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REVISED McDONALD’S CRITERIA
2017
DR SUDHIR KUMAR MD DM
CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, HYDERABAD
Position Paper
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
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
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
2010 vs 2017 McDonald`s DIS Criteria
McDonald`s 2017 DIT Criteria
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)
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
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
Comments/Discussion?

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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
  • 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