Criteria
McDonald criteria (2017 revision) - diagnostic criteria for MS[4]
In a patient with a typical clinically isolated syndrome and fulfillment of clinical or magnetic resonance imaging (MRI) criteria for dissemination in space, and no better explanation for the clinical presentation, demonstration of cerebrospinal fluid (CSF)-specific oligoclonal bands in the absence of other CSF findings atypical of MS allows a diagnosis of this disease to be made. This recommendation is an addition to the 2010 McDonald criteria.
Symptomatic and asymptomatic MRI lesions can be considered in the determination of dissemination in space or time. MRI lesions in the optic nerve in a patient presenting with optic neuritis remain an exception and, owing to insufficient evidence, cannot be used in fulfilling the McDonald criteria. In the 2010 McDonald criteria, the symptomatic lesion in a patient presenting with brainstem or spinal cord syndrome could not be included as MRI evidence of dissemination in space or time.
Cortical and juxtacortical lesions can be used in fulfilling MRI criteria for dissemination in space. Cortical lesions could not be used in fulfilling MRI criteria for dissemination in space in the 2010 McDonald criteria.
The diagnostic criteria for primary progressive MS in the 2017 McDonald criteria remain the same as those outlined in the 2010 McDonald criteria, aside from removal of the distinction between symptomatic and asymptomatic MRI lesions and that cortical lesions can be used.
At the time of diagnosis, a provisional disease course should be specified (relapsing-remitting, primary progressive, or secondary progressive) and whether the course is active or not, and progressive or not, based on the previous year’s history. The phenotype should be periodically re-evaluated based on accumulated information. This recommendation is an addition to the 2010 McDonald criteria.
McDonald criteria (2010 revision) - diagnostic criteria for MS[44]
Two or more attacks; objective clinical evidence of 2 or more lesions or objective clinical evidence of 1 lesion with reasonable historical evidence of prior attack.
No further data needed.
Two or more attacks; objective clinical evidence of 1 lesion
Dissemination in space (DIS) demonstrated by MRI, or await further clinical attack implicating a different site.
One attack, objective clinical evidence of 2 or more lesions
Dissemination in time (DIT) demonstrated by MRI or second clinical attack.
One attack, objective clinical evidence of one lesion (monosymptomatic presentation, clinically isolated syndrome)
DIS, demonstrated by MRI or second clinical attack at a different central nervous system (CNS) site, and
DIT demonstrated by MRI or second clinical attack.
Insidious neurologic progression suggestive of MS
One year of disease progression (retrospectively or prospectively determined) and 2 of the following:
DIS in brain (1 or more T2 lesions in periventricular, juxtacortical, or infratentorial regions)
DIS in spinal cord (2 or more T2 lesions in cord)
Positive CSF (oligoclonal bands or elevated immunoglobulin G [IgG] index).
McDonald criteria (2017 revision) - MRI findings[4]
Dissemination in space (DIS):
One or more T2-hyperintense lesions in 2 or more of 4 areas of the CNS: periventricular, cortical or juxtacortical, infratentorial brain regions, and the spinal cord.
Dissemination in time (DIT):
Simultaneous presence of asymptomatic gadolinium (Gd)-enhancing and nonenhancing lesions at any time, or
New T2 and/or Gd-enhancing lesion on follow-up MRI, irrespective of timing with reference to baseline scan.
Functional systems (FS) criteria[45]
1. Pyramidal function
0 - Normal
1 - Abnormal signs without disability
2 - Minimal disability
3 - Mild/moderate paraparesis or hemiparesis; severe monoparesis
4 - Marked paraparesis or hemiparesis; moderate quadriparesis or monoparesis
5 - Paraplegia, hemiplegia, or marked paraparesis
6 - Quadriplegia
V - Unknown.
2. Cerebellar function
0 - Normal
1 - Abnormal signs without disability
2 - Mild ataxia
3 - Moderate truncal or limb ataxia
4 - Severe ataxia
5 - Unable to perform coordinated movements
V - Unknown
X - Weakness.
