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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses reasons for and against lumbar puncture in the diagnosis of multiple sclerosis, as well as reasons for an against using MRI for therapeutic decisions.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EPrevention \u0026amp; Screening\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ENeuroimaging\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EDemyelinating Diseases\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMagnetic Resonance Imaging\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EIs There Still a Role for Cerebrospinal Fluid Analysis in MS Diagnosis? To Tap or Not to Tap?\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EKarl Vass, MD, University of Vienna, Vienna, Austria, discussed reasons why lumbar puncture still has a role to play in the diagnosis of multiple sclerosis (MS).\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EAccording to Prof. Vass, cerebrospinal fluid (CSF) analysis adds value in several ways, including predicting the progression of clinically isolated syndrome (CIS) to MS, differential diagnosis, and research. It is extremely helpful in patients with an atypical clinical presentation, age of onset, or magnetic resonance imaging (MRI) [Awad A et al. \u003Cem\u003EJ Neuroimmunol\u003C\/em\u003E 2010].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EDiagnostic CSF findings in MS patients include qualitative IgG oligoclonal banding (OCB) and the quantitative IgG index [Mayringer I et al. \u003Cem\u003EEur J Neurol\u003C\/em\u003E 2005]. Other biomarkers include intrathecal immunoglobulin (Ig) synthesis [Awad A et al. \u003Cem\u003EJ Neuroimmunol\u003C\/em\u003E 2010] and elevated kappa free light chains (KFLCs) [Presslauer S et al. \u003Cem\u003EJ Neurol\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003ERecent data show that the presence of OCBs has a higher accuracy than the dissemination in space on MRI in predicting the progression to clinically definite MS (CDMS) in CIS patients (70% vs 58%) [Zipoli V et al. \u003Cem\u003EMult Scler\u003C\/em\u003E 2009]. According to Prof. Vass, CSF analysis may help predict the development of CDMS when MRI changes are not present.\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EIncreased IgG index or the presence of oligoclonal bands in the CSF support an MS diagnosis and aquaporin-4 antibody assays can help in the differential diagnosis process, but CSF analysis is especially important in ruling out infectious and inflammatory mimics (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E) [Herndon RM. \u003Cem\u003EAdv Neurol\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13973\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13973\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13973\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-7\u0022 class=\u0022first-child\u0022\u003EDifferential Diagnosis of MS.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EIn the absence of robust clinical and paraclinical variables to predict disease course in the individual MS patient, CSF biomarkers are a promising source of information with a good potential of quantitative measure, sensitivity, and reliability [Gajofatto A et al. \u003Cem\u003EInt J Mol Sci\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003ECurrently, numerous CSF biomarkers are under investigation, including anti-myelin antibodies, sVCAM-1,24S-hydroxycholesterol [Awad A et al. \u003Cem\u003EJ Immunol\u003C\/em\u003E 2010], glial fibrillary acidic protein [Axelsson M et al. J \u003Cem\u003ENeurol\u003C\/em\u003E 2011], osteopontin (OPN) and interleukin-23 (IL-23) [Wen SR et al. \u003Cem\u003EJ Immunol\u003C\/em\u003E 2012], and proteomic biomarkers [Ottervald J et al. \u003Cem\u003EJ Proteomics\u003C\/em\u003E 2010] (\u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13974\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13974\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13974\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-11\u0022 class=\u0022first-child\u0022\u003ENew potential CSF markers in MS.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cdiv id=\u0022sec-2\u0022 class=\u0022subsection\u0022\u003E\n            \u003Ch3\u003EThe Case Against Spinal Taps\u003C\/h3\u003E\n            \u003Cp id=\u0022p-12\u0022\u003EJoab Chapman, MD, PhD, Tel Aviv University, Tel Aviv, Israel, discussed reasons for not performing spinal taps. Among other subjects, he discussed zone electrophoresis and isofunctioning, differential diagnosis of white matter lesions on MRI, and the autoimmune encephalomyelitis-driven hypothesis.\u003C\/p\u003E\n            \u003Cp id=\u0022p-13\u0022\u003EThe latest revision of the McDonald Criteria [Polman CH et al. \u003Cem\u003EAnn Neurol\u003C\/em\u003E 2011] does not require CSF analyses to make a diagnosis of MS. This has led to earlier diagnosis with a high degree of specificity and sensitivity [Tintore M et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2003], enabling better counseling and earlier treatment.