Diagnosis of myelin oligodendrocyte glycoprotein antibody-associated disease: International MOGAD Panel proposed criteria

Approach to Managing the Initial Presentation of Multiple Sclerosis: A Worldwide Practice Survey

Background and Objectives

Available disease-modifying therapies (DMTs) for multiple sclerosis (MS) are rapidly expanding; although escalation approaches aim to balance safety and efficacy, emerging evidence suggests superior outcomes for people with MS who are exposed to early high-efficacy therapies. We aimed to explore practice differences in prevailing management strategies for relapsing-remitting MS.

Methods

We used a worldwide electronic survey launched by the Practice Current section of Neurology® Clinical Practice. Questions pertained to a case of a 37-year-old woman presenting with optic neuritis. Respondents were asked to indicate their initial investigations, relapse management strategy, choice of disease-modifying therapy, and plan for follow-up imaging (contrast/noncontrast). Survey responses were stratified by key demographic variables along with 95% confidence intervals (95% CIs).

Results

We received 153 responses from 42 countries; 32.3% responders identified as MS specialists. There was a strong preference for intravenous delivery of high-dose corticosteroids (87.7%, 95% CI 80.7-92.5), and most of the responders (61.3%, 95% CI 52.6-69.4) indicated they would treat a nondisabling (mild sensory) MS relapse. When asked to select a single initial DMT, 56.6% (95% CI 47.6-65.1) selected a high-efficacy therapy (67.5% MS specialists vs 53.7% non-MS specialists). The most selected agents overall were fingolimod (14.7%), natalizumab (15.5%), and dimethyl fumarate (20.9%). Two-thirds of respondents indicated they would request contrast-enhanced surveillance MRI.

Discussion

Although there is a slight preference for initiating high-efficacy DMT at the time of initial MS diagnosis, opinions regarding the most appropriate treatment paradigm remain divided.

The atypical faces of optic neuritis: neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease

PURPOSE OF REVIEW

The purpose of this article is to provide a review of neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), with a focus on what renders optic neuritis "atypical" in these two conditions. Clinical features, diagnostic criteria, and epidemiology are outlined. Acute treatments for optic neuritis, as well as immunotherapy for NMOSD and MOGAD are discussed.

RECENT FINDINGS

Updates in NMOSD and MOGAD are highlighted, with an emphasis on novel work including the new 2023 MOGAD diagnostic criteria, our evolving understanding on the epidemiology of these conditions, and recently FDA-approved NMOSD treatments. Pipeline therapies are also discussed.

SUMMARY

A thorough history and examination, supported by ancillary testing, continues to be the mainstay of optic neuritis diagnosis. Stratifying typical versus atypical optic neuritis is paramount. Within the atypical category, NMOSD and MOGAD are important considerations. Clues can point towards these diagnoses and guide steps for treatment, which is increasingly becoming targeted to individual diseases, as the pathophysiology is different for these disorders.

Myelitis associated with glial fibrillary acidic protein IgG: characterization and comparison with aquaporin-4 IgG and myelin oligodendrocyte glycoprotein IgG myelitis

BACKGROUND

Awareness of the characteristics of glial fibrillary acidic protein autoantibody (GFAP-IgG) associated myelitis facilitates early diagnosis and treatment. We explored features in GFAP-IgG myelitis and compared them with those in myelitis associated with aquaporin-4 IgG (AQP4-IgG) and myelin oligodendrocyte glycoprotein IgG (MOG-IgG).

METHODS

We retrospectively reviewed data from patients with GFAP-IgG myelitis at the First Affiliated Hospital of Zhengzhou University and Henan Children's Hospital from May 2018 to May 2023. AQP4-IgG and MOG-IgG myelitis patients served as controls.

RESULTS

Thirty-four patients with GFAP-IgG myelitis were included (15 women, 12 children; median age at onset, 28.5 years). Over half experienced prodromal symptoms and required intensive care support. The median Expanded Disability Status Scale (EDSS) score was 4 at admission and 0 at final follow-up (median, 20 months). Cerebrospinal fluid (CSF) analysis showed markedly elevated leukocyte counts in 23 patients, elevated total protein in 28 patients, and decreased glucose levels in 9 patients. Longitudinally sagittal T2 and gadolinium-enhancing spinal cord lesions were detected. Features favoring GFAP-IgG over the other types included presence of fever and neck stiffness, requirement of intensive care and mechanical ventilation, higher monocyte-to-lymphocyte ratio (MLR), presence of hyponatremia, markedly elevated CSF leukocyte counts, increased CSF total protein levels, and decreased CSF glucose levels. Imaging findings more common in GFAP-IgG than in AQP4-IgG myelitis were longer diseased segments, central canal enhancement, and gadolinium-enhancing brain lesions. Higher EDSS scores at discharge distinguished GFAP-IgG from MOG-IgG.

CONCLUSION

Clinical, laboratory, imaging, and outcome variables facilitate differential diagnosis of myelitis subtypes.

MOGAD: A comprehensive review of clinicoradiological features, therapy and outcomes in 4699 patients globally

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is one of the most common antibody-mediated CNS disorders. Optimal diagnostic and prognostic biomarkers remain unclear. Our aim was to clarify these biomarkers and therapeutic outcomes internationally. We reviewed articles from 2007 to 2022 and identified 194 unique cohorts encompassing 4699 paediatric and adult patients from 31 countries. Where phenotypes were specified, the most common initial presentation overall was optic neuritis (ON; paediatric 34 %; adults 60 %), during which 71 % had papilloedema on fundoscopy. The most common phenotype at latest follow-up was relapsing ON (20 %). Only 47 % of patients with 6-24 months of follow-up exhibited a relapsing course, while this proportion was much higher (72 %) when follow-up was extended beyond 5 years. Despite a similar relapse rate, the time to first relapse was much shorter in paediatric than adult patients (6 vs 17 months). Adult MRI-Brain scans performed at onset were more frequently normal than in paediatric patients (50 % vs 27 %). Abnormal MRI scans showing involvement of deep grey matter, cortico-subcortical, periventricular lesions, leptomeningeal enhancement, H-shaped spinal cord lesions, and bilateral optic nerve abnormalities were more common in paediatric patients compared to adults. Conversely, adults demonstrated higher frequencies of eccentric spinal cord lesions and intraorbital involvement. CSF analysis demonstrated intrathecally restricted oligoclonal bands in 12 %, elevated protein in 35 %, and pleocytosis in 54 %. Peripapillary retinal nerve fibre layer (pRNFL) thickness, measured acutely, frequently demonstrated swelling (weighted-median 145 μm; normal 85-110). Most cohorts demonstrated notable pRNFL atrophy at latest follow-up (weighted-median 67 μm). pRNFL thickness was significantly lower when measured at or after six months following ON onset, compared to measurements taken within the first six months following ON onset (p < 0.001). Therapeutic and outcome data was available for 3031 patients with a weighted-median disease duration of 32 months. Acute immunotherapy was initiated in 97 %, and maintenance immunotherapy in 64 %, with considerable regional variation. Expanded Disability Status Scale (EDSS) scores and visual acuities improved from nadir to latest follow-up in most patients. A negative correlation was noted between follow-up pRNFL thickness and latest follow-up visual acuity (r = -0.56). Based on this unprecedented global aggregation of MOGAD patients, we reveal a higher proportion of relapsing patients than previously recognised. While commonly used measures like EDSS show significant recovery, they underestimate visual disability following optic neuritis, the most frequent clinical presentation. Our findings suggest that RNFL thickness, especially when measured at least 6 months post-ON, may serve as a more sensitive biomarker for long-term visual impairment.

Cerebral cortical encephalitis in adults with myelin oligodendrocyte glycoprotein antibody-associated disease: A national case series

BACKGROUND AND PURPOSE

Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) is a relatively recently described disease, most commonly presenting with optic neuritis and longitudinally extensive transverse myelitis. Cerebral cortical encephalitis is a rare manifestation of MOGAD.

METHODS

We identified patients presenting with cerebral cortical encephalitis with positive MOG antibodies in serum across a large specialized service. Demographic and clinical information were collected. We describe clinical and laboratory characteristics, treatment response, and subsequent relapse risk in adults presenting with this phenotype.

RESULTS

We identified eight patients meeting clinical criteria for cerebral cortical encephalitis with MOG antibodies. All had seizures; four had focal onset seizures with or without secondary generalization. Two patients exhibited encephalopathy, and six demonstrated focal neurological deficits at presentation. All had fluid-attenuated inversion recovery hyperintensities. Five of eight displayed cerebral swelling, and two of eight displayed leptomeningeal enhancement. Where cerebrospinal fluid (CSF) results were available, five of seven had CSF pleocytosis, protein was raised in two of seven, and one patient had oligoclonal bands unique to CSF. Median time to seizure control was 1.25 months, and all clinical features and magnetic resonance imaging abnormalities resolved. Four of eight patients (50%) had a clinical relapse, with a median time to relapse of 6.4 months.

CONCLUSIONS

Cerebral cortical encephalitis appears to share similar CSF findings, steroid responsiveness, and risk of relapse with other clinical manifestations of MOGAD. This informs treatment decisions and patient counselling.

Distinguishing Transient From Persistent Brain Structural Changes in Pediatric Patients With Acute Disseminated Encephalomyelitis

BACKGROUND AND OBJECTIVES

Pediatric patients with acute disseminated encephalomyelitis (ADEM) are at risk of impaired brain growth, with long-term neuropsychiatric consequences. We previously reported transient expansions of cerebral ventricle volume (VV) in experimental autoimmune encephalomyelitis, which subsequently normalized. In this study, we investigated changes in VV in ADEM in relation to other brain structures and clinical outcomes.

METHODS

We investigated brain MRI scans acquired in routine clinical practice from a multicenter cohort of 61 pediatric patients with ADEM, of whom 39 were myelin oligodendrocyte glycoprotein (MOG) antibody-positive. Patients were compared with 1,219 pediatric healthy controls (HCs). Volumes of multiple brain structures were computed using a contrast-agnostic machine learning-based tool and analyzed with mixed-effect models regarding other clinical parameters.

RESULTS

Patients with ADEM had larger VV than HCs at initial clinical presentation, before immune therapy. Most of the patients showed further VV increases within 2 months after disease onset. Patients had smaller brain volumes than HCs, with specific reductions in deep gray matter structures. These changes were more pronounced in MOG antibody-negative patients.Of the patients with more than 2 MRI scans, 12 of 22 resolved their VV expansion back to within 15% of baseline values while 10 of 22 had persistently increased VV at the last available MRI within 1 year from onset. Patients with persistent VV expansion had greater reductions in volumes of other brain structures at the last MRI than patients whose VV resolved and were more likely to have residual neurologic signs. The VV resolving and nonresolving patients did not differ regarding age, sex, elevated CSF cell counts at baseline, or occurrence of relapses. However, patients with a larger magnitude of VV expansion-≥90% of baseline volume-were more likely to be in the nonresolving group.

