Challenges in multiple sclerosis diagnosis: Misunderstanding and misapplication of the McDonald criteria

Mult Scler. 2021 Feb;27(2):250-258. doi: 10.1177/1352458520910496. Epub 2020 Mar 12.


Objective: To assess comprehension and application of the McDonald criteria.

Background: Studies suggest that knowledge gaps for specific core elements of the McDonald criteria may contribute to multiple sclerosis (MS) misdiagnosis.

Methods: Neurology residents (NR) and multiple sclerosis specialists (MSS) in North America completed a web-based survey.

Results: A total of 160 participants were included: 72 NR and 88 MSS. Syndromes incorrectly identified as typical of MS included: complete transverse myelopathy (35% NR and 15% MSS), intractable vomiting/nausea/hiccoughs (20% NR and 5% MSS), and bilateral optic neuritis/unilateral optic neuritis with poor visual recovery (17% NR and 10% MSS). Periventricular magnetic resonance imaging (MRI) lesions were correctly identified by 39% NR and 52% MSS, and juxtacortical lesions were correctly identified by 28% NR and 53% MSS. The correct definition of "periventricular" was chosen by 38% NR and 61% MSS, and that of "juxtacortical" was chosen by 19% NR and 54% MSS. Regions incorrectly identified for MRI dissemination in space fulfillment included the optic nerve (31% NR and 26% MSS) and the subcortical white matter (11% NR and 18% MSS). The majority of participants assessed previous non-specific neurological symptoms without objective evidence of a central nervous system (CNS) lesion as sufficient for clinical dissemination in time.

Conclusion: The McDonald criteria are often misunderstood and misapplied. Concerted educational efforts may prevent MS misdiagnosis.

Keywords: McDonald criteria; Multiple sclerosis; all education; diagnosis; misdiagnosis.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Diagnostic Errors
  • Humans
  • Magnetic Resonance Imaging
  • Multiple Sclerosis* / diagnosis
  • Optic Nerve
  • Optic Neuritis* / diagnosis