---
title: "Spinal MRI Signs for AQP4-IgG–Positive NMOSD Myelitis: Diagnostic Performance of Established and N"
id: "pubmed-42766829"
canonical_url: "https://medichelpline.com/clinical-feed/pubmed-42766829"
content_type: "clinical_feed_article"
specialty: "Neurology"
source_name: "PubMed / NCBI"
source_url: "https://pubmed.ncbi.nlm.nih.gov/42766829/"
doi: "10.1212/WNL.0000000000218507"
published_at: "2026-09-22T00:29:15.000Z"
evidence_level: "Journal Article"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Spinal MRI Signs for AQP4-IgG–Positive NMOSD Myelitis: Diagnostic Performance of Established and N
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/pubmed-42766829
- **Specialty:** [Neurology](https://medichelpline.com/clinical-feed/neurology.md)
- **Primary Source:** PubMed / NCBI
- **Source URL:** [Original Journal Publication](https://pubmed.ncbi.nlm.nih.gov/42766829/)
- **DOI:** [10.1212/WNL.0000000000218507](https://doi.org/10.1212%2FWNL.0000000000218507)
- **Published At:** 2026-09-22T00:29:15.000Z
- **Evidence Rating:** Journal Article
## Executive GIST (TL;DR)
- This retrospective study evaluated spinal MRI features in adults with **AQP4-IgG–seropositive NMOSD** myelitis to determine the diagnostic utility of established and novel MRI signs. - The cohort included 217 patients with AQP4-IgG+ NMOSD (median age 44.5 years, 95.9% women); 170 (78.3%) had myelitis and 331 NMOSD spinal MRI scans were reviewed across acute, subacute, and remission stages. - Key acute MRI signs assessed were **longitudinally extensive transverse myelitis (LETM)**, bright spotty lesions (BSLs), a novel **double-contoured LETM** sign, the H sign, and sagittal ring enhancement. - In first-ever myelitis (53 scans), LETM was present in 88.7%. Sensitivities for BSLs, double-contoured LETM, and sagittal ring enhancement were 64.0%, 47.2%, and 60.0%, respectively; specificities were high (98.6%, 98.6%, and 96.4%). - Combining these MRI signs increased specificity further but reduced sensitivity to ~30%, limiting sensitivity for screening but improving rule-in value. - When including recurrent and first-ever acute myelitis together (161 scans), prevalences of BSLs, double-contoured LETM, and sagittal ring enhancement dropped to 56.5%, 19.9%, and 44.1%, respectively. - During remission (129 scans), only 12.4% showed complete radiologic resolution whereas spinal cord atrophy occurred in 56.6%. - The double-contoured LETM sign is described as a novel feature particularly observed in first-ever acute myelitis and, along with BSLs and sagittal ring enhancement, shows high specificity for NMOSD versus other causes of longitudinally extensive myelopathy. - The comparison cohort was enriched for noninflammatory myelopathies (most commonly spinal cord infarction and idiopathic transverse myelitis), which may limit generalizability; the authors call for validation in independent cohorts.
## Clinical Analysis & Structured Key Points
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Epub 2026 Sep 21. # Diagnostic Utility of Novel and Established Spinal MRI Signs in AQP4-IgG-Seropositive NMOSD Myelitis [Nontapat Sukhonpanich](https://pubmed.ncbi.nlm.nih.gov/?term=Sukhonpanich+N&cauthor_id=42766829)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-1 "Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Chanon Ngamsombat](https://pubmed.ncbi.nlm.nih.gov/?term=Ngamsombat+C&cauthor_id=42766829)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-2 "Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Sittaya Buathong](https://pubmed.ncbi.nlm.nih.gov/?term=Buathong+S&cauthor_id=42766829)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-2 "Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Natapong Thaneerat](https://pubmed.ncbi.nlm.nih.gov/?term=Thaneerat+N&cauthor_id=42766829)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Dachathorn Tharacheewin](https://pubmed.ncbi.nlm.nih.gov/?term=Tharacheewin+D&cauthor_id=42766829)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Sasitorn Siritho](https://pubmed.ncbi.nlm.nih.gov/?term=Siritho+S&cauthor_id=42766829)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-1 "Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-4 "Bumrungrad International Hospital, Bangkok, Thailand; and."), [Tatchaporn Ongphichetmetha](https://pubmed.ncbi.nlm.nih.gov/?term=Ongphichetmetha+T&cauthor_id=42766829)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-1 "Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-5 "Division of Clinical Epidemiology, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Naraporn Prayoonwiwat](https://pubmed.ncbi.nlm.nih.gov/?term=Prayoonwiwat+N&cauthor_id=42766829)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-1 "Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Natthapon Rattanathamsakul](https://pubmed.ncbi.nlm.nih.gov/?term=Rattanathamsakul+N&cauthor_id=42766829)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-1 "Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Jiraporn Jitprapaikulsan](https://pubmed.ncbi.nlm.nih.gov/?term=Jitprapaikulsan+J&cauthor_id=42766829)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-1 "Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#full-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.") Affiliations Expand ### Affiliations * 1 Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. * 2 Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. * 3 Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. * 4 Bumrungrad International Hospital, Bangkok, Thailand; and. * 5 Division of Clinical Epidemiology, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. * PMID: **42766829** * DOI: [ 10.1212/WNL.0000000000218507 ](https://doi.org/10.1212/wnl.0000000000218507) Item in Clipboard # Diagnostic Utility of Novel and Established Spinal MRI Signs in AQP4-IgG-Seropositive NMOSD Myelitis Nontapat Sukhonpanich et al. Neurology. 