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Background Visual acuity has been a significant outcome measure in clinical trials for patients suffering from neuro-ophthalmological diseases and multiple sclerosis; however, there are limited data on the comparison of various testing strategies in pediatric patients with these disorders. Clinical trials using vision as an outcome could include a variety of tools to assess the acuity, including 2-m and 4-m standardized retroilluminated charts. Methods We investigated the difference in Early Treatment Diabetic Retinopathy Study (ETDRS) scores obtained using 2-m and 4-m charts, as well as the impact of optic neuritis, use of vision correction, age, and gender on visual acuity data from 71 patients with pediatric neuroimmunological conditions in a cross-sectional study. Results We determine that the ETDRS letter scores obtained using 4-m charts are on average 3.43 points less (P = 0.0034) when testing monocular ETDRS letter scores and on average 4.14 points less (P = 0.0008) when testing binocular ETDRS letter scores, relative to that obtained using the 2-m charts. However, we find that when performing monocular testing, optic neuritis in the eye being tested did not result in a statistically significant difference between 2-m and 4-m ETDRS letter scores. Conclusions Although visual acuity charts are formatted by the distance, there are significant differences in the number of letters correctly identified between 2-m and 4-m charts. Although the differences may not impact the clinical acuity, research protocols should consider these differences before collapsing data across disparate studies.

Background Duchenne muscular dystrophy (DMD) is a neuromuscular disorder caused by mutations within the dystrophin gene. DMD is characterized by progressive skeletal muscle degeneration and atrophy and progressive cardiomyopathy. It has been observed the severity of cardiomyopathy varies in patients with DMD. Methods and Results A cohort of male patients with DMD and female DMD carriers underwent whole exome sequencing. Potential risk factor variants were identified according to their functional annotations and frequencies. Cardiac function of 15 male patients with DMD was assessed by cardiac magnetic resonance imaging, and various cardiac magnetic resonance imaging parameters and circulating biomarkers were compared between genotype groups. Five subjects carrying potential risk factor variants in the cystic fibrosis transmembrane regulator gene demonstrated lower left ventricular ejection fraction, larger left ventricular end‐diastolic volume, and higher NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) levels compared with 10 subjects who did not carry the potential risk factor variants ( P =0.023, 0.019 and 0.028, respectively). Conclusions This study revealed heterozygous cystic fibrosis transmembrane regulator gene missense variants were associated with worse cardiac function in patients with DMD. The cystic fibrosis transmembrane regulator gene may serve as a genetic modifier that accounts for more severe cardiomyopathy in patients with DMD, who would require more aggressive management of the cardiomyopathy.

BackgroundWe sought to review safety and efficacy of therapeutic plasma exchange (TPE) in a cohort of pediatric patients with transverse myelitis.MethodsBilling data of all plasma exchanges performed at our tertiary care pediatric hospital between August 2010 and August 2016 were compared to electronic medical records to find all patients whose indication for apheresis was transverse myelitis. Patient outcomes were quantified on the modified Rankin Scale.ResultsFifteen of 19 patients (79%) had major improvement in symptoms after a course of 4–7 therapeutic plasma exchanges. The majority required further inpatient (6, 32%) or outpatient (8, 42%) physical therapy. Four (21%) patients returned to baseline and over 75% regained their ability to ambulate as of last follow-up. Four adverse events were noted over 114 treatments.ConclusionsTPE can be a useful treatment for pediatric transverse myelitis. The retrospective nature of this study without a comparator group limits conclusions about efficacy. However, controlled trials would help to validate our results.Classification of evidenceThis study provides Class IV evidence that plasma exchange is safe and effective in pediatric transverse myelitis.

Pediatric acute transverse myelitis (ATM) is an immune-mediated CNS disorder and contributes to 20% of children experiencing a first acquired demyelinating syndrome (ADS). ATM must be differentiated from other presentations of myelopathy and may be the first presentation of relapsing ADS such as neuromyelitis optica (NMO) or multiple sclerosis (MS). The tenets of the diagnostic criteria for ATM established by the Transverse Myelitis Consortium Working Group can generally be applied in children; however, a clear sensory level may not be evident in some. MRI lesions are often centrally located with high T2 signal intensity involving gray and neighboring white matter. Longitudinally extensive ATM occurs in the majority. Asymptomatic lesions on brain MRI are seen in more than one-third and predict MS or NMO. The role of antibodies such as myelin oligodendrocyte glycoprotein in monophasic and relapsing ATM and their significance in therapeutic approaches remain unclear. ATM is a potentially devastating condition with variable outcome and presents significant cumulative demands on health and social care resources. Children generally have a better outcome than adults, with one-half making a complete recovery by 2 years. There is need for standardization of clinical assessment and investigation protocols to enable international collaborative studies to delineate prognostic factors for disability and relapse. There are no robust controlled trials in children or adults to inform optimal treatment of ATM, with one study currently open to recruitment. This review provides an overview of current knowledge of clinical features, investigative workup, pathogenesis, and management of ATM and suggests future directions.

