This presentation discusses the revised McDonald's criteria (2017) for the diagnosis of multiple sclerosis. Major changes from the last diagnostic criteria proposed in 2010 have been discussed. Clinical and MRI criteria for dissemination in space and time have been discussed.

1. REVISED McDONALD’S CRITERIA
2017
DR SUDHIR KUMAR MD DM
CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, HYDERABAD

2. Position Paper

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
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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
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11. Comments/Discussion?