2026. Show details Display options Display options Format Abstract PubMed PMID Neurology Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Neurology%22%5Bjour%5D&sort=date&sort_order=desc) * [ Search in NLM Catalog ](https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22Neurology%22%5BTitle+Abbreviation%5D) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42766829/) . 2026 Oct 13;107(7):e218507. doi: 10.1212/WNL.0000000000218507. Epub 2026 Sep 21. ### Authors [Nontapat Sukhonpanich](https://pubmed.ncbi.nlm.nih.gov/?term=Sukhonpanich+N&cauthor_id=42766829)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-1 "Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Chanon Ngamsombat](https://pubmed.ncbi.nlm.nih.gov/?term=Ngamsombat+C&cauthor_id=42766829)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-2 "Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Sittaya Buathong](https://pubmed.ncbi.nlm.nih.gov/?term=Buathong+S&cauthor_id=42766829)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-2 "Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Natapong Thaneerat](https://pubmed.ncbi.nlm.nih.gov/?term=Thaneerat+N&cauthor_id=42766829)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Dachathorn Tharacheewin](https://pubmed.ncbi.nlm.nih.gov/?term=Tharacheewin+D&cauthor_id=42766829)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Sasitorn Siritho](https://pubmed.ncbi.nlm.nih.gov/?term=Siritho+S&cauthor_id=42766829)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-1 "Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-4 "Bumrungrad International Hospital, Bangkok, Thailand; and."), [Tatchaporn Ongphichetmetha](https://pubmed.ncbi.nlm.nih.gov/?term=Ongphichetmetha+T&cauthor_id=42766829)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-1 "Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-5 "Division of Clinical Epidemiology, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Naraporn Prayoonwiwat](https://pubmed.ncbi.nlm.nih.gov/?term=Prayoonwiwat+N&cauthor_id=42766829)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-1 "Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Natthapon Rattanathamsakul](https://pubmed.ncbi.nlm.nih.gov/?term=Rattanathamsakul+N&cauthor_id=42766829)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-1 "Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand."), [Jiraporn Jitprapaikulsan](https://pubmed.ncbi.nlm.nih.gov/?term=Jitprapaikulsan+J&cauthor_id=42766829)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-1 "Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42766829/#short-view-affiliation-3 "Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.") ### Affiliations * 1 Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. * 2 Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. * 3 Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. * 4 Bumrungrad International Hospital, Bangkok, Thailand; and. * 5 Division of Clinical Epidemiology, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. * PMID: **42766829** * DOI: [ 10.1212/WNL.0000000000218507 ](https://doi.org/10.1212/wnl.0000000000218507) Item in Clipboard Cite Display options Display options Format Abstract PubMed PMID ## Abstract **Background and objectives:** Myelitis is a common manifestation of aquaporin-4 immunoglobulin G-seropositive (AQP4-IgG+) neuromyelitis optica spectrum disorder (NMOSD), with longitudinally extensive transverse myelitis (LETM) as a characteristic MRI feature. Bright spotty lesions (BSLs) and a novel "double-contoured LETM" sign have also been increasingly observed, but their prevalence and diagnostic utility are unclear. This study aimed to characterize spinal cord MRI findings and evaluate the diagnostic performance of established and novel MRI signs in AQP4-IgG+ NMOSD myelitis. **Methods:** We retrospectively reviewed spinal cord MRI scans from adults with AQP4-IgG+ NMOSD myelitis at a university-based hospital across acute ( 3 months) stages. MRI features were descriptively analyzed. Acute scans were assessed for specific MRI signs, including the H sign, double-contoured LETM sign, BSLs, and sagittal ring enhancement and compared with other causes of myelopathy. Sensitivity, specificity, and likelihood ratios were calculated. **Results:** Among 217 patients with AQP4-IgG+ NMOSD (median age at onset 44.5 years, 95.9% women), 170 (78.3%) experienced myelitis. A total of 331 NMOSD spinal MRI scans were reviewed. The comparison group included 72 scans, most commonly from patients with spinal cord infarction (39) and idiopathic transverse myelitis (14). Restricting the analysis to first-ever myelitis (53 scans), LETM was observed in 88.7%, and sensitivities of BSLs, the double-contoured LETM sign, and sagittal ring enhancement were 64.0% (95% CI 50.1%-75.9%), 47.2% (95% CI 34.4%-60.3%), and 60.0% (95% CI 46.2%-72.4%), respectively, with specificities of 98.6% (95% CI 92.2%-99.7%), 98.6% (95% CI 92.4%-99.8%), and 96.4% (95% CI 87.9%-99.0%). Combining these signs increased specificity further but reduced sensitivity to approximately 30%. When acute first-ever and recurrent myelitis were analyzed together (161 scans), the prevalence of these signs decreased to 56.5%, 19.9%, and 44.1%, respectively. During remission, complete radiologic resolution was observed in 12.4% of 129 scans, whereas spinal cord atrophy was present in 56.6%. **Discussion:** BSLs, the double-contoured LETM sign, and sagittal ring enhancement demonstrate high specificity and may aid in differentiating NMOSD from other causes of longitudinally extensive myelopathy. The double-contoured LETM sign represents a novel imaging feature, particularly in first-ever acute myelitis. However, the comparison cohort was enriched with noninflammatory myelopathies, which may limit generalizability. Further validation in independent cohorts is warranted. 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