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Implementing the 2017 Mcdonald Criteria for the Diagnosis of Multiple VIEWPOINT are needed to identify those lesions. The good news is that the lack of access to MRI Implementing the 2017 McDonald sequences that allow detection of cortical lesions is not a limiting factor for the use of criteria for the diagnosis of multiple the 2017 McDonald criteria. In addition to these two parameters, the sclerosis diagnostic criteria have not changed for patients with primary progressive MS. Frauke Zipp , Jiwon Oh , Yara Dadalti Fragoso and Emmanuelle Waubant Have the new criteria affected the speed Abstract | The latest revision of the McDonald criteria for the diagnosis of multiple and accuracy of diagnosis? sclerosis (MS) was published online in 2017. New features of the criteria, which J.O. By far the most important impact were designed to facilitate earlier diagnosis of MS, include the recognition of of the 2017 revisions to the McDonald oligoclonal bands in the cerebrospinal fluid as a possible marker of dissemination criteria is that they allow earlier diagnosis of MS pathology in time, the introduction of symptomatic lesions as a parameter of relapsing–remitting MS (RRMS) when to demonstrate spatial or temporal pathology dissemination, and the use of an individual presents with a characteristic cortical lesions to demonstrate dissemination in space. In this Viewpoint, a panel clinical syndrome and suggestive MRI findings6. The ability to reach a more rapid of world- renowned MS specialists share their personal experiences of the new diagnosis of RRMS is mainly attributable to criteria to date. two changes: the presence of CSF-specific OCBs can demonstrate dissemination in How do the 2017 McDonald criteria defined in the 2017 revision. However, time, and there is no longer a distinction compare with the 2010 criteria? these parameters require specific protocols between symptomatic and asymptomatic for MRI and cerebrospinal fluid (CSF) lesions. As a result of these changes, the Frauke Zipp. The previous McDonald analyses. Specialized MS units may use these vast majority of patients with characteristic criteria for the diagnosis of multiple sclerosis protocols regularly, but this is not the reality clinical syndromes will receive a diagnosis (MS)1 included simplified criteria for for general neurologists in some countries. of RRMS after the first clinical presentation. MRI lesion assessment. The 2017 criteria2 The main challenge is to keep the With respect to primary progressive MS, on have further improved on the ease of physician working on differential diagnoses the other hand, the 2017 revisions do not implementation by including symptomatic rather than concluding, perhaps too soon, substantially affect the speed of diagnosis. lesions. This inclusion means that lesions that the patient has full-blown MS. The The benefit of more rapid diagnosis of can simply be counted without having first implications of a rushed diagnosis go far RRMS is countered by a small decrease to determine whether they are associated beyond giving a name to a disease. The in specificity in comparison to the 2010 with clinical symptoms. therapeutic options for MS are not harmless revisions7. However, the incremental as they directly affect the patient’s immune decrease in specificity is unlikely to be Jiwon Oh. Another noteworthy change in system. Once a patient receives the diagnosis a major issue as these clinical criteria the 2017 McDonald criteria is the inclusion of MS, it will be very complicated to should be applied only to individuals with of cortical lesions to demonstrate ‘undiagnose’ it and to tell the patient that, in suggestive clinical syndromes, and clinical dissemination of MS pathology in space. fact, he or she has another disease. In daily judgement is always key to making any Although this change is reflective of medical practice, it is unusual to recheck the diagnostic or treatment decisions. accumulating scientific evidence of the diagnosis unless something serious happens. clinical relevance of cortical lesions in MS3, Y.D.F. In order to increase the speed of it does not materially change the practical Emmanuelle Waubant. The 2017 McDonald diagnosis, one might have to accept a utility of the revised criteria, as cortical criteria may be a little easier for neurologists decrease in accuracy. Although this balanced lesions are not easily detected with the to use than previous criteria. For example, equation may seem strange to neurologists routine MRI sequences and magnet strengths an enhancing lesion on the first MRI scan, with extensive experience in MS, those who that are typically used in clinical practice4,5. regardless of whether it is a symptomatic see fewer patients might find the decreased lesion, counts towards dissemination in sensitivity challenging. Yara Dadalti Fragoso. The new criteria are time. Of note, another change to the criteria In countries where the prevalence of not particularly difficult to implement. The in 2017, the presence of cortical lesions, is CNS infections far outweighs that of MS, inclusion