Certain symptoms and abnormal findings in imaging studies may be useful to differentiate the first attack of neuromyelitis optica spectrum disorder (NMOSD) from multiple sclerosis (MS), according to a study recently published in Frontiers in Neurology.

The authors registered demographic, clinical manifestations, Expanded Disability Status Scale (EDSS) scores, and head magnetic resonance imaging (MRI) findings of a total of 52 patients diagnosed with NMOSD and 58 with MS. 

Clinical manifestations such as pyramidal symptoms, vomiting, and central hiccups appeared more frequently in patients with NMOSD, while alterations in eye movement were less common when compared to the MS group.

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MRI lesions located in the medulla oblongata with central distribution and larger size were greatly associated with NMOSD, whereas patchy, peripheral lesions located mostly in the pons and midbrain were less common in this group. Plasma anti-aquaporin-4 antibody was only detected in patients with NMOSD.

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Overall, the group with NMOSD had greater age at the time of the first attack, more females, and more patients with a history of autoimmune diseases than the group with MS.

No differences were observed regarding EDSS scores and other symptoms such as vertigo, diplopia, limb weakness, numbness, and difficulty eating, as shown by this retrospective study conducted by Ji et al.

“Ultimately, these features may offer the means to create an algorithm that clinicians can follow in order to diagnose MS and NMOSD patients who present with brainstem lesions as the first manifestation, ultimately expediting initiation of treatment to improve overall prognosis,” the authors explained.

Although completely different entities, distinguishing them from one another could sometimes be challenging. Regardless, producing the correct diagnosis is of utmost importance since it dictates the therapeutic approach, which very much differs among these diseases. Some drugs effective for MS could even worsen the clinical status of patients with NMOSD.

“The present study sought to clarify diagnostic decision-making by characterizing the clinical manifestations and imaging features in patients who initially present with symptoms of brainstem involvement,” the authors concluded.


Ji Q, Dong H, Lee H, et al. Clinical characteristics and outcomes of multiple sclerosis and neuromyelitis optica spectrum disorder with brainstem lesions as heralding prodrome. Front Neurol. Published online May 9, 2022. doi:10.3389/fneur.2022.836337