This article presents data about inflammatory myelopathies, also referred to as transverse myelitis. While the idiopathic form of this condition is rare, the prevalence of transverse myelitis is relatively common when including all of the secondary causes, such as multiple sclerosis (MS). Thus, clinicians and researchers should be familiar with the presentations, diagnostic algorithms, treatment options, and long-term symptom management for patients with transverse myelitis. This review presents data about the idiopathic and secondary forms of transverse myelitis.As research has expanded, the presentations of transverse myelitis have been clarified and the secondary causes explored. With the identification of the aquaporin-4 (AQP4) antibody, more patients with transverse myelitis have been categorized as having neuromyelitis optica (NMO), and more variable presentations have been published. A growing experience with various treatment options has expanded the therapeutic approaches to acute inflammatory myelopathies beyond standard corticosteroid intervention regimens.Transverse myelitis can occur in isolation or as part of a larger systemic condition. An empiric approach to patient evaluation can accelerate diagnosis of secondary conditions. Mounting evidence suggests that an aggressive approach to therapy can improve patient outcomes, but large-scale prospective trials are lacking.

Objective: The objective of this randomized, double-blind, placebo-controlled, crossover study was to examine if patients with optic neuropathy would derive a therapeutic benefit from 4-aminopyridine (4-AP) treatment. Furthermore, the study was intended to determine if patients with certain P100 latencies or retinal nerve fiber layer (RNFL) measures would be more likely to respond to therapy. Methods: Patients were enrolled in a randomized, placebo-controlled, double-blind, crossover study of 10 weeks duration. Patients underwent visual evoked potentials (VEP), optical coherence tomography (OCT), and visual acuity before starting 5 weeks of either placebo or 4-AP. After 5 weeks, they completed a second evaluation (VEP, OCT, and visual acuity) and were crossed over between treatment arms. Five weeks later, they had their final evaluation. All investigators were blinded to treatment arm until after data analysis. Results: On average, patients had faster P100s on 4-AP when compared to placebo. A subset of patients had distinct responses to 4-AP as measured by improvements in visual acuity. Finally, eyes with an RNFL measure between 60 and 80 µm had the highest response rate. Conclusions: 4-Aminopyridine is useful for improving vision in patients with demyelinating optic neuropathy. Future clinical trials may be able to enrich a patient population for potential responders using OCT and VEP measures. Selecting patients for future trials should use RNFL measures as part of inclusion/exclusion criteria. Classification of evidence: This study provides Class IV evidence supporting the use of 4-AP in certain patients with optic neuropathy to improve visual function (patients with RNFL between 60 and 80 µm).

To test the hypothesis that patients with multiple sclerosis (MS) with intereye asymmetry on low contrast letter acuity, and thickness of the retinal nerve fiber layer (RNFL), would exhibit corresponding changes in cortical timing and amplitude responses on pattern reversal multifocal visual evoked potentials (mfVEP), contingent upon variable stimulus contrast.In a cross-sectional study, we investigated a cohort of 11 normal subjects and 40 patients with MS, 21 of whom had a history of acute optic neuritis (MS-AON) with an intereye asymmetry with respect to RNFL thickness, and on low contrast letter acuity performance. Pattern reversal mfVEP was performed at high (100%), low (33.3%), and very low (14.2%) Michelson-contrast levels.Compared to baseline measures at 100% contrast, the mean amplitude of the mfVEP was reduced in MS-AON eyes, upon pattern-reversal stimulation at the 2 lower contrast levels (p0.0001). With respect to changes in timing responses, the intereye asymmetry was increased in the MS-AON patients upon lower contrast pattern-reversal stimulation (p0.0001 for 33.3% compared to 100%, and p0.001 for 14.2% compared to 100%). The fellow eye in 12 (57%; p0.001) of the patients with an abnormal eye, and a history of AON, revealed abnormal amplitude and timing responses upon low contrast stimulation (signifying unmasking of occult damage).Our findings support the hypothesis that mfVEP metric abnormalities are contingent upon contrast magnitude during pattern reversal stimulation. Further, this paradigm was capable of unmasking occult abnormalities in a significant number of apparently unaffected eyes.

