New AAN Guidance on Treating Stroke Patients With PFO

A practice advisory update from the American Academy of Neurology (AAN) warns against routinely offering percutaneous closure of patent foramen ovale (PFO) in patients with cryptogenic ischemic stroke outside of a research setting.

It adds, however, that in rare circumstances, such as recurrent strokes despite adequate medical therapy with no other mechanism identified, clinicians may offer the Amplatzer PFO Occluder (St. Jude Medical Inc) if it is available.

The update was published online July 27 in Neurology.

Potentially Serious Complications

“Clinicians must counsel patients considering percutaneous PFO closure that having a PFO is common; it occurs in about 1 in 4 people; it is impossible to determine with certainty whether their PFOs caused their strokes or TIAs [transient ischemic attacks]; the effectiveness of the procedure [of closing the PFO] for reducing stroke risk remains uncertain; and the procedure is associated with relatively uncommon, yet potentially serious, complications,” the authors, led by Steven R. Messé, MD, University of Pennsylvania School of Medicine, Philadelphia, note.

“We issued this new guidance as we believe it is important for patients to be educated as to what we know about PFO closure and recurrent stroke risk. They need to know that PFO is common and the risk of stroke recurrence is low,” Dr. Messé told Medscape Medical News.

“There is some evidence that one closure device — the Amplatzer — may reduce risk of a subsequent stroke, but this evidence is weak and so we are not recommending routine PFO closure for this indication. In addition, the Amplatzer device is not currently available for this indication in the US — it is currently being reviewed by the FDA [Food and Drug Administration],” he added.

On the matter of ongoing preventive medical treatment, the advisory notes that there is insufficient evidence to determine the efficacy of anticoagulation compared with antiplatelet therapy in preventing recurrent stroke.

Therefore, it recommends that in the absence of another indication for anticoagulation, clinicians may routinely offer antiplatelet medications instead of anticoagulation to patients with cryptogenic stroke and PFO.
“There really isn’t enough data to recommend anticoagulation over antiplatelets in this population, and so we are sticking with the advice to use aspirin unless there is another indication for anticoagulation,” Dr Messé added.

The authors explain that these recommendations form an update to the 2004 AAN guideline for patients with stroke and PFO, which concluded that the optimal therapy for secondary stroke prevention in this population was unknown.

“Since that time, additional studies necessitated that we update our prior guideline,” they note.

PFO: What the Literature Says

From a systematic literature review, the authors identified three relevant studies on PFO closure.

The CLOSURE I study (Class I) was a multicenter, randomized, open-label trial of percutaneous closure with a STARFlexdevice (NMT Medical) compared with medical therapy alone in adult patients with PFO and a cryptogenic stroke/TIA.

Results showed similar rates of recurrent stroke in the two groups. And use of the STARFlex device was linked to a higher rate of atrial fibrillation and major vascular procedural complications.

The authors of the current AAN guidance conclude that the STARFlex device “possibly does not provide a large benefit in preventing stroke in place of medical therapy alone, possibly increases the risk of new-onset AF [atrial fibrillation], and probably is associated with a serious periprocedural complication risk.”

The Amplatzer PFO Occluder has been studied in two randomized trials that compared it with medical therapy.

The PC Trial showed a recurrent stroke rate of 0.5% in the closure group vs 2.4% in the medically treated group (P = .14). New-onset AF was reported in 2.9% in the closure group vs 1.0% in the medical treatment group, and bleeding adverse events occurred in 3.9% in the closure group and in 5.7% in the medically treated group.

In the second trial, RESPECT, the intention-to-treat analysis showed a recurrent stroke rate of 1.8% in the device group vs 3.3% in the medical group (P = .08).

A prespecified per-protocol analysis showed a statistically significant benefit favoring closure. The clinical AF incidence did not differ significantly between the two groups, but there were six pulmonary embolisms in the closure group compared with one in the medical group.

