How Germinal Centers Generate Antibodies Through Noisy Rounds of Mutation and Selection

A study tracking thousands of B cells across more than 100 germinal centers (GCs) in mice has revealed how the system consistently produces highly effective antibodies. The findings overturn longstanding ideas about how germinal centers function, revealing that they are far more selective than once thought, and challenge the idea that antibody improvement is driven mainly by rare growth “bursts” among the most successful B cells. The discovery could have implications for immune cell evolution, and ultimately guide the design of vaccines against rapidly mutating pathogens like influenza. It could also lead to new ways of studying evolution itself.

“The traditional, mechanistic view of germinal centers is to think of them as selection machines sorting out the best antibodies,” said research lead Gabriel D. Victora, PhD, head of the Laboratory of Lymphocyte Dynamics at The Rockefeller University. “But when you look very, very closely, you see a process that’s almost essentially random—a little bit better than a coin toss—which repeats many times until the immune system arrives at the right answer consistently. That’s much more akin to how evolution operates than the way a machine does.”

Victora and colleagues reported on their findings in Cell, in a paper titled “Replaying germinal center evolution on a quantified affinity landscape.”

Inside germinal centers, B cells rapidly mutate and compete to produce antibodies that bind successively better to pathogens. “Darwinian evolution of immunoglobulin genes within germinal centers (GCs) underlies the progressive increase in antibody affinity following antigen exposure,” the authors wrote. That puts B cells under intense pressure to optimize a single trait: binding affinity, or how well an antibody recognizes its target.

But how they accomplish that feat has very much remained an open question, the team noted. “Whereas the cellular mechanics of how competition between B cells increases affinity are well established, the evolutionary dynamics of this process are less clear.” Because weak and strong B cells often coexist side by side in the germinal center, scientists have long wondered whether the immune system temporarily preserves weaker cells in case they later acquire useful mutations. The phenomenon of clonal bursts, in which the descendants of a single B cell rapidly take over an entire germinal center, are also poorly understood.

The authors explained that GC B cells evolve by rapidly mutating only two Ig genes, which are the heavy chain (Igh) and light chain (either Igk or Igl). Victora’s team engineered mice in which all competing B cells began with the same antibody sequences, allowing them to replay a single evolutionary process across more than 100 germinal centers at once. “… we established a system in which GCs are composed entirely of B cells carrying the same pre-rearranged Igh and Igk genes, ensuring identical starting specificity and affinity,” they explained. Victora added, “We simplified it to the bare bones, and asked how repeatable is the exact sequence of mutations that leads to stronger antibodies.”

Once each of the B cells was primed with the exact same unmutated antibody sequence, the team triggered germinal center formation through immunization. They then tracked the resulting sprint toward immune efficiency with multiphoton microscopy and laser-based photoactivation, and sequenced thousands of individual B cells across 119 germinal centers.

With this data, the team managed to construct a detailed family tree that mapped how different lineages of B cells had developed. They also built a mutational dictionary, using deep mutational scanning (DMS), a technique that links almost every possible amino-acid change to antibody performance. This advance allowed the team to determine how mutations affected binding strength and structural stability simply by reading a cell’s DNA sequence.

“DMS was the big technical advance here,” says first author Ashni Vora, PhD, a graduate fellow in the lab. “With it we could determine the affinities of thousands of cells just by looking at their sequence, without having to produce an antibody.”

The researchers compare the resulting picture to a casino game. Watching a single B cell evolve inside a germinal center looked almost random, with some cells rapidly expanding, others disappearing, and even promising mutations failing as if random chance ruled the day. Some germinal centers were overtaken by clonal bursts while others contained many competing lineages with no clear winner. The differences had little to do with affinity or merit. “We find that, even in this simplified setting, GC selection yields widely divergent tree topologies, ranging from clonal-burst-type structures to multi-pronged GCs where multiple line ages evolve in parallel,” they noted.

But the team discovered that the germinal center game is rigged. In a casino, the house always wins not because of the odds on any individual game, but because a slight statistical bias is built into the system and repeated thousands of times. Germinal centers appear to operate similarly. Each round of cellular competition is only slightly biased toward cells carrying beneficial mutations, and random chance means that there is often little correlation between affinity and success. But by repeating that same noisy, almost random process over and over across many germinal centers, the immune system ultimately produces stronger antibodies.

“If you see someone get a jackpot, you might wonder how the casino makes money,” Victora says. “The answer is that the casino puts in a little bit of bias, so that you win and you lose, but on average, you lose more than you win. If there are just one or two people playing, the casino might lose money due to random chance. But if there are a thousand people playing, it’s going to average out and the house wins. That’s essentially how germinal centers work.”

