# Characteristics of MRI lesions in AQP4 antibody-positive NMOSD, MOGAD, and multiple sclerosis: a systematic review and meta-analysis

## TL;DR

This study compares MRI lesion patterns in three demyelinating diseases to help distinguish them using imaging features.

## Contribution

The study provides a systematic review and meta-analysis of MRI lesion characteristics specific to MS, NMOSD, and MOGAD.

## Key findings

- MRI features like periventricular T2 lesions are more common in MS.
- Optic chiasm T2 lesions are more specific to AQP4-Ab + ve NMOSD.
- Fluffy and perineural enhancement lesions are associated with MOGAD.

## Abstract

Multiple sclerosis (MS), aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder (AQP4-Ab + ve NMOSD), and myelin oligodendrocyte glycoprotein-associated disease (MOGAD) are demyelinating diseases with differing pathophysiological processes and treatments. The objective of this study was to compile a comprehensive list of MRI lesions, and to quantify the utility of these lesions in distinguishing between these conditions.

We searched for articles comparing MRI lesion frequency in MS, AQP4-Ab + ve NMOSD, MOGAD and healthy controls. Bayesian network meta-analysis together with pairwise and pooled case-case comparison analyses to develop sensitivity, specificity, and positive predictive values were undertaken.

Sixty-six articles were reported on 2933 MS, 3296 AQP4-Ab + ve NMOSD, and 1559 MOGAD cases, and 561 healthy controls. MRI lesions associated with MS were: periventricular T2, subcortical white matter T2, Dawson's finger, U-fibre T2 lesion, posterior spinal column T2, inferior temporal T2, cortical T2, brain T1 hypointensity (black holes), peripheral spinal cord T2, pons T2, unilateral optic nerve T2 and brain gadolinium enhancing lesions. Optic chiasm T2, LETM, bright spotty spinal cord T2, area postrema T2, hypothalamic T2, spinal cord atrophy and optic tract T2 lesions were associated with AQP4-Ab + ve NMOSD. Conus medullaris T2, fluffy, perineural enhancement, peri-ependymal 3rd ventricle T2 and peri-ependymal 4th ventricle T2 lesions were associated with MOGAD.

This review identified MRI features supportive of a diagnosis of MS, NMOSD or MOGAD, and has clarified the diagnostic utility of various MRI lesion characteristics, to aid in future clinical decision-making and guide future approaches to research.

The online version contains supplementary material available at 10.1007/s00415-025-13303-w.