Pooled Analysis

The guidance authors conducted a pooled meta-analysis of the two Amplatzer studies that did suggest a significant reduction in recurrent stroke with PFO closure, with a number needed to treat of 56 to prevent 1 stroke during the 3 to 4 years of the studies.

“Although this result is significant…the precision of the pooled studies is consistent with a magnitude of benefit that many would deem unimportant,” they write.

They note that the meta-analysis also showed that serious procedural or device-related events occurred in 3.4% of patients undergoing closure, and also a significant increased risk for AF in the closure group.

They conclude that PFO closure with the Amplatzer device “possibly decreases the risk of recurrent stroke,” “possibly increases the risk of new-onset AF,” and “is highly likely to be associated with a procedural complication risk.”

“Because of the limitations of the efficacy evidence and the potential for serious AEs [adverse events], we judge the risk–benefit tradeoffs of PFO closure by either the STARFlex or Amplatzer PFO Occluder to be uncertain,” they add.

On the question of anticoagulation vs antiplatelet therapy for cryptogenic stroke patients with a PFO, the 2004 guideline identified one study relevant to this question.


The PICSS study showed no significant difference in recurrent stroke or death at 2 years between patients receiving warfarin or those receiving aspirin, although there was a numeric reduction in the warfarin group. The authors note that the results are similar for patients without a PFO, suggesting that any effect was unrelated to the presence of a PFO.

 The latest updated search identified a second randomized study comparing aspirin with warfarin for secondary prevention in patients with cryptogenic stroke and PFO. Results of this trial showed no significant difference in ischemic stroke or TIA risk between treatment groups (with a slight trend in favor of aspirin).

Combining the two studies in a random-effects meta-analysis showed no significant difference between treatments, and the summary estimate of effect was a risk difference of 2% favoring antiplatelet treatment (95% confidence interval, –21% to 25%).

“For patients with cryptogenic stroke and PFO, there is insufficient evidence to determine the efficacy of anticoagulation compared with antiplatelet therapy in preventing recurrent stroke,” the authors conclude.

 For the future, they note that at least three large randomized trials comparing PFO closure with medications are ongoing, and even more studies may be necessary to clarify this issue.

Finally, the authors suggest that it would be reasonable to consider trials of the new anticoagulants (factor Xa inhibitors and direct thrombin inhibitors), which have a lower bleeding risk and greater convenience than warfarin, in patients with stroke and a PFO.

Firm Claims Biotin Drug Improves Function in Progressive MS

One-year study meets primary disability-based endpoint, company says.

Patients with progressive multiple sclerosis showed improvements in standard measures of disability after taking large doses of biotin in a phase III study, the product’s developer announced.

Paris-based MedDay SAS said the 154-patient, placebo-controlled trial met its primary endpoint — either a decrease in Expanded Disability Status Score (EDSS) of at least 1 point for baseline EDSS ≤5.5 and 0.5 points for EDSS ≥6, or an improvement in 25-foot walk time of at least 20% — but the firm did not indicate what proportion of patients achieved these outcomes.

 MedDay promised that full results would be presented next week at the American Academy of Neurology’s annual meeting here.

The drug, called MD1003, delivers 300 mg/day of biotin — a massively greater dose than the usual recommendation of 30-100 mcg/day. Patients in the trial received the drug for 48 weeks. The primary endpoint was assessed at 9 months, with another assessment at 12 months.

According to the published abstract for the AAN presentation, biotin acts “as a coenzyme for carboxylases involved in key steps of energy metabolism and fatty acids synthesis. Among others, biotin activates acetylCoA carboxylase, a potentially key-enzyme in myelin synthesis.”

Demyelination and resulting neuronal dysfunction and death is thought to be the main basis for progressive MS. Consequently, agents that prompt new myelin synthesis are considered one way to slow, stop, or even reverse disability progression.

The abstract cited a 23-patient pilot study, in which open-label biotin doses of up to 600 mg/day “resulted in progressive and sustained improvement of disability in primary and secondary [progressive MS] patients.”