The researchers also found that the immune system favors mutations that are easiest for its cellular machinery to generate, rather than the mutations that would produce the strongest antibodies. And by tracking B cell lineages over time, they also showed that germinal centers are far more selective than previously thought, rapidly eliminating inferior B cells. “By combining phylogenetic reconstructions with a fitness landscape inferred from populations sampled over time, we show that both the apparent permissiveness of GCs to low-affinity lineages and the apparent early plateau in affinity maturation are best explained by survivorship biases that distort the histories of lineages present at sampling,” the investigators wrote in summary.

Taken together, the findings overturn several longstanding ideas about how germinal centers function and may provide new tools for vaccine developers hoping to steer antibody evolution against influenza and HIV. “What was once theoretical speculation about what must happen in the germinal center, we are now showing in action—the real thing,” Victora says.

At the same time, this work also illustrates how germinal centers could become a powerful model for studying evolution more broadly. Scientists have long relied on bacteria grown in the lab over many generations to plumb the depths of evolutionary biology and determine how much of evolution is driven by random chance. In clarifying the rules governing germinal centers, the researchers revealed why the immune system could offer a potentially more tractable experimental avenue: Unlike bacterial evolution, which centers around adapting to many possible survival strategies, B cells are all aiming for the same target. “I see this as an opening salvo in a longer effort to understand evolution by using the immune system as a model,” Victora added.

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Microglial State Shift May Determine Whether Alzheimer’s Disease Pathology Leads to Dementia

Researchers from the VIB-KU Leuven Center for Neuroscience, the UK Dementia Research Institute, and Muna Therapeutics have discovered a biological transition that occurs in Alzheimer’s disease (AD) that may influence whether the accumulation of amyloid-β plaques and tau pathology progresses to dementia. Using human brain tissue from octogenarians with and without dementia as well as cognitively healthy centenarians, the team found that a shift in the behavior of microglia occurs at a critical point between amyloid-driven inflammation and tau-associated neurodegeneration. The research, published in Nature Medicine, point to these microglial transitions as a potential new target for treating the disease.

“This has been an exciting journey with many partners,” said co-senior author Bart De Strooper, MD, PhD, a professor at VIB-KU Leuven Center for Neuroscience, Belgium. “The study, entirely based on human donor material, provides insight into one type of resilience mechanism in the progression of AD to dementia.”

Alzheimer’s disease affects more than 55 million people worldwide, but prior research has not been able to fully explain why some people with AD remain cognitively healthy despite having significant amounts of amyloid plaques and tau tangles in their brains. Current models of AD progression have assumed a linear path from amyloid accumulation to tau pathology, neurodegeneration, and cognitive decline. However, observations of cognitively intact older adults with substantial pathology have indicated there may be other biological factors that influence dementia development.

“AD is not an inevitable outcome of pathology but a dynamic process shaped by how brain cells respond to amyloid-β (Aβ) and tau,” the researchers wrote, adding that “Clinical symptoms may thus arise only when these compensatory mechanisms fail, crossing inflection points that shift the brain from adaptation to degeneration.”

Previous studies using single-cell and spatial transcriptomics had shown that microglia, astrocytes, oligodendrocytes, and neurons undergo stage-specific changes in response to amyloid accumulation. Those findings, combined with observations that some centenarians maintain cognition despite extensive pathology, suggested that immune-cell responses might influence disease outcomes and were the underpinnings of the current research.

To further understand these mechanisms, the investigators examined 24 well-characterized octogenarian brains and 20 brains from cognitively intact centenarians enrolled in the Dutch 100-plus Study. Using spatial transcriptomics, single-nucleus RNA sequencing, and in situ hybridization to tissue from the superior frontal gyrus, the team was able to analyze gene activity at single-cell resolution while preserving the spatial relationships between cells and pathological features in the brain.

Their analysis identified six distinct tissue domains representing a continuum of Alzheimer’s disease progression. Within this “spatial pathological” continuum of AD the researchers found a “key inflection point marked by a shift from Aβ-associated inflammatory changes to tau-associated cellular programs.”

This transition coincided with a significant change in microglial behavior. Early in the disease process, microglia adopted inflammatory states associated with amyloid plaques. Later, they shifted into antigen-presenting states linked to emerging tau pathology. The researchers described these as early and late plaque-induced gene, or PIG, programs.