DISCUSSION

We could distinguish between 2 outcomes of VV changes in ADEM: one in which the VV expanded but ultimately returned to normal and one in which the expansions continued after disease onset and treatment but failed to resolve. The latter was associated with reduced brain volume, particularly in deep gray matter structures. This highlights the necessity for patients with ADEM to undergo regular MRI scans to assess whether developing VV expansions indicate a greater risk of permanent brain atrophy.

Increased Intracranial Pressure in Myelin-Oligodendrocyte Glycoprotein Antibody-Associated Disease

OBJECTIVES

To assess characteristics of increased intracranial pressure (ICP) in myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD).

METHODS

This is a multicenter retrospective review of 84 MOGAD cases at the University of Florida, Baylor College of Medicine, the University of California San Diego, and Providence Health and Services, Portland, Oregon, to identify cases with a documented increased opening pressure >25 cm H2O. A literature review was conducted to identify previously reported MOGAD cases with an opening pressure >25 cm H2O.

RESULTS

Of 28 MOGAD cases with available opening pressures, 6 (21.4%) patients (age: 5 to 36 y; 2/6 females) had documented increased ICP with an opening pressure of 26 to 46 cm H2O and optic nerve head edema on funduscopic examination. The increased ICP occurred in the setting of bilateral optic neuritis in all cases. In 5/6 patients, this was the initial presentation of the disorder. Anti-MOG titers were 1:40 (n = 1), 1:100 (n = 4), and 1:1000 (n = 1). In our literature review, we identified 13 additional MOGAD cases with ICP elevations in the setting of meningo-cortical presentations (n = 10), as well as bilateral optic neuritis (n = 3).

CONCLUSIONS

Increased ICP may occur in MOGAD and may be more common in patients with optic neuritis or meningoencephalitis.

"Lupus Myelitis" Revisited: A Retrospective Single-Center Study of Myelitis Associated With Rheumatologic Disease

BACKGROUND AND OBJECTIVES

Previous reports of patients with myelitis associated with rheumatologic disease may have had unrecognized aquaporin-4 (AQP4)-IgG seropositive neuromyelitis optica spectrum disorder (NMOSD) or myelin oligodendrocyte glycoprotein (MOG)-IgG-associated disease (MOGAD). We clinicoradiologically and serologically characterized patients with myelitis associated with rheumatologic disease evaluated in the era of availability of MOG-IgG and more sensitive AQP4-IgG cell-based assays.

METHODS

A retrospective cohort (2018-2023) at Johns Hopkins Medicine with diagnoses of myelopathy and rheumatologic comorbidity was identified by electronic medical record (EMR) query. All patients with myelitis unrelated to typical multiple sclerosis (MS) were included and analyzed by chart review.

RESULTS

Of 238 patients identified by EMR query, 197 were excluded (148 not meeting prespecified inclusion criteria, 49 had typical MS), resulting in 41 patients for review. The mean age at myelitis onset was 44 ± 15 years; 39 (95%) were female. Rheumatologic diagnoses included 17 (41.5%) with systemic lupus erythematosus (SLE), 10 (24.3%) Sjögren syndrome (SS), 6 (15%) undifferentiated connective tissue disease (UCTD), 5 (12%) combinations of SLE/SS/UCTD with antiphospholipid antibody syndrome, 1 (2.4%) rheumatoid arthritis, 1 (2.4%) psoriatic arthritis, and 1 (2.4%) Behçet disease. 20 patients (49%) were diagnosed with AQP4-IgG seropositive NMOSD, 3 (7%) with MOGAD, and 18 (44%) had "double-seronegative" myelitis. Of these 18, 3 were diagnosed with AQP4-IgG seronegative NMOSD, 1 neuro-Behçet disease, and 14 other (unclassifiable) myelitis. Excluding 1 patient with neuro-Behçet disease, 18 (90%) of 20 AQP4-IgG seropositive patients had longitudinally extensive cord lesions compared with 5 (29%; p < 0.001) of 17 "double-seronegative" patients and 2 (67%) of 3 with MOGAD. "Double-seronegative" patients more commonly had CSF-restricted oligoclonal bands. Functional outcomes did not differ by diagnosis, and most patients received acute immunotherapy at the time of initial myelitis diagnosis with at least partial recovery over a median follow-up of 38 (interquartile range: 9-74) months.

DISCUSSION

Approximately half of our rheumatologic disease cohort with myelitis unrelated to MS had AQP4-IgG seropositive NMOSD while MOGAD accounted for a small but clinically relevant proportion of patients. Further research is needed to characterize myelitis etiology in patients who are seronegative for both AQP4-IgG and MOG-IgG.

Spectrum of Clinical and Imaging Features of Children With GFAP Astrocytopathy

BACKGROUND AND OBJECTIVES

Glial fibrillary acidic protein (GFAP) antibodies (abs) have been described primarily in adults with a spectrum of autoimmune-mediated diseases. In children, data on clinical and neuroradiologic features of children with autoimmune GFAP astrocytopathy are limited. The aim of this study was to describe the clinical and radiologic features in children with GFAP-ab-associated diseases.

METHODS

We retrospectively recruited children from 13 clinical centers between 2020 and 2023 who (1) tested positive for GFAP-ab in serum and/or CSF and (2) of whom a complete clinical and MRI data set was available.

RESULTS

We identified and included 15 children (5 girls, 10 boys). The median age at onset was 9.9 years (range: 2-16 years). All children presented with features of AE or meningitis, acute cerebellitis, or transverse myelitis. CSF pleocytosis was common (13/15, median 245 cells/μL), and 13 (87%) of 15 harbored GFAP-abs in their CSF, 8 (53%) of whom did not have detectable GFAP-abs in their serum. MRI was abnormal in 15 (100%) of 15 children: Specific patterns included confluent lesions in the pons or caudate nucleus (11/15; 73%), peri-aqueductal regions (13/15; 87%), and spinal cord (6/10; 60%). 12 children had a favorable outcome (mRS score of

DISCUSSION

GFAP-ab-associated diseases encompass a wide spectrum of clinical presentation associated with a particular set of MRI features clearly distinct to other antibody-mediated diseases or MOGAD. We recommend that testing for GFAP-abs in serum and CSF be included in the workup of children with AE, particularly if brainstem involvement occurs.

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MESH Headings

• Humans
• Child
• Glial Fibrillary Acidic Protein/blood
• Glial Fibrillary Acidic Protein/cerebrospinal fluid
• Glial Fibrillary Acidic Protein/immunology
• Male
• Female
• Adolescent
• Child, Preschool
• Retrospective Studies
• Magnetic Resonance Imaging
• Autoantibodies/blood
• Autoantibodies/cerebrospinal fluid
• Astrocytes/pathology
• Autoimmune Diseases of the Nervous System/immunology
• Autoimmune Diseases of the Nervous System/diagnostic imaging
• Autoimmune Diseases of the Nervous System/diagnosis
• Autoimmune Diseases of the Nervous System/cerebrospinal fluid
• Autoimmune Diseases of the Nervous System/blood

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Grants Collapse

Affiliation(s)

Simon Sommer From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Andreas Panzer From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Annikki Bertolini From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Robert Cleaveland From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Vivek Jain From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Tugba Kapanci From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Ute Derichs From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Tobias Geis From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Axel Neu From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Christa Löhr-Nilles From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Rahel Aeschimann-Huhn From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Marina Flotats-Bastardas From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Kumaran Deiva From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Thais Armangue From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Gemma Olivé-Cirera From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Sudheeran Kannoth From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Anne Koy From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Hadas Meirson From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Aviva Fattal-Valevski From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Esther Ganelin-Cohen From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Heike Losch From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Annacarin Horne From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Ronny Wickström From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Justina Dargvainiene From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Frank Leypoldt From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany
Kevin Rostasy From the Departments of Pediatric Neurology (S.S., A.B., K.R.), and Pediatric Radiology (A.P., R.C.), Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany; Consultant Child Neurologist and Epileptologist at Neoclinic Children's Hospital (V.J.), Jaipur, India; Department of Pediatric Neurology (T.K.), Children's Hospital Datteln, University Witten/Herdecke; Faculty of Health (T.K.), Department of Psychology and Psychotherapy, Chair of Personality Psychology and Diagnosis, Witten/Herdecke University; Center for Paediatric and Adolescent Medicine (U.D.), University Medical Clinic, Mainz; University Children's Hospital Regensburg (KUNO) (T.G.), Hospital St. Hedwig of the Order of St. John, University of Regensburg; Department of Pediatric Neurology (A.N.), VAMED Klinik Geesthacht; Department of Pediatrics (A.N.), University Medical Center Hamburg-Eppendorf; Department of Pediatric Neurology (C.L.-N.), Mutterhaus der Borromäerinnen, Trier; Department of Pediatric Intensive Care (R.A.-H.), University Children's Hal Marburg; Department of Pediatric Neurology (M.F.-B.), Saarland University Medical Center, Homburg/Saar, Germany; Assistance Publique-Hôpitaux de Paris (K.D.), Paris-Saclay University Hospitals, Bicêtre Hospital, Pediatric Neurology Department, National Referral Center for Rare Inflammatory and Auto-immune Brain and Spinal Diseases, Paris Saclay University, France; Neuroimmunology Unit (T.A.), in Sant Joan de Déu Children's Hospital, Esplugues de Llobregat, Barcelona; Neuroimmunology Program (T.A., G.O.-C.), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona; Neurology Unit (G.O.-C.), Hospital Parc Taulí de Sabadell, Sabadell, Barcelona, Spain; Neuroimmunology Laboratory (S.K.), Amrita Institute of Medical Sciences, School of Medicine, Amrita University, Kochi, India; Department of Pediatrics (A.K.); Center for Rare Diseases (A.K.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Department of Pediatric Neurology (H.M.); Pediatric Neurology Institute (A.F.-V.), Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center; Sackler Faculty of Medicine, Tel Aviv University; Institute of Pediatric Neurology (E.G.-C.), Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel; University Children's Hospital Oldenburg (H.L.), Department of Neuropediatrics, Oldenburg; Neuropediatric Unit (A.H., R.W.), Karolinska University Hospital and Karolinska Institute Stockholm, Sweden; and Institute of Clinical Chemistry (J.D., F.L.), Neuroimmunology Unit and Department of Neurology, University Medical Center Schleswig-Holstein Campus, Kiel, Germany

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Complement Activation Profiles Predict Clinical Outcomes in Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease

BACKGROUND AND OBJECTIVES

The role of the complement system in myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is not completely understood, and studies exploring its potential utility for diagnosis and prognosis are lacking. We aimed to investigate the value of complement factors (CFs) as diagnostic and prognostic biomarkers in patients with MOGAD.

