Evaluation and Treatment Checklist for Multiple Sclerosis and MOGAD
The evaluation and treatment of patients with suspected multiple sclerosis (MS) or Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD) requires distinct diagnostic approaches as these conditions have different pathophysiological mechanisms, treatment responses, and prognoses.
Initial Clinical Evaluation
History
- Acute vs. subacute onset of symptoms
- Evolution pattern (hours/days vs. weeks)
- Previous neurological events
- Family history of demyelinating disease
- Specific symptom patterns:
- MS: Diplopia, paresthesia, paraparesis, optic neuritis, myelopathy
- MOGAD: ADEM-like presentation, bilateral optic neuritis, flares after steroid tapering
- NMOSD: Area postrema syndrome (intractable hiccups/vomiting), severe optic neuritis, myelitis
Neurological Examination
- Visual acuity and fields
- Fundoscopy for optic disc evaluation
- Motor strength and tone assessment
- Sensory examination
- Coordination testing
- Gait assessment
- Check for Lhermitte's sign (electric shock sensation with neck flexion)
Laboratory Investigations
Blood Tests
- Complete blood count
- Comprehensive metabolic panel
- Erythrocyte sedimentation rate
- C-reactive protein
- Vitamin B12 and folate levels
- Thyroid function tests
- MOG-IgG antibody testing (serum is specimen of choice) 1
- AQP4-IgG antibody testing
- HIV, syphilis serology
- Autoimmune panel (ANA, ENA, etc.)
Cerebrospinal Fluid Analysis
- Cell count and differential
- MS: Normal or mild lymphocytic pleocytosis
- MOGAD: Lymphomonocytic pleocytosis with neutrophils in 43% of cases 1
- NMOSD: Neutrophilic pleocytosis
- Protein and glucose levels
- Oligoclonal bands (present in 84-98% of MS cases but only 12-13% of MOGAD cases) 1
- IgG index
- Cytology
- Infectious studies (if indicated)
Imaging Studies
Brain MRI
- Sequences: T1, T2, FLAIR, T1 with gadolinium, DWI
- MS-specific findings:
- Periventricular lesions (Dawson's fingers)
- Juxtacortical lesions
- Infratentorial lesions
- Spinal cord lesions
- Contrast-enhancing lesions
- MOGAD-specific findings:
- ADEM-like presentation with large white matter lesions
- Absence of Dawson's finger lesions (98.6% of cases)
- Absence of U-fiber lesions (94.2% of cases)
- Normal supratentorial MRI in some cases 1
- Follow-up MRI schedule:
Spinal Cord MRI
- Sequences: T1, T2, STIR, T1 with gadolinium
- MS: Short segment lesions, typically <3 vertebral segments
- MOGAD: Both short and longitudinally extensive lesions 1
- NMOSD: Longitudinally extensive transverse myelitis (≥3 vertebral segments)
Optic Nerve MRI
- Sequences: Fat-suppressed T1 with gadolinium, T2
- MS: Unilateral involvement, often partial nerve involvement
- MOGAD: Often bilateral involvement, may involve optic chiasm 1
- NMOSD: Severe involvement, may extend into optic chiasm and tracts
Electrophysiological Studies
- Visual evoked potentials
- Somatosensory evoked potentials
- Motor evoked potentials
Differential Diagnosis Considerations
- MS vs. MOGAD vs. NMOSD
- Acute disseminated encephalomyelitis (ADEM)
- Neurosarcoidosis
- CNS vasculitis
- Infectious causes (Lyme, syphilis, HIV)
- Nutritional deficiencies
- Metabolic disorders
- Vascular disease
Treatment Approach
Acute Attack Management
- High-dose intravenous methylprednisolone (1g daily for 3-5 days) is the first-line treatment for acute attacks in both MS and MOGAD 1
- For MOGAD: Follow with slow oral steroid taper to prevent early relapse 1
- For inadequate response:
- Plasma exchange (5-7 exchanges)
- IVIG (particularly for MOGAD)
Disease-Modifying Therapy for MS
- First-line options:
- Injectable: Interferon-beta, glatiramer acetate
- Oral: Dimethyl fumarate, teriflunomide
- Second-line options:
- Oral: Fingolimod, siponimod
- Infusion: Ocrelizumab, natalizumab
- Treatment selection based on:
- Disease activity
- Risk tolerance
- Comorbidities
- Patient preference
- Pregnancy plans
Maintenance Therapy for MOGAD
- IVIG, rituximab, mycophenolate mofetil, or azathioprine are recommended for maintenance therapy in MOGAD 1
- Avoid MS-specific treatments like interferon-beta or natalizumab, which may increase relapse rates in MOGAD 1
- Check serum IgA level before administering IVIG to prevent severe reactions in patients with IgA deficiency 1
Symptomatic Management
- Fatigue: Energy conservation techniques, amantadine, modafinil
- Spasticity: Physical therapy, baclofen, tizanidine
- Pain: Gabapentin, pregabalin, duloxetine
- Bladder dysfunction: Anticholinergics, intermittent catheterization
- Bowel dysfunction: Dietary modifications, laxatives
- Depression: Counseling, SSRIs
Multidisciplinary Care
- Neurologist
- Nutritionist/dietitian (early detection and treatment of malnutrition) 2
- Speech and language therapist (for swallowing evaluation) 2
- Physiotherapist (for mobility and exercise programs) 2
- Occupational therapist (for adaptive equipment) 2
- Nurse specialist
- Mental health professional
Monitoring and Follow-up
- Regular clinical assessments (every 3-6 months)
- MRI monitoring:
- Laboratory monitoring based on specific DMT
- Assessment of treatment response and side effects
- Evaluation for disease progression
Special Considerations
- Pregnancy planning
- Vaccination schedule
- Lifestyle modifications:
- Smoking cessation
- Regular exercise
- Adequate vitamin D
- Stress management
This comprehensive checklist provides a structured approach to evaluate and manage patients with MS or MOGAD, emphasizing the importance of early and accurate diagnosis to guide appropriate treatment decisions that can significantly impact morbidity, mortality, and quality of life.