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Solomon AJ, Arrambide G, Brownlee WJ, Flanagan EP, Amato MP, Amezcua L, Banwell BL, Barkhof F, Corboy JR, Correale J, Fujihara K, Graves J, Harnegie MP, Hemmer B, Lechner-Scott J, Marrie RA, Newsome SD, Rocca MA, Royal W, Waubant EL, Yamout B, Cohen JA. Differential diagnosis of suspected multiple sclerosis: an updated consensus approach. Lancet Neurol 2023; 22:750-768. [PMID: 37479377 DOI: 10.1016/s1474-4422(23)00148-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/14/2023] [Accepted: 03/31/2023] [Indexed: 07/23/2023]
Abstract
Accurate diagnosis of multiple sclerosis requires careful attention to its differential diagnosis-many disorders can mimic the clinical manifestations and paraclinical findings of this disease. A collaborative effort, organised by The International Advisory Committee on Clinical Trials in Multiple Sclerosis in 2008, provided diagnostic approaches to multiple sclerosis and identified clinical and paraclinical findings (so-called red flags) suggestive of alternative diagnoses. Since then, knowledge of disorders in the differential diagnosis of multiple sclerosis has expanded substantially. For example, CNS inflammatory disorders that present with syndromes overlapping with multiple sclerosis can increasingly be distinguished from multiple sclerosis with the aid of specific clinical, MRI, and laboratory findings; studies of people misdiagnosed with multiple sclerosis have also provided insights into clinical presentations for which extra caution is warranted. Considering these data, an update to the recommended diagnostic approaches to common clinical presentations and key clinical and paraclinical red flags is warranted to inform the contemporary clinical evaluation of patients with suspected multiple sclerosis.
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Affiliation(s)
- Andrew J Solomon
- Department of Neurological Sciences, Larner College of Medicine at the University of Vermont, University Health Center, Burlington, VT, USA.
| | - Georgina Arrambide
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Wallace J Brownlee
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Eoin P Flanagan
- Departments of Neurology and Laboratory Medicine and Pathology and the Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Lilyana Amezcua
- Department of Neurology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Brenda L Banwell
- Department of Neurology, University of Pennsylvania, Division of Child Neurology, Philadelphia, PA, USA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing, University College London, London, UK
| | - John R Corboy
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jorge Correale
- Department of Neurology, Fleni Institute of Biological Chemistry and Physical Chemistry (IQUIFIB), Buenos Aires, Argentina; National Council for Scientific and Technical Research/University of Buenos Aires, Buenos Aires, Argentina
| | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University School of Medicine, Koriyama, Japan; Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Koriyama, Japan
| | - Jennifer Graves
- Department of Neurosciences, University of California, San Diego, CA, USA
| | | | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, Medical Faculty, Technische Universität München, Munich, Germany; Munich Cluster for Systems Neurology, Munich, Germany
| | - Jeannette Lechner-Scott
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia; Hunter Medical Research Institute Neurology, University of Newcastle, Newcastle, NSW, Australia
| | - Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Scott D Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Walter Royal
- Department of Neurobiology and Neuroscience Institute, Morehouse School of Medicine, Atlanta, GA, USA
| | - Emmanuelle L Waubant
- Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, CA, USA
| | - Bassem Yamout
- Neurology Institute, Harley Street Medical Center, Abu Dhabi, United Arab Emirates
| | - Jeffrey A Cohen
- Mellen Center for MS Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Solomon AJ, Arrambide G, Brownlee W, Cross AH, Gaitan MI, Lublin FD, Makhani N, Mowry EM, Reich DS, Rovira À, Weinshenker BG, Cohen JA. Confirming a Historical Diagnosis of Multiple Sclerosis: Challenges and Recommendations. Neurol Clin Pract 2022; 12:263-269. [PMID: 35747540 PMCID: PMC9208427 DOI: 10.1212/cpj.0000000000001149] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/14/2021] [Indexed: 11/15/2022]
Abstract
Patients with a historical diagnosis of multiple sclerosis (MS)-a patient presenting with a diagnosis of MS made previously and by a different clinician-present specific diagnostic and therapeutic challenges in clinical practice. Application of the McDonald criteria is most straightforward when applied contemporaneously with a syndrome typical of an MS attack or relapse; however, retrospective application of the criteria in some patients with a historical diagnosis of MS can be problematic. Limited patient recollection of symptoms and evolution of neurologic examination and MRI findings complicate confirmation of an earlier MS diagnosis and assessment of subsequent disease activity or clinical progression. Adequate records for review of prior clinical examinations, laboratory results, and/or MRI scans obtained at the time of diagnosis or during ensuing care may be inadequate or unavailable. This article provides recommendations for a clinical approach to the evaluation of patients with a historical diagnosis of MS to aid diagnostic confirmation, avoid misdiagnosis, and inform therapeutic decision making.
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Affiliation(s)
- Andrew J Solomon
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Georgina Arrambide
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Wallace Brownlee
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Anne H Cross
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - María I Gaitan
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Fred D Lublin
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Naila Makhani
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Ellen M Mowry
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Daniel S Reich
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Àlex Rovira
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Brian G Weinshenker
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Jeffrey A Cohen
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
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