METHODS

Multicentric retrospective cohort study including patients with MOGAD, multiple sclerosis (MS) and aquaporin-4 seropositive neuromyelitis optica spectrum disorder (AQP4-NMOSD) with available paired serum and CSF samples. A panel of CFs were measured by multiplex ELISA, and the levels were compared between the 3 conditions. Univariable and multivariable analyses were performed to evaluate the association between levels of CFs and relapse and disability outcomes in MOGAD patients.

RESULTS

Ninety-four patients (MOGAD, n = 60; MS, n = 18; AQP4-NMOSD, n = 16) were included. Mean (SD) age at sampling was 39.4 (16.7), 40.7 (7.0), and 43.3 (21.0), respectively. Female were predominant, especially in AQP4-NMOSD (88%). Combination of the serum levels of C3a, C4a, and C3a/C3 ratio showed excellent potential to discriminate MOGAD from patients with MS (area under the curve [AUC] [95% CI] 0.95 [0.90-0.99]) and from AQP4-NMOSD (AUC 0.88 [0.76-1.00]). In patients with MOGAD, CSF levels of CFs of the classical/lectin pathway influenced relapse-related outcomes, and lower C4 levels were associated with higher number of relapses during follow-up (incidence rate ratio [95% CI] 0.88 [0.78-0.99]; p = 0.04 in multivariable analysis), and a high C4a/C4 ratio was associated with increased risk of second relapse during the first year (hazard ratio [95% CI] 3.68 [1.26-10.78]; p = 0.02 in multivariable analysis). Time to second relapse was shorter in patients with MOGAD with a high CSF C4a/C4 ratio (log-rank p = 0.01). CSF levels of the membrane attack complex SC5b9 influenced disability-related outcomes, and baseline CSF SC5b9 levels were higher in patients who reached the final Expanded Disability Status Scale (EDSS) ≥ 3.0 (p = 0.002), and elevated SC5b9 levels were associated with increased risk of reaching EDSS ≥ 3.0 (odds ratio [95% CI] 1.79 [1.16-3.67]; p = 0.04 in multivariable analyses).

DISCUSSION

Our results suggest that serum and CSF levels of CFs have diagnostic and prognostic value respectively in patients with MOGAD. These findings support the use of complement inhibitors as a therapeutic approach in these patients.

Neurofilament Light Chain as a Discriminator of Disease Activity Status in MOG Antibody-Associated Disease

BACKGROUND AND OBJECTIVES

In patients with myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD), acute disease activity is generally identified through medical history, neurologic examination, and imaging. However, these may be insufficient for detecting disease activity in specific conditions. This study aimed to investigate the dynamics of serum neurofilament light chain (sNfL) and serum glial fibrillary acidic protein (sGFAP) after clinical attacks and to assess their utility in discriminating attacks from remission in patients with MOGAD.

METHODS

We conducted a multicenter, retrospective, longitudinal study including 239 sera from 62 MOGAD patients assessed from 1995 to 2023 in a discovery and validation setup. Sera were measured for sNfL and sGFAP with a single-molecule array assay and for MOG-IgG with a live cell-based assay. sNfL and sGFAP Z scores and percentiles adjusted for age, body mass index, and sex (sGFAP) were calculated from a healthy control normative database. Mixed-effects regression models were used to characterize biomarkers' dynamics and to investigate associations between serum biomarkers, clinical variables, and disease activity status.

RESULTS

Among the 62 study participants, 29 (46.8%) were female, with a median age at baseline of 40.0 years (interquartile range [IQR] 29.5-49.8) and a median duration of follow-up of 20.0 months (IQR 3.0-62.8). sNfL and sGFAP Z scores were nonlinearly associated with time from attack onset (p < 0.001 and = 0.002, respectively). During attacks, both biomarkers presented higher median values (sNfL Z score 2.9 [IQR 1.4-3.5], 99.8th; sGFAP Z score 0.4 [IQR -0.5 to 1.5], 65.5th) compared with remission (sNfL Z score 0.9 [IQR -0.1 to 1.6], 81.6th, p < 0.001; sGFAP Z score -0.2 [IQR -0.8 to 0.5], 42.1th; p < 0.001) across all clinical phenotypes. sNfL values consistently discriminated disease activity status in the discovery and validation cohorts, showing a 3.5-fold increase in the odds of attacks per Z score unit (odds ratio 3.5, 95% confidence interval 2.3-5.1; p < 0.001). Logistic models incorporating sNfL Z scores demonstrated favorable performance in discriminating disease activity status across both cohorts.

DISCUSSION

sNfL Z scores may serve as a biomarker for monitoring disease activity in MOGAD.

Cerebellar Involvement in Attacks of Aquaporin-4-IgG Positive Neuromyelitis Optica Spectrum Disorder

OBJECTIVES

To characterize the frequency and clinicoradiologic phenotype of cerebellar involvement in attacks of aquaporin-4-IgG positive neuromyelitis optica spectrum disorder (AQP4+NMOSD) which are incompletely captured in current diagnostic criteria.

METHODS

Brain MRI scans from patients with AQP4+NMOSD in the Mayo Clinic database were reviewed, and those with cerebellar T2-hyperintense lesions ≤30 days from attack onset were included for clinical and radiologic characterization.

RESULTS

From 432 patients with AQP4+NMOSD, we identified 17 (4%) with cerebellar attacks. The median age at attack onset was 47 years (range, 7-74). Cerebellar symptoms and signs were noted in 16 (94%) of 17 and the remaining patient was intubated preventing a detailed cerebellar exam. The median Expanded Disability Status Scale score at nadir was 5 (range, 2-9.5). Sixteen (94%) had other regions involved during the attack, most frequently with brainstem or area postrema involvement. Cerebellar MRI T2-lesions (8 single; 11 contiguous with the brainstem; 6/15 [35%] enhancing) were located in cerebellar peduncles, 15 (inferior, 5; middle, 10; superior, 10), and cerebellar parenchyma, 8 (dentate, 4; medial, 2; lateral, 4). T2-lesions persisted in 9 (82%) of 11 beyond 6 months.

DISCUSSION

Cerebellar involvement during attacks of AQP4+NMOSD is rare but the associated neurologic deficits tend to be severe. Cerebellar peduncle or dentate nucleus T2-lesions are frequent MRI accompaniments. Clinical features and MRI lesion patterns of cerebellar involvement could be incorporated into future iterations of AQP4+NMOSD criteria.

Recent Advancement in Inhaled Nano-drug Delivery for Pulmonary, Nasal, and Nose-to-brain Diseases

Pulmonary, nasal, and nose-to-brain diseases involve clinical approaches, such as bronchodilators, inhaled steroids, oxygen therapy, antibiotics, antihistamines, nasal steroids, decongestants, intranasal drug delivery, neurostimulation, and surgery to treat patients. However, systemic medicines have serious adverse effects, necessitating the development of inhaled formulations that allow precise drug delivery to the airways with minimum systemic drug exposure. Particle size, surface charge, biocompatibility, drug capacity, and mucoadhesive are unique chemical and physical features that must be considered for pulmonary and nasal delivery routes due to anatomical and permeability considerations. The traditional management of numerous chronic diseases has a variety of drawbacks. As a result, targeted medicine delivery systems that employ nanotechnology enhancer drug efficiency and optimize the overall outcome are created. The pulmonary route is one of the most essential targeted drug delivery systems because it allows the administering of drugs locally and systemically to the lungs, nasal cavity, and brain. Furthermore, the lungs' beneficial characteristics, such as their ability to inhibit first-pass metabolism and their thin epithelial layer, help treat several health complications. The potential to serve as noninvasive self-administration delivery sites of the lung and nasal routes is discussed in this script. New methods for treating respiratory and some systemic diseases with inhalation have been explored and highlight particular attention to using specialized nanocarriers for delivering various drugs via the nasal and pulmonary pathways. The design and development of inhaled nanomedicine for pulmonary, nasal, and respiratory medicine applications is a potential approach for clinical translation.

MOG IgG antibody positivity from laboratory to clinical practice: A real world experience

BACKGROUND AND OBJECTIVES

Myelin oligodendrocyte glycoprotein (MOG) associated disease (MOGAD) is an antibody-mediated inflammatory demyelinating disorder of the CNS with varied presentations like optic neuritis (ON), transverse myelitis, and cortical encephalitis. This study aims to highlight the significance of low MOG IgG antibody positivity and its diagnostic implications in a real-world cohort.

METHODS

In this retrospective observational study, serum and CSF from suspected MOGAD cases were tested at a tertiary healthcare centre's Neuroimmunology Laboratory. MOG autoantibodies were detected using a EUROIMMUN commercial kit, and seropositivity was determined by visual agreement of fluorescence by two trained observers. Patient data were retrieved from Electronic Medical records.

RESULTS

Out of 103 MOG IgG seropositive patients, 95 were included in the final analysis (Mean age: 32.47±4.63 years; 42 males, 53 females; 36 pediatric, 59 adult) after excluding those with alternate diagnoses. The most common clinical event was ON (37.89%). The 2023 International MOGAD Diagnostic Criteria was met by 35/67 low-strength and 27/28 high-strength patients. Adults were more likely to have atypical presentations and low serum MOG levels. Pediatric patients had better EDSS at discharge but relapsed more. There were no significant differences between low and high positive groups in terms of treatment received, EDSS, relapse, or outcome.

DISCUSSION

Low and high levels of MOG seropositivity showed similar diagnostic value in terms of clinical features, treatment outcome, and prognosis, except for age distribution. Many patients exhibited low-strength positivity and atypical disease presentations, requiring strong clinical judgement for diagnosis.

Etiological and clinical characterization of longitudinally extensive spinal cord lesions: A 12-year tertiary center experience

INTRODUCTION

Longitudinally extensive spinal cord lesions (LESCL) are characterized by T2-hyperintense signals spanning at least three vertebral body segments, with neuromyelitis optica spectrum disorders (NMOSD) being a significant cause. This study aimed to characterize the clinical, radiological, serological, and cerebrospinal fluid (CSF) features of LESCL and to compare NMOSD and non-NMOSD cases.

METHODS

We conducted a retrospective cross-sectional study of adult patients diagnosed with LESCL at our center over a twelve-year period collecting data on demographics, clinical presentations, MRI findings, CSF analysis, and serological testing for AQP4-IgG and MOG-IgG antibodies. Etiologies were reviewed based on current diagnostic criteria, with comparisons made between NMOSD and non-NMOSD LESCL.

RESULTS

We identified 41 LESCL cases, with NMOSD as the most common etiology (29.3 %) followed by ischemia (14.6 %) and multiple sclerosis (9.8 %). The median length of lesions was seven vertebral segments. Pleocytosis was present in 48.6 % of CSF analyses, with oligoclonal bands found in 10 cases. AQP4-IgG antibodies were positive in 11 of 12 NMOSD patients. NMOSD patients were more likely to be female (p = p.006), and exhibit severe symptoms, such as quadriparesis (p = 0.03) and a cervical sensory level (p = 0.04). MRI findings showed a preference for cervical lesions in NMOSD (p = 0.001) and thoracic lesions in non-NMOSD LESCL (p = 0.007).