MedDay said the phase III trial design had been “discussed with U.S. and European regulators” and that it was “pleased” with the results. But the firm didn’t indicate whether it planned to seek marketing approvals on the basis of the trial findings. Aseparate trial is currently underway with visual endpoints in patients with MS-related optic neuritis. A third trial in the adult form of X-linked adrenoleukodystrophy has also launched, the company said.

High Glucose Linked to Poorer Memory, Even in People Without Diabetes.

Higher levels of both short-term and long-term blood glucose markers are significantly associated with poorer memory and with decreased volume and microstructure of the hippocampus in persons without diabetes or impaired glucose tolerance (IGT), according to a new study.

The results imply that lowering blood glucose levels, possibly even to relatively low levels, might help preserve cognition, study author Agnes Flöel, MD, Department of Neurology and Center for Stroke Research Berlin, Charite-University Medicine, Berlin, Germany, toldMedscape Medical News.

Strategies that help lower blood glucose levels include a healthy Mediterranean-type diet and regular physical activity, she added.

The study is published online October 23 in Neurology.

Direct Relationship

The cross-sectional study included 141 healthy persons (mean age, 63.1 years) who were recruited through advertising. Persons with diabetes, IGT, or neurologic disorders and those taking antidepressants were excluded.

Researchers obtained blood measurements, including glycosylated hemoglobin (HbA1c), which reflects peripheral glucose levels of the preceding 8 to 12 weeks; fasting glucose; and insulin. They also carried out apolipoprotein E (APOE) genotyping.

Participants underwent cognitive testing using the German version of the Rey Auditory Verbal Learning Test. Researchers calculated hippocampal volume from MRI scans and assessed hippocampal microstructure by mean diffusivity (MD) estimated by using diffusion tensor imaging.

According to Dr. Flöel, this was the first time that this MD method provided data on the association between hippocampal microstructure and glucose metabolism.

The investigators found that lower performance on 3 memory tasks (delayed recall, learning ability, and consolidation) was associated with higher levels of both the long-term marker of glucose control (HbA1c) and the short-term glucose marker (all P ≤ .01).

For insulin, there was a “general trend going in the same direction” but correlations were less clear, and without the same direct relationship, said Dr. Flöel.

Potential Mechanisms

Memory performance was correlated with hippocampal volume (P = .001) and lower MD (P = .01), lower age, and, in part, lower blood pressure and female sex. Researchers did not find a statistically significant association between memory performance and APOE genotype, body mass index, Beck Depression Inventory score, physical activity, or smoking.

Lower levels of HbA1c were associated with larger hippocampal volume (nonsignificant trend; P = .06). The associations between lower fasting glucose levels and higher hippocampal volume did reach significance (P = .01). There was no significant relationship between hippocampal volume and insulin.

As for hippocampal microstructure, the researchers noted that lower levels of all 3 markers of glucose metabolism significantly correlated with lower MD within the hippocampus.

There was no significant association between glucose markers and volume or MD in brain areas other than the hippocampus (eg, gray matter and thalamus).

The hippocampus is particularly vulnerable to disturbances in metabolic supply, including glucose, said Dr. Flöel.

“Elevated blood sugar levels may damage the outer membrane of the cells, or decrease neurotransmitter levels, which would disturb signaling within and between hippocampal cells. Information transfer between cells, which is indispensable for memory encoding, storage and retrieval, would then be compromised.”

Elevated blood sugar levels may also damage small and large vessels in the brain, leading to decreased blood and nutrient flow to brain cells or even brain infarcts, and this may further damage memory-relevant brain structures, added Dr. Flöel.

The current findings are in line with studies of patients with type 2 diabetes mellitus and IGT, but earlier research was unable to confirm the deleterious effects of nondiabetic glucose levels on cognition. This, said the authors, may be because of different methods for classifying glucose levels and varying cognitive tests used.

Prevention Research

The authors also pointed out that the current study used MRI with higher magnetic field strength, which offers a higher sensitivity of hippocampal volumetry and greater statistical power to observe significant associations.

