Imaging Parameters Help Distinguish Multiple Sclerosis From NMOSD and MOGAD

Central vein sign lesions, cortical lesions, and optic nerve markers can help distinguish NMOSD from MS with an accuracy of 95%, a specificity of 92%, and sensitivity of 97%.

Relapsing-remitting multiple sclerosis (RRMS) could be distinguished from aquaporin4 antibody-positive neuromyelitis optica spectrum disorder (AQP4-NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) using optic nerve markers, cortical lesions, and the central vein sign (CVS). These are the findings of a prospective study published in Neurology.

Clinical and imaging parameters overlap between MS and NMOSDs. There are highly specific serological tests available that can help distinguish between disorders, however, these tests are not widely available and may return false negative results.

To determine whether other clinical parameters can aid in patient stratification, patients meeting the clinical criteria for RRMS (n=31), AQP4-NMOSD (n=30), and MOGAD (n=30) were recruited at 2 sites in the United Kingdom between 2014 and 2019. Participants underwent optical coherence tomography (OCT) and magnetic resonance imaging (MRI), and features were compared between groups.

The RRMS, AQP4-NMOSD, and MOGAD groups were mean age, 45.7, 49.4, and 36.9 years and the men-to-women ratios were 12:19, 6:24, and 10:20, respectively.

Comparing RRMS with AQP4-NMOSD, in the brain, 9 of the 11 measured features differed (all P £.014), in the cervical cord, none of the 6 measured features differed, and in the optic nerve, 3 of the 6 features differed (all P £.007) between groups. For the RRMS and MOGAD comparison, 6 of the 11 brain features differed (all P £.007), 1 of the 6 cervical cord features differed (P <.001), and 4 of the 6 optic nerve features differed (all P £.009).

Future studies may investigate the added value of these imaging markers for MS diagnosis, considering also clinical and demographic variables.

In the comparison between AQP4-NMOSD and MOGAD, only 1 brain and 1 cervical cord feature (both P £.001) differed between cohorts.

The best distinguishing characteristics between RRMS and AQP4-NMOSD were as follows:

  • Proportion of lesions with CVS (odds ratio [OR], 1.09; area under the curve [AUC], 0.93; best cutoff, 54%)
  • Number of cortical lesions (OR, 32.52; AUC, 0.91; best cutoff, 1)
  • Number of white matter lesions (OR, 1.07; AUC, 0.85; best cutoff, 11)
  • Deep grey matter fraction (OR, 0.48; AUC, 0.80; best cutoff, 0.022)
  • Brain parenchymal fraction (OR, 0.48; AUC, 0.76; best cutoff, 0.726)
  • Magnetization transfer ratio of the whole optic nerve (OR, 1.32; AUC, 0.73; best cutoff, 31,74 au)

The best distinguishing characteristics between RRMS and MOGAD were as follows:

  • The number of white matter lesions (OR, 1.89; AUC, 0.99; best cutoff, 5)
  • Number of cortical lesions (OR, 24.68; AUC, 0.87; best cutoff, 1)
  • Retinal nerve fiber layer thickness (OR, 1.06; AUC, 0.83; best cutoff, 88 mm)
  • Deep grey matter fraction (OR, 0.24; AUC, 0.89; best cutoff, 0.022)
  • Presence of at least one cervical cord lesion (OR, 80.01; AUC, 0.86; best cutoff, 1)

This study may have been limited by the lack of scans at disease onset.

“Future studies may investigate the added value of these imaging markers for MS diagnosis, considering also clinical and demographic variables,” the researchers concluded.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Cortese R, Carrasco FP, Tur C, et al. Differentiating multiple sclerosis from AQP4-neuromyelitis optica spectrum disorder and MOG-antibody disease with imaging. Neurology. 2022;10.1212/WNL.0000000000201465. doi:10.1212/WNL.0000000000201465