CONCLUSIONS

LESCL exhibit considerable clinical diversity, with NMOSD being the predominant etiology. Characteristics such as female sex and cervical MRI involvement may indicate a higher likelihood of NMOSD, while cases in males with thoracic segment involvement may suggest non-NMSOD etiologies such as ischemia.

MRZ-reaction maybe influenced by immunization status and is not exclusive to multiple sclerosis

BACKGROUND

Among white populations, a poly-specific antibody response against measles (M), rubella (R) and varicella zoster(Z) otherwise known as MRZR is seen in ∼70 % of MS and rarely in other demyelinating disorders. While the basis for MRZR is unclear, vaccination exposure / community acquired infections may have an influence on its frequency.

OBJECTIVE

To determine the frequency and specificity of MRZR in MS and related disorders in a non- white population with historically low vaccinations and to contrast against oligoclonal bands (OCB).

METHODS

In all, 167 consecutive patients (MS -96, MOGAD-33, AQP4-IgG + NMOSD-12 & double seronegative disorders[DSD] -26) were included. Clinical diagnosis, vaccination history and past infections contributing to MRZR were queried, OCB results were reviewed and MRZR measured.

RESULT

MRZR+ response was seen in 50 % MS, 21.2 % MOGAD, 8.3 %NMOSD and 3.8 % of DSN disease. Vaccination history was limited, a past history of Z was notably associated (p 0.005) with MRZR-Z+ and a high median antibody index was detected for Z and R (p 0.001) in MS. Among MRZR+ patients with MOGAD, a disseminated disease that included LETM (p 0.007), relapsing course (p 0.02), higher relapse rate (p 0.001) and lumbar puncture performed after 2 or more attacks(p 0.009) were significant. CSF specific OCB was more sensitive (71.9 %;95 %CI 61.8-80.6) and specific (94.4 %;95 %CI 86.2-98.4) than MRZR (sensitivity 50 % [95 %CI 39.62-60.4] and specificity 87.3 %(95 %CI 77.3-94.04) for MS patients.

CONCLUSION

In this south Indian cohort with historically low vaccination status, community acquired immunity may have in part influenced MRZR+ results, especially MRZR-Z. A chronic inflammatory state is a likely pre-requisite, that may not be disease specific, for MRZR positivity in immunologically overlapping CNS disorders such as MS, MOGAD and others.

Visual quality of life in NMOSD and MOGAD: profiles, dynamics and associations with ageing and vision

OBJECTIVE

In this multicentric study, we were interested in the vision-related quality of life and its association with visual impairment in neuromyelitis optica spectrum disorders (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) in comparison to multiple sclerosis (MS) and healthy controls.

METHODS

We analysed extracted data from the German NEMOS registry including National Eye Institute Visual Function Questionnaire (NEI-VFQ) scores, high and low contrast visual acuity (HCVA, LCVA), visually evoked potentials (VEP) and the scores for the expanded disability status scale (EDSS) and other neurological tests which assessed their disease-related impairment. The mean follow-up time of our patients was 1.2 years. We used adjusted linear mixed effect models to analyse NEI-VFQ differences and interactions with visual acuity among NMOSD, MOGAD, a matched MS cohort and healthy controls.

RESULTS

Despite a younger age in the MOGAD cohort (39 y.o.), vision and socioemotional-related quality of life reduction was similar over all patient subgroups in comparison to healthy controls. The most impacted life quality dimension was general health, followed by general vision, driving and role difficulties. Decline in some of the NEI-VFQ subscales scores is mostly predicted by age. The HCVA was the best predictor for most of the subscales of the NEI-VFQ.

DISCUSSION

Despite important age differences, NMOSD, MOGAD and MS seem to share a rather similar perception on their vision and quality of life impairment, which is overall poorer than that of healthy controls.

The epidemiology and clinical presentation of seropositive neuromyelitis optica spectrum disorder in a US population

OBJECTIVE

To define the epidemiology and clinical presentation of seropositive neuromyelitis optica spectrum disorder (NMOSD) in a large US health system.

METHODS

We completed a retrospective observational study of adult patients in the University of Colorado Health System from 1 January 2011 to 31 December 2020, using Health Data Compass (HDC), a data warehouse that combines electronic health information with claims and public health data in Colorado. We screened HDC for patients with either (1) an abnormal aquaporin-4 IgG test or (2) any G36 ICD-10 code. We extracted key clinical elements by chart review and confirmed diagnosis by the 2015 International Panel for NMO Diagnosis criteria. Annual incidence and prevalence rates were calculated.

RESULTS

Our population consisted of 2,475,591 individuals contributing 11,103,522.72 person-years of observation. In total, 115 seropositive NMOSD patients were identified. The average yearly incidence was 0.22 per 100,000 person-years. Age and sex-adjusted prevalence (per 100,000) was 4.33, and highest among those identifying as Asian or Pacific Islander (17.72), and Black (14.74), as separately by Hispanic ethnicity (8.02). Prevalence was higher in women (6.20:1 female:male ratio). Transverse myelitis (45%) and optic neuritis (43%) were the most common presenting clinical syndromes. In total, 6% of initial presentations were characterized by short-segment transverse myelitis without other features.

INTERPRETATION

Seropositive NMOSD incidence is higher in our cohort than many contemporary studies. Women and those identifying as Asian or Pacific Islander, Black, and Hispanic shoulder the highest burden of disease. Clinical onset with short-segment myelitis underscores the need for serum aquaporin-4 IgG testing in acute myelitis presentations.

Pediatric Neuroimaging of Multiple Sclerosis and Neuroinflammatory Diseases

Using a pediatric-focused lens, this review article briefly summarizes the presentation of several demyelinating and neuroinflammatory diseases using conventional magnetic resonance imaging (MRI) sequences, such as T1-weighted with and without an exogenous gadolinium-based contrast agent, T2-weighted, and fluid-attenuated inversion recovery (FLAIR). These conventional sequences exploit the intrinsic properties of tissue to provide a distinct signal contrast that is useful for evaluating disease features and monitoring treatment responses in patients by characterizing lesion involvement in the central nervous system and tracking temporal features with blood-brain barrier disruption. Illustrative examples are presented for pediatric-onset multiple sclerosis and neuroinflammatory diseases. This work also highlights findings from advanced MRI techniques, often infrequently employed due to the challenges involved in acquisition, post-processing, and interpretation, and identifies the need for future studies to extract the unique information, such as alterations in neurochemistry, disruptions of structural organization, or atypical functional connectivity, that may be relevant for the diagnosis and management of disease.

Evidence-based diagnostic prediction score for pediatric NMDA receptor encephalitis

OBJECTIVE

Early diagnosis and treatment of anti-N-methyl-D-aspartate receptor encephalitis (NMDARE) are crucial for a favorable prognosis. Detecting the causative autoantibodies can be challenging. Probable diagnostic criteria are useful in adults less so in children. We aimed to develop a novel diagnostic score for pediatric NMDARE using cohort data.

METHODS

We retrospectively analyzed pediatric participants (0-18 years) with suspected autoimmune encephalitis who underwent cerebrospinal fluid analysis for antineuronal antibodies (Abs) between January 2015 and March 2023. Clinical data, including symptoms and laboratory findings, were analyzed. Symptoms were selected through univariate analysis and then analyzed with multivariate logistic regression model. Resulting odds ratios were used to calculate scores. Scoring systems were developed and evaluated with five-fold validation and univariate logistic regression. One scoring system was selected to create a diagnostic prediction score for pediatric NMDARE.

RESULTS

Of the 504 patients, 264 met the inclusion criteria, and 39 tested positive for NMDAR Abs. Comparing clinical symptoms between cohorts and identified 15 variables significantly different (p < 0.05) to create a pediatric NMDARE prediction score. This score showed 82.1 % sensitivity and 82.2 % specificity, with an 8-point cutoff. The area under the curve was 0.888 (95 % confidence interval: 0.838-0.939). A five-fold cross-validation showed a sensitivity of 95.6 %, specificity of 71.4 %, and kappa coefficient of 0.670.

CONCLUSION

We developed a novel evidence-based diagnostic prediction score for pediatric NMDARE that incorporates specific clinical features and laboratory findings. This score may improve diagnostic accuracy and guide early therapy in children with suspected autoimmune encephalitis.

Predictors of a relapsing course in myelin oligodendrocyte glycoprotein antibody-associated disease

BACKGROUND

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a recently described demyelinating disorder, and children represent about 50% of all cases. Almost half of the patients experience relapses, but very few studies have evaluated predictors of relapse risk, challenging clinical management. The study aimed to identify predictors at MOGAD onset that are associated with a relapsing course.

METHODS

Prospectively collected data from paediatric patients with MOGAD seen by the US Network of Paediatric MS Centres were leveraged. Univariable and adjusted multivariable models were used to predict recurrent disease.

RESULTS

We identified 326 MOGAD cases (mean age at first event 8.9 years [SD 4.3], 57% female, 77% white and 74% non-Hispanic) and 46% relapsed during a mean follow-up of 3.9 years (SD 4.1). In the adjusted multivariable model, female sex (HR 1.66, 95% CI 1.17 to 2.36, p=0.004) and Hispanic/Latino ethnicity (HR 1.77, 95% CI 1.19 to 2.64, p=0.005) were associated with a higher risk of relapsing MOGAD. Maintenance treatment initiated before a second event with rituximab (HR 0.25, 95% CI 0.07 to 0.92, p=0.037) or intravenous immunoglobulin (IVIG) (HR 0.35, 95% CI 0.14 to 0.88, p=0.026) was associated with lower risk of a second event in multivariable analyses. Conversely, maintenance steroids were associated with a higher estimated relapse risk (HR 1.76, 95% CI 0.90 to 3.45, p=0.097).

CONCLUSION

Sex and ethnicity are associated with relapsing MOGAD. Use of rituximab or IVIG therapy shortly after onset is associated with a lower risk of the second event. Preventive treatment after a first event could be considered for those with a higher relapse risk.

MOGAD presenting as fulminant intracranial hypertension

OBJECTIVES

Myelin oligodendrocyte glycoprotein antibody disease (MOGAD) has an expanding phenotype. We describe two cases of MOGAD with associated severe intracranial hypertension. Case 1: A 21-year-old male presented with diffuse cortical encephalitis and intracranial hypertension with both serum and CSF MOG antibody positivity. Initial brain CT scan was normal but subsequent demyelination was evident on MRI. Case 2: A 44-year-old female presented with a progressive brainstem encephalitis and intracranial hypertension and normal MRI, with later development of subcortical demyelination which was confirmed on brain biopsy. CSF-restricted MOG antibody was detected following the biopsy results.

RESULTS

Both patients presented with clinical features of severe intracranial hypertension requiring surgical management followed by immunosuppressive therapy (methylprednisone and plasma exchange; and intravenous immunoglobulin and plasma exchange) leading to clinical improvement.

