May 2008 • www.clinicalneurologynews.com News 5 Parasite Linked to Dementia, Cognitive Impairment

ARTICLES BY AMY ROTHMAN that 5 (12.5%) of treatment-naive patients but other lesions also can be related, and are SCHONFELD diagnosed with neurocysticercosis met located anywhere in the brain. Contributing Writer DSM IV criteria for dementia, significant- Humans become infected with neuro- ly more than the normal control group (P cysticercosis through consumption of food C HICAGO — Untreated central nervous less than .05). Major memory impairment or water contaminated with the feces of a

system infection with the parasitic neuro- was found in 23 (57.5%). On a battery of NDRADE Taenia solium tapeworm carrier. The adult cysticercosis may present as cognitive im- cognitive tests that evaluated memory, at- A tapeworms are found only in the intestine pairment ranging from mild deficit to tention, praxis, and executive function, all of humans. Once the tapeworm lays its IAMPI DE

full-blown dementia. those with neurocysticercosis demon- C eggs, the larvae may invade tissue and Neurocysticercosis is the most common strated one or more cognitive deficits, a through the bloodstream infect skeletal parasitic infection of the CNS. Even physi- significantly higher rate than observed for ANIEL muscles, the eyes, brain, and spinal cord. A . D R

cians may be unaware of infection’s ad- the normal controls (P less than .05). In- D person can be infested by T. solium and be verse effects on cognition, according to Dr. terestingly, when compared with patients a carrier, but not develop cysticercosis. Daniel Ciampi de Andrade. with cryptogenic epilepsy, neurocysticer- Dr. Andrade advises clinicians to keep OURTESY

