Neurology September 2009 Volume 73 Issue 9

Objective: This study aimed to determine the frequency and factors associated with obesity in a cohort of children and adolescents with newly diagnosed untreated epilepsy.Methods: Body mass index (BMI) Z-scores and percentiles, both adjusted for age, were used as measures for obesity. Potential covariates associated with these BMI measures included age, etiology (cryptogenic, idiopathic, symptomatic), seizure type (generalized, partial, unclear), concomitant medications (stimulants, nonstimulants, none), and insurance status (privately insured, Medicaid). The primary analysis compared the epilepsy patients' BMI Z-scores to Centers for Disease Control and Prevention data for healthy children. The secondary analysis compared the epilepsy patients' BMI Z-scores to those of a regional healthy control group. Additional analyses incorporated the secondary outcome measure BMI percentiles indexed for age.Results: Children with newly diagnosed untreated epilepsy had higher BMI Z-scores compared to standard CDC growth charts (p < 0.0001) and the healthy control cohort (p = 0.0002) specifically at both of the 2 tail ends of the distribution. Overall, 38.6% of the epilepsy cohort were overweight or obese (BMI >=85th percentile for age). Differences in age, etiology, and concomitant nonepilepsy medications were significantly associated with variability in age-adjusted BMI Z-score. Patients in adolescence had higher adjusted BMI Z-scores than younger patients. Patients with symptomatic epilepsy had lower adjusted BMI Z-scores than patients with idiopathic epilepsy. Patients on stimulant psychotropics exhibited lower adjusted BMI Z-scores than patients on no medication.Conclusion: Obesity is a common comorbidity in children with newly diagnosed untreated epilepsy and correlates with increasing age, idiopathic etiology, and absence of concomitant medication.(C)2009AAN Enterprises, Inc.

Background: There is growing evidence that vascular risk factors (VRF) contribute to cognitive decline. Whether their treatment can slow down the progression of Alzheimer disease (AD) remains unsettled. The aim of this observational study was to evaluate whether the treatment of VRF is associated with a slower cognitive decline in patients who have AD without cerebrovascular disease (CVD).Methods: We recruited 301 consecutive patients who had AD without CVD (mean age 71.7 years; 69.4% women; first Mini-Mental State Examination [MMSE] mean score 21.6; mean follow-up 2.3 years), who had attended a memory clinic between 1997 and 2003. VRF sought were high blood pressure, dyslipidemia, diabetes mellitus, tobacco smoking, and atherosclerotic disease. Only 21 patients (7.0%) had no VRF. Others were classified as having no VRF treated (n = 72; 25.7%), some VRF treated (n = 119; 42.5%), or all VRF treated (n = 89; 31.8%). We compared MMSE progression over time among these 3 groups using a mixed random effects regression model.Results: Baseline MMSE scores were similar in the 3 groups. With adjustment for confounding factors, MMSE progression over time differed significantly between groups (p = 0.002). Patients with all their VRF treated declined less than those with none of their VRF treated. Those with some VRF treated tended to have an intermediate decline.Conclusions: In patients who have Alzheimer disease without CVD, treatment of vascular risk factors (VRF) is associated with a slower decline in Mini-Mental State Examination score. Randomized controlled trials are needed to confirm this association, but our data suggest that dementia should not prevent treatment of VRF.(C)2009AAN Enterprises, Inc.

Background: Detection of serum antibodies to myelin-associated glycoprotein (MAG) by Western blot (WB) is a valuable assay to diagnose a distinct type of demyelinating polyneuropathy with immunoglobulin M (IgM) monoclonal gammopathy. In this study, the diagnostic accuracy of a new and more practical ELISA to detect these antibodies was validated.Methods: Routine WBs from 2 independent laboratories and ELISA were used to detect anti-MAG IgM in serum from 207 patients with neuropathy and controls. The sensitivity and specificity of these assays were compared and related to the patient clinical and electrophysiologic characteristics.Results: In ELISA, anti-MAG antibodies were found in serum from 49 (72%) of 68 patients with demyelinating polyneuropathy and IgM monoclonal gammopathy. However, in this subgroup of patients, only 30 (44%) and 37 (54%) were positive in the 2 WBs. All of the patients positive in the 2 WBs were also positive in ELISA. A high correlation was found for IgM activity in ELISA to MAG and sulfate-3-glucuronyl paragloboside (SGPG) (Spearman [rho] = 0.72, p < 0.0001), supporting the notion that the shared sulfated glucuronic acid moiety of MAG and SGPG is preserved. Most patients positive in anti-MAG ELISA had a slowly progressive sensory-motor demyelinating polyneuropathy, even if the WB was negative. In control groups, however, 4 WB-negative patients with a nondemyelinating monoclonal gammopathy-related polyneuropathy were positive in anti-MAG ELISA. The remaining samples were negative in ELISA.Conclusion: ELISA is more sensitive than Western blot to diagnose anti-myelin-associated glycoprotein related polyneuropathy, although a positive serology may be found in other forms of polyneuropathy as well.(C)2009AAN Enterprises, Inc.

