Diagnostic performance of central vein sign, paramagnetic rim lesion and cortical lesion in Asian patients with multiple sclerosis

Background: The 2024 revised McDonald criteria for multiple sclerosis (MS) incorporate central vein sign (CVS) and paramagnetic rim lesion (PRL), but their utility in Asian patients remains unclear. Objective: To evaluate the performance of CVS, PRL and cortical lesion (CL) in distinguishing MS from neuromyelitis optica spectrum disorders (NMOSD) and myelin-oligodendrocyte glycoprotein antibody-associated disease (MOGAD) in Japanese patients. Methods: We conducted a cross-sectional study of 139 MS, 41 NMOSD and 12 MOGAD patients who underwent 3-Tesla magnetic resonance imaging (MRI), including susceptibility-weighted imaging. Results: At least one CVS was identified in 95% of MS, 59% of NMOSD and 42% of MOGAD, while PRL occurred in 63% of MS only. The CVS number (cutoff ⩾ 2) yielded 85.6% sensitivity and 75.5% specificity (area under the curve (AUC) 0.856), which improved in patients <50 (AUC 0.920) or <70 years (AUC 0.907), and when combined with PRL and CL (AUC 0.926). The Select 6 algorithm achieved 69.1% sensitivity and 98.1% specificity (AUC 0.836), which were comparable in patients <50 (AUC 0.879) or <70 years (AUC 0.839), but improved when combined with PRL and CL (AUC 0.925). Conclusions: Combining Select 6 or CVS number with PRL and CL, particularly in patients <50 or <70 years, provides robust diagnostic performance for MS in the Asian population.