Data from the study indicated that resilience to disease progression involved different microglial responses in the different groups studied. Octogenarians who accumulated amyloid plaques but remained free of dementia mounted the early inflammatory microglial response but did not progress to the later antigen-presenting state. This compared with cognitively intact centenarians in which the later microglial program was activated, but this activation occurred without the corresponding buildup of tau pathology typically associated with neurodegeneration.

“Resilient individuals showed distinct pathological patterns: octogenarians without dementia lacked late PIGs, whereas centenarians showed late PIG activation that was uncoupled from tau accumulation,” the researchers wrote.

According to the investigators, these findings indicate that resilience to development of dementia in AD is not simply a matter of avoiding pathology, but may depend on how the brain regulates the cellular consequences of AD pathology.

The research also revealed clues about how microglia might be targeted therapeutically. The researchers suggest that preserving beneficial early microglial functions involved in amyloid clearance and synaptic maintenance while preventing chronic antigen-presenting activation associated with tau pathology could help slow disease progression. Potential targets include pathways involving TREM2, CSF1R, and molecules associated with microglial state transitions.

“These findings open new opportunities to target microglial states—especially pathways such as TREM2—and extend resilience rather than simply focusing on plaque removal,” said co-senior author Niels Plath, PhD, chief scientific officer of Muna Therapeutics. “We are excited to continue this journey and understand the causal role of microglial transitions leading to the identification of novel therapeutic approaches to delay or prevent disease progression.”

Continued research will look to determine the causal mechanisms that drive these microglial state transitions and identifying the genetic, immune, or aging-related factors that allow some individuals to remain resilient despite significant Alzheimer’s pathology.

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Universal Coronavirus Vaccine Could Provide Protection Against Future Strains

Results from the first human trial of a universal coronavirus vaccine show early promise for a new approach to vaccine design that could protect against a broad range of strains within major virus groups, including strains that have not emerged yet. These findings were published today in the Journal of Infection.  

“Viruses like influenza, coronaviruses, and the Ebola group are evolving continuously and by the time vaccines are rolled out, they may be poorly matched. The current “reactive” vaccine system struggles to keep pace,” said Saul Faust, PhD, professor of pediatric immunity and infection at the University of Southampton and director of the NIHR Southampton Clinical Research Facility, who acted as chief investigator of the clinical trial.

Currently, vaccines contain antigens from specific viral strains that have been detected and predicted to be circulating in humans seasonally. However, because viruses mutate rapidly, the protection these vaccines offer can be limited by the time the vaccines are manufactured and distributed. In contrast, the PanSarbeco vaccine evaluated in this trial is designed to train the immune system to recognize and fend off a broad range of Sarbeco coronaviruses, including the SARS-CoV2 virus responsible for the COVID-19 pandemic.  

“This new class of universal vaccines are future-proofed,” said Faust. “They not only protect against many variants simultaneously, but potentially against related viruses that haven’t yet emerged and spilt over to humans. If we can develop and clinically advance this new class of vaccines before a virus outbreak begins, millions of lives could be saved, lockdowns avoided, and the economy preserved.”

The technology behind this vaccine uses machine learning to design a super antigen that can provide lasting protection against a broad range of viruses within a group, such as the Ebola group or the Sarbeco coronavirus group, even as they continue to mutate and evolve. This approach originated at the University of Cambridge and is currently being developed by DIOSynVax (Digitally Immune Optimised Synthetic Vaccines), a spin-out company established in 2017. 

“We’ve converted vaccine development from being reactive to being future proof. Our vaccines will continue to provide protection against viruses even as they mutate into new strains,” said Jonathan L. Heeney, DVM, PhD, professor of comparative pathology at the University of Cambridge and chief scientific officer of DIOSynVax. “We’ve overcome the problem of traditional vaccines, which have limited protection. It means we can escape the constant cycle of chasing the virus variants circulating in humans and updating the vaccines to try to catch up, like a dog chasing its tail.”

The PanSarbeco vaccine was tested in 39 healthy volunteers between 18 and 50 years old at NIHR research facilities at Southampton and Addenbrookes Hospital. The super antigen is compatible with most vaccine delivery systems; in this study it was delivered as a DNA vaccine using a needle-free delivery system in two doses administered 28 days apart. All four doses tested were well tolerated by the participants, with no significant safety concerns reported. 

While participants developed immune responses to epitopes of sarbecovirus antigens conserved across strains, preliminary measurements of immunogenicity were modest in some participants potentially due to previous immunization with COVID-19 vaccines. Going forward, a larger Phase II trial will assess the vaccine’s ability to induce a strong, broadly protective immune response. 