3. Brainstem function
0 - Normal
1 - Signs only
2 - Moderate nystagmus or other mild disability
3 - Severe nystagmus, marked extraocular weakness, or moderate disability of other cranial nerves
4 - Marked dysarthria or other marked disability
5 - Inability to speak or swallow
V - Unknown.
4. Sensory function
0 - Normal
1 - Vibration or figure-writing decrease only, in 1 or 2 limbs
2 - Mild decrease in touch or pain or proprioception, and/or moderate decrease in vibration in 1 or 2 limb, or vibration in 3 or 4 limbs
3 - Moderate decrease in touch or pain or proprioception, and/or essentially lost vibration in 1 or 2 limbs; or mild decrease in touch or pain and/or moderate decrease in all proprioceptive tests in 3 or 4 limbs
4 - Marked decrease in touch or pain or loss of proprioception, alone or combined in 1 or 2 limbs; or moderate decrease in touch or pain and/or severe proprioceptive decrease in more than two limbs
5 - Loss of sensation in 1 or 2 limbs; or moderate decrease in touch or pain and/or loss of proprioception for most of the body below the head
6 - Sensation essentially lost below the head
V - Unknown.
5. Bowel and bladder function
0 - Normal
1 - Mild urinary hesitancy, urgency, or retention
2 - Moderate hesitancy, urgency, or retention of bowel or bladder, or rare urinary incontinence
3 - Frequent urinary incontinence
4 - Almost constant catheterization
5 - Loss of bladder function
6 - Loss of bowel function
V - Unknown.
6. Visual function
0 - Normal
1 - Scotoma with visual acuity >20/30 (corrected)
2 - Worse eye with scotoma with maximal acuity 20/30 to 20/59
3 - Worse eye with large scotoma or decrease in fields, acuity 20/60 to 20/99
4 - Marked decrease in fields, acuity 20/100 to 20/200; grade 3 plus maximal acuity of better eye <20/60
5 - Worse eye acuity <20/200; grade 4 plus better eye acuity <20/60
V - Unknown.
7. Cerebral function
0 - Normal
1 - Mood alteration
2 - Mild decrease in mentation
3 - Moderate decrease in mentation
4 - Marked decrease in mentation
5 - Dementia
V - Unknown.
8. Other function
0 - Normal
1 - Other neurologic finding.
The expanded disability status scale (EDSS)[45]
0.0 - Normal neurologic exam.
1.0 - No disability, minimal signs on 1 functional system (FS).
1.5 - No disability, minimal signs on 2 of 7 FS.
2.0 - Minimal disability in 1 of 7 FS.
2.5 - Minimal disability in 2 FS.
3.0 - Moderate disability in 1 FS or mild disability in 3 to 4 FS, though fully ambulatory.
3.5 - Fully ambulatory but with moderate disability in 1 FS and mild disability in 1 or 2 FS, or moderate disability in 2 FS, or mild disability in 5 FS.
4.0 - Fully ambulatory without aid; up and about 12 hours a day despite relatively severe disability; able to walk without aid 500 meters.
4.5 - Fully ambulatory without aid, up and about much of day, able to work a full day, may otherwise have some limitations of full activity or require minimal assistance; relatively severe disability; able to walk without aid 300 meters.
5.0 - Ambulatory without aid for about 200 meters; disability impairs full daily activities.
5.5 - Ambulatory for 100 meters; disability precludes full daily activities.
6.0 - Intermittent or unilateral constant assistance (cane, crutch, or brace) required to walk 100 meters with or without resting.
6.5 - Constant bilateral support (cane, crutch, or braces) required to walk 20 meters without resting.
7.0 - Unable to walk beyond 5 meters even with aid, essentially restricted to wheelchair, wheels self, transfers alone, active in wheelchair about 12 hours a day.
7.5 - Unable to take more than a few steps, restricted to wheelchair, may need aid to transfer; wheels self, but may require motorized chair for full day's activities.
8.0 - Essentially restricted to bed, chair, or wheelchair but may be out of bed much of day, retains self care functions, generally effective use of arms.
8.5 - Essentially restricted to bed much of day, some effective use of arms, retains some self-care functions
9.0 - Helpless bed-patient, can communicate and eat.
9.5 - Unable to communicate effectively or eat/swallow.
10.0 - Death.
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