Last reviewed: January 2018
Last updated: February  2018

Important updates

2017 revisions to the McDonald diagnostic criteria for multiple sclerosis

The 2017 McDonald criteria include the following changes:

  • In patients with a typical clinically isolated syndrome and clinical or MRI demonstration of dissemination in space, the presence of CSF-specific oligoclonal bands allows a diagnosis of multiple sclerosis.

  • Symptomatic lesions can be used to demonstrate dissemination in space or time in patients with supratentorial, infratentorial, or spinal cord syndrome; cortical lesions can be used to demonstrate dissemination in space.

See Diagnosis: criteria

Original source of update

Fingolimod: UK MHRA introduces new contraindications for patients with cardiovascular disorders

Fingolimod can cause persistent bradycardia, which can increase the risk of serious cardiac arrhythmias.

Following an EU review that identified 44 reports of serious ventricular tachyarrhythmia and 6 reports of sudden death worldwide, the UK Medicines and Healthcare products Regulatory Agency (MHRA) has ruled that fingolimod is now contraindicated in patients with a history of cardiovascular disorders including (but not limited to):

  • Myocardial infarction or unstable angina

  • Transient ischaemic attack or stroke

  • Decompensated heart failure requiring inpatient treatment or NYHA class III/IV heart failure within the last 6 months.

See Management: approach

Original source of update



History and exam

Key diagnostic factors

  • visual disturbance in one eye
  • peculiar sensory phenomena

Other diagnostic factors

  • female
  • age 20 to 40 years
  • foot dragging or slapping
  • leg cramping
  • fatigue
  • urinary frequency
  • bowel dysfunction
  • spasticity/increased muscle tone
  • increased deep tendon reflexes
  • imbalance/incoordination
  • pale optic disc or non-correctable visual loss
  • incorrect responses to Ishihara colour blindness test plates
  • abnormal eye movements

Risk factors

  • genetic factors
  • female sex
  • northern latitude
  • smoking
  • vitamin D deficiency
  • autoimmune disease

Diagnostic investigations

1st investigations to order

  • MRI - brain
  • MRI - spinal cord
  • FBC
  • comprehensive metabolic panel
  • thyroid-stimulating hormone (TSH)
  • vitamin B12
Full details

Investigations to consider

  • anti-NMO antibody
  • CSF evaluation
  • evoked potentials
Full details

Treatment algorithm


Authors VIEW ALL

Staff Neurologist

Mellen Center for MS Treatment and Research

Neurological Institute

Cleveland Clinic Foundation




MAW has received payment for participating on the speakers' bureaus of Biogen and Genzyme. MAW also serves on the board of directors for the Multiple Sclerosis Association of America, and on the editorial board for the International Journal of MS Care.

Dr Mary Alissa Willis would like to gratefully acknowledge Dr Lael A. Stone, a previous contributor to this monograph. LAS declares that she has no competing interests.

Peer reviewers VIEW ALL

Project Leader for Neurology

Neurological Institute

Cleveland Clinic




ARG declares that he has no competing interests.

Associate Professor of Neurology

Department of Clinical Neurological Sciences

London Health Sciences Centre

University Hospital




SAM declares that she has no competing interests.


The London Multiple Sclerosis Clinic

Associate Professor

Schulich School of Medicine

University of Western Ontario


Clinical Neurological Sciences Department

University Hospital

London Health Sciences Centre




MK declares that he has no competing interests.

Consultant Neurologist

Department of Neurology

Queen’s Hospital




AC declares that he has no competing interests.

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