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Neurology High Value Care Recommendations The American College of Physicians, in collaboration with drug doses and are at increased risk of interactions and multiple other organizations, is engaged in a worldwide decreased drug clearance (see Item 74). initiative to promote the practice of High Value Care e The U.S. Preventive Services Task Force does not recom (HVC). The goals of the HVC initiative are to improve mend screening for carotid artery stenosis in the general health care outcomes by providing care of proven benefit adult population (see Item 78). and reducing costs by avoiding unnecessary and even In the evaluation of transient ischemic attack, carotid harmful interventions. The initiative comprises several ultrasonography is a low-cost, readily available test not programs that integrate the important concept of health associated with radiation and should be performed care value (balancing clinical benefit with costs and emergently in order to identify patients who may require harms) for a given intervention into a broad range of surgery (see Item 95). educational materials to address the needs oftrainees, Supplemental oxygen in patients with normal oxygen practicing physicians, and patients. saturation as measured by pulse oximetry increases mor tality in patients with acute stroke (see Item 27). HVC content has been integrated into MKSAP 19 in sev- The use of transesophageal echocardiography to evaluate eral important ways. MKSAP 19 includes HVC-identified for an intracardiac source of stroke is not routinely indicated. key points in the text, HVC-focused multiple-choice ques- Transthoracic echocardiography with agitated saline tions, and, in MKSAP Digital, an HVC custom quiz. From injection is indicated in younger patients with stroke the text and questions, we have generated the following without other risk factors and is less invasive than other list of HVC recommendations that meet the definition imaging procedures (see Item 66). below of high value care and bring us closer to our goal Routine internal carotid artery revascularization for of improving patient outcomes while conserving finite primary prevention of stroke is not warranted unless resources. high-risk stroke features are present, such as stenosis High Value Care Recommendation: A recommendation to greater than 80% or rapid progression of stenosis. choose diagnostic and management strategies for patients Symptomatic high-grade intracranial arterial stenosis is in specific clinical situations that balance clinical benefit associated with a high risk of recurrent stroke, but stent- with cost and harms with the goal of improving patient ing of the affected artery is associated with a high risk of outcomes. procedural stroke and should be avoided. e Acute administration of anticoagulation in ischemic Below are the High Value Care Recommendations for the strokes does not reduce the short-term risk of recurrent Neurology section of MKSAP 19. stroke and increases the risk of intracerebral hemorrhage e Stable headaches meeting criteria for most primary (see Item 77). headaches usually do not require imaging. e Long-term use of combination aspirin- clopidogrel is ¢ Nonpharmacologic treatment strategies, such as relax- associated with no reduction in risk of stroke but an ation training and cognitive behavioral therapy, should increased risk of hemorrhage and death when compared be considered for all patients with tension-type headache with single-agent antiplatelet use. (see Item 6). e Aspirin is preferred to rivaroxaban or dabigatran in the The monoclonal antibodies erenumab, fremanezumab, secondary prevention of stroke in patients with embolic eptinezumab, and galcanezumab should be considered stroke of undetermined origin (see Item 85). for migraine prophylaxis only after two or three adequate ¢ Routine use of platelet transfusion in patients with intra but unsuccessful trials of first-line preventive medications cerebral hemorrhage who are being treated with anti (see Item 70). platelet agents is not indicated. e After a single unprovoked seizure with no abnormalities e Aneurysms less than 7 millimeters in diameter in the on MRI or electroencephalography and with no risk fac- posterior circulation and less than 12 millimeters in the tors for epilepsy, antiepileptic drug therapy is typically anterior circulation can be managed conservatively with withheld. annual noninvasive neuroimaging. e The dosing strategy for antiepileptic drug therapy in older e Medications, vitamin, and herbal supplements do not adults can be summarized as “start low and go slow” prevent cognitive decline in healthy people or in patients because older adults usually require lower antiepileptic with mild cognitive impairment (sce Item 25).