“The remarkable success of this AI-designed ‘super-antigen’ trial marks a pivotal leap forward in our ability to deliver broad, lasting viral protection,” said Marian Knight, MBChB, DPhil, professor of maternal and child population health at the University of Oxford and scientific director for NIHR Infrastructure.

 

The post Universal Coronavirus Vaccine Could Provide Protection Against Future Strains appeared first on Inside Precision Medicine.

Preferences for Telehealth Physical Activity Participation Among a Cohort of Children and Youth With Disabling Conditions: Cross-Sectional Survey Study

Background: Children with disabling conditions encounter numerous challenges in participating in physical activity within their community. Telehealth has emerged as an ideal method for promoting physical health and wellness, but there is a need to identify optimal implementation strategies. Objective: This study aimed to describe the telehealth physical activity preferences of active children and youth with disabling conditions to rapidly inform the development of a pilot telehealth program that could be delivered nationally. Methods: A cross-sectional survey was conducted among a convenience sample of pediatric members of a community-based wellness program. Questions probed preferences for delivery method; programming frequency, intensity, duration, and type; desired outcomes; technology access and proficiency; and additional needed supports. Of the initial 56 respondents, 4 (7.1%) over the age of 18 years were excluded, leaving 52 (92.9%) for analysis. Outcomes were summarized descriptively. Results: Of 392 wellness program members, 56 (14.3%) responses were gathered. The mean age of the 52 analyzed respondents was 10 (SD 3; range 5-16) years. The sample predominantly comprised male (32/52, 61.5%) and White (34/52, 65.4%) individuals, with autism spectrum disorder and developmental disorder as the most common disability types (22/52, 42.3% each). Social and psychological barriers were the most frequently reported challenges to physical activity participation (36/52, 69.2% and 27/52, 51.9%, respectively). Most respondents reported an ideal exercise dose of 1 to 2 sessions per week of 30 to 45 minutes at a novice or beginner difficulty level. Winter was the preferred season for participation. The 2 most desired delivery formats were live videoconferencing and prerecorded videos. Desired program outcomes included strength improvement, mental health, developing new hobbies and activities, and social connection. Over 90% of respondents (47/52, 90.4%) reported having adequate technology at home to support virtual participation. Conclusions: Optimal telehealth programs for this cohort should be brief and low intensity and offered seasonally, with both live and prerecorded delivery options. Although this preferred dose does not meet US physical activity guidelines, it may represent an appropriate starting point for many inactive children with disabilities. Future research should examine behavior change strategies that motivate children to enroll in these programs and support gradual increases in physical activity over time.
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Interpretable Machine Learning Framework for Predicting Major Adverse Cardiovascular Events in Rheumatoid Arthritis Using Electronic Health Records: Multicenter Cohort Study

Background: Patients with rheumatoid arthritis (RA) face higher risks of major adverse cardiovascular events than the general population. While machine learning offers powerful predictive capabilities, its clinical adoption is hindered by the “black-box” nature of complex algorithms. Objective: This study aimed to develop interpretable survival models to predict the risk of major adverse cardiovascular events in patients with RA, providing transparent and actionable insights for personalized clinical prognosis management. Methods: Using data from the Taipei Medical University Clinical Research Database (2011-2022) for 2461 patients with RA, machine learning survival models, including random survival forest (RSF), DeepSurv, and Cox-Time, were compared with the traditional Cox proportional hazards model. Performance was evaluated using the C-index and integrated Brier score. Permutation importance and Shapley additive explanations (SHAP) analyses were integrated to provide explainability for individual-level risk predictions. Results: RSF demonstrated superior performance, achieving a C-index of 0.8771 and an integrated Brier score of 0.0775. Permutation importance identified key features, including creatinine, conventional synthetic disease-modifying antirheumatic drugs, C-reactive protein, alanine aminotransferase, and age at RA diagnosis. SHAP analysis further quantified feature-specific effects, revealing both protective and risk-increasing associations between medications and laboratory indicators. Conclusions: RSF outperformed traditional methods, and integrating SHAP enabled transparent, personalized risk interpretation, translating complex models into actionable insights for clinicians. This approach empowers clinicians to identify high-risk individuals and advances precision medicine in rheumatology. Future work should include temporal validation using data from later years and external validation using datasets from other health care systems to further assess model generalizability.
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A Billion-Dollar Deal, Trial Trouble, Biohub Updates, and Vaccine Research News

In this week’s episode, we start with news that Fulcrum Therapeutics is scrapping its lead pipeline program for sickle cell disease following concerns from the FDA about the drug’s risks and benefits. Also on the docket, news of Eli Lilly’s latest spending. The pharma giant has added its genetic medicines pipeline and capabilities by signing a $1.9 billion agreement with Ascidian Therapeutics to develop RNA exon editors for treating inherited kidney diseases. Next up, updates to an open-source model for binder design and protein function mapping. Finally, on the peer-review front, we dive into some of the latest vaccine research including insights into the mechanisms that cross-reactive T cells use to target multiple viral species in a single family and an improvement to standard polio vaccines.

