Diagnosing MS The MacDonald and Poser Criteria

1. Diagnosing MSThe MacDonald and Poser Criteria

2. MacDonald vs. Poser • The MacDonald criteria succeeded the Poser criteria in 2001 • Many clinical papers and data published before this date still refer to the Poser criteria, therefore it has been included in this presentation

3. Guidelines for accurate diagnosis • Should be made by an experienced clinician with expert knowledge of MS and similar neurological conditions • The prior probability of MS depends age, ethnicity and geographical location • Objective evidence of dissemination in time and space of lesions in mandatory • Historical reports of symptoms suggesting previous episodes of demyelination cannot be used without objective evidence • Can be diagnosed on purely clinical evidence of lesions separated in time and space McDonald WI, et al. Ann Neurol 2001 Jul; 50(1): 121-7

4. Guidelines for accurate diagnosis • Radiological (MRI) and laboratory evidence is desirable • Choice of investigation is determined by the clinical situation • MRI is less useful in older people and in other inflammatory conditions McDonald WI, et al. Ann Neurol 2001 Jul; 50(1): 121-7

5. Guidelines for diagnosis Diagnostic criteria for suspected MS (two or more attacks) Two or more clinical attacks with two or more objective lesions MS diagnosed • Brain MR shows dissemination in space • One Gd-enhancing lesion or • nine T2 hyperintense lesions if no Gd-enhancing • lesion plus • one or more infratentorial lesions plus • one or more juxtacortical lesions plus • three or more periventricular lesions • NB: One cord lesion can substitute for one brain lesion. Two or more clinical attacks with one objective lesion Plus Plus Positive CSF (oligoclonal IgG bands in CSF and not serum or elevated IgG index) Plus Plus Further clinical attack involving a different site Brain MR shows two or more lesions consistent with MS MS diagnosed McDonald WI, et al. Ann Neurol 2001 Jul; 50(1): 121-7

6. Guidelines for diagnosisDiagnostic criteria for suspected MS (monosymptomatic) • Brain MR shows • dissemination in space • One Gd enhancing lesion or • nine T2 hyperintense • lesions if no Gd enhancing • lesion plus • one or more infratentorial • lesions plus • one or more juxtacortical • lesions plus • three or more periventricular • lesions • NB: One cord lesion can • substitute for one brain lesion Brain MR shows dissemination in time One Gd enhancing lesion demonstrated in a scan done at least three months following onset of a clinical attack at a site different from attack Or In absence of Gd-enhancing lesions at three month scan, follow-up scan after an additional three months showing Gd-enhancing lesion or new T2 lesion Single attack with one objective lesion Plus Plus Plus Positive CSF (oligoclonal IgG bands in CSF and not serum or elevated IgG index) Plus Brain MR shows two or more lesions consistent with MR MS diagnosed McDonald WI, et al. Ann Neurol 2001 Jul; 50(1): 121-7

7. Guidelines for diagnosisDiagnostic criteria for suspected MS (single attack) Brain MR shows dissemination in time One Gd-enhancing lesion demonstrated in a scan done at least three months following onset of a clinical attack at a site different from attack Or In absence of Gd-enhancing lesions at three month scan, follow-up scan after an additional three months showing Gd-enhancing lesion or new T2 lesion Single clinical attack with two objective lesions Plus Plus Second clinical attack MS diagnosed McDonald WI, et al. Ann Neurol 2001 Jul; 50(1): 121-7

8. No attacks but progression from onset with one objective lesion Guidelines for diagnosisDiagnostic criteria for suspected MS (progressive from onset) Brain MR shows dissemination in space • by nine T2 hyperintense brain lesions or • two or more cord lesions or • four to eight brain and one cord lesion or • positive VEP with four to eight brain lesions or • positive VEP with less than four brain lesions plus one cord lesion Brain MR shows dissemination in time One Gd-enhancing lesion demonstrated in a scan done at least three months following onset of a Clinical attack at a site different from attack Or In absence of Gd-enhancing lesions at three month scan, follow-up scan after an additional three months Showing Gd-enhancing lesion or new T2 lesion No attacks but progression from onset with one objective lesion Plus Positive CSF (oligoclonal IgG bands in CSF and not serum or elevated IgG index) Plus Plus Plus Continued progression for one year MS diagnosed McDonald WI, et al. Ann Neurol 2001 Jul; 50(1): 121-7

9. Poser Criteria • Clinically definite MS • 2 attacks and clinical evidence of 2 separate lesions • 2 attacks, clinical evidence of one and paraclinical evidence of another separate lesion • Laboratory supported Definite MS • 2 attacks, either clinical or paraclinical evidence of 1 lesion, and cerebrospinal fluid (CSF) immunologic abnormalities • 1 attack, clinical evidence of 2 separate lesions & CSF abnormalities • 1 attack, clinical evidence of 1 and paraclinical evidence of another separate lesion, and CSF abnormalities Poser CM et al. Ann Neurol 1983; 13(3); 227-231

10. Poser Criteria • Clinically probable MS • 2 attacks and clinical evidence of 1 lesion • 1 attack and clinical evidence of 2 separate lesions • 1 attack, clinical evidence of 1 lesion, and paraclinical evidence of another separate lesion • Laboratory supported probable MS • 2 attacks and CSF abnormalities Poser CM et al. Ann Neurol 1983; 13(3); 227-231