The 2010 McDonald criteria for the diagnosis of multiple sclerosis are widely used in research and clinical practice. Scientific advances in the past 7 years suggest that they might no longer provide the most up-to-date guidance for clinicians and researchers. The International Panel on Diagnosis of Multiple Sclerosis reviewed the 2010 McDonald criteria and recommended revisions. The 2017 McDonald criteria continue to apply primarily to patients experiencing a typical clinically isolated syndrome, define what is needed to fulfil dissemination in time and space of lesions in the CNS, and stress the need for no better explanation for the presentation. The following changes were made: in patients with a typical clinically isolated syndrome and clinical or MRI demonstration of dissemination in space, the presence of CSF-specific oligoclonal bands allows a diagnosis of multiple sclerosis; symptomatic lesions can be used to demonstrate dissemination in space or time in patients with supratentorial, infratentorial, or spinal cord syndrome; and cortical lesions can be used to demonstrate dissemination in space. Research to further refine the criteria should focus on optic nerve involvement, validation in diverse populations, and incorporation of advanced imaging, neurophysiological, and body fluid markers.
Natalizumab added to interferon beta-1a was significantly more effective than interferon beta-1a alone in patients with relapsing multiple sclerosis. Additional research is needed to elucidate the benefits and risks of this combination treatment. (ClinicalTrials.gov number, NCT00030966.).
Background and objectivesDiagnosis of multiple sclerosis (MS) requires exclusion of diseases that
could better explain the clinical and paraclinical findings. A systematic
process for exclusion of alternative diagnoses has not been defined. An
International Panel of MS experts developed consensus perspectives on MS
differential diagnosis.MethodsUsing available literature and consensus, we developed guidelines for MS
differential diagnosis, focusing on exclusion of potential MS mimics,
diagnosis of common initial isolated clinical syndromes, and differentiating
between MS and non-MS idiopathic inflammatory demyelinating diseases.ResultsWe present recommendations for 1) clinical and paraclinical red flags
suggesting alternative diagnoses to MS; 2) more precise definition of
“clinically isolated syndromes” (CIS), often the first
presentations of MS or its alternatives; 3) algorithms for diagnosis of
three common CISs related to MS in the optic nerves, brainstem, and spinal
cord; and 4) a classification scheme and diagnosis criteria for idiopathic
inflammatory demyelinating disorders of the central nervous system.ConclusionsDifferential diagnosis leading to MS or alternatives is complex and a strong
evidence base is lacking. Consensus-determined guidelines provide a
practical path for diagnosis and will be useful for the non-MS specialist
neurologist. Recommendations are made for future research to validate and
support these guidelines. Guidance on the differential diagnosis process
when MS is under consideration will enhance diagnostic accuracy and
precision.
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