 

 

Listed below are links to the GEN stories referenced in this episode of Touching Base:

Fulcrum Halts Development of SCD Candidate Pociredir, Sets Strategic Review
By Alex Philippidis and Kevin Davies, PhD, GEN Edge, June 2, 2026

Lilly, Ascidian Launch Up-to-$1.9B RNA Exon Editor Collaboration Targeting Inherited Kidney Diseases
By Alex Philippidis, GEN Edge, June 3, 2026

Biohub Releases Protein Biology World Model to Address Disease
By Fay Lin, PhD, GEN Edge, May 27, 2026

Cross-Reactive T Cells Could Point to Broad Vaccines or Treatments for Measles, Nipah Virus
GEN, June 2, 2026

Experimental Adjuvant Could Strengthen Mucosal Immunity with Injectable Polio Vaccines 
GEN, June 4, 2026

Touching Base Podcast
Hosted by Corinna Singleman, PhD

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Hosted by Jonathan D. Grinstein, PhD


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Influenza Drugs Could Prevent Cognitive Decline in Chronic Viral Infections 

Researchers at Northwestern University have found that a combination of influenza drugs could reduce cognitive impairment and premature aging in people living with chronic infections. In a study published today in the journal Med, the team uncovered a previously unknown mechanism by which viruses like HIV drive cognitive decline over time even when effectively treated. 

“We are not saying yet that people should take flu drugs to prevent cognitive decline,” explains Mohamed Abdel-Mohsen, PhD, associate professor of medicine in the division of infectious diseases at Northwestern University’s Feinberg School of Medicine. “We are saying that our findings open the door to testing whether this drug class, or better next-generation versions, could be repurposed for brain and aging-related complications.”

At least 25% of people living with HIV develop symptoms affecting their memory and thinking, even when the infection is effectively managed using antiretroviral therapy.  Until now, the reason for it remained unclear. 

Abdel-Mohsen’s team analyzed blood samples from more than 100 people in the AIDS Clinical Trials Group, all of which were infected with HIV and taking antiretroviral therapy. Based on clinical testing, the patients were separated in two groups, one having normal cognition and another cognitive impairment. 

Results showed that those who developed cognitive impairment had reduced levels of glycans in their blood. These protective sugar molecules normally keep inflammation under control, but when they are degraded, inflammation becomes chronic and accelerates aging processes. 

The researchers also found that glycan degradation was more pronounced among women in the study. While men saw changes in glycan levels evolve gradually and steadily over time, women experienced an acceleration around menopause. 

“Before menopause, women show a slower loss of anti-inflammatory glycans and slower accumulation of pro-inflammatory glycans compared with men, but around menopause there is a rapid shift toward a more inflammatory glycan profile,” says Abdel-Mohsen.

In human immune cells and mouse models, a combination of two influenza drugs successfully preserved glycans and reduced inflammation, slowing down aging and protecting memory. The treatment was composed of oseltamivir, sold as Tamiflu, and an experimental drug. Both are glycan-based drugs belonging to the sialidase inhibitor drug class, which block an enzyme that the influenza virus relies on to replicate itself. 

In future studies, the researchers will investigate whether glycans can serve as biomarkers of future cognitive decline, which could eventually lead to the development of predictive blood tests The team is also planning to further study and optimize potential treatment strategies based on the influenza drugs to prevent cognitive impairment.

“On the treatment side, we want to do more preclinical work to optimize the approach,” says Abdel-Mohsen. “Although some sialidase inhibitors are already used safely in people for influenza, they have not been tested for this purpose, dose or duration.”