\u003C\/p\u003E\n            \u003Cp id=\u0022p-14\u0022\u003ENon-invasive imaging methods have become essential for assessing the effects of damage or disease processes [Stroman PW et al. \u003Cem\u003EClin Neurol Neurosurg\u003C\/em\u003E 2012]. MS is being studied extensively with functional MRI, in both the brain and spinal cord [Filippi M, Rocca MA. \u003Cem\u003ENeuroimaging Clin N Am\u003C\/em\u003E 2009].\u003C\/p\u003E\n            \u003Cp id=\u0022p-15\u0022\u003EMRI may be the most widely used method for detecting pathology in the central nervous system because of its high tissue contrast and relatively high spacial resolution. It also offers several different methods for visualizing tissues and pathology. In addition to detailed anatomical imaging, it allows for angiography as well as diffusion-weighted and functional imaging [Stroman PW et al. \u003Cem\u003EClin Neurol Neurosurg\u003C\/em\u003E 2012].\u003C\/p\u003E\n            \u003Cp id=\u0022p-16\u0022\u003EMRI techniques may also be useful in the prediction of outcome. Structural techniques, such as diffusion tensor imaging, have been used to associate the structural integrity of white matter tracts with prediction of outcome. Diffusion tensor imaging has also been used to predict recovery following relapse in MS [Freund P et al. \u003Cem\u003EMult Scler\u003C\/em\u003E 2010].\u003C\/p\u003E\n            \u003Cp id=\u0022p-17\u0022\u003EAdvanced MRI techniques image gray matter (GM) lesions \u003Cem\u003Ein vivo\u003C\/em\u003E and quantify structural and functional damage of the cortical and subcortical GM [Pirko I et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2007]. Evidence indicates that high and ultra-high field MRI may be useful in imaging nuclei, such as \u003Csup\u003E31\u003C\/sup\u003EP, and metabolites, such as glutamate [Srinivasan R et al. \u003Cem\u003EMagn Reson Imaging\u003C\/em\u003E 2009]. This suggests the potential to elucidate the pathological mechanisms of neurodegeneration and disease progression.\u003C\/p\u003E\n            \u003Cp id=\u0022p-18\u0022\u003EHigh and ultra-high field strength magnets and sophisticated coil technology hold great promise for the development and implementation of techniques with greater sensitivity and specificity to the pathological mechanisms underlying disease processes [Inglese M et al. \u003Cem\u003EMt Sinai J Med\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EUsing MRI for Therapeutic Decisions\u003C\/h2\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EUlf Baumhackl, MD, Department of Neurology, Landesklinikum, Poelten, Austria, discussed the use of MRI for early diagnosis, prognosis, and treatment monitoring of MS (the first 5 years).\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EAccording to the European Federation of Neurological Society guidelines, conventional MRI is the most important paraclinical tool available to diagnose MS and establish prognosis at the onset of the disease. Rational decision-making can be facilitated through \u201csurveillance MRI,\u201d tracking treatment response status, and monitoring disease-modifying therapies.\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EFifty to 80% of CIS patients have lesions consistent with prior disease activity. The number and extent of T2 brain lesions, and the presence of infratentorial [Minneboo A et al. \u003Cem\u003EArch Neurol\u003C\/em\u003E 2004] and gadolinium-enhanced (Gd+) lesions have the strongest predictive value.\u003C\/p\u003E\n         \u003Cp id=\u0022p-22\u0022\u003ESpecifically, three or more T2-hyperintense lesions and two or more Gd+ lesions at baseline predict the progression to CDMS within 7 to 10 years [Frohman EM et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2003]. Near-term development of MS can be predicted based on the appearance of Gd+ (3 months) or new T2\/Gd+ lesions 6 months after confirmation of CIS (baseline) [Frohman EM et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2003].\u003C\/p\u003E\n         \u003Cp id=\u0022p-23\u0022\u003EIn the review and recommendations for current practice, L\u00f6vblad et al. [\u003Cem\u003EAm J Neuroradiol\u003C\/em\u003E 2010] note that MRI in combination with characteristic symptoms provides earlier and more confident diagnosis than symptoms alone; and that the use of contrast agents can identify response to treatment in individual patients, not only predicting their disease course in the short-term, but also their disability and progression in the long-term. The technology can also detect strategic lesions that may influence treatment decisions, and new lesions that may indicate a need for a change in treatment.\u003C\/p\u003E\n         \u003Cp id=\u0022p-24\u0022\u003EIn established MS, disease activity is detected 5 to 10 times more frequently with MRI than with clinical assessment of relapses [Miller JC, Thrall JH. \u003Cem\u003EJ Am Coll Radiol.