Neurology: An Evidence-Based Approach


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Report from the Committee of Principal Investigators. Br Heart J. Multiple sclerosis: long-term remission after a high dose of cyclophosphamide. Acta Neurol Scand. Effect of open label pulse cyclophosphamide therapy on MRI measures of disease activity in five patients with refractory relapsing-remitting multiple sclerosis. J Neuroimmunol. Multiple sclerosis and antecedent infections: a case-control study. Prevalence and severity of multiplesclerosis-associated fatigue in treated and untreated patients.

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J Clin Epidemiol. Rules of evidence and clinical recommendations on the use of antithrombotic agents. Grades of recommendation for antithrombotic agents. Accessed Feb Clinical practice guideline process manual, Edition, Appendix 9. The American Academy of Neurology. Guyatt G. Evidence-based medicine. Grading Recommendations in Guidelines! The vascular neurology community has then proposed new criteria, where by definition the clinical symptoms would be transient without a specific time frame defined and most importantly there would be no evidence of infarction.

Aguilar and B. Demaerschalk TIAs are caused by different clinical situations, i.

An Evidence-Based Approach

The causes of TIA are identical to those of stroke, so secondary prevention strategies are similar for both entities. Many episodes never come to medical attention and the above is probably an underestimate. It is presumed that about five million Americans have been given the diagnosis of TIA [1, 6]. The diagnostic evaluation is divided into four groups: general evaluation, brain imaging, carotid imaging, and cardiac evaluation. General Evaluation General evaluation should include electrocardiogram EKG , full blood count, serum electrolytes and creatinine, fasting blood sugar, and lipids.

Computed tomography CT or magnetic resonance imaging MRI of the head should be included in the initial diagnostic evaluation. Carotid Imaging Conventional angiography CA of the cerebral vessels remains the gold standard diagnostic modality to assess the presence and quantify the location and degree of carotid stenosis. CA is invasive, expensive, and not free of risk contrast exposure, risk of arterial vasospasm, plaque embolization. Doppler ultrasonography DUS is a useful screening tool that provides accurate information [8]. It is noninvasive and inexpensive when compared to other imaging modalities, like magnetic resonance angiography MRA or computed tomographic angiography CTA.

The recent AHA guidelines [2] emphasize again the importance of prompt evaluation as soon as possible after an event and recommend the following imaging studies class I recommendations : 1. CT is an alternative Level of Evidence B. Routine noninvasive imaging of cervicocephalic vessels Level A.

Noninvasive testing of the intracranial vasculature, when knowledge of intracranial steno-occlusive disease alters management Level A. Cardiac Imaging If a cardioembolic mechanism is suspected, transthoracic echocardiography TTE is indicated. Transesophageal echocardiography TEE is recommended for patients younger than 45 years, when brain, carotid, and general evaluation provide no clue to the cause of TIA.

Need for admission to the hospital is a topic of great debate, especially in this era of financial grief. Clinical Case Example A year-old woman present to the emergency department after a min episode of numbness involving the left side of her face and her left arm.

She has no vascular risk factors and is currently on no prescription medications. From this set, eight articles were reviewed [14—21]. No randomized-controlled trials were identified. Multiple prediction models have been proposed to help clinicians risk stratify these patients, and the unified ABCD2 score [23] has been shown to be the most predictive of shortterm recurrence [14, 23, 24]. She then belongs in the low-risk group and she probably does not require inpatient evaluation.

She should expeditiously, though, undergo general evaluation, brain and carotid imaging, and cardiac evaluation. The higher the score on the ABCD2 risk stratification model, the higher the risk of an adverse event.

Clinical Guidelines: Diagnostic Imaging

Also the higher the score, the higher the likelihood that the episode was indeed a TIA [17]. Treatment Introduction Treatment after a TIA is directed toward stroke and cardiovascular disease prevention. Noncardioembolic TIA Daily long-term antiplatelet therapy should be prescribed immediately [7]. The guidelines recommend aspirin plus extended-release dypiridamole as the firstline agent. Demaerschalk Clopidogrel is indicated when aspirin alone or in combination with dypiridamole is not tolerated.

The recent PRoFESS trial though [26], published 2 years after the guidelines, has shown that clopidogrel is somewhat better than previous evidence suggests, and probably aspirin plus extended-release dypiridamole is somewhat worse than previous evidence suggests [27]. Cardioembolic TIA For patient with paroxysmal or sustained atrial fibrillation valvular or nonvalvular who have had a cardioembolic TIA, long-term anticoagulation with warfarin is indicated to a goal INR of 2.

Risk stratification schemes are available when considering the use of anticoagulation vs. Clinical Case Example While undergoing evaluation at the emergency department, the above mentioned year-old woman goes into atrial fibrillation and has a second TIA, this time with left-sided hemiparesis and dysarthria. Her ABCD2 score is now a 5, 2 points added for unilateral weakness and 1 for speech impairment. CT of the brain is unremarkable; CTA shows no significant stenosis at either carotid bifurcation or intracranial vasculature.

TTE shows normal ejection fraction and severe left atrial enlargement.

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AF is documented on EKG. No randomized trials addressed our clinical question. The Evidence One randomized single-blinded trial addressed the use of a heparin bolus vs. In the absence of evidence, information is extrapolated from trials regarding the use of IV heparin after a cardioembolic stroke not TIA.


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A meta-analysis of seven trials involving almost 5, patients [37] showed that early anticoagulation in this clinical scenario is associated with a nonsignificant reduction in the recurrence of ischemic stroke, no substantial reduction in death and disability, and an increased risk of intracranial bleeding. We then recommend against the use of IV heparin after cardioembolic stroke or TIA as either acute therapy or as bridging therapy to long-term anticoagulation. Summary Bottom Lines TIA is a neurological emergency, and as such mandates prompt evaluation with the goal to identify the etiologic cause of the event and implement early therapy to prevent TIA recurrence, stroke, cardiovascular events, and death.

Neurology: An Evidence-Based Approach Neurology: An Evidence-Based Approach
Neurology: An Evidence-Based Approach Neurology: An Evidence-Based Approach
Neurology: An Evidence-Based Approach Neurology: An Evidence-Based Approach
Neurology: An Evidence-Based Approach Neurology: An Evidence-Based Approach
Neurology: An Evidence-Based Approach Neurology: An Evidence-Based Approach
Neurology: An Evidence-Based Approach Neurology: An Evidence-Based Approach
Neurology: An Evidence-Based Approach Neurology: An Evidence-Based Approach
Neurology: An Evidence-Based Approach Neurology: An Evidence-Based Approach

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