Following a diet high in lean protein and complex carbohydrates (such as whole grains, vegetables, fruits, and fiber) and low in heavily refined foods will help lower blood glucose, said Dr. Flöel. Another important lifestyle strategy is regular physical activity.

How low is it safe to go in terms of blood glucose levels? According to Dr. Flöel, that depends in part on lifestyle. “If you’re used to low blood sugar levels, you can go quite low,” she said.

She likened this to the situation with blood pressure. “At one time, it was assumed that you needed a certain level to function, but that actually is not true. You can go very low and still maintain normal function, and it might actually be better in the long run.”

Although the study uncovers the protective potential of lower blood glucose levels, the relationship between high blood glucose and poor memory “seems to be more linear” and changing recommended cutoffs may not make much of a difference, said Dr. Flöel.

On the other hand, what could be key is prevention, she said.

“There have been some initiatives to put prevention more on the agenda of dementia research,” she said. “There has been so much money spent on treatment of Alzheimer’s disease and it has already been established that this is not very successful. “

Dementia prevention strategies could include taking measures at an earlier stage to encourage physical fitness and control hypertension, blood lipids (including cholesterol and triglycerides), and now, possibly, blood glucose levels, she said.

Patients should have their fasting glucose and HbA1c levels measured as part of a regular medical check-up starting at age 55 years, unless there’s a personal or family history of diabetes or the patient is obese, in which case the family doctor may opt for earlier and more intense monitoring, said Dr. Flöel. She pointed out that such tests are easy to do and are already carried out regularly in pregnant women.

Fresh Eyes

Commenting on the findings for Medscape Medical News, Marwan N. Sabbagh, director, Banner Sun Health Research Institute, Sun City, Arizona, said that the study looks at the link between glucose metabolism and cognition with fresh eyes.

“This is saying that immediate learning and A1c levels, and potentially even blood sugars, interact even in people who are nondemented, and I don’t think anyone has looked at it that way before,” said Dr. Sabbagh.

“The idea is that the lower the A1c the better your brain function. This is a very exciting development and clearly helps put a frame around the Alzheimer’s discussion, but more importantly, it talks about how blood sugar metabolism and cognitive function directly interact.”

The study opens “a whole new territory” because until now, HbA1c and blood glucose have been looked at only in the context of diabetes and the risk for diabetes, added Dr. Sabbagh. “Maybe we need to rethink our normalization of glucose with an eye toward cognition and not simply a diabetes risk.”

Epilepsy Risk for Men Reduced with Exercise.

Story at-a-glance

  • Men who had a high level of fitness when they were young were 79 percent less likely to develop epilepsy later in life compared to those with low fitness levels
  • Compared to young men with average fitness levels, the high-fitness group was still 36 percent less likely to develop epilepsy
  • Exercise may protect the brain and create a stronger brain reserve, which may reduce epilepsy risk
  • If you have epilepsy, exercising may help to reduce the frequency of seizures.


The next time you work out, take a moment to think about all of the wonderful ways it is benefitting your body. And I’m not only talking about your muscles or your six-pack abs… I’m referring to you brain.

Exercise is emerging as a key player in brain health at various stages of life and has been shown to prevent cognitive decline, moderate brain damage caused by drinking and even lower your risk of brain diseases like Alzheimer’s. Now, researchers have uncovered yet another brain benefit of exercise – a reduced risk of epilepsy.

Vigorous Exercise May Reduce Epilepsy Risk by Up to 80 Percent

In a study involving more than 1.1 million men who were followed for an average of 25 years, those who had a high level of fitness when they were young were 79 percent less likely to develop epilepsy later in life compared to those with low fitness levels.1

Compared to young men with average fitness levels, the high-fitness group was still 36 percent less likely to develop epilepsy. This is the first study in humans to reveal that exercise may impact epilepsy risk. One of the study’s researchers noted:2

Exercise may affect epilepsy risk in two ways. It may protect the brain and create stronger brain reserve, or it may simply be that people who are fit early in life tend to also be fit later in life, which in turn affects disease risk.”

