Neurology Journal

Objective: To determine the frequency of acute infarction detected by diffusion-weighted imaging (DWI)-MRI and stroke risk in TIA patients with different symptom duration in a population-based study.Methods: During a 54-month period (starting November 2007), 3,724 admitted patients (mean age, 67 +/- 14 years; 45% women) with transient neurologic symptoms lasting <24 hours from 15 hospitals were included. All patients underwent DWI-MRI during hospitalization.Results: Of 3,724 patients, 1,166 showed an acute infarction (32.2%; 95% confidence interval [CI], 30.8%-33.8%) and 88 (2.4%; 95% CI, 1.9%-2.9%) had a stroke during hospitalization (7 days). Stroke risk was higher in patients with tissue-positive DWI than in those with tissue-negative DWI (4.5% vs 1.5%, respectively; p < 0.001). Logistic regression analysis revealed that stroke risk was correlated with positive DWI (odds ratio [OR], 3.1; 95% CI, 2.0-4.8; p < 0.001), atrial fibrillation (OR, 2.1; 95% CI, 1.3-3.5; p = 0.001), and symptom duration <1 hour (OR, 1.5; 95% CI, 1.0-2.4; p = 0.042). Patients with symptoms lasting <1 hour had a lower rate of acute infarction than those with symptoms lasting >=1 hour (24% vs 36%, respectively; p < 0.001), whereas stroke risk did not differ between the groups (2.8% vs 2.1%, respectively; p = 0.22). Stroke risk was higher after tissue-positive events than tissue-negative ones in patients with symptom duration <1 hour (5.2% vs 2.0%, respectively; p = 0.002) and in those with symptom duration >=1 hour (4.1% vs 1.1%, respectively; p < 0.001).Conclusion: Stroke risk was higher after tissue-positive events than tissue-negative ones in TIA patients with different symptom duration.(C)2013 American Academy of Neurology

Objective: To evaluate plasma 8-hydroxy-deoxy-guanosine (8OHdG) levels as a potential biomarker of premanifest and early Huntington disease (HD).Methods: Personnel from 2 independent laboratories quantified 8OHdG in blinded longitudinal plasma samples taken 24 months apart from 160 TRACK-HD participants, as well as samples containing control plasma with added ("spiked") 8OHdG. One laboratory used a liquid chromatography-electrochemical array (LCECA) assay, and the other used liquid chromatography-mass spectrometry (LCMS).Results: The LCMS assay was more accurate than the LCECA assay for measurements of "spiked" 8OHdG levels in plasma. Neither assay demonstrated cross-sectional differences in plasma 8OHdG among controls, premanifest HD, and early symptomatic HD. Similarly, neither assay showed longitudinal changes in any disease group over 24 months.Conclusions: Plasma concentration of 8OHdG is not a biomarker of disease state or progression in HD. We recommend that future putative biomarker studies use blinded sample analysis, standard curves, independent analytical methods, and strict quality control of sample collection and storage.(C)2013 American Academy of Neurology

Objective: To examine the import of prior cervical trauma (PCT) in patients with cervical artery dissection (CeAD).Methods: In this observational study, the presence of and the type of PCT were systematically ascertained in CeAD patients using 2 different populations for comparisons: 1) age- and sex-matched patients with ischemic stroke attributable to a cause other than CeAD (non-CeAD-IS), and 2) healthy subjects participating in the Cervical Artery Dissection and Ischemic Stroke Patients Study. The presence of PCT within 1 month was assessed using a standardized questionnaire. Crude odds ratios (ORs) with 95% confidence intervals (CIs) and ORs adjusted for age, sex, and center were calculated.Results: We analyzed 1,897 participants (n = 966 with CeAD, n = 651 with non-CeAD-IS, n = 280 healthy subjects). CeAD patients had PCT in 40.5% (38.2%-44.5%) of cases, with 88% (344 of 392) classified as mild. PCT was more common in CeAD patients than in non-CeAD-IS patients (ORcrude 5.6 [95% CI 4.20-7.37], p < 0.001; ORadjusted 7.6 [95% CI 5.60-10.20], p < 0.001) or healthy subjects (ORcrude 2.8 [95% CI 2.03-3.68], p < 0.001; ORadjusted 3.7 [95% CI 2.40-5.56], p < 0.001). CeAD patients with PCT were younger and presented more often with neck pain and less often with stroke than CeAD patients without PCT. PCT was not associated with functional 3-month outcome after adjustment for age, sex, and stroke severity.Conclusion: PCT seems to be an important environmental determinant of CeAD, but was not an independent outcome predictor. Because of the characteristics of most PCTs, the term mechanical trigger event rather than trauma may be more appropriate.(C)2013 American Academy of Neurology

