The 2017 McDonald criteria for the diagnosis of multiple sclerosis in patients with an attack at onset

	Number of lesions with objective clinical evidence	Additional data needed for a diagnosis of multiple sclerosis
≥2 clinical attacks	≥2	None*
	1 (as well as clear-cut historical evidence of a previous attack involving a lesion in a distinct anatomical location^¶)	None*
	1	Dissemination in space demonstrated by an additional clinical attack implicating a different CNS site or by MRI^Δ
1 clinical attack	≥2	Dissemination in time demonstrated by an additional clinical attack or by MRI^◊ OR demonstration of CSF-specific oligoclonal bands^§
1 clinical attack	1	Dissemination in space demonstrated by an additional clinical attack implicating a different CNS site or by MRI^Δ AND Dissemination in time demonstrated by an additional clinical attack or by MRI^◊ OR demonstration of CSF-specific oligoclonal bands^§

If the 2017 McDonald Criteria are fulfilled and there is no better explanation for the clinical presentation, the diagnosis is multiple sclerosis. If multiple sclerosis is suspected by virtue of a clinically isolated syndrome but the 2017 McDonald Criteria are not completely met, the diagnosis is possible multiple sclerosis. If another diagnosis arises during the evaluation that better explains the clinical presentation, the diagnosis is not multiple sclerosis. An attack is defined as a monophasic clinical episode with patient-reported symptoms and objective findings typical of multiple sclerosis, reflecting a focal or multifocal inflammatory demyelinating event in the CNS, developing acutely or subacutely, with a duration of at least 24 hours, with or without recovery, and in the absence of fever or infection. Attack, relapse, exacerbation, and (when it is the first episode) clinically isolated syndrome are synonyms.

CNS: central nervous system; MRI: magnetic resonance imaging; CSF: cerebrospinal fluid.
* No additional tests are required to demonstrate dissemination in space and time. However, unless MRI is not possible, brain MRI should be obtained in all patients in whom the diagnosis of multiple sclerosis is being considered. In addition, spinal cord MRI or CSF examination should be considered in patients with insufficient clinical and MRI evidence supporting multiple sclerosis, with a presentation other than a typical clinically isolated syndrome, or with atypical features. If imaging or other tests (eg, CSF) are undertaken and are negative, caution needs to be taken before making a diagnosis of multiple sclerosis, and alternative diagnoses should be considered.
¶ Clinical diagnosis based on objective clinical findings for two attacks is most secure. Reasonable historical evidence for one past attack, in the absence of documented objective neurological findings, can include historical events with symptoms and evolution characteristic for a previous inflammatory demyelinating attack; at least one attack, however, must be supported by objective findings. In the absence of residual objective evidence, caution is needed.
Δ The MRI criteria for dissemination in space are described in the text of the UpToDate topic on the diagnosis of multiple sclerosis in adults.
◊ The MRI criteria for dissemination in time are described in the text of the UpToDate topic on the diagnosis of multiple sclerosis in adults.
§ The presence of CSF-specific oligoclonal bands does not demonstrate dissemination in time per se but can substitute for the requirement for demonstration of this measure.

Reproduced from: Thompson AJ, Banwell BL, Barkhof F, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol 2018; 17:162. Table used with the permission of Elsevier Inc. All rights reserved.

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The 2017 McDonald criteria for the diagnosis of multiple sclerosis in patients with an attack at onset