Multiple sclerosis: Revised diagnostic criteria
- 1. REVISED McDONALD’S CRITERIA 2017 DR SUDHIR KUMAR MD DM CONSULTANT NEUROLOGIST APOLLO HOSPITALS, HYDERABAD
- 3. Rationale and methods for the 2017 revisions Performance of the 2010 McDonald criteria in diverse populations The distinction between multiple sclerosis and other diseases with potentially overlapping clinical and imaging features, such as neuromyelitis optica spectrum disorders (NMOSDs) Challenges in making the diagnosis in individuals with presentations other than a typical clinically isolated syndrome The frequency and consequences of misdiagnosis CSF and other paraclinical tests that could be used to diagnose multiple sclerosis 3
- 4. 2010 vs 2017 McDonald`s Criteria Attack Onset Clinical Attacks Additional Data Needed ≥2 attacks Objective evidence of ≥2 lesions or objective clinical evidence of 1 lesion with reasonable historical evidence None. Clinical evidence is sufficient. ≥2 attacks Objective clinical evidence of 1 lesion For dissemination in space (DIS), demonstrated by ≥1 T2 lesion in at least 2 of 4 MS-typical regions of the CNS*; or await a further clinical attack implicating a different CNS site 1 attack Objective clinical evidence of ≥2 lesions For dissemination in time (DIT), demonstrated by Simultaneous presence of asymptomatic Gd+ and nonenhancing lesions; or a new T2 and/or Gd+ lesion on follow-up MRI, irrespective of timing with reference to a baseline scan; or await a second clinical attack 1 attack Objective clinical evidence of 1 lesion (CIS) For DIS: ≥1 T2 lesion in at least 2 of 4 MS- typical regions of the CNS*; or await a further clinical attack implicating a different CNS site For DIT: Simultaneous presence of asymptomatic Gd+ and nonenhancing lesions; or a new T2 and/or Gd+ lesion on follow-up MRI, irrespective of timing with reference to a baseline scan; or await a second clinical attack Polman CH et al. Ann Neurol. 2011;69:292-302 McDonald`s 2010 Attack onset Clinical Attacks Additional Data Needed ≥2 Clinical attacks and objective clinical evidence of ≥2 lesions None ≥2 clinical attacks and objective evidence of 1 lesion DIS- an additional clinical attack implicating a different CNS site or by MRI 1 Clinical attack and objective clinical evidence ≥2 lesions DIT- an additional clinical attack OR by MRI OR demonstration of CSF-specific oligoclonal bands 1 clinical attack and objective clinical evidence of 1 lesion DIS -an additional clinical attack implicating a different CNS site or by MR AND DIT - an additional clinical attack or by MRI OR demonstration of CSF-specific oligoclonal bands McDonald`s 2017 Attack onset
- 5. MAGNIMS vs McDonald`s 2017 ( DIS Criteria) 5 MAGNIMS 2017 McDonald`s 2017 Lancet Neurol 2016; 15: 292–303 • MAGNIMS recommended Three Periventricular Lesions and optic nerve lesion which is not included in McDonald 2017
- 6. 2010 vs 2017 McDonald`s DIS Criteria
- 7. McDonald`s 2017 DIT Criteria
- 8. McDonald`s 2017 DIT Criteria DIT can be demonstrated by • Simultaneous presence of gadolinium-enhancing and non-enhancing lesions at any time, OR • A new T2W hyperintense or gadolinium-enhancing lesion on the follow up MRI with reference to the baseline scan, irrespective of the timing of baseline MRI. (Change from 2010: No difference between symptomatic and asymptomatic lesions)
- 9. HIGHLIGHTS CSF-specific OCBs are back (were part of Poser criteria) – and allow an MS diagnosis in certain situations Symptomatic and asymptomatic MRI lesions can be considered in the determination of DIS or DIT Cortical and juxtacortical lesions can be used in fulfilling MRI criteria for DIS A provisional disease course should be provided and periodically reassessed according to Lublin 2014 MS phenotypes PPMS No changes beyond the removal of the distinction between symptomatic and asymptomatic lesions and that cortical lesions can be used
- 10. Impact on India • Optic lesions are not included • OCB testing is not yet standardized in India • Differentiation between Juxtacortical and Cortical will be a challenge because of Low Tesla MRI 10