of cortical lesions, symptomatic not yet within the reach of routine clinical the 2017 McDonald criteria could pose an lesions (except for the optic nerve) and practice. Cortical lesions are often not extra problem. The presence of OCBs in oligoclonal bands (OCBs) as parameters for detectable with conventional MRI, even the CSF is now considered to be a marker dissemination in space and time is clearly with a 3T scanner, as specific sequences of dissemination of MS pathology in time. NATURE REVIEWS | NEUROLOGY VOLUME 15 | AUGUST 2019 | 441 VIEWPOINT However, OCBs can also be found in be considered to have MS if their MRI scan with MS at baseline using the 2017 criteria. patients with infections, brain tumours or shows T2-bright changes in the deep white OCB positivity dropped from 74% in the lymphoproliferative disorders and can be matter and one focus displays enhancement original CIS cohort to 52% in the CIS cohort absent in patients with a definite diagnosis or OCBs are reported in the CSF, although reclassified according to the 2017 criteria. of MS, particularly in some areas of the they actually have another disorder. For world. In Brazil, for example, irrespective this reason, it remains crucial to carefully What has been the impact of the new of the method used for detecting OCBs in consider the clinical presentation when criteria on clinical practice? the CSF, only 54.4% of patients with definite making a diagnosis of MS. MS are positive for OCBs8. Furthermore, J.O. As a neurologist, I have found that the the African ancestry in Brazilian patients F.Z. Under the new criteria, discussion with revised diagnostic criteria have substantial increases the odds of OCBs in patients patients about their diagnosis is clearer at benefits in clinical practice, as I can more with MS. One study reported that 73.9% of an earlier stage. Previously, we would have easily make a definitive diagnosis in patients patients of African descent with definite MS advised patients with CIS who are positive presenting with a first clinical attack. had OCBs in the CSF, whereas only 48.5% of for intrathecal OCBs that they have potential Having a definitive diagnosis of MS allows patients of white ancestry had these bands9. early- stage MS, but OCBs are now included me to counsel patients appropriately and The same group of researchers showed that in the criteria for MS. Certainly, we will have with less uncertainty. In addition, the lack OCBs were present in 17.9% of patients with to follow up to see whether more people may of distinction between symptomatic and other disorders of the CNS, such as syphilis, be misdiagnosed under the new criteria. asymptomatic lesions obviates the need to hepatitis, schistosomiasis or human T- This is why diagnosing patients is an expert perform serial MRI scans in rapid succession, lymphotropic virus (HTLV) myelopathy8. activity, and neurologists should — as we which also has benefits with respect to If a patient with an infection is do — interpret original MRI scans as part of health- care resource utilization. Although misdiagnosed as having MS and is given the diagnostic process. the more frequent need for a lumbar immunosuppressive therapy, the 2017 puncture at diagnosis to demonstrate CSF- criteria will have done more harm than good Y.D.F. I am not particularly comfortable specific OCBs can utilize more resources for that person. Although it can be argued with the inclusion of OCBs as a marker of initially, the benefit of a more rapid diagnosis that clinical red flags should have been taken dissemination in time. From our point of of RRMS, and the ability to initiate DMT, if into consideration before prescribing MS view, many cases of ‘CIS’ have become MS appropriate, will result in substantial long- therapy, this expectation might not always be because the specialists who defined the term benefits that greatly outweigh the small realistic in the busy daily practice of general 2017 criteria voted for this, and there is no increase in resource use at diagnosis. neurologists. particular recommendation in the 2017 criteria to further investigate patients in E.W. The new criteria have had no impact E.W. The speed of MS diagnosis may whom dissemination in time is confirmed on my treatment decision-making as I treat be slightly increased for a few patients. exclusively through detection of OCBs. early (usually after the first clinical event) and However, confirming the diagnosis earlier Therapeutic decisions need to be accurate MS drugs are available in the USA for most is not necessarily meaningful in terms and not all drugs that are used to treat RRMS patients after a first demyelinating event, even of access to treatment in countries such have been evaluated for CIS. if they do not meet the McDonald criteria as the USA or Canada where patients for MS. Early treatment implementation is with clinically isolated syndrome (CIS) Is the distinction between CIS and MS especially important in patients with poor are allowed to receive disease-modifying still meaningful? prognostic features at onset.
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