imaging criteria for DIS and DIT,24 the Panel believes that even further liberalizing MRI requirements in CSF- positive patients is not appropriate, as CSF status was not evaluated for its contribution to the MAGNIMS criteria for DIS and DIT.22,24 Prospective studies using widely available standardized techniques and the most sensitive methods of detection of oligoclonal bands in the CSF to- gether with the new imaging requirements are needed to confirm the additional diagnostic value of CSF.32,33 MAKING A DIAGNOSIS OF PRIMARY PROGRESSIVE MULTIPLE SCLEROSIS. In 2005, the Panel recom- mended revising the McDonald Criteria for diagnosis of primary progressive multiple sclerosis (PPMS) to require, in addition to 1 year of disease progression, 2 of the fol- lowing 3 findings: positive brain MRI (9 T2 lesions or 4 or more T2 lesions with positive VEP); positive spinal cord MRI (2 focal T2 lesions); or positive CSF. These criteria reflected the special role of both CSF examina- tion and spinal cord MRI in PPMS, have been found to be practical and are generally well accepted by the neuro- logical community,34 and have been used as inclusion cri- teria for PPMS clinical trials.35 To harmonize MRI criteria within the diagnostic criteria for all forms of MS, while recognizing the special diagnostic needs for PPMS, the Panel recommends that the McDonald Criteria require- ment of fulfilling 2 of 3 MRI or CSF findings be main- tained for PPMS, with replacement of the previous brain imaging criterion with the new MAGNIMS brain imaging criterion for DIS (2 of 3 of the following: 1 T2 lesions in at least 1 area characteristic for MS [periventricular, jux- tacortical, or infratentorial]; 2 T2 lesions in the cord; or positive CSF [isoelectric focusing evidence of oligoclonal bands and/or elevated IgG index]) (Table 3). This consen- sus-based recommendation is justified by comparing diag- nostic criteria for PPMS36 and by a subsequent reanalysis of these data (X. Montalban, personal communication). Use of MAGNIMS-based imaging criteria for PPMS with or without associated CSF evaluation should be supported by additional data further documenting the sensitivity and specificity of the criteria in this population. APPLICABILITY OF THE MCDONALD CRITERIA IN PEDIATRIC, ASIAN, AND LATIN AMERICAN POPULA- TIONS. The McDonald Criteria were developed with data gathered largely from adult Caucasian European and North American populations, and their applicability has been questioned for other populations, particularly pedi- atric cases,37,38 Asians,39,40 and Latin Americans.41 Pediatric MS Over 95% of pediatric MS patients have an initial relaps- ing–remitting disease course, whereas PPMS is excep- February 2011 Polman et al: 2010 Revisions to MS Diagnosis TABLE 3: 2010 McDonald Criteria for Diagnosis of MS in Disease with Progression from Onset PPMS May Be Diagnosed in Subjects With: 1. One year of disease progression (retrospectively or prospectively determined) 2. Plus 2 of the 3 following criteriaa: 1 T2b A. Evidence for DIS in the brain based on lesions in at least 1 area characteristic for MS (periventricular, juxtacortical, or infratentorial) B. Evidence for DIS in the spinal cord based on 2 T2b lesions in the cord C. Positive CSF (isoelectric focusing evidence of oligoclonal bands and/or elevated IgG index) aIf a subject has a brainstem or spinal cord syndrome, all symptomatic lesions are excluded from the Criteria. bGadolinium enhancement of lesions is not required. MS ¼ multiple sclerosis; PPMS ¼ primary progressive MS; DIS ¼ lesion dissemination in space; CSF ¼ cerebrospinal fluid; IgG ¼ immunoglobulin G. tional in children and should prompt detailed considera- tion of alternative diagnoses.42–45 About 80% of pediatric cases, and nearly all adolescent onset cases, present with attacks typical for adult CIS, with a similar or greater total T2 lesion burden.46–48 In children younger than 11 years, lesions are larger and more ill-defined than in teenagers.49 Imaging criteria for demonstrating DIS in pediatric MS show high sensitivity and/or specificity.38,50,51 The Panel’s consensus was that the proposed MAG- NIMS-based MRI revisions for DIS will also serve well for most pediatric MS patients, especially those with acute demyelination presenting as CIS, because most pediatric patients will have >2 lesions and are very likely to have lesions in 2 of the 4 specified CNS locations (periventricu- lar, brainstem-infratentorial, juxtacortical, or spinal cord). The frequency of spinal cord lesions in pediatric MS patients is currently unreported, but the appearance of cord lesions in pediatric MS patients with spinal cord symptoms appears generally similar to that of adults.52 However, approximately 15 to 20% of pediatric MS patients, most aged <11 years, present with ence- phalopathy and multifocal neurological deficits difficult to distinguish from acute disseminated encephalomyelitis (ADEM).43,50 Current operational international consen- sus criteria for MS diagnosis in children with an ADEM- like first attack require confirmation by 2 or more non- ADEM like attacks, or 1 non-ADEM attack followed by accrual of clinically silent lesions.53 Although children with an ADEM-like first MS attack are more likely than children with monophasic ADEM to have 1 or more non-enhancing T1 hypointense lesions, 2 or more 295