DISCUSSION

MOGAD should be in the differential diagnosis of acute severe intracranial hypertension even in the absence of demyelination on initial neuroimaging. Clinicians should be alert of this syndrome that requires combined management of intracranial pressure in addition to early and intensive immunotherapy.

Children with MOG-IgG positive bilateral optic neuritis misdiagnosed as fulminant idiopathic intracranial hypertension

BACKGROUND

Fulminant idiopathic intracranial hypertension (IIH) is characterized by headache, rapid decrease of vision and elevated CSF-opening pressure.

OBJECTIVE

To delineate a subgroup of MOGAD mimicking fulminant IIH.

METHODS

In this case series children with MOGAD with vision loss, optic disc swelling and elevated CSF opening pressure, initially diagnosed with fulminant IIH, were included.

RESULTS

8 MOGAD patients (median age 12.5y, f:m = 7:1) with an initial diagnosis of fulminant IIH were included. Rapid bilateral visual loss and headache was present in all patients in addition to bilateral optic disc swelling and decreased visual acuity. In 2 patients cMRI showed prominent optic discs or an empty sella sign. In 7 patients the CSF opening pressure was markedly elevated. Patients were treated with Acetazolamide (n = 6), CSF external drainage (n = 2) or implantation of VP shunt (n = 1). Intravenous Methylprednisolone was administered in all patients because of worsening of symptoms, positive MOG-ab titers and/or new MRI white matter lesions. Visual recovery was good with residuals in 1/8 children. OCT revealed thickening of pRNFL in the acute stage in all patients with a rapid declining of pRNFL and retinal atrophy thereafter.

CONCLUSION

Children with bilateral MOGAD-ON presenting with loss of vision and elevated CSF opening pressure are at risk of being misdiagnosed as fulminant IIH. The role of elevated CSF opening pressure in MOGAD warrants further investigations. We recommend to include measurement of CSF opening pressure in the work up of neuroinflammatory diseases, in particular in patients with suspected MOGAD, to consider adapted pressure management.

Application and interpretation of core elements of the 2015 NMOSD diagnostic criteria in routine clinical practice

Background

We evaluated comprehension and application of the 2015 neuromyelitis optica spectrum disorder (NMOSD) criteria core elements by neurologists in Latin America (LATAM) who routinely diagnose and care for NMOSD patients by (i) identifying typical/suggestive NMOSD syndromes, (ii) detecting typical MRI NMOSD lesions and meeting MRI dissemination in space (DIS) criteria, and (iii) evaluating historical symptoms suggestive of NMOSD.

Methods

We conducted an anonymous, voluntary, self-administered web- and case-based survey cross-sectional study from October 2023 to January 2024 of neurologists identified through the LACTRIMS database. Questions were presented first through iterative clinical cases or imaging, followed by questions directly evaluating comprehension of definitions. "Correct" responses were based on the 2015 criteria and adjudicated by the consensus of the experts leading the project.

Results

A total of 106 neurologists (60.3% female; mean age: 46.6 ± 12.5 years) were included. Between 10.4% and 49.1% of neurologists inaccurately identified clinical or paraclinical aspects for DIS and 32.1% accurately identified the three non-cardinal (brainstem, diencephalic, and cerebral) syndromes for seronegative patients. Between 35.8% and 64.1% of neurologists identified the "optimal timing" of AQP4-IgG testing (e.g., during an attack or before receiving immunosuppressant treatments, among others); 56.6% considered live cell-based assay as the gold standard method for serological testing. Most neurologists accurately identified typical NMOSD MRI lesions, but periventricular, juxtacortical/cortical, fluffy infratentorial, corticospinal tract, and hypothalamic lesions were frequently misidentified.

Conclusion

Clinical scenarios were identified where the 2015 NMOSD criteria were susceptible to misinterpretation and misapplication by expert neurologists in LATAM. Implementing collaborative educational initiatives could improve NMOSD diagnosis and raise patient care standards.

Epstein-Barr virus infection in patients with MOGAD

BACKGROUND

Epstein-Barr virus (EBV) infection increases the risk of having multiple sclerosis (MS). Data on adults with myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) are lacking.

OBJECTIVE

To compare EBV serological status in MOGAD versus MS.

METHODS

We measured antibodies to Epstein-Barr nuclear antigen (EBNA-1) and viral capsid antigen (VCA) antigens in 129 patients (MS = 74, MOGAD = 55) by chemiluminescence immunoassays.

RESULTS

VCA-IgG were detected in 97.3% of MS and 96.4% of MOGAD cases, while EBNA-1-IgG in 97.3% of MS and 80% of MOGAD (p = 0.001). EBNA-1 (p < 0.001) and VCA (p = 0.03) antibodies levels were higher in MS patients.

CONCLUSION

EBV antibodies are higher in MS versus MOGAD, suggesting a possible different role of EBV in the pathogenesis of the two conditions.

MOG-IgG is rare in AQP4-IgG seronegative NMO phenotype in Brazil

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune disease most frequently characterized by a neuromyelitis optica (NMO) phenotype, comprising both simultaneous or sequential optic neuritis (ON) and longitudinally extensive transverse myelitis (LETM). Symptoms of brainstem, diencephalic and cerebral involvement may also occur. While most NMOSD patients test positive for serum aquaporin-4 (AQP4) antibodies, some seronegative patients test positive for oligodendrocyte glycoprotein-IgG (MOG-IgG). Early identification of seropositive MOG-IgG seropositive patients among those with AQP4-IgG seronegative NMO phenotype may impact disease treatment and outcome.

OBJECTIVE

To determine the frequency of MOG-IgG in patients with AQP4-IgG seronegative NMO phenotype at a single reference center in Brazil and to analyze factors influencing their identification.

METHODS

A retrospective review of medical records of patients who presented with NMO phenotype and met the 2015 IPND criteria for NMOSD without AQP4 antibodies was conducted in a single center in Brazil. Patients were tested for serum AQP4 antibodies and retrospectively for MOG-IgG using cell-based assays. In addition to demographic, clinical, and imaging data, information on time intervals between disease onset and MOG-IgG testing, as well as the most recent relapse to MOG-IgG testing, was collected.

RESULTS

Out of 118 patients tested for MOG-IgG, 28 (23.7 %) presented with NMO phenotype and met the 2015 IPND criteria for NMOSD without AQP4-IgG. Three (10.7 %) of them tested positive for MOG-IgG serostatus. All were females and had a median age of 26 (11-34) years at disease presentation. The median disease duration was 11.2 yrs. Two patients had a relapsing course. Optic neuritis, myelitis, and brainstem syndrome were the most common presenting symptoms. The median annualized relapse rate was 0.25, and the median EDSS score at the most recent visit was 2.0 (1.5-5.0). There were 25 double seronegative patients, 21 (84 %) of whom were female and non-Caucasian; the median age at disease onset was 30 years (2-60), and the median EDSS at most recent visit was 4.0 (0 - 8.0).

DISCUSSION

The study identified MOG-IgG antibodies in 10.7 % of a cohort with AQP4-IgG seronegative NMO phenotype. Immunosuppressive treatment and long intervals between disease attacks and antibody testing may have impacted the frequency of MOG-IgG seropositivity. As MOG-IgG testing is crucial for diagnosing MOGAD in AQP4-IgG seronegative NMO phenotype, we highlight the need for broader and timely testing to improve diagnostic accuracy in resource-limited settings.

MOGAD and NMOSD: insights on patients' radiological and laboratory findings from a single UAE center

Introduction

Although neuromyelitis optica spectrum disorders (NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOGAD) are rare diseases, they pose a significant burden on both society and the healthcare system. This study aims to discuss the demographics and patient characteristics of these diseases in a single center in the United Arab Emirates (UAE).

Methods

This is a retrospective, descriptive study that included patients with either NMOSD or MOGAD treated at Rashid Hospital, UAE during the period between January 2019 and January 2024. Patients were selected and categorized according to NMOSD criteria, aquaporin-4 antibodies, and MOG antibodies. Patient demographics, clinical characteristics, and medical history were retrieved from their medical records and descriptively analyzed in the light of patients' serological data.

Results

We identified 34 patients with non-multiple sclerosis atypical CNS inflammatory/demyelinating syndromes. Twenty-seven patients (79.4%) fulfilled the criteria for NMOSD, while seven (20.6%) tested positive for MOG antibodies, fulfilling the criteria for MOGAD. In the NMOSD cohort, 19% (n = 5) were AQP4-antibody negative. Seventy-four percent of the NMOSD cohort and 43% of the MOGAD cohort were female. For MOGAD patients, disease onset was at a younger age (median onset age of 25 years) compared to the overall study population (mean onset age of 28.94 years). Long segment transverse myelitis was only detected in NMOSD patients (33.3%), and brainstem syndrome with area postrema syndrome was more common in the MOGAD cohort (29% vs. 4%). The rate of positive response to intravenous methylprednisolone as initial therapy was comparable across both cohorts (74% in case of NMOSD and 71% in case of MOGAD).

Conclusion

This study provides valuable insights into the status of NMOSD and MOGAD in the UAE, highlighting the need for larger, prospective studies to further characterize these diseases in the local population, as well as the need for improved understanding of the epidemiology and management of these rare but debilitating conditions.

Turncoat antibodies unmasked in a model of autoimmune demyelination: from biology to therapy

Autoantibodies contribute to many autoimmune diseases, yet there is no approved therapy to neutralize them selectively. A popular mouse model, experimental autoimmune encephalomyelitis (EAE), could serve to develop such a therapy, provided we can better understand the nature and importance of the autoantibodies involved. Here we report the discovery of autoantibody-secreting extrafollicular plasmablasts in EAE induced with specific myelin oligodendrocyte glycoprotein (MOG) antigens. Single-cell RNA sequencing reveals that these cells produce non-affinity-matured IgG antibodies. These include pathogenic antibodies competing for shared binding space on MOG's extracellular domain. Interestingly, the synthetic anti-MOG antibody 8-18C5 can prevent the binding of pathogenic antibodies from either EAE mice or people with MOG antibody disease (MOGAD). Moreover, an 8-18C5 variant carrying the NNAS mutation, which inactivates its effector functions, can reduce EAE severity and promote functional recovery. In brief, this study provides not only a comprehensive characterization of the humoral response in EAE models, but also a proof of concept for a novel therapy to antagonize pathogenic anti-MOG antibodies.

Fewer relapses and worse outcomes of patients with late-onset myelin oligodendrocyte glycoprotein antibody-associated disease

BACKGROUND

To delineate the clinical characteristics and outcomes of late-onset myelin oligodendrocyte glycoprotein antibody-associated disease (LO-MOGAD) and compare them with those of early-onset MOGAD (EO-MOGAD).

METHODS

This observational cohort study included 199 adult patients with MOGAD. We reviewed the patients' demographic and clinical data and performed comparative analyses between EO-MOGAD and LO-MOGAD (onset age 18-50 and ≥50 years, respectively).

