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Cacciaguerra L, Abdel-Mannan O, Champsas D, Mankad K, Krecke KN, Chen JJ, Syc-Mazurek SB, Redenbaugh V, Lopez-Chiriboga AS, Valencia-Sanchez C, Hemingway C, Tillema JM, Ciccarelli O, Pittock SJ, Hacohen Y, Flanagan EP. Radiologic Lag and Brain MRI Lesion Dynamics During Attacks in MOG Antibody-Associated Disease. Neurology 2024; 102:e209303. [PMID: 38710000 DOI: 10.1212/wnl.0000000000209303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Knowledge of the evolution of CNS demyelinating lesions within attacks could assist diagnosis. We evaluated intra-attack lesion dynamics in patients with myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) vs multiple sclerosis (MS) and aquaporin-4 antibody seropositive neuromyelitis optica spectrum disorder (AQP4+NMOSD). METHODS This retrospective observational multicenter study included consecutive patients from Mayo Clinic (USA) and Great Ormond Street Hospital for Children (UK). Inclusion criteria were as follows: (1) MOGAD, MS, or AQP4+NMOSD diagnosis; (2) availability of ≥2 brain MRIs (within 30 days of attack onset); and (3) brain involvement (i.e., ≥1 T2 lesion) on ≥1 brain MRI. The initial and subsequent brain MRIs within a single attack were evaluated for the following: new T2 lesions(s); resolved T2 lesion(s); both; or no change. This was compared between MOGAD, MS, and AQP4+NMOSD attacks. We used the Mann-Whitney U test and χ2/Fisher exact test for statistical analysis. RESULTS Our cohort included 55 patients with MOGAD (median age, 14 years; interquartile range [IQR] 5-34; female sex, 29 [53%]) for a total of 58 attacks. The comparison groups included 38 patients with MS, and 19 with AQP4+NMOSD. In MOGAD, the initial brain MRI (median of 5 days from onset [IQR 3-9]) was normal in 6/58 (10%) attacks despite cerebral symptoms (i.e., radiologic lag). The commonest reason for repeat MRI was clinical worsening or no improvement (33/56 [59%] attacks with details available). When compared with the first MRI, the second intra-attack MRI (median of 8 days from initial scan [IQR 5-13]) showed the following: new T2 lesion(s) 27/58 (47%); stability 24/58 (41%); resolution of T2 lesion(s) 4/58 (7%); or both new and resolved T2 lesions 3/58 (5%). Findings were similar between children and adults. Steroid treatment was associated with resolution of ≥1 T2 lesion (6/28 [21%] vs 1/30 [3%], p = 0.048) and reduced the likelihood of new T2 lesions (9/28 vs 18/30, p = 0.03). Intra-attack MRI changes favored MOGAD (34/58 [59%]) over MS (10/38 [26%], p = 0.002) and AQP4+NMOSD (4/19 [21%], p = 0.007). Resolution of ≥1 T2 lesions was exclusive to MOGAD (7/58 [12%]). DISCUSSION Radiologic lag is common within MOGAD attacks. Dynamic imaging with frequent appearance and occasional disappearance of lesions within a single attack suggest MOGAD diagnosis over MS and AQP4+NMOSD. These findings have implications for clinical practice, clinical trial attack adjudication, and understanding of MOGAD pathogenesis.