For a disease whose cause remains elusive, there has been a paradoxical growth in multiple sclerosis (MS) therapeutics. During the past 17 years, six therapeutic drugs for MS were brought to market. All of these disease-modifying therapies (DMTs) have shown a beneficial effect in reducing the number of exacerbations in double-blind placebo-controlled trials, and three drugs (subcutaneous [SC]/IM interferon beta-1a, natalizumab) have been shown to reduce relapses, decrease MRI activity, and reduce the risk of sustained disability after 2 years of treatment. No controlled studies exist to show long-term benefit with any of the current DMTs. Immunosuppressive drug (ISD) therapies continue to play a role in the management of patients who fail to respond to immunomodulatory agents. These agents, however, have shown mixed data in terms of efficacy and put patients at higher risk for the development of secondary cancers. Plasma exchange for severe relapses not responsive to corticosteroid therapy has regained interest in the past few years. Furthermore, six new agents that will dramatically impact our ability to prevent disability in patients with MS are in late-stage or have completed phase 3 clinical development. Determining the risk-benefit calculations that we will need to employ toward these new drugs and the algorithms for switching therapies will be critical issues in the next 5 years. This article highlights the clinical efficacy of the current DMTs/ISDs and discusses the current treatment options for clinically isolated syndrome, relapsing-remitting MS (RRMS), and exacerbations of RRMS. It also addresses the management of a suboptimal response to the DMTs; discusses the challenge of primary progressive MS; and presents an overview of emerging therapeutic options.

Often patients with systemic lupus erythematosus (SLE) suffer from neurologic symptoms and at times the diagnosis of SLE is made after patients present with neurologic events. Although diagnostic criteria for SLE have included seizures and psychosis, there are 19 recognized neurologic manifestations of the disease.The various neurologic manifestations of SLE are reviewed as are the various treatment options. The pathophysiology of the major syndromes is reviewed.Neurologists need to be familiar with the various ways SLE can present and the various neurologic complications known lupus patients can experience. Because of the various treatment options available, rapid recognition of these syndromes is critical.

Background: Varicella zoster virus (VZV) vasculopathy produces stroke secondary to viral infection of cerebral arteries. Not all patients have rash before cerebral ischemia or stroke. Furthermore, other vasculitides produce similar clinical features and comparable imaging, angiographic, and CSF abnormalities. Methods: We review our 23 published cases and 7 unpublished cases of VZV vasculopathy. All CSFs were tested for VZV DNA by PCR and anti-VZV IgG antibody and were positive for either or both. Results: Among 30 patients, rash occurred in 19 (63%), CSF pleocytosis in 20 (67%), and imaging abnormalities in 29 (97%). Angiography in 23 patients revealed abnormalities in 16 (70%). Large and small arteries were involved in 15 (50%), small arteries in 11 (37%), and large arteries in only 4 (13%) of 30 patients. Average time from rash to neurologic symptoms and signs was 4.1 months, and from neurologic symptoms and signs to CSF virologic analysis was 4.2 months. CSF of 9 (30%) patients contained VZV DNA while 28 (93%) had anti-VZV IgG antibody in CSF; in each of these patients, reduced serum/CSF ratio of VZV IgG confirmed intrathecal synthesis. Conclusions: Rash or CSF pleocytosis is not required to diagnose varicella zoster virus (VZV) vasculopathy, whereas MRI/CT abnormalities are seen in almost all patients. Most patients had mixed large and small artery involvement. Detection of anti-VZV IgG antibody in CSF was a more sensitive indicator of VZV vasculopathy than detection of VZV DNA ( p GLOSSARY: EIA = enzyme immunoabsorbent assay; VZV = varicella zoster virus.

Transverse myelitis is a focal disorder of the spinal cord in which an immune-mediated process results in neural injury. In this large retrospective study, we compare patients who received one of four treatments to identify the most effective therapies. We identified subsets of patients who received clinical benefit from plasma exchange or cyclophosphamide being included in their treatment regimen.

