Multiple Sclerosis Diagnostic Criteria

Although MRI provides a superb diagnostic testing modality, it always needs to be accompanied by an appropriate clinical setting to make an unequivocal diagnosis of MS. Clinicians utilize a set of consensus criteria that continually evolve as new technological advances become available. Clinical history and examination were the mainstays of diagnosis in 1965 when Schumacher et al. issued the first widely used criteria for MS; these required that five of six of the conditions shown in Box 46-1 Be met before making a clinically definite diagnosis of multiple sclerosis.

1.  Age on onset between 10 and 50 years.

2.  Objective neurological signs on exam.

3.  Neurological symptoms and signs referable to CNS white matter.

4.  Dissemination in time with

A.  Two or more attacks lasting at least 24 hours and separated by at least 1 month.

B.  Progression of signs and symptoms over 6 months.

5.  Dissemination in space with respect to localization by clinical exam.

6.  No other explanation for symptoms (always required).

1.  Two or more attacks with objective clinical evidence of two or more clinical lesions is enough to make a diagnosis of MS.

2.  Two or more clinical attacks:

A.  But only one clearly defined lesion on clinical examination,

B.  Fulfillment of additional criteria of dissemination in space may be evidenced by

1.  New MRI lesion.

2.  Combination of an MRI lesion plus positive CSF findings or another clinical attack at a new site.

3.  Isolated clinical attack occurs; criteria for MS may be met if there are two or more lesions with evidence of dissemination in time by either

A.  New lesion by MRI or

B.  Second clinical attack

4.  Clinically isolated syndrome with only one objective lesion PLUS, can make a diagnosis of MS with

A.  Dissemination in space demonstrated by second MRI lesion with positive CSF findings.

B.  Dissemination in time if demonstrated by

1.  MRI or

2.  Second clinical attack.

5.  Insidious progression of disease can lead to a diagnosis of MS

A.  If disease has progressed for at least 1 year and

B.  Two of the following three conditions are met:

1.  positive brain MRI findings,

2.  positive spinal cord MRI findings (given more weight than previously), and

3.  positive CSF findings.

Box 46-1 Schumacher Criteria for Diagnosis of MS

Box 46-2 McDonald Criteria for Diagnosis of MS

MS diagnostic criteria were revised in 1983 as evoked response testing and neuroimaging began to allow the identification of lesions that were not clinically evident and gave credence to laboratory data supportive of MS. The latter included CSF findings of specific increased number of oligoclonal bands in the CSF in comparison to the serum, elevated IgG levels, and increased IgG index. Most recently in 2001, the McDonald criteria became the standard almost universally applied in clinical research as well as to justify disease-modifying therapies specific for MS treatment.

These preserved the traditional requirement of multiple attacks of disease separated in time and space. Additionally, these new criteria provided for consideration of MRI and CSF findings when only one objective MRI lesion is found, only a single clinical attack has occurred, or when disease progression is insidious. The McDonald Diagnostic Criteria were revised in 2005 to incorporate the growing role of MR imaging for making a diagnosis of multiple sclerosis as well as to foster early treatment without sacrificing sensitivity and specificity (Box 46-2).

The ability to make a diagnosis of MS as early and accurately as possible is critical to patient care and to producing the most meaningful clinical research. Once the diagnosis of MS can be confirmed, the issue of when to initiate therapy becomes paramount.

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