Use of MRI in neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease — MAGNIMS consensus recommendations

Aquaporin 4-positive neuromyelitis optica spectrum disorder (AQP4+ NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) are antibody-mediated inflammatory disorders of the CNS with distinct immunopathogenic, clinical and imaging profiles. MRI is fundamental for diagnosis, monitoring and treatment decisions in these disorders, yet challenges persist, including overlap of imaging features, variable lesion evolution and the absence of standardized acquisition protocols. In this Expert Recommendation on behalf of the Magnetic Resonance Imaging in Multiple Sclerosis (MAGNIMS) study group, we provide recommendations for the practical use of conventional and non-conventional MRI for diagnosis, monitoring and research in AQP4+ NMOSD and MOGAD. We consider characteristic conventional MRI findings, recommend standardized core and optional MRI sequences for standardized protocols, and offer guidance on the timing of MRI at different phases of disease. We highlight the role of MRI in assessing acute attacks, distinguishing between true relapses and pseudo-relapses, and evaluating post-attack recovery. We also outline the added value of non-conventional MRI techniques for probing microstructural damage, inflammatory activity and tissue repair. Finally, we address the diagnostic complexity of seronegative NMOSD and the need for novel imaging biomarkers to improve classification and treatment precision.