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Exploring ceramide as a novel biomarker and therapeutic target for Alzheimer’s disease

Metabolic dysregulation is increasingly being recognized as a hallmark across various neurodegenerative diseases. While Alzheimer’s disease (AD) is well-established as a dual proteinopathy characterized by amyloid-beta (Aβ) deposition and tau protein tangles, the specific mechanisms mediating lipid homeostasis imbalance have garnered increasing attention. However, translating these findings into safe clinical therapeutic targets remains a formidable challenge, primarily hindered by the pleiotropic roles of ceramides in maintaining neural and immune homeostasis, as well as the blood–brain barrier (BBB) penetration issues and systemic safety limitations of current sphingolipid-targeting strategies. We conducted a comprehensive search of electronic databases, including PubMed, Web of Science, and Google Scholar, to identify relevant studies published from database inception through March 2026. The search term combinations included: “Alzheimer’s disease,” “AD,” “ceramide,” “sphingolipid metabolism,” “biomarker,” “therapeutic target,” “neuroinflammation,” and “mitochondrial dysfunction.” To ensure the depth and rigor of this review, priority was given to peer-reviewed original research, systematic reviews, and meta-analyses. The search was restricted to English-language literature. Additionally, the reference lists of retrieved articles were manually screened to identify further relevant studies. This narrative review aims to comprehensively elucidate the potential roles of ceramides in AD pathogenesis, exploring their associations with triggering inflammatory responses, mediating apoptosis, interfering with signal transduction, and inducing mitochondrial dysfunction.

A novel fixel-based approach for resolving neonatal white matter microstructure from clinical diffusion MRI

IntroductionPreterm birth is a major risk factor for disrupted brain development and subsequent neurodevelopmental disorders, yet the underlying mechanisms remain poorly understood. Further, typical neuroimaging analyses are particularly challenging in the neonatal brain: data is frequently low quality, and a lack of cellular development violates the assumptions relied on by many commonly-used techniques. In this study, we develop and present an advanced diffusion magnetic resonance imaging method to examine the microstructural organization of white matter in a clinically-acquired cohort of premature neonates.MethodsUsing a novel approach that resolves multiple tissue compartments within the brain, we provide highly detailed orientation and quantification of white matter fibers and tissue signal fraction. We also utilize a series of automated segmentation algorithms to identify and measure these metrics across key tracts and subcortical regions. We investigate how these measures relate to postmenstrual age, as well as to clinical factors reflecting neonatal illness severity.ResultsWe report successful segmentation and reconstruction of numerous white matter tracts throughout the neonatal brain. We further demonstrate the utility and functionality of microstructural analysis in a variety of pathologies commonly encountered in the neonatal clinical environment. Our results demonstrate tract-specific developmental trajectories, with early-maturing pathways showing higher microstructural organization. Exploratory analyses suggest that neonatal illness severity has modest, tissue-specific associations with microstructural properties.DiscussionThis work demonstrates that advanced microstructural imaging methods can extract meaningful white matter measurements from clinically-acquired scans, providing a practical framework for studying neonatal brain development in real-world hospital settings. These metrics are able to be calculated at extremely young ages, potentially allowing non-invasive study of vulnerable populations before detailed behavioral or neurological assessments are feasible.

Mirrored structural symmetry index (VMSSI): a novel approach for diagnosing MR-negative focal cortical dysplasia using structural MRI

BackgroundFocal cortical dysplasia (FCD) is a common cause of drug-resistant epilepsy, yet its diagnosis remains challenging, particularly for magnetic resonance imaging (MRI)-negative FCD. In this study, we propose a novel metric, the Voxel-Mirrored Structural Symmetry Index (VMSSI), to quantify hemispheric structural symmetry using T1-weighted MRI.MethodsA total of 104 patients with suspected FCD and 104 age and sex matched healthy controls from two centers were enrolled, and their brain images were mirrored along the longitudinal axis to create a dataset. The diagnostic discriminatory ability of magnetic resonance signal intensity value symmetry, cortical thickness symmetry and VMSSI was further verified by subject receiver operating characteristic (ROC) curve analysis. The sensitivity and specificity were used to assess the performance of VMSSI at different diagnostic thresholds.ResultsThe cortical thickness symmetry index (MeanThicknessDiff) was significantly different between the two groups (p < 0.001). The values of the combined symmetry index were significantly higher in the MR-negative FCD patient group than in the healthy control group (p < 0.001). The area under the curve (AUC) of VMSSI was 0.80 (95% CI: 0.72–0.88).VMSSI exhibited 77% sensitivity and 85% specificity at the optimal thresholds of 3.4.ConclusionThese results demonstrate that VMSSI is a reliable and effective tool for detecting MR- negative FCD, providing a quantitative structural biomarker that may aid in improving diagnostic accuracy in clinical practice.