The American College of Physicians, in collaboration with drug doses and are at increased risk of interactions and multiple other organizations, is engaged in a worldwide decreased drug clearance (see Item 74). initiative to promote the practice of High Value Care e The U.S. Preventive Services Task Force does not recom (HVC). The goals of the HVC initiative are to improve mend screening for carotid artery stenosis in the general health care outcomes by providing care of proven benefit adult population (see Item 78). and reducing costs by avoiding unnecessary and even In the evaluation of transient ischemic attack, carotid harmful interventions. The initiative comprises several ultrasonography is a low-cost, readily available test not programs that integrate the important concept of health associated with radiation and should be performed care value (balancing clinical benefit with costs and emergently in order to identify patients who may require harms) for a given intervention into a broad range of surgery (see Item 95). educational materials to address the needs oftrainees, Supplemental oxygen in patients with normal oxygen practicing physicians, and patients. saturation as measured by pulse oximetry increases mor tality in patients with acute stroke (see Item 27). HVC content has been integrated into MKSAP 19 in sev- The use of transesophageal echocardiography to evaluate eral important ways. MKSAP 19 includes HVC-identified for an intracardiac source of stroke is not routinely indicated. key points in the text, HVC-focused multiple-choice ques- Transthoracic echocardiography with agitated saline tions, and, in MKSAP Digital, an HVC custom quiz. From injection is indicated in younger patients with stroke the text and questions, we have generated the following without other risk factors and is less invasive than other list of HVC recommendations that meet the definition imaging procedures (see Item 66). below of high value care and bring us closer to our goal Routine internal carotid artery revascularization for of improving patient outcomes while conserving finite primary prevention of stroke is not warranted unless resources. high-risk stroke features are present, such as stenosis High Value Care Recommendation: A recommendation to greater than 80% or rapid progression of stenosis. choose diagnostic and management strategies for patients Symptomatic high-grade intracranial arterial stenosis is in specific clinical situations that balance clinical benefit associated with a high risk of recurrent stroke, but stent- with cost and harms with the goal of improving patient ing of the affected artery is associated with a high risk of outcomes. procedural stroke and should be avoided. e Acute administration of anticoagulation in ischemic Below are the High Value Care Recommendations for the strokes does not reduce the short-term risk of recurrent Neurology section of MKSAP 19. stroke and increases the risk of intracerebral hemorrhage e Stable headaches meeting criteria for most primary (see Item 77). headaches usually do not require imaging. e Long-term use of combination aspirin- clopidogrel is ¢ Nonpharmacologic treatment strategies, such as relax- associated with no reduction in risk of stroke but an ation training and cognitive behavioral therapy, should increased risk of hemorrhage and death when compared be considered for all patients with tension-type headache with single-agent antiplatelet use. (see Item 6). e Aspirin is preferred to rivaroxaban or dabigatran in the The monoclonal antibodies erenumab, fremanezumab, secondary prevention of stroke in patients with embolic eptinezumab, and galcanezumab should be considered stroke of undetermined origin (see Item 85). for migraine prophylaxis only after two or three adequate ¢ Routine use of platelet transfusion in patients with intra but unsuccessful trials of first-line preventive medications cerebral hemorrhage who are being treated with anti (see Item 70). platelet agents is not indicated. e After a single unprovoked seizure with no abnormalities e Aneurysms less than 7 millimeters in diameter in the on MRI or electroencephalography and with no risk fac- posterior circulation and less than 12 millimeters in the tors for epilepsy, antiepileptic drug therapy is typically anterior circulation can be managed conservatively with withheld. annual noninvasive neuroimaging. e The dosing strategy for antiepileptic drug therapy in older e Medications, vitamin, and herbal supplements do not adults can be summarized as “start low and go slow” prevent cognitive decline in healthy people or in patients because older adults usually require lower antiepileptic with mild cognitive impairment (sce Item 25). xi

¢ Specialized tests for dementia—including cerebrospinal e Any patient with a suspected relapse of multiple sclerosis fluid tests, dopamine transporter single-photon emission should be screened for causes of Uhthoff phenomenon CT and PET scans-should be reserved for uncertain diag- (transient worsening of neurologic symptoms associated noses or atypical presentations. with increased body temperature) masquerading as a No medications are currently approved for the treatment relapse (or “pseudorelapse”) to avoid unnecessary of mild cognitive impairment, and no medications or treatment.