INTRODUCTION AND OBJECTIVES: Transverse myelitis (TM) is a heterogenous inflammatory syndrome characterized by acute or subacute spinal cord dysfunction resulting in paresis, sensory deficit, and frequently significant symptomatic autonomic impairment. We sought to characterize the lower urinary tract dysfunction in patients with TM by describing urodynamic (UDS) findings in patients referred with TM and lower urinary tract symptoms (LUTS). METHODS: This is a retrospective review from an IRBapproved neurogenic bladder database of patients followed for LUTS by a single surgeon between 2001 and 2013. Patient demographics (age, gender, BMI), baseline questionnaire data (PGI-S, UDI-6, OAB-Q) and UDS parameters were analyzed. UDS parameters assessed included mean cystometric capacity (MCC), compliance, detrusor overactivity (DO), threshold volume (TV) at first involuntary contraction, maximum detrusor pressure (pdet.max), detrusor sphincter dyssynergia (DSD), post void residual (PVR), as well as pressure flow parameters. RESULTS: Of the 836 patients with neurogenic bladder conditions in our database, 19 patients (13 females, 6 males) were referred with a principle diagnosis of TM (2.3%). Fifteen of 19 (78.9%) underwent UDS testing. Overall, mean age was 53 years (31-72), and mean age at diagnosis of TM was 47 years (2-69). Mean time from TM diagnosis to UDS was 31 months (3-153). Level of injury was cervical in 8 patients and thoracic in 10 patients, with 1 patient’s level of injury unknown. Bladder management at baseline was CIC or urethral catheter for 10/19 patients (52.6%). Mean MCC was 312 mL 207.1, DO was present in 12/15 (80%), DSD in 6/15 (40%), and decreased compliance in 5/15 (33.3%). The mean TV was 175 mL 96, and mean pdet.max was 49 20.8 cmH20. Five patients (33.3%) were unable to void during UDS. For those voiding, mean Qmax was 13.5 11.6 ml/ sec and pdet at Q max was 39.8 17.7 cmH20. No correlation was found between questionnaire data and UDS parameters (Table 1). CONCLUSIONS: Significant UDS abnormalities are noted in the majority of TM patients referred with LUTS, with over 30% having altered compliance. Patients with TM require ongoing close surveillance of lower urinary tract dysfunction and urological care based on these data.

Neuromyelitis optica (NMO) is an inflammatory demyelinating disorder characterized by monophasic or recurrent attacks of optic neuritis (ON) and transverse myelitis. NMO spectrum disorders include patients who are seropositive for NMO-IgG antibody and have experienced at least 1 demyelinating attack. NMO has been associated with other autoimmune conditions. We describe a patient diagnosed with autoimmune hemolytic anemia and marginal zone lymphoma, who later developed NMO-IgG seropositive ON. The coexistence of multiple immunologic abnormalities in this patient points to a generalized dysfunction of the humoral immune system. History of autoimmunity should alert the clinician to the possibility of NMO spectrum disorder in a patient presenting with isolated ON.

Objective: To determine the impact on resident training and patient safety of a dedicated lumbar puncture (LP) service utilizing mid-level practitioners (MLP). Background LP is a common bedside procedure. An unsuccessful LP may lead to repeated procedures or fluoroscopy guided LP, increasing patient risks associated with radiation exposure. With reduction in resident work hours by the ACGME, many academic institutions are using MLPs to supplement the provision of patient care, including performing LPs. To our knowledge, the impact of the utilization of specialized MLPs on resident training and patient safety specific to LPs has not been studied. Design/Methods: We conducted a retrospective chart review of inpatients undergoing bedside LP by either a neurology resident physician or neurology MLP from July 2009 through August 2011. Results: A total of 97 LPs were reviewed, 40 performed by a MLP and 57 by a resident physician. Successful bedside LP was documented in 70% and 71.9% of cases by the MLP and residents, respectively (p=0.1815). The average number of skin punctures required to obtain CSF was 1.53 by the MLP vs. 1.67 by residents (p=0.252). There was a numerical but non-significant trend toward improvement when comparing success rate and number of puncture attempts of the MLP in the first six months compared to the second six months of clinical practice (70% vs 77%, p=0.252 and 1.57 to 1.47, p=0.659, respectively). There was insufficient recorded data to make similar comparisons for residents. Conclusions: This study demonstrates no difference between a trained neurology MLP and neurology resident physicians in success rates or safety of performing bedside LP. Nor did we find evidence for negative impact on resident training or proficiency. Specifically there was no evidence for decreased LP success rates in the resident group following introduction of a specialized MLP. Disclosure: Dr. Jordan has nothing to disclose. Dr. Greenberg has received personal compensation for activities with DioGenix, Greater Good Foundation, Biogen Idec, Serono, Inc., Sanofi-Aventis Pharmaceuticals, Inc., the Multiple Sclerosis Association of America and Teva Neuroscience as a consultant and/or speaker. Dr. Greenberg holds stock and/or stock options in Diogeix. Dr. Greenberg has received research support from Guthy-Jackson Charitable Foundation, Amplimmune, Inc. and the Accelerated Cure Project. Dr. Lee has received personal compensation for activities with Boehringer Ingelheim as a speaker.

