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Comment & Response
March 4, 2019

Time Is Brain and Spine

Author Affiliations
  • 1Department of Neurology, Medical College of Wisconsin, Milwaukee
JAMA Neurol. 2019;76(5):623. doi:10.1001/jamaneurol.2019.0146

To the Editor I read with interest the article by van der Vuurst de Vries et al.1 The authors concluded that the clinical application of the revised 2017 McDonald criteria2 would result in the diagnosis of multiple sclerosis (MS) in more patients with a projected less active disease over 5 years.1 I would like to highlight that the natural history of MS has evolved into a disease with overall lesser morbidity and disability.3 The favorable outcomes are partially due to earlier diagnosis and treatment.3 The recent revisions of the McDonald criteria aimed to provide the clinician with the ability to diagnose MS at an earlier stage, allowing for prompt commencement of the disease-modifying therapy. van der Vuurst de Vries and colleagues1 confirmed the substantial increase in sensitivity when applying the 2017 criteria. However, they were critical of the observed decrease in the specificity for MS diagnosis compared with the 2010 McDonald criteria at a mean follow-up of 5 years. As noted in their article’s Limitations section, a duration of 5 years might not be sufficient, especially considering that the 2017 revisions allowed for earlier diagnosis. Longer follow-up periods are necessary to provide accurate conclusions about the specificity of the revised criteria. The figure of survival curves provided by the authors highlighted an expected trend.1 The longer the duration of follow-up was, the stronger was the agreement between the 2017 criteria, 2010 criteria, and clinically definite MS. This observation calls for studies with longer durations to generate a more relevant specificity data of the revised 2017 criteria. The new criteria are still in their infancy and they need to be validated for longer follow-up periods and in diverse patient populations. Finally, earlier diagnosis and treatment of MS matters, as time is brain and spine.