Continuing Medical Education 213 Diagnosis of Multiple Sclerosis Chih-Chao Yang Abstract- Multiple sclerosis (MS) is an inflammatory demyelinating autoimmune disease of the central ner- vous system. The disorder displays marked clinical heterogeneity. In certain cases, making diagnosis can be challenging. Diagnosis of MS has become more important in the era of treatments that change the natural history of the disease. Several general diagnostic principles are useful to guide the diagnostic approach to MS. Clinically, MS requires neurological problems associated with objective abnormalities. Certain basic principles, first outlined by Schumacher et al. (1965) are still pertinent. Poser et al. (1983) have further modified the criteria using data derived from clinical evaluation and laboratory studies, including cere- brospinal fluid analysis, evoked potentials, and imaging studies. Poser criteria have long been familial for most neurologists. The most recent addition to our diagnostic armamentarium are the McDonald crite- ria(2001), which are the first attempt to incorporate standardized MRI criteria into the MS diagnostic process. The most innovative use of MRI to support an MS diagnosis is dissemination of demyelination can be demonstrated by MRI alone, in the absence of any new clinical attacks. Diagnosing MS by such sensitive MRI criteria will occur more quickly than waiting for a second clinical event. This has added some sensitiv- ity, some controversy, and a lot of confusion. The application of the new criteria on Asian MS patients remains to be validated. Each of the criteria will be discussed, with major emphasis on the McDonald crite- ria. Key Words: Multiple sclerosis, Criteria, Schumacher criteria, Poser criteria, McDonald criteria From the Department of Neurology, National Taiwan Reprint requests and correspondence to: Chih-Chao Yang, MD. University Hospital, Taipei, Taiwan. Department of Neurology, National Taiwan University Received November 10, 2005. Hospital, No. 7, Chung-Shan S. Road, Taipei, Taiwan. Revised and Accepted November 28, 2005. E-mail: [email protected] Acta Neurologica Taiwanica Vol 14 No 4 December 2005 214 Multiple Sclerosis MS MS MS MS Schumacher 1965 Poser 1983 McDonald 2001 McDonald Schumacher Poser McDonald Acta Neurol Taiwan 2005;14:214-220 Multiple Sclerosis MS MS MS (1) Schumacher 1965 Poser 2005 11 10 7 2005 11 28 E-mail: [email protected] Acta Neurologica Taiwanica Vol 14 No 4 December 2005 215 1983 MS ADEM 15~20% McDonald 2001 ADEM (2) McDonald MS Schumacher (7,8,9,10) MS (11,12) Schumacher (3,4) MS MS 24 (13) MS RRMS (5) Poser (14) sec- (15) IgG IgG index ondary progressive MS SPMS MS 90-95% (16) primary progressive MS PPMS IgG Poser Schumacher ADEM Schumacher MS A1 C1 C2 . Schumacher 1. MS MS Poser laboratory supported MS 10 50 2. MS MS IgG IgG MS 50~90% IgG 90~95% MS Acta Neurologica Taiwanica Vol 14 No 4 December 2005 216 . Poser (Poser criteria for MS diagnosis) Category Attacks Clinical evidence Paraclinical evidence CSF OB/IgG1 OB/IgG A. Clinical definite ( MS) CDMS A1 2 2 CDMS A2 2 1 and 1 B. Laboratory supported definite ( MS) LSDMS B1 2 1 or 1 + LSDMS B2 1 2 + LSDMS B3 1 1 and 1 + C. Clinical probable ( MS) CPMS C1 2 1 CPMS C2 1 2 CPMS C3 1 1 and 1 D. Laboratory-supported Probable ( MS) LSPMS D1 2 + OB/IgG: IgG A. MS CDMS 1. 2. B. MS LSDMS IgG IgG IgG 1. IgG 2. IgG 3. IgG ADEM MS MS C. MS CPMS 1. 2. 3. D. MS LSPMS 1. IgG IgG index MS A2 C3 B1 B3 MS paraclinical evidence Acta Neurologica Taiwanica Vol 14 No 4 December 2005 217 Poser MRI paraclinical MRI CDMS A2 MRI paraclinical MRI B1 B3 MS MRI C3 MS (23,24) International Panel on the Diagnosis of MS MRI McDonald (25) McDonald Schumacher Poser Poser B1 B2 B3 MS B2 B3 progressive McDonald MS CSF Poser SPMS PPMS McDonald MS IgG IgG index Poser IgG IgG MS McDonald MRI MS IgG MRI MS IgG MS McDonald MS (17,18) MRI MS MRI CSF T2 MRI CSF gadolinium McDonald a b 1990 MRI MS Schumacher MS 90~95% MS MRI McDonald MRI gadolinium MS MRI (19,20) MS gadolinium MRI Acta Neurologica Taiwanica Vol 14 No 4 December 2005 218 . McDonald MS MRI ( a.) MRI MRI ( b.) MRI ( a.) MRI MRI MS MRI (1) 9 T2 (2) (3) 4-8 MRI (1) 4-8 (2) 4 (1) MRI (2) a. MS 1. gadolinium T2 2. 3. 4. b. 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