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Affiliation(s)
- Laura Cacciaguerra
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Omar Abdel-Mannan
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Dimitrios Champsas
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Kshitij Mankad
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Karl N Krecke
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - John J Chen
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Stephanie B Syc-Mazurek
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Vyanka Redenbaugh
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Alfonso S Lopez-Chiriboga
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Cristina Valencia-Sanchez
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Cheryl Hemingway
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Jan-Mendelt Tillema
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Olga Ciccarelli
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Sean J Pittock
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Yael Hacohen
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
| | - Eoin P Flanagan
- From the Department of Neurology and Mayo Clinic Center for Multiple Sclerosis and Autoimmune Neurology (L.C., J.J.C., S.B.S.-M., V.R., J.-M.T., S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Queen Square MS Centre (O.A.-M., D.C., C.H., O.C., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.-M., D.C., C.H., Y.H.), and Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London, United Kingdom; Department of Radiology (K.N.K.), Department of Ophthalmology (J.J.C.), and Laboratory Medicine and Pathology (S.J.P., E.P.F.), Mayo Clinic, Rochester, MN; Department of Neurology (A.S.L.-C.), Mayo Clinic, Jacksonville, FL; Department of Neurology (C.V.-S.), Mayo Clinic, Phoenix, AZ; and NIHR University College London Hospitals Biomedical Research Centre (O.C.), United Kingdom
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Elsbernd P, Cacciaguerra L, Krecke KN, Chen JJ, Gritsch D, Lopez-Chiriboga AS, Sechi E, Redenbaugh V, Morris PP, Carter JL, Wingerchuk DM, Tillema JM, Valencia-Sanchez C, Thakolwiboon S, Pittock SJ, Flanagan EP. Cerebral enhancement in MOG antibody-associated disease. J Neurol Neurosurg Psychiatry 2023; 95:14-18. [PMID: 37221051 PMCID: PMC10679850 DOI: 10.1136/jnnp-2023-331137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/08/2023] [Indexed: 05/25/2023]
Abstract
INTRODUCTION Limited data exist on brain MRI enhancement in myelin-oligodendrocyte-glycoprotein (MOG) antibody-associated disease (MOGAD) and differences from aquaporin-4-IgG-positive-neuromyelitis-optica-spectrum-disorder (AQP4+NMOSD), and multiple sclerosis (MS). METHODS In this retrospective observational study, we identified 122 Mayo Clinic MOGAD patients (1 January 1996-1 July 2020) with cerebral attacks. We explored enhancement patterns using a discovery set (n=41). We assessed enhancement frequency and Expanded Disability Status Scale scores at nadir and follow-up in the remainder (n=81). Two raters assessed T1-weighted-postgadolinium MRIs (1.5T/3T) for enhancement patterns in MOGAD, AQP4+NMOSD (n=14) and MS (n=26). Inter-rater agreement was assessed. Leptomeningeal enhancement clinical correlates were analysed. RESULTS Enhancement occurred in 59/81 (73%) MOGAD cerebral attacks but did not influence outcome. Enhancement was often patchy/heterogeneous in MOGAD (33/59 (56%)), AQP4+NMOSD (9/14 (64%); p=0.57) and MS (16/26 (62%); p=0.63). Leptomeningeal enhancement favoured MOGAD (27/59 (46%)) over AQP4+NMOSD (1/14 (7%); p=0.01) and MS (1/26 (4%); p<0.001) with headache, fever and seizures frequent clinical correlates. Ring enhancement favoured MS (8/26 (31%); p=0.006) over MOGAD (4/59 (7%)). Linear ependymal enhancement was unique to AQP4+NMOSD (2/14 (14%)) and persistent enhancement (>3 months) was rare (0%-8%) across all groups. Inter-rater agreement for enhancement patterns was moderate. CONCLUSIONS Enhancement is common with MOGAD cerebral attacks and often has a non-specific patchy appearance and rarely persists beyond 3 months. Leptomeningeal enhancement favours MOGAD over AQP4+NMOSD and MS.
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Affiliation(s)
- Paul Elsbernd
- Department of Neurology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Laura Cacciaguerra
- Department of Neurology, Vita-Salute San Raffaele University, Milano, Italy
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Karl N Krecke
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - John J Chen
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
| | - David Gritsch
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
- Department of Neurology, Mass General Brigham Inc, Boston, Massachusetts, USA
| | | | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Vyanka Redenbaugh
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Jan-Mendelt Tillema
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of pediatrics, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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