Objective: To characterize a high precision and clinically useful paradigm for multifocal, digitally generated, visual evoked potential responses. Background Conventional visual evoked potential techniques are performed with sophisticated, multi-focal stimulators, coupled with digital amplifiers that generate a heterogeneity of cortical responses, with wide variability when compared to the traditional black and white CRT stimulators. While contemporary stimulators represent a technical refinement capable of yielding multi-focal data, with high spatial resolution using m-sequence patterns, no paradigm has been validated to produce a physiologic signature commensurate with the p-100 metric. Design/Methods: Patients with a history of unilateral optic neuritis, along with a control group of healthy patients with no known ophthalmic or neurologic disease, were scanned using the Veris FMS3 Stimulator with a Grass Digital Amplifier. Patients were tested using a 7 minute 120 sector m-sequence multi-focal visual evoked potential test. A standard template was used for each patient. Each electrode was monitored for impedance. The Veris Scientific software was used to formulate an analysis paradigm that would yield valid and reproducible signatures reflecting visual cortical responses. Various combinations of analysis patterns were tested. Results: ROC curves were utilized to assess sensitivity and specificity of data. By dividing the central 20 degrees into three rings, and deriving a single wave form for each of the corresponding geometries, a simulated and reproducible metric was derived, the application of which was confirmed as a highly sensitive and specific discriminator for differentiating normal vs abnormal cortical responses. Conclusions: While multi-focal VEP techniques have impressive spatial resolution, and appear to have utility for confirming pathophysiologic evidence for unilateral visual system dysfunction, the results are not yet comparable to the conventional gold standard p-100 metric. Our proposed technique was effective in segregating geometric ring ratios into a single codified waveform metric, from which normative values can be established. Supported by: DADS Foundation, VIRAGH Family Foundation. Disclosure: Dr. Conger has nothing to disclose. Dr. Conger has nothing to disclose. Dr. Frohman has received personal compensation for activities with Biogen Idec and Teva Pharmaceuticals. Dr. Balcer has received personal compensation for activities with Biogen Idec, Vaccinex and Bayer as a consultant and has received honoraria from Biogen Idec and Novartis. Dr. Calabresi has received personal compensation for activities with Teva, Biogen Idec, Novartis, Genzyme, Johnson & Johnson, and Vertex. Dr. Calabresi has received research support from Biogen Idec, Teva, EMD Serono, Vertex, Genentech, Abbott, and Bayer. Dr. Beh has nothing to disclose. Dr. Greenberg has received personal compensation for activities with DioGenix, Greater Good Foundation, Biogen Idec, Serono, Inc., Sanofi-Aventis Pharmaceuticals, Inc., the Multiple Sclerosis Association of America and Teva Neuroscience as a consultant and/or speaker. Dr. Greenberg holds stock and/or stock options in Diogeix. Dr. Greenberg has received research support from Guthy-Jackson Charitable Foundation, Amplimmune, Inc. and the Accelerated Cure Project. Dr. Frohman has received personal compensation for activities with Biogen Idec, Teva Neuroscience, Acorda Therapeutics, Novartis, Astellas, and Abbott Laboratories, Inc.