RESULTS

Among the 199 patients, 42 had LO-MOGAD. Compared with patients with EO-MOGAD, those with LO-MOGAD patients exhibited a significantly higher incidence of optic neuritis both at the initial attack (66.67% vs 43.31%, p=0.007) and throughout all attacks (72.15% vs 52.51%, p=0.001). Over a similar disease duration, patients with LO-MOGAD exhibited significantly fewer relapsing courses (45.16% vs 70.97%), higher Expanded Disability Status Scale (EDSS) and visual functional system scores at the last visit (all p<0.05). Compared with patients with EO-MOGAD, those with LO-MOGAD had a significantly lower risk of relapse (HR 0.512, 95% CI 0.268 to 0.978, p=0.034), but higher risks of reaching EDSS ≥2 (HR 2.893, 95% CI 1.524 to 5.494, p<0.001) and visual acuity ≤0.6 (HR 3.097, 95% CI 1.073 to 8.937, p=0.022). Immunosuppressive therapies significantly reduced the annualised relapse rates of patients with LO-MOGAD, although adverse events leading to drug discontinuation and hospitalisation were observed.

CONCLUSIONS

Compared with patients with EO-MOGAD, patients with LO-MOGAD exhibited fewer relapsing courses but worse disability outcomes and should be actively treated.

Blood neutrophils, oligoclonal bands and bridging corticosteroids as predictive factors for MOGAD course: Insights from a multicentric Portuguese cohort

BACKGROUND

Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) is a heterogeneous entity with either a monophasic or relapsing course. Well-established predictors of relapsing disease are lacking.

OBJECTIVE

Identifying predictors of relapsing MOGAD, particularly at disease onset.

METHODS

A multicentre observational retrospective study was conducted to characterise a cohort of Portuguese adult MOGAD patients. Patients were identified from participating centre databases. Clinical and demographic data were collected from medical records. Bivariate analysis was conducted to compare patients with relapsing and monophasic MOGAD. Significant variables were included in a stepwise multiple regression analysis to identify independent predictors of relapse.

RESULTS

Eighty-seven MOGAD patients from 8 public hospitals were included. Relapsing MOGAD was found in 35.6% (n = 31). Mean diagnostic delay was 3.2 (±6.2) years and time to relapse was 4.4 (±6.4) years. Multiple logistic regression showed that higher neutrophil count (p < 0.01), presence of oligoclonal bands (p = 0.025) and no bridging corticosteroids (p = 0.038) at first attack were predictive of relapsing MOGAD.

CONCLUSION

Neutrophil count and oligoclonal bands at first attack may facilitate early decision-making regarding maintenance immunotherapy. Bridging corticosteroids may also influence the course of MOGAD. Further studies with prospective design are warranted.

MRI management of NMOSD and MOGAD: Proposals from the French Expert Group NOMADMUS

BACKGROUND

Currently, there are no available recommendations or guidelines on how to perform MRI monitoring in the management of neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). The issue is to determine a valuable MRI monitoring protocol to be applied in the management of NMOSD and MOGAD, as previously proposed for the monitoring of multiple sclerosis.

OBJECTIVES

The objectives of this work are to establish proposals for a standardized and feasible MRI acquisition protocol, and to propose control time points for systematic MRI monitoring in the management of NMOSD and MOGAD.

METHODS

A steering committee composed of 7 neurologists and 5 neuroradiologists, experts in NMOSD and MOGAD from the French group NOMADMUS, defined 8 proposals based on their expertise and a review from the literature. These proposals were then submitted to a Rating Group composed of French NMOSD / MOGAD experts.

RESULTS

In the management of NMOSD and MOGAD, a consensus has been reached to perform systematic MRI of the brain, optic nerve and spinal cord, including cauda equina nerve roots, at the time of diagnosis, both without and after gadolinium administration. Moreover, it has been agreed to perform a systematic MRI scan 6 months after diagnosis, focusing on the area of interest, both without and after gadolinium administration. For long-term follow-up of NMOSD and MOGAD, and in the absence of clinical activity, it has been agreed to perform gadolinium-free MRI of the brain (+/- optic nerves) and spinal cord, every 36 months. Ideally, these MRI scans should be performed on the same MRI system, preferably a 3T MRI system for brain and optic nerve MRI, and at least a 1.5T MRI system for spinal cord MRI.

CONCLUSIONS

This expert consensus approach provides physicians with proposals for the MRI management of NMOSD and MOGAD.

The real-world applicability of the 2023 international myelin oligodendrocyte glycoprotein antibody-associated disease criteria in a Latin American cohort

BACKGROUND AND PURPOSE

The diagnostic criteria for myelin oligodendrocyte glycoprotein antibody (MOG-IgG)-associated disease (MOGAD) were published in 2023. We aimed to determine the performance of the new criteria in Latin American (LATAM) patients compared with the 2018 criteria and explore the significance of MOG-IgG titers in diagnosis.

METHODS

We retrospectively reviewed the medical records of LATAM (Argentina, Chile, Brazil, Peru, Ecuador, and Colombia) adult patients with one clinical MOGAD event and MOG-IgG positivity confirmed by cell-based assay. Both 2018 and 2023 MOGAD criteria were applied, calculating diagnostic performance indicators.

RESULTS

Among 171 patients (predominantly females, mean age at first attack = 34.1 years, mean disease duration = 4.5 years), 98.2% patients met the 2018 criteria, and of those who did not fulfill diagnostic criteria (n = 3), all tested positive for MOG-IgG (one low-positive and two without reported titer). Additionally, 144 (84.2%) patients met the 2023 criteria, of whom 57 (39.5%) had MOG-IgG+ titer information (19 clearly positive and 38 low-positive), whereas 87 (60.5%) patients had no MOG-IgG titer. All 144 patients met diagnostic supporting criteria. The remaining 27 patients did not meet the 2023 MOGAD criteria due to low MOG-IgG (n = 12) or lack of titer antibody access (n = 15), associated with the absence of supporting criteria. The 2023 MOGAD criteria showed a sensitivity of 86% (95% confidence interval = 0.80-0.91) and specificity of 100% compared to the 2018 criteria.

CONCLUSIONS

These findings support the diagnostic utility of the 2023 MOGAD criteria in an LATAM cohort in real-world practice, despite limited access to MOG-IgG titration.

Long-term follow-up MR imaging in children with transverse myelitis

BACKGROUND

We recently described magnetic resonance imaging (MRI) features of children with transverse myelitis (TM) at first event with important and unique differences depending on the underlying disease entity.

OBJECTIVE

To study the resolution of lesions over time in children with TM due to MOG-antibody associated disorders (MOGAD), multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSD) or double seronegative TM.

PATIENTS AND METHODS

In this prospective study, 78 children from 29 different medical centres with TM as part of MOGAD (n = 34), MS (n = 20), NMOSD (n = 5) and in double seronegative children (n = 19) were included. A grading system consisting of 4 grades (grade 0 = complete resolution; grade 3 = no resolution at all) was used to compare the degree of lesion resolution over time in the different disease entities. Time to lesion resolution was evaluated by Kaplan-Meier statistics and log-rank test.

RESULTS

Significant differences of the interval between first MRI until resolution of lesions were observed between the four disease entities. The most rapid and complete resolution was seen in MOGAD, followed by double seronegative, MS and NMOSD. Median periods until total resolution (grade 0) were 191 days (MOGAD), 750 days (double seronegative), 1117 days (MS), while none of the patients with NMOSD reached a complete resolution during the observation period. The better prognosis of MOGAD compared to MS was independent of sex, age, oligoclonal bands and cell count in the multivariate Cox analysis (P < 0.001).

CONCLUSION

Children with TM and antibodies to MOG show a faster resolution of radiological lesions compared to children with MS and NMOSD.

Clinical characteristics of pediatric and adult myelin oligodendrocyte antibody-associated disease (MOGAD): A single-center study in the Northeast

BACKGROUND

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an immune-mediated, inflammatory, demyelinating disorder with a range of clinical presentations including acute disseminated encephalomyelitis (ADEM), optic neuritis (ON), myelitis, and cerebral cortical encephalitis. Phenotypic expression of MOGAD varies with age. MOG antibody (MOG-Ab) titers at disease onset, as well as longitudinally, may predict clinical disease course. The objectives of this study were to (1) describe a cohort of pediatric and adult patients with MOGAD at a single center and (2) investigate if clinical outcomes correlate with ethnicity and MOG-Ab.

METHODS

The clinical data of 36 pediatric and adult patients with MOGAD who were evaluated at onset and longitudinally were collected between January 2018 and June 2023 at our center. Inclusion criteria were positive MOG-Ab titers, a presentation consistent with proposed consensus criteria for MOGAD, and at least one initial or follow-up visit at our center. Patients were divided into monophasic and relapsing courses. Demographic data and clinical phenotypes were assessed as possible predictors of relapsing disease.

RESULTS

We describe demographic and clinical characteristics of 36 patients with MOGAD. Hispanic adults and children had increased rates of disease relapse compared to other ethnicities. Male sex and pediatric onset disease were also associated with increased risk of relapse. MOG-Ab titers at disease onset were not associated with a particular disease course. In adults, an initial phenotype of unilateral optic neuritis was associated with monophasic disease.

CONCLUSION

Our findings within a diverse population suggest that specific characteristics, both of patients and of disease presentation, may be associated with a monophasic or relapsing course. Additional studies with larger cohorts are needed.

Preceding hepatitis B virus infection is highly prevalent in patients with neuromyelitis optica spectrum disorder in Taiwan

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune inflammatory disease of the central nervous system, characterized by pathogenic anti-Aquaporin-4 antibodies (AQP4-Ab). Given that infections can trigger autoimmune responses, we investigated the association between Hepatitis B virus (HBV) infection and NMOSD.

METHODS

HBV and hepatitis C virus serologies were analyzed in 105 NMOSD patients, 85 multiple sclerosis (MS) patients, and 1,661 healthy Taiwanese controls. Participants were classified into four HBV infection statuses (acute, chronic, resolved, and never infected), and further grouped by vaccination status. Logistic regression was used to estimate odds ratios (OR) for NMOSD development in individuals with chronic or resolved HBV infection.

RESULTS

Among those born before the Taiwan's universal vaccination program, 63.4 % of NMOSD patients had resolved HBV infection, compared to 30.6 % of MS patients and 16.4 % of controls. Resolved HBV infection was associated with a 2.3-fold increased risk for NMOSD development (95 % CI, 1.4-3.8), but not with MS risk. In the post-vaccination cohort, resolved HBV infection remained more frequent in NMOSD patients (8.7 %) than in MS (0 %) and controls (1.8 %). NMOSD patients with resolved HBV infection had later disease onset by 14.6 years and higher Expanded Disability Status Scale (EDSS) scores compared to those without HBV infection, even after adjusting for age and sex (3.5 ± 1.9 vs. 2.2 ± 1.8, p < 0.001).

