Reply to: "Insights and considerations on predicting cognitive and Behavioral disturbances in MND with pure motor onset".

In this letter, we respond to the comments by Dr. Wang and Dr. Zhang regarding our recent study on cognitive and/or behavioral impairment (C/BI) development in motor neuron diseases (MNDs), acknowledging sample size limitations and the low prevalence of cases carrying genetic mutations. We underscore that the exclusion of patients lacking follow-up data may actually have resulted in an underrepresentation of fast-progressing rather than slow-progressing cases. We also express our agreement on the potential of integrating clinical and biomarkers-derived predictors into clinical guidelines for MNDs to enable earlier, personalized interventions. We appreciate the authors' recognition of our work and share their expectations for future advancements in the field.