Version June 2024
| Red flags (clinical/laboratory) |
| 1. Clinical features and laboratory findings |
| Progressive overall clinical course (neurologic deterioration unrelated to attacks; consider MS) |
| Atypical time to attack nadir: Less than four hours (consider cord ischemia/infarction); continual worsening for more than four weeks from attack onset (consider sarcoidosis or neoplasm) |
| Partial transverse myelitis, especially when not associated with LETM MRI lesion (consider MS) |
| Presence of CSF oligoclonal bands (oligoclonal bands occur in <20% of cases of NMO versus >80% of MS) |
| 2. Comorbidities associated with neurologic syndromes that mimic NMOSD |
| Sarcoidosis, established or suggestive clinical, radiologic, or laboratory findings thereof (eg, mediastinal adenopathy, fever and night sweats, elevated serum angiotensin converting enzyme or interleukin-2 receptor levels) |
| Cancer, established or with suggestive clinical, radiologic, or laboratory findings thereof; consider lymphoma or paraneoplastic disease (eg, collapsin response mediator protein-5 associated optic neuropathy and myelopathy or anti-Ma-associated diencephalic syndrome) |
| Chronic infection, established or with suggestive clinical, radiologic, or laboratory findings thereof (eg, HIV, syphilis) |
| Red flags (conventional neuroimaging) |
| 1. Brain |
| a. Imaging features (T2-weighted MRI) suggestive of MS (MS-typical) |
| Lesions with orientation perpendicular to a lateral ventricular surface (Dawson fingers) |
| Lesions adjacent to lateral ventricle in the inferior temporal lobe |
| Juxtacortical lesions involving subcortical U-fibers |
| Cortical lesions |
| b. Imaging characteristics suggestive of diseases other than MS and NMOSD |
| Lesions with persistent (>3 months) gadolinium enhancement |
| 2. Spinal cord |
| Characteristics more suggestive of MS than NMOSD |
| Lesions <3 complete vertebral segments on sagittal T2-weighted sequences |
| Lesions located predominantly (>70%) in the peripheral cord on axial T2-weighted sequences |
| Diffuse, indistinct signal change on T2-weighted sequences (as sometimes seen with longstanding or progressive MS) |
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