CONCLUSION

Preceding HBV infection is prevalent among Taiwanese NMOSD patients and is associated with increased disease risk, older age at onset, and greater disability. Screening for HBV is essential for NMOSD patients, particularly in endemic regions.

Slowly Expanding Lesions Differentiate Pediatric Multiple Sclerosis from Myelin Oligodendrocyte Glycoprotein Antibody Disease

Slowly expanding lesions (SELs) in adults with multiple sclerosis (MS) indicate a progressive pathological process. Whether SELs are present in pediatric-onset MS (POMS) or myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is unknown. We studied 19 children with POMS and 14 with MOGAD (median age 14.3 and 9.4 years, respectively) recruited to the Canadian Pediatric Demyelinating Disease Study with: (1) ≥3 research scans 12 months apart; and (2) ≥1 T2-lesions on the earliest scan. A total of 70 SELs from 16 POMS participants and 1 SEL in the MOGAD group were detected. SELs are an early feature of POMS and essentially not a feature of MOGAD. ANN NEUROL 2024;96:1086-1091.

New insights into the use of high dose corticosteroids and plasmapheresis in persons with MOGAD and NMOSD

BACKGROUND

Anti-myelin oligodendrocyte glycoprotein associated disease (MOGAD) and neuromyelitis optica spectrum disease (NMOSD) are antibody mediated diseases characterized by neurological symptoms including recurrent relapses of optic neuritis and/or myelitis, as well as other less frequent syndromes. The current treatment for acute attacks of NMOSD/MOGAD are based on clinical studies for other demyelinating diseases(i.e. Multiple Sclerosis). In NMOSD, high dose corticosteroids (HDS) are considered the standard first line therapy, with emerging evidence supporting the use of plasmapheresis (PLEX) as an acute therapy. In MOGAD, being a relatively new clinical syndrome, the consensus on acute treatments is yet to be reached. The objective of our study was to assess the efficacy of treatment regimens (no treatment vs. HDS vs. HDS and PLEX) on disability outcomes in persons with NMOSD and MOGAD-optic neuritis and myelitis.

METHODS

We retrospectively extracted data from the MuSicaL-NeMo database using a mixed Natural Language Processing followed by investigators verification. We assessed the change in Expanded Disability Status Scale (EDSS) and Visual Acuity (VA) following HDS and PLEX, in persons with MOGAD and NMOSD following myelitis and optic neuritis. We used the novel statistical measure Wilcoxon-Mann-Whitney Odd (WMW-Odd) to calculate the change through all the spectrum of each ordinal scale (VA and EDSS).

RESULTS

Eleven myelitis and 12 optic neuritis in 22 persons with MOGAD and 30 myelitis and 12 optic neuritis in 20 persons with NMOSD were included(15 Aquaporin-4 seropositive). In persons with MOGAD-optic neuritis the group receiving HDS had a WMW-Odd of 15.33(p ≤ 0.001), however those not receiving treatment also tended to improve (WMW-Odd=3.17, p = 0.06). NMOSD-optic neuritis treated with HDS only improve 33.3 % of the times (p=NS). Persons with MOGAD-myelitis receiving HDS significantly improved (WMW-Odd=7.33, p = 0.002). Persons with NMOSD-myelitis treated with HDS had an WMW-Odd of 2.56 (p = 0.002) and those treated with PLEX plus HDS (PLEX+), had similar WMW-Odd of 2.51 (p = 0.03). When correcting for disease severity by restricting inclusion to persons with NMOSD with EDSS≥4, both treatments showed a higher WMW-Odd, however the group receiving HDS continued to show higher WMW-Odd than the PLEX+ group(WMW-Odd= 3.75, p = 0.002 vs. WMW-Odd =3.05, p = 0.02, respectvely) CONCLUSION: Our study suggests that persons with MOGAD-optic neuritis improve without acute treatments, however they have very marked improvement when using HDS, as previously suggested. Patient with MOGAD-myelitis are also very responsive to HDS, however, as compared to MOGAD-optic neuritis, they displayed less improvement, if not treated. In the NMOSD group the use of PLEX in addition to HDS did not demonstrate any significant difference in EDSS outcomes. Contrary to previous suggestions, when adjusting for group differences (by only including EDSS ≥4), the use of HDS and PLEX+ did not show better results than the group using HDS.

Frequency of anti-MOG antibodies in serum and CSF of patients with possible autoimmune encephalitis: Results from a Brazilian multicentric study

INTRODUCTION

MOGAD encephalitis and ADEM share several clinical features with autoimmune encephalitis (AE) associated with antineuronal antibodies (ANeA); nonetheless, treatment and prognosis differ. Anti-MOG antibodies (abs) are not routinely tested in possible AE, and epidemiological studies on MOGAD encephalitis are scarce.

OBJECTIVES

To determine the frequency of anti-MOG abs in the serum and CSF in a cohort of possible AE and to compare the clinical characteristics of MOGAD patients and those with seropositive AE.

METHODS

481 patients with possible AE from the Brazilian Autoimmune Encephalitis Network underwent tissue-based assay and cell-based assay (CBA) for ANeA. Anti-MOG abs were assessed in serum and CSF with in-house CBA. Clinical and laboratory characteristics of MOGAD and seropositive AE patients were compared.

RESULTS

Of the 481 patients, 87 (18 %) had ANeA, and 17 (3.5 %) had anti-MOG abs. Three AE patients with anti-MOG abs and ANeA were excluded from further analysis. Anti-MOG abs were detected in 4 (1.2 %) of the 328 adults and 10 (6.5 %) of the 153 children. Of the 14 patients with MOGAD, nine had ADEM (mostly children), and five had encephalitis (including three adults). Only one patient with ADEM had anti-MOG abs exclusively in CSF. All patients with MOGAD encephalitis were seropositive for anti-MOG abs, and three had normal brain MRI. Patients with MOGAD had fewer behavioral changes (MOGAD 21 % x AE 96 %, p ≤ 0.0001) and movement disorders (MOGAD 42 % x AE 81 %, p = 0.0017) and more demyelinating symptoms, such as myelitis and optic neuritis (MOGAD 14 % x AE 0 %, p = 0.013).

CONCLUSION

Approximately 3.5 % of patients with possible AE harbor anti-MOG abs, and 0.9 % of the adults had MOGAD encephalitis. Anti-MOG abs were more frequent than other ANeAs regularly tested in AE. We provide evidence that MOGAD is a differential diagnosis in possible AE, even in adult patients with normal brain MRI, and that serum anti-MOG should be considered as an add-on diagnostic tool in AE among adults and pediatric patients.

Pediatric MOG-Ab-Associated Encephalitis: Supporting Early Recognition and Treatment

BACKGROUND AND OBJECTIVES

Antibodies to myelin oligodendrocyte glycoprotein (MOG-Ab) have recently been reported in patients with encephalitis who do not fulfill criteria for acute disseminated encephalomyelitis (ADEM). We evaluated a cohort of these children and compared them with children with ADEM.

METHODS

This retrospective, multicenter cohort study comprised consecutive patients <18 years of age with MOG-Ab who fulfilled criteria for autoimmune encephalitis. These patients were stratified into (1) children not fulfilling criteria for ADEM (encephalitis phenotype) and (2) children with ADEM. Clinical/paraclinical data were extracted from the electronic records. Comparisons were made using the Mann-Whitney U test and χ2 Fisher exact test for statistical analysis.

RESULTS

From 235 patients with positive MOG-Ab, we identified 33 (14%) with encephalitis and 74 (31%) with ADEM. The most common presenting symptoms in children with encephalitis were headache (88%), seizures (73%), and fever (67%). Infective meningoencephalitis was the initial diagnosis in 67%. CSF pleocytosis was seen in 79%. Initial MRI brain was normal in 8/33 (24%) patients. When abnormal, multifocal cortical changes were seen in 66% and unilateral cortical changes in 18%. Restricted diffusion was demonstrated in 43%. Intra-attack new lesions were seen in 7/13 (54%). When comparing with children with ADEM, children with encephalitis were older (median 8.9 vs 5.7 years, p = 0.005), were more likely to be admitted to intensive care (14/34 vs 4/74, p < 0.0001), were given steroid later (median 16.6 vs 9.6 days, p = 0.04), and were more likely to be diagnosed with epilepsy at last follow-up (6/33 vs 1/74, p = 0.003).

DISCUSSION

MOG-Ab should be tested in all patients with suspected encephalitis even in the context of initially normal brain MRI. Although exclusion of infections should be part of the diagnostic process of any child with encephalitis, in immunocompetent children, when herpes simplex virus CSF PCR and gram stains are negative, these features do not preclude the diagnosis of immune mediated disease and should not delay initiation of first-line immunosuppression (steroids, IVIG, plasma exchange), even while awaiting the antibody results.

Pediatric acquired demyelinating syndromes: updates in diagnosis, testing, and management

PURPOSE OF REVIEW

To highlight the clinical presentation, diagnostic approach, and management of acquired inflammatory demyelinating syndromes in children.

RECENT FINDINGS

The identification of myelin oligodendrocyte glycoprotein antibody-associated disease in 2017 and evolving evidence regarding best practices for management has had a significant impact on pediatric neuroimmunology, as has the shift in treatment of pediatric-onset multiple sclerosis, with the use of high-efficacy disease-modifying therapies early in the disease course.

SUMMARY

With expanding awareness and growing interest in pediatric onset neuroinflammatory conditions, the number of children diagnosed with acquired demyelinating syndromes is rising. It is critical to refine our understanding of the underlying pathophysiological mechanisms in these disorders to provide the most effective care. Much of our practice continues to be modeled on adult care, and further large-scale pediatric studies are necessary to explore the natural history and assess the safety and efficacy of immunotherapies in childhood-onset demyelinating diseases.

Extensive brainstem lesions in myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD): A case report

Myelin oligodendrocyte glycoprotein antibody-associated disease is a group of central nervous system demyelinating disorders caused by autoantibodies. While myelin oligodendrocyte glycoprotein antibody-associated disease typically presents as optic neuritis and myelitis in adults, this case report details a patient with brainstem lesions. A 45-year-old male presented with episodes of vertigo, nystagmus, and diplopia in left lateral gaze, which had persisted for 2 months, accompanied by headache. Computed tomography showed hyperdensity extending from the left side of the pons to the middle cerebellar peduncle. Magnetic resonance imaging revealed lesions exhibiting heterogeneous diffusion restriction, with enhancement that included granular and linear patterns. 18F-fluorodeoxyglucose positron emission tomography demonstrated increased uptake in these lesions. Following further evaluation, myelin oligodendrocyte glycoprotein antibody-associated disease was diagnosed. Treatment with high-dose corticosteroids initially alleviated symptoms, but symptoms flared upon reduction of the steroids. This case underscores the importance of considering myelin oligodendrocyte glycoprotein antibody-associated disease in the differential diagnosis of brainstem lesions and discusses distinguishing imaging features from similar conditions.

