symptom suggestive of demyelination, the self-administered questionnaire had an overall sensitivity of 93% and specificity of 80% (table 1). Sensitivity was then analysed for each symptom reported by the patient or identified by the neurologist (see online table 2). Sensitivity was excellent, but the rate of false positives was high for vertigo (77%), hearing disturbance (75%), bladder problems (63%) and fatigue (58%). Conversely, positive predictive value was good (>70%) for facial paralysis, sensation and visual disturbance. Comparison of MRI findings with the presence or absence of prior symptoms suggestive of demyelination showed that abnormal MRI was more frequent in patients with prior symptoms (95% compared to 84%, p=0.039).
Flow chart.
Sensitivity and specificity of the self-administered questionnaire (Analysis in terms of patients)
Sequelae attesting to prior demyelinating events were reported for 14 patients (8% of all patients and 26% of patients reporting validated prior symptoms). Finally, according to McDonald criteria, 70% of patients with prior symptoms had MS (figure 1).
Discussion
New MS diagnosis criteria based on MRI findings9 have good sensitivity and specificity.10–13 In this pilot study, paraclinical results were taken into account to standardise diagnosis of a first event of inflammatory demyelination. In addition, a self-administered questionnaire was tested to identify previous neurological inflammatory events suggestive of MS and possible sequelae present at examination to fulfil criteria for MS. Characteristics of the cohort of patients included in this study were consistent with those previously described for patients with inflammatory demyelinating disease.
Neurologists could identify previous relevant events suggestive of CNS demyelination in 33% of patients coming to the neurology department for a perceived initial inflammatory demyelinating event. Half of these patients had even reported several suggestive prior symptoms. There was an average interval of 46 months between these antecedents and the current episode leading to neurology department consult. Interesting findings were that most of these previous events led patients to visit a general practitioner, a specialist or both, but did not lead to further investigation and special follow-up. The self-administered questionnaire was revealed to be a useful tool with which to identify patients with prior symptoms suggestive of demyelination. Reported prior symptoms were validated by a neurologist for 70% of patients. Neurologists identified only four more patients with suggestive prior symptoms that were not reported in the self-administered questionnaire. Finally, symptoms or signs at examination attesting to these prior demyelinating events were reported for 24% of patients and criteria for dissemination in space were fulfilled in another 46%, leading to a diagnosis of MS in 70% of these patients.
Acknowledgments
This study was sponsored by the Fondation Ophtalmologique A de Rothschild and received financial support from Teva Pharmaceuticals and Sanofi Aventis. Thanks to the members of the PEDIAS Group: O Heinzlef, CHI Poissy/St Germain, Poissy; E Roullet, Hôpital Tenon, Paris; P Hautecoeur, CH St Philibert, Lomme; J De Seze, CHU de Strasbourg, Hôpital civil, Strasbourg; W Camu, Hôpital G. de Chauliac, Montpellier; G Defer, CHU Côte de Nacre, Caen; J Pelletier, CHU La Timone, Marseille; M Debouverie, Hôpital Central, Nancy; B Barroso, Hôpital F. Mitterrand, Pau; M Coustans, Centre hospitalier de Cornouaille, Quimper; D Laplaud, Hôpital Laënnec, Nantes; L Rumbach, Hopital J. Minjoz, Besançon; O Lyon-caen, A Tourbah, Hôpital de la Pitié-Salpétrière, Paris; PE Lebiez, CH Louis Pasteur, Cherbourg; T Moreau, CHU Dijon, Dijon; L Magy, CHU Dupuytren, Limoges.
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Footnotes
↵* PEDIAS, Premier Evènement Démyélinisant Inflammatoire et Antécédents Suggestifs (First Inflammatory Demyelinating Event and Suggestive Antecedents).
Competing interests The authors report no conflicts of interest, except for SA.
Provenance and peer review Not commissioned; externally peer reviewed.