Objective: A retrospective analysis of our experience with patients treated with Fingolimod. Background Fingolimod 0.5 mg oral treatment for relapsing remitting multiple sclerosis was released in September 2010. Fingolimod-phosphate binds to sphingosine-1-phosphate receptors tissue throughout the body. Monitoring is recommended to assess for potential side effects mediated by recepter binding and immune suppression including those associated with cardiovascular (first dose), ocular, pulmonary, and hepatic. Design/Methods: Patients on Fingolimod were identified from our data base. Records were reviewed including patient history, pregnancy status, electrocardiogram, optical coherence tomography, pulmonary function studies, laboratory and consultant reports. Records were also reviewed to assess for side effects or treatment discontinuation. Results: 132 patients ( ages16-72) were initiated on Fingolimod between November 2010 and October 2011. 122 patients were given first dose at our clinic, 1 patient began medication on his own, and 9 were initiated at outside facilities. Nine patients developed asymptomatic first degree atrioventricular block with first dose. One patient failed to resolve and medication was stopped. One patient developed atrial fibrillation. One patient developed macular edema which resolved one week after discontinuation. Fingolimod was restarted with monthly OCT. One patient developed uveitis and medication was stopped. Two patients developed shingles. Two patients were discontinued after diagnosis of cancer (liver, bladder). One patient was admitted for bowel obstruction 6 weeks after beginning treatment. Preliminary biopsy results reported 9lymphoid infiltrates9. One patient developed recurrent bronchitis and medication was stopped. Two patients were taken off of treatment for disease activity. Conclusions: Fingolimod was generally well tolerated. Medication was stopped in 8 patients for a variety of reasons: uveitis (1), cancer(2), persistent first degree AV block(1), bowel obstruction (1), recurrent infection(1) and disease activity(2). There were no significant first dose cardiac events or life threatening infections. Disclosure: Dr. Courtney has received personal compensation for activities with Biogen Idec, Novartis, the MSAA, and Teva Neuroscience as a speaker. Dr. Rodriguez has nothing to disclose. Dr. Abraham has received personal compensation for activities with Teva Neuroscience. Dr. Conger has nothing to disclose. Dr. Conger has nothing to disclose. Dr. Greenberg has received personal compensation for activities with DioGenix, Greater Good Foundation, Biogen Idec, Serono, Inc., Sanofi-Aventis Pharmaceuticals, Inc., the Multiple Sclerosis Association of America and Teva Neuroscience as a consultant and/or speaker. Dr. Greenberg holds stock and/or stock options in Diogeix. Dr. Greenberg has received research support from Guthy-Jackson Charitable Foundation, Amplimmune, Inc. and the Accelerated Cure Project. Mrs. Remington has received personal compensation for activities with Biogen Idec, Teva Neuroscience, MSAA, and NMSS.Mrs. Remington has received personal compensation in an editorial capacity for Teva Neuroscience. Dr. Frohman has received personal compensation for activities with Biogen Idec, Teva Neuroscience, Acorda Therapeutics, Novartis, Astellas, and Abbott Laboratories, Inc.

Objective: The objective of this study was to quantify the prevalence and severity of cognitive dysfunction among pediatric transverse myelitis (TM) patients, controlling for concomitant medication use and depression. Background Idiopathic TM is diagnosed based on evidence of inflammation within the spinal cord, in the absence of cerebral involvement. This differentiates it from acute disseminated encephalomyelitis (ADEM) and multiple sclerosis (MS). In pediatric ADEM and MS, cognitive dysfunction is expected and well described within the literature. Up to 20% of transverse myelitis (TM) cases manifest before adulthood. Problems with cognitive and psychological functioning in TM patients have been observed anecdotally; however, no empirical data exists regarding cognitive and psychological outcomes in this population. Within our pediatric demyelinating disease center, we had observed some individual cases of cognitive dysfunction among our TM population and began a formal assessment of these patients. At the initiation of this project, any evidence of cognitive dysfunction was typically attributed to concomitant depression or medication use. This abstract provides the first ever evidence of unexplained cognitive dysfunction in pediatric TM patients. Design/Methods: TM patients seen at our multidisciplinary care clinic were routinely screened for evidence of depression and/or cognitive deficits. This data was retrospectively reviewed under an IRB approved protocol. Data about diagnosis, medication use, comorbid depression, MRI findings, and cognitive function were extracted from the clinical record into SPSS. Twenty-four patients were included in the analysis and the prevalence of cognitive deficits determined. Results: Forty-seven percent of pediatric TM patients were found to be cognitively impaired if screening tests included fine-motor components. Seventeen percent of pediatric TM had evidence of cognitive dysfunction when tasks requiring a fine-motor component were excluded. There was not a contribution from medication use or depression. Conclusions: This is the first study ever to document evidence of cognitive dysfunction among pediatric TM patients. Disclosure: Dr. Harder has nothing to disclose. Dr. Graves has nothing to disclose. Dr. Spurgin has nothing to disclose. Dr. Greenberg has received personal compensation for activities with DioGenix, Greater Good Foundation, Biogen Idec, Serono, Inc., Sanofi-Aventis Pharmaceuticals, Inc., the Multiple Sclerosis Association of America and Teva Neuroscience as a consultant and/or speaker. Dr. Greenberg holds stock and/or stock options in Diogeix. Dr. Greenberg has received research support from Guthy-Jackson Charitable Foundation, Amplimmune, Inc. and the Accelerated Cure Project.