\u003C\/em\u003E 2004]. MRI provides objective and sensitive measures of activity, and is an established tool for monitoring response to treatment [Filippi M et al. \u003Cem\u003EEur J Neurol\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cp id=\u0022p-25\u0022\u003EProf. Baumhackl pointed out that MRI may facilitate rational therapeutic decisions in multiple ways, including reliable detection and description of older and newer lesions that represent subclinical disease activity. Sailer et al. [\u003Cem\u003ERofo\u003C\/em\u003E 2008] noted that such reports can be substituted for the clinical confirmation of a relapse\u003C\/p\u003E\n         \u003Cp id=\u0022p-26\u0022\u003ET2 brain lesions have a moderate correlation to disability, with the greatest predictive value early in the disease, and a higher rate of lesion growth in those who develop secondary progression MS [Fisniku LK et al. \u003Cem\u003EBrain\u003C\/em\u003E 2008]. MRI activity outcomes can be recommended as the primary measure of treatment efficacy [Freedman MS et al. \u003Cem\u003EAdv in Neurol\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cdiv id=\u0022sec-4\u0022 class=\u0022subsection\u0022\u003E\n            \u003Ch3\u003EConsider Other Factors\u003C\/h3\u003E\n            \u003Cp id=\u0022p-27\u0022\u003EFlorian Deisenhammer, MD, Innsbruck Medical University, Innsbruck, Austria, presented reasons why MRI should not be used for therapeutic decision-making. To make this point, he relied on MRIs from landmark trials (BENEFIT [Kappos L et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2006]; ETOMS [Fillipi M et al. \u003Cem\u003ELancet\u003C\/em\u003E 2004]; and CHAMPS [Kappos L et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2006])\u2014all double-blind, placebo-controlled, randomized, multicenter trials.\u003C\/p\u003E\n            \u003Cp id=\u0022p-28\u0022\u003EIn the BENEFIT trial, researchers examined the effect of treatment on the rate of conversion to CDMS as defined in the Poser criteria [Poser CM et al. \u003Cem\u003EAnn Neurol\u003C\/em\u003E 1983]. They also explored therapeutic effects on the rate of conversion according to a diagnosis of MS as defined by the McDonald Criteria. [McDonald WI et al. \u003Cem\u003EAnn Neurol\u003C\/em\u003E 2001]. These criteria systematically incorporate paraclinical findings, in particular MRI, to increase sensitivity without compromising specificity [Polman CH et al. \u003Cem\u003EAnn Neurol\u003C\/em\u003E 2005; Dalton CM et al. \u003Cem\u003EAnn Neurol\u003C\/em\u003E 2002; Tontore M et al. \u003Cem\u003ENeurology\u003C\/em\u003E 2003]. In the post-hoc analyses of MRI data reading predictability of the therapeutic response according to MRI activity, no common pattern was found. In some studies, patients with high MRI activity responded better while in other studies, the opposite was true (patients with low MRI activity responded better to the treatment). To date, no prospective investigation has looked at the value of MRI for treatment decisions. There is simply not enough good quality data to rely solely on MRI to decide whether individual patients should be put on a particular treatment or should have their treatment changed.\u003C\/p\u003E\n            \u003Cp id=\u0022p-29\u0022\u003EProf. Deisenhammer discussed further reasons why clinicians should not rely on MRIs by describing a recent neuroloy workshop. Participants, who routinely read scans were simultaneously provided with a series of cases from clinical studies, such as BENEFIT, and study-grade MRIs\u2014highly sophisticated imaging with perfect resolution. The goal of the exercise was for neurologists to judge changes in T2 lesions and to indicate how many they thought they saw.\u003C\/p\u003E\n            \u003Cp id=\u0022p-30\u0022\u003E\u201cThis was a very humbling experience for them,\u201d he explained. \u201cThe number of lesions identified ranged from none to 30 or 40 new ones. In one instance, there was only one lesion, but the average neurologist saw six. In another case, there were at lest 20 lesions, and the average neurologist saw only two.\u201d\u003C\/p\u003E\n            \u003Cp id=\u0022p-31\u0022\u003EThe technology is accurate, but our eyes may be not be, he said, noting the high volume of scans read by radiologists and the small amount of time spent on each one. Under those circumstances, the opportunity for errors in interpretations over time, especially in routine scanning, is great.\u003C\/p\u003E\n            \u003Cp id=\u0022p-32\u0022\u003EClinicians who make judgments based on the presence of new T2 lesions, need to be very sure that they are actually seeing T2 lesions; this is especially true for small ones.\u003C\/p\u003E\n            \u003Cdiv id=\u0022T3\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13975\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13975\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13975\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 3.\u003C\/span\u003E \n                  \u003Cp id=\u0022p-33\u0022 class=\u0022first-child\u0022\u003E2010 McDonald Criteria for Diagnosis of MS in Disease with Progression from Onset.\u003C\/p\u003E\n               \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003C\/div\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2012 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/12\/2\/4.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nznhr1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nznhr1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}