Cortical Seizures and MOG-IgG Positivity: A Multidisciplinary Case of FLAMES in MOGAD
Christian Santiago1, William Tatum2
1Oakland University William Beaumont School of Medicine, 2Mayo Clinic
Objective:
To describe a case of MOGAD-spectrum unilateral cortical encephalitis presenting with drug-resistant focal epilepsy, and to highlight the role of advanced diagnostics and surgical intervention in guiding individualized treatment.
Background:
Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an autoimmune demyelinating disorder of the central nervous system, classically presenting with optic neuritis, myelitis, or ADEM. More recently, cortical encephalitis with seizures, known as FLAMES (FLAIR-hyperintense Lesions in Anti-MOG-associated Encephalitis with Seizures), has emerged as a distinct adult phenotype.
FLAMES is characterized by unilateral cortical FLAIR abnormalities and focal seizures, but can overlap with other causes of new-onset epilepsy, complicating diagnosis and management.
To our knowledge, this is the first reported case of MOGAD in which the patient underwent stereo-EEG (SEEG) monitoring and radiofrequency ablation (RFA) for seizure control.
Design/Methods:
We conducted a retrospective case review of a 21-year-old male from Ecuador who developed new-onset focal epilepsy following a febrile illness in March 2024. The patient underwent serial MRI, lumbar punctures, infectious and autoimmune panels, continuous and ambulatory EEG, and inpatient EMU monitoring. MOG-IgG was evaluated using both commercial and research-based assays. After failing immunotherapy, the patient underwent SEEG placement for seizure localization, followed by cortical stimulation mapping and RFA of identified epileptogenic zones.
Results:
SEEG localized seizures to the right frontotemporal and parasagittal regions. RFA was performed following cortical mapping, sparing eloquent cortex. He is currently under post-ablation monitoring for reduction in seizure frequency.
Conclusions:
This case illustrates that MOGAD can result in drug-resistant focal epilepsy requiring invasive monitoring and surgical intervention. To our knowledge, this is the first reported use of SEEG and RFA in a patient with MOGAD, suggesting that surgical strategies may be beneficial in select autoimmune epilepsy cases. These findings expand the clinical management framework for MOGAD and support the integration of tailored electro-physiologic and surgical approaches when standard immunotherapy fails.
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