Objective: To explore the association of nonmelanoma skin cancer (NMSC) and Alzheimer disease (AD) in the Einstein Aging Study, an epidemiologic study of aging in New York City.Methods: Community-residing volunteers aged 70 years or older were assessed annually, followed by multidisciplinary diagnostic consensus. Cancer status and type was obtained by self-report. Cox proportional hazards models were used to test associations between NMSC and subsequent risk of developing a neurocognitive disorder. To deduce a biologically specific association between AD and NMSC, we considered 3 nested outcomes groups: only AD (probable or possible AD as the sole diagnosis), any AD (probable AD or possible AD, as well as mixed AD/vascular dementia), and all-cause dementia.Results: We followed 1,102 adults with a mean age of 79 years at enrollment. Prevalent NMSC was associated with reduced risk of only AD (hazard ratio = 0.21; 95% confidence interval = 0.051-0.87; p = 0.031) among subjects after adjustment for demographics, hypertension, diabetes, and coronary heart disease. APOE [epsilon]4 genotypes were available in 769 individuals. The association was similar in magnitude, but nonsignificant, when the number of APOE [epsilon]4 alleles was included in the model. No significant association was found between NMSC and subsequent development of any AD or all-cause dementia.Conclusions: This population-based longitudinal study shows that individuals older than 70 years with NMSC have a significantly reduced risk of developing AD compared with individuals without NMSC. We deduce Alzheimer-specific neuroprotection, because the effect is attenuated or eliminated when considering less-specific diagnoses such as AD with another diagnosis (any AD) or all-cause dementia.(C)2013 American Academy of Neurology

As the US population ages, the burden of neurodegenerative disorders, including Alzheimer disease and Parkinson disease, will increase substantially. However, many of these patients and their families currently do not receive neurologic care. For example, a recent study found that over 40% of Medicare beneficiaries with an incident Parkinson disease diagnosis did not receive neurologist care early after diagnosis and those who did not were more likely to fracture a hip, be placed in a nursing home, and die. While geography, age, race, and sex likely contribute to these observed disparities in care and outcomes, a large barrier may be Medicare's reimbursement policies, which value procedures over care. With further reductions in Medicare reimbursement constantly on the horizon, the devaluing of clinical care will likely continue. Rather than guaranteeing access to care, Medicare's reimbursement policies may increasingly be an impediment to care.(C)2013 American Academy of Neurology

Objective: To report a case of Lambert-Eaton myasthenic syndrome (LEMS) in a child and review the existing literature of LEMS in children.Methods: We report a pediatric case of LEMS with the classic clinical triad of proximal weakness, autonomic dysfunction, and areflexia; the characteristic increment in compound motor action potential on high-frequency repetitive nerve stimulation; and positive serum P/Q-type voltage-gated calcium channel antibodies. Only 11 pediatric cases of LEMS have been reported in the literature.Results: The patient's presentation with LEMS led to the diagnosis of occult neuroblastoma. Based on review of the existing pediatric literature, no consistent clinical or electrodiagnostic criteria exist to diagnose LEMS in children.Conclusions: There exists a need for consistent clinical criteria and electrodiagnostic testing for prompt diagnosis of LEMS in children. Prompt identification of LEMS will alert the physician to search for malignancy or another immune-mediated process.(C)2013 American Academy of Neurology