Exercise May Reduce Seizure Frequency in People with Epilepsy

Epilepsy is a neurological disorder involving disturbed nerve cell activity in your brain. This results in seizures that may include a staring spell, confusion, uncontrollable jerking movements and loss of consciousness or awareness. Obviously, this presents risks of falls and injuries that may occur if you have a seizure while driving or even exercising.

For this reason, people with epilepsy have previously been discouraged from participating in physical activity, and this stigma remains today even though medical recommendations have long since changed.

Now, exercise is highly recommended for people with epilepsy, for starters because it helps to reduce stress levels, which can sometimes trigger seizures. In fact, physical activity has been shown to decrease seizure frequency,3 as well as lead to improved cardiovascular and psychological health in people with epilepsy.4

Tips for Exercising if You Have Seizures

If you have epilepsy, make sure you exercise with a buddy or a personal trainer who knows what to do if you have a seizure. A medical alert bracelet can also be worn.

Try to exercise in a safe area, such as a grassy field or on a gym mat, and wear elbow and knee pads. If you’ll be swimming, be sure you wear a life vest and never go swimming alone (a strong swimmer should be with you at all times in case you need help).

If you’ll be exercising on a bicycle, stay away from busy streets (and wear a helmet)… likewise if you’ll be hiking — stick to simpler trails, not those with steep drop-offs or cliffs. If you have epilepsy, you’ll need to take special care during activities that pose a risk of a blow to your head, such as football; if you do engage in such sports be sure to wear a helmet.

Generally speaking, however, you can exercise normally if you have epilepsy, but do use commonsense precautions – avoid getting over-tired or overheated, and avoid exercising when it’s very hot. As an aside, if you have epilepsy, be sure to get your vitamin D levels checked. When epileptic patients improved their vitamin D levels, their seizures were reduced by an average of 40 percent in one study.5

What Else Can Exercise Do for Your Brain?

Along with potentially reducing your risk for epilepsy quite significantly, scientific evidence shows that physical exercise helps you build a brain that not only resists shrinkage, but also increases cognitive abilities.6 In one review of more than 100 studies, both aerobic and resistance training were found to be important for maintaining cognitive and brain health in old age.7 Moderate exercise may even reverse normal brain shrinkage by 2 percent, effectively reversing age-related hippocampus degeneration, which is associated with dementia and poor memory, by one to two years.8

Not to mention, other contributing factors to brain disease caused by the normal aging process may also include a decrease in blood flow to your brain, and the accumulation of environmental toxins in your brain. Exercise can help ameliorate both of these conditions by increasing blood flow to your brain, thereby increasing oxygen supply to your brain and encouraging a more vigorous release and removal of accumulated toxins through better blood circulation.

You’ve Got to Move It… Or You Might Lose It

If you work out religiously for three months, then suddenly stop for an extended period, your muscle tone will definitely suffer. This is one of the more obvious examples that your body is designed for regular exercise, not sporadic or infrequent activity.

Likewise, research suggests that the brain benefits of exercise also quickly fade if your exercise program stops. The silver lining is that the opposite also appears to hold true. While the benefits of exercise might fade fast, they can also be achieved relatively quickly.

Exercising – even briefly – can change your DNA in a way that readies your body for increased muscle strength and fat burning. It also boosts your natural human growth hormone (HGH) production, which is important for maintaining muscle mass as you age. If you’re approaching middle-age or beyond, you might be thinking that it’s too late for you to get in shape, but this is not the case. Remember, you are never too old to start exercising and start reaping the mental and physical benefits that physical activity has to offer.


If you have epilepsy and are unable to control the seizures, or have refractory epilepsy – or know someone who is affected – please view the video above, which is my interview with Dr. Thomas Seyfried about the ketogenic diet. The ketogenic diet has been used for managing seizures for quite some time, and is now recognized as an important component for the management of refractory seizures in children. A ketogenic diet calls for eliminating all but non-starchy vegetable carbohydrates, and replacing them with healthy fats and high-quality protein.

