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Multiple Sclerosis Centers of Excellence

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Diagnosing MS Using the McDonald Criteria

Overview
Criteria for the diagnosis of MS have been based on diagnosis by "lesions" separated in space and over time. The first set of criteria was known as the Schumacher Criteria. These were followed by the Poser Criteria. The best and most current set of criteria for diagnosing MS is the McDonald Criteria. The McDonald Criteria were developed in April 2001 by an international panel in association with the National MS Society of America, modified in 2005, and revised in 2010.  The primary goal of the McDonald Criteria is to enable the diagnosis of MS sooner and to permit earlier treatment of MS. For clinical research trials, it is important to ensure that those without a definite diagnosis of MS are not enrolled. 

McDonald Criteria

Diagnosing MS
The diagnosis of MS can only be made after an extensive evaluation and is not based on one specific physical finding, laboratory test, or symptom. The diagnosis of MS involves excluding other causes of symptoms and signs, and using imaging findings. It takes time and is challenging.

The symptoms of MS can come and go, and they are not the same for every person. A health care provider will take a clinical history and perform a physical examination. Additional testing may be necessary, including imaging (an MRI) of the brain and spinal cord, blood tests, spinal fluid analysis, and visual tests. 

The VA is committed to providing our Veterans the specialized testing needed to establish an accurate diagnosis of MS. There are specific guidelines that have been developed to help a health care provider (usually a neurologist) diagnose MS.

Diagnosis Criteria
The best and most current set of criteria for diagnosing MS is the McDonald Criteria. An international panel in association with the National MS Society of America developed the first set of criteria in April 2001. It was modified in 2005 and 2010. The primary goal of the 2010 Revised McDonald Criteria for MS is to enable the diagnosis of MS sooner and to permit earlier treatment of MS.

Diagnosis Requirements
MS diagnosis requires objective clinical evidence of two or more lesions or objective clinical evidence of one lesion with reasonable historical evidence of a prior attack. The criteria require dissemination in both space and time, meaning that patients have to have more than one part of the nervous system involved (dissemination in space) at more than one time (dissemination in time). Dissemination in time and space is the cornerstone of MS diagnosis. 

In VA, the vast majority of Veterans have already been diagnosed – often in the military or in the private sector. The basis for the diagnosis needs to be reviewed in light of the 2010 Revised McDonald Criteria AND documented view of imaging.

Diagnosing Veterans
Veterans presenting with symptoms of MS should be diagnosed using the 2010 Revised McDonald Criteria. A knowledgeable physician, usually a neurologist or another provider with experience working with MS makes the MS diagnosis. Diagnosis should not be made simply by an MRI scan of the brain or spinal cord. 

Basic Requirements for an MS Diagnosis
·   There is no single test for MS.
·   The goal is to diagnosis MS as soon as possible after an initial neurological attack and initiate therapy.
·   There is evidence of disease in different parts of the CNS at different times.
·   The diagnosis of MS can be based on the patient’s history and neurological examination.

Clinically Isolated Syndrome
Clinically Isolated Syndrome (CIS) is a term that describes a person’s single episode of neurological symptoms suggesting an inflammatory disease of the brain or spinal cord. The symptoms generally last from a few hours up to 24 hours and can include facial numbness or pain, limb weakness, and/or optic neuritis. CIS can be defined into the classes, Monofocal and Multifocal based upon the type and number of neurological symptoms.

Monofocal episode
A person experiences a single neurologic sign or symptom, for example, optic neuritis, that’s caused by a single lesion.

Multifocal episode
A person experiences more than one sign or symptom, for example, optic neuritis accompanied by weakness on one side, that’s caused by lesions in more than one place. People who experience a CIS may or may not go on to develop MS. In diagnosing CIS, the physician faces two challenges: first, to determine whether the person is experiencing a neurologic episode caused by damage in the CNS and second, to determine the likelihood that a person experiencing this type of demyelinating event is going to develop MS.

A person has a higher risk of developing MS when the CIS is accompanied by MRI-detected brain lesions that are similar to those seen in MS. Conversely, there is a lower risk for MS when the MRI does not show brain lesions.

An accurate diagnosis at this time is important because people with a high risk of developing MS are encouraged to begin treatment with a disease-modifying medication to delay or prevent a second neurologic episode and, therefore, the onset of MS. In addition, early treatment may minimize future disability caused by further inflammation and damage to nerve cells, which are sometimes silent (occurring even if no symptoms can be observed). Several medications are now approved by the FDA for CIS.

Links
National MS Society and the European Committee for the Treatment and Research in MS-2010 Revised McDonald Criteria Tip Sheet
McDonald Criteria

Polman, C. H., et al.. (2011), Diagnostic criteria for multiple sclerosis: 2010 Revisions to the McDonald criteria. Annals of Neurology, 69: 292–302. doi: 10.1002/ana.22366. http://onlinelibrary.wiley.com/doi/10.1002/ana.22366/abstract

Results of a study comparing the McDonald to the Poser Criteria.
http://www.neurology.org/cgi/content/abstract/60/1/27?etoc 

Diagnostic Criteria for MS: 2005 Revisions to the “McDonald” Criteria. Annals of Neurology (2005) 58:840-846.

Updated: July 2015