Objective: HIV enters the brain soon after infection causing neuronal damage and microglial/astrocyte dysfunction leading to neuropsychological impairment. We examined the impact of HIV on resting cerebral blood flow (rCBF) within the lenticular nuclei (LN) and visual cortex (VC).Methods: This cross-sectional study used arterial spin labeling MRI (ASL-MRI) to measure rCBF within 33 HIV+ and 26 HIV- subjects. Nonparametric Wilcoxon rank sum test assessed rCBF differences due to HIV serostatus. Classification and regression tree (CART) analysis determined optimal rCBF cutoffs for differentiating HIV serostatus. The effects of neuropsychological impairment and infection duration on rCBF were evaluated.Results: rCBF within the LN and VC were significantly reduced for HIV+ compared to HIV- subjects. A 2-tiered CART approach using either LN rCBF <=50.09 mL/100 mL/min or LN rCBF >50.09 mL/100 mL/min but VC rCBF <=37.05 mL/100 mL/min yielded an 88% (29/33) sensitivity and an 88% (23/26) specificity for differentiating by HIV serostatus. HIV+ subjects, including neuropsychologically unimpaired, had reduced rCBF within the LN (p = 0.02) and VC (p = 0.001) compared to HIV- controls. A temporal progression of brain involvement occurred with LN rCBF significantly reduced for both acute/early (<1 year of seroconversion) and chronic HIV-infected subjects, whereas rCBF in the VC was diminished for only chronic HIV-infected subjects.Conclusion: Resting cerebral blood flow (rCBF) using arterial spin labeling MRI has the potential to be a noninvasive neuroimaging biomarker for assessing HIV in the brain. rCBF reductions that occur soon after seroconversion possibly reflect neuronal or vascular injury among HIV+ individuals not yet expressing neuropsychological impairment.(C)2009AAN Enterprises, Inc.

Background: Scarce information is available on the usefulness of new prediction markers for identifying young ischemic stroke patients at highest risk of recurrence.Methods: The predictive effect of traditional risk factors as well as of the 20210A variant of prothrombin gene, the 1691A variant of factor V gene, and the TT677 genotype of the methylenetetrahydrofolate reductase (MTHFR) gene on the risk of recurrence was investigated in a hospital-based cohort study of 511 ischemic stroke patients younger than 45 years followed up for a mean of 43.4 months. Outcome measures were fatal/nonfatal myocardial infarction, ischemic stroke, or TIA. Risk prediction was assessed with the use of the concordance c (c index), and the Net Reclassification Improvement (NRI).Results: The risk of recurrence increased with increasing number of traditional factors (hazard ratio [HR] 2.29, 95% confidence interval [CI] 1.57-3.35 for subjects with 1 factor: HR 5.25, 95% CI 2.45-11.2 for subjects with 2), as well as with that of predisposing genotypes (HR 1.96, 95% CI 1.33-2.89 for subjects carrying 1 at-risk genotype; HR 3.83, 95% CI 1.76-8.34 for those carrying 2). The c statistics increased significantly when the genotypes were included into a model with traditional risk factors (0.696 vs 0.635, test z = 2.41). The NRI was also significant (NRI = 0.172, test z = 2.17).Conclusions: Addition of common genetic variants to traditional risk factors may be an effective method for discriminating young stroke patients at different risk of future ischemic events.(C)2009AAN Enterprises, Inc.

In this article, we advocate for advanced training for child neurologists in behavior and development in order to facilitate the investigation of childhood behavioral and neurodevelopmental disabilities, with autism serving as a model disorder. We explore the current training options and then propose alternative subspecialty training options that focus on behavior and development, with appreciation that most developmental disabilities are not static encephalopathies but, rather, dynamic processes representing the influence of genetics and environment on neural circuitry.(C)2009AAN Enterprises, Inc.