Cognitive test findings from 40 patients cosis patients continued to present lower C neurocysticercosis on their radar and al- with neurocysticercosis were compared scores for most cognitive tests. A frontal cystic lesion is seen on MRI in ways ask whether a patient, especially with those of 49 normal controls from the “People having traveled to endemic areas a patient with neurocysticercosis. with seizures, has migrated from an en- same regional population, as well as with and immigrants from these regions pre- demic area, traveled to one, or has people 28 patients with cryptogenic epilepsy ex- senting with cognitive decline should be as- drade, who won the International Schol- residing with them who originate from an periencing similar rates of seizure fre- sessed for the presence of neurocysticer- arship Award at this year’s annual meeting endemic area, including regions of South quency and antiepileptic drug use, ac- cosis. Look for lesions on MRI or CT scans. of the American Academy of Neurology, America, Central America, or Asia. Neu- cording to Dr. Andrade, a neurologist at Blood tests and CSF screening are also where he presented his findings. The clas- rocysticercosis has also become a public the University of São Paulo (Brazil). available to make the diagnosis that some- sical finding is a cystic lesion with a scolex health problem in urban New York, Los Dr. Andrade and his colleagues found times is not straightforward,” said Dr. An- (a small point in the center of the lesion), Angeles, Texas, and Europe. ■ Drugs, Surgery Commonly Misused Gabapentin Prodrug In Psychogenic Movement Disorders Alleviates Restless Legs C HICAGO — The investigational drug XP13512 has been C HICAGO — Before being correctly diagnosed were found to have undergone a total of 17 surgeries shown in a large, randomized, double-blind, placebo-con- with a psychogenic movement disorder, 12 of 54 chil- for symptoms related to their PMD or to associated trolled clinical trial to successfully control symptoms of rest- dren underwent one or more unnecessary and un- symptoms that were eventually determined to have less legs syndrome and to improve sleep quantity and adequacy. helpful surgeries and 43 were prescribed needless no identifiable basis. Children with dystonic postures “This is the first nondopaminergic agent studied in a large medications, according to data from one small study. were most likely to undergo surgery. “In no case did trial for [restless legs syndrome], and it was developed to over- “Psychogenic movement disorders should be on the the surgeries help,” he said. “Such interventions may come pharmacokinetic deficiencies of gabapentin,” said Dr. radar screen of neurologists because failure to recog- impede effective psychiatric therapy.” Clete A. Kushida, describing the agent that is converted to nize the diagnosis can lead to adverse consequences Medications for a presumed organic movement gabapentin after absorption in the intestine. from unnecessary, invasive treatments,” said Dr. Joseph disorder were prescribed to 43 children. These drugs In this multicenter trial, 220 patients with RLS received ei- Ferrara of the Baylor College of Medicine, Houston. included antispasmodics, antiepileptics, anticholiner- ther 1,200 mg XP13512 (n = 112) or placebo at 5 p.m. daily. Psychogenic movement disorders (PMD) are so- gics, levodopa, antiadrenergics, dopamine recep- About 60% were female in both groups and the average age was matoform disorders in which psychological stressors tor–blocking agents, botulinum toxin, steroids (oral or 50. Participants typically had symptoms for 13 years or more. unconsciously produce abnormal movements, and are IV), immunoglobulins, and tetanus immunoglobulin. Using the International Restless Legs Syndrome (IRLS) considered to be a type of conversion disorder, said There is a paucity of data regarding effective treat- scale, the mean change from baseline was significantly greater Dr. Ferrara. They are not thought to have an organ- ments for PMD, said Dr. Ferrara. People with other in the treated group than in those on placebo (–13.2 vs. –8.8; ic etiology and often occur in association with conversion disorders should be treated with cognitive P = .0003). underlying psychiatric disease. behavior therapy, supportive psychotherapy, and phys- More patients treated with XP13512 were rated as “much Little is known about PMD in children, said Dr. Fer- ical therapy, he recommended. Symptoms of comor- improved” or “very much improved” by the investigator us- rara. Symptoms typically appear suddenly at about age bid anxiety and depression should also be recognized ing the Clinical Global Impression–Improvement scale than 14 years and affect girls more than boys. A trigger, such and promptly addressed, he said. were those receiving placebo (76.1% vs. 38.9%; P less than as an injury, accident, minor illness, or social problem, Dr. Ferrera reported having no financial interests .0001). By the end of the 12-week trial, 50% of XP13512-treat- can be identified in about two-thirds of cases. to disclose. ■ ed patients were symptom free over a 24-hour period, com- Of the 1,722 children seen at the clinic, 54 (3%) met pared with 17.7% of placebo-treated patients. Fahn and Williams criteria for PMD. Of these 54 Treatment also resulted in better subjective sleep quality and individuals, 35 had tremor or shaking, 23 had dysto- Most Common quantity, and beneficial effects were detected within 1 week. nia, 20 had myoclonus or jerking, 12 had astasia- One serious adverse event occurred in the placebo group. abasia and gait disorders, 6 had convergence spasm, Unnecessary Surgeries Somnolence and dizziness, the two most frequently reported and 4 had disrupted speech. Symptoms often treatment-linked events, were mild to moderate and generally appeared only on one side, and many children had he following unnecessary procedures were transient, said Dr. Kushida, director of the center for human more than one symptom. The majority had episodic Tconducted on children before their psy- sleep research at Stanford (Calif.) University, who presented the symptoms, but 13 had continuous symptoms and 7 chogenic movement disorders were diagnosed results at the annual meeting of the American Academy of had continuous symptoms with periods of remission. accurately: Neurology. About half had comorbid anxiety, depression, or Ǡ Ulnar nerve transposition for arm stiffness Gabapentin is approved for the management of posther- persistent irritability. Three had histories of suicidal and finger curling. petic neuralgia and the treatment of partial seizures. It is also ideation and two had made some suicidal gesture. Al- Ǡ Shoulder stabilization for arm posturing. helpful for the treatment of neuropathic pain. Although ear- most all had somatic or neurologic complaints. Ǡ Surgeries for painful thumb posturing. ly testing showed it controls RLS symptoms, it has shortfalls About one-quarter of the children in the PMD Ǡ Bilateral ocular surgeries for misalignment. that limit its therapeutic potential, including unpredictable ab- group were unable to attend regular schools and were Ǡ Arthroscopic knee explorations for pain. sorption and a short half-life, says Dr. Kushida. homeschooled—a rate 10 times the national average. Ǡ Percutaneous endoscopic gastrostomy for XP13512, a gabapentin prodrug with extended release, is ab- While PMD symptoms eventually remit with sup- dysphagia. sorbed by transporter proteins located throughout the GI tract portive care in most cases, symptoms remain in- Ǡ Port-A-Cath placement. and is rapidly converted to gabapentin. Pharmacokinetic tractable in some, Dr. Ferrara said in reporting his find- Ǡ Surgeries for abdominal pain (Nissen fundo- studies show this results in higher peak concentration with ings at the 60th annual meeting of the American plication, appendectomy, cholecystectomies). longer duration of exposure. Academy of Neurology. In a chart review of 54 chil- Ǡ Sinus surgery. Dr. Kushida disclosed relationships to numerous companies, dren who were eventually diagnosed with PMD, 12 including XenoPort Inc., the maker of XP13512. ■