Eating this way will help you convert from carb-burning mode to fat burning, as well, so it provides many benefits beyond seizure control. According to Dr. Seyfried, the mechanism by which the ketogenic diet manages seizures is not clear, but the results speak for themselves. You can learn more about the ketogenic diet here.

Want to Boost Your Brainpower? Try This Exercise ‘Prescription’

The more active you stay, the better your brain (and overall health) is likely to be. This includes not only specifically engaging in exercise and other physically demanding activities but also making an effort to sit less. To get all the benefits exercise has to offer, you’ll want to strive for a varied and well-rounded fitness program that incorporates a variety of exercises. I recommend incorporating the following types of exercise into your program:

    • High-Intensity Interval (Anaerobic) Training: This is when you alternate short bursts of high-intensity exercisewith gentle recovery periods. The HIIT approach I personally prefer and recommend is the Peak Fitness method of 30 seconds of maximum effort followed by 90 seconds of recuperation.

I personally modified the number of repetitions from 8 to 6 this year, as it was sometimes just too strenuous for me to do all 8. So by listening to my body and cutting it back to 6 reps, I can now easily tolerate the workout and go full out. You can see a demonstration of Peak Fitness in the video I did.

    • Strength Training: If you want, you can increase the intensity by slowing it down. You need enough repetitions to exhaust your muscles. The weight should be heavy enough that this can be done in fewer than 12 repetitions, yet light enough to do a minimum of four repetitions. It is also important NOT to exercise the same muscle groups every day. They need at least two days of rest to recover, repair and rebuild. For more information about using super slow weight training as a form of HIIT, please see my interview with Dr. Doug McGuff.
    • Core Exercises: Your body has 29 core muscles located mostly in your back, abdomen and pelvis. This group of muscles provides the foundation for movement throughout your entire body, and strengthening them can help protect and support your back, make your spine and body less prone to injury and help you gain greater balance and stability.

Exercise programs like Pilates, yoga and Foundation Training are great for strengthening your core muscles, as are specific exercises you can learn from a personal trainer.

    • Stretching: My favorite type of stretching is Active Isolated Stretching (AIS) developed by Aaron Mattes. With AIS, you hold each stretch for only two seconds, which works with your body’s natural physiological makeup to improve circulation and increase the elasticity of muscle joints. This technique also allows your body to repair itself and prepare for daily activity. You can also use devices like the Power Plate to help you stretch.
    • Non-Exercise Activity: One of the newest recommendations I have is based on information from NASA scientist Dr. Joan Vernikos, who I recently interviewed: simply set a timer when you are sitting and stand up every 10 minutes. I even modify this further by doing jump squats at times in addition to standing up. This will help counteract the dangerous consequences of excessive sitting.

Going to the gym a few times a week for an hour simply isn’t going to counteract hours upon hours of chronic uninterrupted sitting, which essentially mimics a microgravity situation, i.e. you’re not exerting your body against gravity. Only frequent non-exercise movement will do that. The key point is to move and shift position often, when you’re sitting down. Meaning, you want to interrupt your sitting as often as possible.

Stroke Survivors Should Continue Antithrombotics During Dental Procedures.

Patients who’ve had a stroke should continue taking warfarin or aspirin when undergoing dental procedures, according to new guidelines from the American Academy of Neurology.

The guidelines, published in Neurology, also state that stroke patients should probably continue aspirin during invasive ocular anesthesia, cataract surgery, dermatologic procedures, transrectal ultrasound-guided prostate biopsy, spinal or epidural procedures, and carpal tunnel surgery. However, clinicians should counsel patients that aspirin likely increases bleeding risk during orthopedic hip procedures.

Stroke patients should probably continue warfarin for dermatologic procedures, the guidelines also note.

Source: Neurology 

Venous Angioplasty Fails to Help MS Patients in First Randomized Trial .