Cognitive Impairment, Associated Clinical Factors, and MR Volumetric Measures in Myelin Oligodendrocyte Glycoprotein-IgG-Associated Disease

BACKGROUND AND OBJECTIVES

Cognitive impairment is a common and challenging symptom in multiple sclerosis and neuromyelitis optica spectrum disease; however, data in myelin oligodendrocyte glycoprotein-IgG-associated disease (MOGAD) remain scarce. In this cross-sectional study, we investigated the frequency of cognitive impairment, associated clinical factors, and MRI volumetric measures in MOGAD.

METHODS

Participants were investigated in a single center by certified psychologists and underwent a standardized 3-T-MRI protocol. MRI data were processed with FreeSurfer for gray and white matter volume estimation, presented as a fraction of total intracranial volume. Sera screening for antineural antibodies has been conducted using cell-based assays. The following clinical factors were included in the multivariate logistic regression analysis: sex, age, overall number of previous relapses, and specifically the history of acute disseminated encephalomyelitis (ADEM)/ADEM-like episodes and other brain relapses.

RESULTS

Thirty-two patients with MOGAD (19 female, median age 29.4 years) after a median of 2 relapses with a median EDSS of 1.0 were recruited. Seven patients (21.9%) demonstrated cognitive impairment with the most prevalent deficits in mental flexibility (16.7%), attention (11.1%-14.8%), and verbal working memory (10.3%). 72.4% suffered from fatigue and 42.9% from signs of depression, moderate to severe in 28.6%. The overall number of previous relapses (odds ratio [OR] 1.789, 95% CI 1.041-3.074) and specifically ADEM/ADEM-like episodes (OR 16.929, 95% CI 1.228-233.427) were the only clinical factors associated with cognitive impairment in a multivariate logistic regression model. Screening for antineuronal antibodies remained negative. Cerebral white matter (WM) (0.300 vs 0.317, p = 0.003) and deep gray matter (DGM) (0.036 vs 0.038, p = 0.002) volumes were reduced in patients with MOGAD compared with healthy controls (n = 32). Both cognitive impairment (0.031 vs 0.036, p = 0.003) and history of ADEM/ADEM-like episodes (0.032 vs 0.036, p = 0.006) were associated with reduced DGM volume compared with unaffected patients with MOGAD.

DISCUSSION

Despite a low overall disability, every 5th patient with MOGAD experiences cognitive impairment. Cognitive impairment is associated with a higher number of relapses and particularly ADEM/ADEM-like attacks. Although both WM and DGM atrophies are apparent in MOGAD, the latter only seems to have an association with cognitive impairment.

The magnetic resonance imaging (MRI) features of intracranial lesions in myelin oligodendrocyte glycoprotein-immunoglobulin G-associated disease (MOGAD)

AIM

This study aimed to summarise and analyse the magnetic resonance imaging (MRI) characteristics of patients with myelin oligodendrocyte glycoprotein-immunoglobulin G-associated disease (MOGAD), and to enhance the accuracy of disease diagnosis and advance scientific research.

MATERIALS AND METHODS

A retrospective collection of clinical data from 103 patients with MOGAD was conducted. The distribution and signal characteristics of intracranial lesions on MRI were analysed. Further subgroup statistical analysis based on age was performed to explore differences in lesion locations among different subgroups. Statistical comparisons were made using the χ2 test or Fisher's exact test, with a significance level of P < 0.05 considered statistically significant.

RESULTS

MRI revealed variable lesion morphologies in patients with MOGAD. Lesions were predominantly located in the cerebral deep white matter (47.6%), subcortical white matter (38.8%), and cortex (38.8%) of the supratentorial region, as well as in the brainstem (35.9%) of the infratentorial region. Notably, there was a significantly higher proportion of juvenile patients with thalamic involvement than adult patients (P = 0.013). Juvenile patients were more likely to have lesions involving both the thalamus and cerebral cortex (P = 0.040), thalamus and deep white matter (P = 0.026), or thalamus and brainstem (P = 0.014). Conversely, lesions involving both the corpus callosum and subcortical white matter were more frequently observed in adult patients, with statistically significant differences (P = 0.046). Contrast-enhanced MRI showed mild enhancement in some lesions, with a half of cases exhibiting leptomeningeal enhancement. One rare case presented extensive thickening and enhancement of the falx cerebri.

CONCLUSION

The distribution of intracranial lesions on MRI exhibits distinct characteristics. The differences in the spatial distribution of intracranial lesions between juvenile and adult patients suggest that MOGAD may represent a heterogeneous disease spectrum that varies with age.

Association of peripapillary retinal nerve fiber layer atrophy with cognitive impairment in patients with neuromyelitis optica spectrum disorder

BACKGROUND

We aimed to explore the association between peripapillary retinal nerve fiber layer thickness (pRNFL), macular ganglion cell-inner plexiform layer (mGCIPL), and cognitive impairment (CI) in patients with neuromyelitis optica spectrum disorder (NMOSD).

METHOD

In this cross-sectional study, 38 (28 aquaporin-4 (AQP4) IgG-seropositive) NMOSD patients and 20 healthy controls (HC) underwent cognitive assessment using Minimal Assessment of Cognitive Function in Multiple Sclerosis (MACFIMS) battery. Spectral-domain optical coherence tomography (OCT) was performed for both eyes of all NMOSD patients. First, we examined the association of pRNFL and mGCIPL with cognitive function in all patients, regardless of the history of previous optic neuritis (ON). We then included only eyes without a prior history of ON, incorporating non-ON eyes in patients with unilateral ON and the average of OCT measures for both non-ON eyes in patients without a history of ON.

RESULTS

Sixteen (42.1%) NMOSD patients exhibited global CI. There was a significant decrease in pRNFL (Δ: 24.33 μm, p = 0.002) and mGCIPL (Δ: 9.20 μm, p = 0.009) in NMOSD patients with CI compared to those without. The atrophy of pRNFL showed an inverse association with CI before (OR = 1.059, 95% CI: 1.015, 1.105) and after adjustment for age, sex, and disease duration (OR = 1.072, 95%CI: 1.009, 1.139). An inverse significant association was observed between mGCIPL atrophy and CI before adjustment (OR = 1.102, 95% CI: 1.017, 1.194), but not after adjustment (OR = 1.106, 95%CI: 0.999, 1.224). After narrowing our analysis to non-ON eyes, the same results for pRNFL and CI were observed (unadjusted: OR = 1.054, 95% CI: 1.004, 1.106; adjusted: OR = 1.081, 95%CI: 1.000, 1.168). There was no significant association found between mGCIPL thickness and CI in both unadjusted and adjusted models. In sensitivity analyses, we observed no significant association between pRNFL and mGCIPL with CI in AQP-IgG-seropositive NMOSD patients.

CONCLUSION

This study, for the first time, provide a preliminary evidence for a possible relation between pRNFL atrophy and occurrence of cognitive impairment in NMOSD patients. Further studies are required to explore the possible association of OCT parameters with cognition function in NMOSD patients.

Clinical, prognostic and pathophysiological implications of MOG-IgG detection in the CSF: the importance of intrathecal MOG-IgG synthesis

BACKGROUND

Cerebrospinal fluid myelin oligodendrocyte glycoprotein IgG (CSF MOG-IgG) are found in a proportion of patients with MOG antibody-associated disorder (MOGAD) and have been associated with severe disease presentations. However, most studies did not systematically investigate the role of MOG-IgG intrathecal synthesis (ITS).

METHODS

We retrospectively studied 960 consecutive patients with paired serum and CSF samples screened for MOG-IgG using a live cell-based assays. MOG-IgG-specific antibody index (AIMOG) was systematically calculated using serum and CSF titres to assess MOG-IgG ITS, and clinical features were compared between MOG-IgG CSF+/CSF- and ITS+/ITS- patients.

RESULTS

MOG-IgG were found in 55/960 patients (5.7%; serum+/CSF-: 58.2%, serum+/CSF+: 34.5%; serum-/CSF+: 7.3%). Serum/CSF MOG-IgG titres showed a moderate correlation in patients without ITS (ρ=0.47 (CI 0.18 to 0.68), p<0.001), but not in those with ITS (ρ=0.14 (CI -0.46 to -0.65), p=0.65). There were no clinical-paraclinical differences between MOG-IgG CSF+ vs CSF- patients. Conversely, patients with MOG-IgG ITS showed pyramidal symptoms (73% vs 32%, p=0.03), spinal cord involvement (82% vs 39%, p=0.02) and severe outcome at follow-up (36% vs 5%, p=0.02) more frequently than those without MOG-IgG ITS. A multivariate logistic regression model indicated that MOG-IgG ITS was an independent predictor of a poor outcome (OR: 14.93 (CI 1.40 to 19.1); p=0.03). AIMOG correlated with Expanded Disability Status Scale (EDSS) scores at disease nadir and at last follow-up (p=0.02 and p=0.01).

CONCLUSIONS

Consistently with physiopathology, MOG-IgG ITS is a promising prognostic factor in MOGAD, and its calculation could enhance the clinical relevance of CSF MOG-IgG testing, making a case for its introduction in clinical practice.

Myelin oligodendrocyte glycoprotein antibody-associated disease with histopathologic features of primary CNS angiitis without demyelination: Case report and literature review

Primary angiitis of the central nervous system (PACNS) is a rare inflammatory disease that affects both small- and medium-sized vessels of the CNS, while myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) is a novel antibody-mediated inflammatory demyelinating disorder that causes damage to the myelin in CNS. We report a case diagnosed as MOGAD due to a history of recurrent myelitis, brain lesions, and positive anti-MOG, but the brain biopsy showed vasculitis without demyelination.

Spectrum of Auto-antibodies in NMO and MOG Associated CNS Demyelination- The SANMAD Study

This observational study explored coexisting organ-specific and non-organ-specific autoantibodies in Neuromyelitis optica spectrum disorder(NMOSD) and Myelin oligodendrocyte glycoprotein-IgG-1(MOG-IgG1) associated central nervous system demyelination(MOGAD) in a South Asian cohort from March 2017-2023. Of the 250 cases, 148 were MOGAD(82pediatric) and 102 were NMOSD(15 pediatric). 17.6 % tested positive for ≥1 antibody, with NMOSD showing a higher positivity rate (25.5 %) than MOGAD(12.2 %,p = 0.011). Double antibody positivity occurred more in NMOSD (5.9 %vs.MOGAD,1.4 %,p = 0.045). Three NMOSD cases had Sjogren syndrome with higher Anti-Ro-52 prevalence(12.7 %vs.4.1 %,p = 0.014). NMOSD patients with ≥1 antibody positivity had more constitutional symptoms (45.5 %vs.23.1 %,p = 0.045). Significant associations were found between NMOSD and female gender, having ≥1 antibody-positive status, and testing positive for Anti-Ro-52 and SS-A antibodies (p < 0.05).