Discussion | We found that most patients with MOGAD had a favorable long-term outcome without secondary progression despite frequent relapses, differing from that reported with multiple sclerosis (MS) and aquaporin-4-IgG neuromyelitis optica spectrum disorders (NMOSDs).Our finding of just 7% having an EDSS score of 6 or greater and 7% unilaterally blind or worse after a median of 14 years of follow-up is similar to outcomes in previous studies with shorter follow-up. 1,2,4 While some long-term deficit was accumulated from the presenting attack (similar to prior reports), 1 additional attack-related EDSS score worsening in most patients suggests that attack prevention may be associated with lower long-term disability in relapsing MOGAD. Disability is less than with aquaporin-4-IgG NMOSD, with 65% being unilaterally blind or worse and 30% having an EDSS score of 6 or greater after a median of 8.3 years in a prior study. 5 These contrasting outcomes support biomarker-based over syndromic-based diagnostic criteria, as NMOSD prognosis with MOG IgG differs markedly from prognosis with aquaporin-4 IgG.A normal MRI (brain/spine) despite multiple radiologically confirmed relapses favors MOGAD over MS where residual T2 lesions are almost universal. No patients with MOGAD developed secondary progression, and a previous study of 200 patients with progressive MS found no MOG IgG seropositives, 6 but younger age and frequent immunosuppressant use in this study could be associated with longer time to progression. Thus, more studies with longer follow-up are needed.Our limitations include risk of acquisition bias from irregular follow-up, overrepresentation of severe cases from referral bias, and underrepresentation of monophasic or milder cases less likely to undergo follow-up. Nonetheless, the inclusion of additional patients with milder disease would support our conclusion that outcomes are good.
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