Percutaneous transluminal venous angioplasty is ineffective in correcting chronic cerebrospinal venous insufficiency in patients with multiple sclerosis, according to the first randomized trial of the procedure, presented at the American Academy of Neurology‘s annual meeting.

Researchers studied venous angioplasty in 10 patients with MS in an open-label safety assessment, after which they randomized 19 patients to either angioplasty or a sham control. Primary outcomes included safety at 1 day and 1 month, venous outflow restoration, and new lesion activity and relapse over 6 months.

The researchers concluded that the procedure is not only ineffective but also may exacerbate MS disease activity in the short-term.

Source: American Academy of Neurology meeting website

Neuroenhancement of Kids ‘Not Justifiable,’ Neurology Groups Say.

Neuroenhancement — the use of prescription drugs (e.g., stimulants) by healthy people in order to increase normal brain function — “is not justifiable” for children without diagnosed neurological disorders, according to a new position paper published in Neurology.

The paper also notes that for “nearly autonomous” adolescents, neuroenhancement is “inadvisable because of numerous social, developmental, and professional integrity issues.”

The authors offer a series of discussion points to guide physicians’ conversations with parents who request neuroenhancement medications for healthy children and teens.

The position paper is endorsed by the American Academy of Neurology, Child Neurology Society, and American Neurological Association.

Source: Neurology 

Top Five Recommendations to Reduce Unnecessary Medical Expenses.


The American Academy of Neurology provides evidence-based guidelines for practitioners and patients with the aim of reducing costs.

To reduce wasteful practices in medicine, the American Board of Internal Medicine and Consumer Reports developed the “Choosing Wisely” campaign. As a participant in the campaign, The American Academy of Neurology (AAN) selected a diverse panel with experience in evidence-based guidelines and practice parameters. The AAN sought from its members recommendations of practices that are common in neurology yet have strong evidence of lacking benefit (or causing harm) and are costly. From 178 submissions, the AAN selected 5 as having strong supporting rationales and obtained input from relevant subspecialty experts and patient advocacy groups. These practices are as follows:

  • Don’t perform electroencephalography (EEG) for headache disorders. Rationale: Clinical features have better diagnostic accuracy for primary headaches. Neuroimaging has higher sensitivity than EEG to evaluate for a mass lesion, if clinically suspected.
  • Don’t perform carotid ultrasound for syncope without other neurological symptoms. Rationale: Syncope is common, carotid disease causes focal neurological symptoms, and indiscriminate use of ultrasound results in unnecessary procedures.
  • For migraine, reserve opioids and butalbital as a last resort. Rationale: Nonopioid analgesics often work, and migraine-specific treatments are available. Opioids and butalbital increase the risk for analgesia-overuse headaches and chronic headaches. Opioids can be considered for ≤9 days per month when other treatments fail or medical comorbidity prevents use of first-line treatments.
  • Don’t prescribe disease-modifying therapies (DMTs) for those with progressive, nonrelapsing multiple sclerosis (MS). Rationale: DMTs have not shown efficacy in reducing disability in progressive MS and have potential adverse effects.
  • Don’t recommend carotid endarterectomy (CEA) for asymptomatic carotid stenosis unless the complication rate is <3%. Rationale: A benefit for asymptomatic carotid disease requires very low angiographic and surgical complication rates.

Comment: Patients have expectations for testing and treatment, and clinicians can feel obliged to reassure patients and reduce legal risk. The Choosing Wisely campaign seeks to inform patients and lend credence to clinicians to act more conservatively. Insurance providers are increasingly creating such guidelines, but guidelines created through the AAN may be more valid and accepted.

These recommendation are useful, especially the limitations on opioids for migraine. DMTs should not be started for primary or nonrelapsing, secondary progressive MS. However, some patients on a DMT long-term may have transitioned to secondary progressive MS with no relapses for 3 years, but may still relapse or worsen upon DMT withdrawal. Knowing the CEA complication rate for each surgeon in your center is a good idea, but these data are not always available, despite the long-standing recommendation that they should be.

Source: Journal Watch Neurology