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Table 1. Poser’s criteria17 for the diagnosis of multiple sclerosis (MS)
* Symptoms lasting more than 24 hours would constitute an attack even if they were “completely subjective and anamnestic.” † Evidence of two separate lesions found on neurologic examination. Bilateral optic neuritis would constitute only one lesion provided that the episodes of optic neuritis were separated by less than 15 days. ‡ Includes lesions detected by MRI or evoked potentials. § CSF analysis demonstrates the presence of oligoclonal bands or an increased CNS synthesis of immunoglobulin G. Clinically definite MS A1: 2 Attacks* + 2 lesions on examination† A2: 2 Attacks + 1 lesion on examination + 1 paraclinical lesion‡ Laboratory-supported definite MS B1: 2 Attacks + 1 lesion on examination or 1 paraclinical lesion + abnormal CSF§ B2: 1 Attack + 2 lesions on examination + abnormal CSF§ B3: 1 Attack + 1 lesion on examination + 1 paraclinical lesion‡ + abnormal CSF§ Clinically probable MS C1: 2 Attacks + 1 lesion on examination C2: 1 Attack + 2 lesions on examination C3: 1 Attack + 1 lesion on examination + 1 paraclinical lesion‡ Laboratory-supported probable MS D1: 2 Attacks + abnormal CSF§ Table 2. Diagnostic considerations in patients with suspected multiple sclerosis or MRI white matter abnormalities
Age-related white matter changes Acute disseminated encephalomyelitis Behçet disease Bacterial infections (syphilis, Lyme disease) Cerebral autosomal dominant arteriopathy, subcortical infarcts, and leukoencephalopathy Cervical spondylosis or stenosis HIV infection Human T-lymphotrophic virus I/II Ischemic optic neuropathy (arteritic and nonarteritic) Leukodystrophies (e.g., adrenoleukodystrophy, metachromatic leukodystrophy) Neoplasms (e.g., lymphoma, glioma, meningioma) Migraine Sarcoid Sjögren syndrome Stroke and ischemic cerebrovascular disease Systemic lupus erythematosus, antiphospholipid antibody syndromes, and related collagen vascular disorders Unidentified bright objects Vascular malformations Vasculitis (primary CNS or other) Vitamin B12 deficiency Table 3. Proposed McDonald criteria18 for the diagnosis of multiple sclerosis (MS)
* If the criteria are fulfilled and met, the diagnosis is MS. If the criteria are not completely met, the diagnosis is possible MS. If the criteria are fully explored and not met, the diagnosis is not MS. † Symptoms lasting at least 24 hours would constitute an attack provided that the episode was not a pseudoattack such as due to fever or infection. ‡ Objective evidence of two lesions necessarily separated in space found on neurologic examination. A typical subclinical lesion detected by visual evoked potential testing (delayed response, well preserved waveform) can substitute for one clinical lesion. § MRI (a): Criteria for dissemination in space: three of the four following criteria need to be met: 1. ≥1 gadolinium (Gd)-enhancing lesion or ≥9 T2 lesions 2. ≥1 infratentorial MRI lesion 3. ≥1 juxtacortical lesion 4. ≥3 periventricular lesions 1 spinal cord lesion can substitute for 1 brain lesion ¶ CSF analysis demonstrates the presence of oligoclonal bands different from any such bands in the serum or an increased immunoglobulin G index. ∥ MRI (b): Criteria for dissemination in time: 1. If original MRI was performed <3 months after the clinical attack, a follow-up MRI (>3 months after event) is necessary. A new Gd-enhancing lesion on this follow-up MRI provides evidence of dissemination in time. Otherwise, another follow-up MRI (>3 months after first MRI) is necessary. A new Gd-enhancing or a new T2 lesion on this second follow-up MRI provides evidence of dissemination in time. 2. If the original MRI was performed ≥3 months after the clinical attack, a Gd-enhancing lesion (at a site not implicated by the clinical event) provides evidence of dissemination in time. Otherwise, a follow-up MRI is necessary (suggested to be 3 months after original MRI). A new Gd-enhancing or a new T2 lesion on this MRI provides evidence of dissemination in time. Clinically definite MS* 1: 2 Attacks† + 2 lesions on examination‡ 2: 2 Attacks + 1 lesion on examination + [MRI (a)§ or 2 MRI lesions + abnormal CSF¶] 3: 1 Attack + 2 lesions on examination + MRI (b)∥ 4: 1 Attack + 1 lesion on examination + [MRI (a)§ or 2 MRI lesions + abnormal CSF] + MRI (b)∥ 5: Progressive disease + abnormal CSF + MRI (b)∥ + a) [≥9 T2 MRI lesions or ≥2 spinal cord lesions or 4–8 brain MRI lesions + 1 spinal cord lesion] OR b) Abnormal VEP‡ + [≥4 brain MRI lesions or <4 MRI lesions + 1 spinal cord lesion] Table 4. Clinically isolated syndromes characteristic of MS
Syndrome Features Optic neuritis 1. Typically unilateral 2. Retrobulbar 3. Typically painful 4. Some recovery expected 5. No retinal exudates 6. No macular star 7. Disc hemorrhages infrequent Myelitis 1. Partial sensory or motor 2. Sensory more common 3. Lhermitte sign 4. Bowel and bladder dysfunction is common 5. “Band-like” abdominal or chest pressure 6. Acute dystonias Brainstem/cerebrum 1. Ocular motor syndromes (e.g., internuclear ophthalmoparesis/nystagmus) 2. Hemisensory, crossed sensory syndromes 3. Hemiparesis 4. Trigeminal neuralgia 5. Hemifacial spasm Cerebellum 1. Cerebellar outflow tremor 2. Acute ataxic syndrome Paroxysmal 1. Tonic spasms symptoms 2. Paroxysmal dysarthria/ataxia Rating of recommendation Translation of evidence to recommendations Rating of diagnostic article A = Established as useful/predictive or not useful/predictive for the given condition in the specified population Level A rating requires at least one convincing class I study or at least two consistent, convincing class II studies Class I: Evidence provided by a prospective study in a broad spectrum of persons with the suspected condition, using a “gold standard” for case definition, where test is applied in a blinded evaluation, and enabling the assessment of appropriate tests of diagnostic accuracy. In addition, there must be adequate accounting for drop-outs with numbers sufficiently low to have minimal potential for bias. B = Probably useful/predictive or not useful/predictive for the given condition in the specified population Level B rating requires at least one convincing class II study or at least three consistent class III studies Class II: Evidence provided by a prospective study of a narrow spectrum of persons with the suspected condition, or a well designed retrospective study of a broad spectrum of persons with an established condition (by “gold standard”) compared to a broad spectrum of controls, where test is applied in a blinded evaluation, and enabling the assessment of appropriate tests of diagnostic accuracy. C = Possibly useful/predictive or not useful/predictive for the given condition in the specified population Level C rating requires at least two convincing and consistent class III studies Class III: Evidence provided by a retrospective study where either persons with the established condition or controls are of a narrow spectrum, and where test is applied in a blinded evaluation. U = Data inadequate or conflicting. Given current knowledge, test/predictor is unproven Class IV: Any design where test is not applied in blinded evaluation OR evidence provided by expert opinion alone or in descriptive case series (without controls).
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Disputes & Debates: Rapid online correspondence
- The utility of MRI in suspected MS: Report of the Therapeutics and Technology Assessment Subc.
- Reply to Uitdehaag et al
- The utility of MRI in suspected MS: Report of the Therapeutics and Technology Assessment Subcommitte
- The utility of MRI in suspected MS: Report of the Therapeutics and Technology Assessment Subcommitte
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