¢ Specialized tests for dementia—including cerebrospinal e Any patient with a suspected relapse of multiple sclerosis fluid tests, dopamine transporter single-photon emission should be screened for causes of Uhthoff phenomenon CT and PET scans-should be reserved for uncertain diag- (transient worsening of neurologic symptoms associated noses or atypical presentations. with increased body temperature) masquerading as a No medications are currently approved for the treatment relapse (or “pseudorelapse”) to avoid unnecessary of mild cognitive impairment, and no medications or treatment. dietary agents have been shown to prevent progression to Disease-modifying therapy should be discontinued in dementia once reversible causes have been excluded. patients with secondary progressive multiple sclerosis e There is no evidence of benefit of memantine in the who have been nonambulatory for more than 2 years treatment of mild stage of Alzheimer dementia (see and who have had no relapsing activity during that same Item 43). period (see Item 50). ¢ In the absence of a clear response to either high-volume e MRI is the preferred initial imaging test for most patients cerebrospinal fluid removal or lumbar drainage, a perma- with findings of myelopathy (see Item 3). nent ventricular shunt to treat normal pressure hydro- e In classic Bell palsy, brain imaging and laboratory testing cephalus should not be pursued (see Item 22). is not required. In the evaluation of delirium, a head CT scan or MRI of e Plasma exchange and intravenous immunoglobulin are the brain should be reserved for patients with focal find- equally effective treatment options for Guillain-Barré ings on the neurologic examination that suggest an intra- syndrome, but combination therapy is no more effective cerebral process, such as ischemic stroke or hemorrhage than either modality alone (see Item 73). (see Item 56). e In patients with central nervous system tumors not asso- In Parkinson disease, a dopamine transporter single- ciated with seizures, prophylactic antiepileptic drugs are photon emission CT scan of the brain is unnecessary not recommended. except to differentiate between Parkinson disease and ¢ Meningiomas are benign dural-based tumors that require essential tremor or drug-induced parkinsonism if the no management in asymptomatic patients and are usually distinction cannot be made on clinical grounds. followed clinically (see Item 10). A positive pull test is the most reliable predictor of a risk In patients with metastatic spinal compression, surgical of backward falls in Parkinson disease. decompression should be reserved for patients younger Treatment of periodic leg movement of sleep is required than 65 years with a single area of compression, para- only if it causes marked sleep fragmentation (see Item 68). plegia for less than 48 hours, and a predicted survival of In the treatment of refractory essential tremor, deep- longer than 6 months (see Item 49). brain stimulation results in greater functional improve- In patients with suspected central nervous system lym- ments than thalamotomy and fewer adverse events, such phoma, the finding of lymphomatous cells in vitreous or as dysarthria, sensory disturbances, and gait disturbances cerebrospinal fluid samples (identified by cytology and flow (see Item 76). cytometry) may obviate the need for biopsy (see Item 67).

dietary agents have been shown to prevent progression to Disease-modifying therapy should be discontinued in dementia once reversible causes have been excluded. patients with secondary progressive multiple sclerosis e There is no evidence of benefit of memantine in the who have been nonambulatory for more than 2 years treatment of mild stage of Alzheimer dementia (see and who have had no relapsing activity during that same Item 43). period (see Item 50). ¢ In the absence of a clear response to either high-volume e MRI is the preferred initial imaging test for most patients cerebrospinal fluid removal or lumbar drainage, a perma- with findings of myelopathy (see Item 3). nent ventricular shunt to treat normal pressure hydro- e In classic Bell palsy, brain imaging and laboratory testing cephalus should not be pursued (see Item 22). is not required. In the evaluation of delirium, a head CT scan or MRI of e Plasma exchange and intravenous immunoglobulin are the brain should be reserved for patients with focal find- equally effective treatment options for Guillain-Barré ings on the neurologic examination that suggest an intra- syndrome, but combination therapy is no more effective cerebral process, such as ischemic stroke or hemorrhage than either modality alone (see Item 73). (see Item 56). e In patients with central nervous system tumors not asso- In Parkinson disease, a dopamine transporter single- ciated with seizures, prophylactic antiepileptic drugs are photon emission CT scan of the brain is unnecessary not recommended. except to differentiate between Parkinson disease and ¢ Meningiomas are benign dural-based tumors that require essential tremor or drug-induced parkinsonism if the no management in asymptomatic patients and are usually distinction cannot be made on clinical grounds. followed clinically (see Item 10). A positive pull test is the most reliable predictor of a risk In patients with metastatic spinal compression, surgical of backward falls in Parkinson disease. decompression should be reserved for patients younger Treatment of periodic leg movement of sleep is required than 65 years with a single area of compression, para- only if it causes marked sleep fragmentation (see Item 68). plegia for less than 48 hours, and a predicted survival of In the treatment of refractory essential tremor, deep- longer than 6 months (see Item 49). brain stimulation results in greater functional improve- In patients with suspected central nervous system lym- ments than thalamotomy and fewer adverse events, such phoma, the finding of lymphomatous cells in vitreous or as dysarthria, sensory disturbances, and gait disturbances cerebrospinal fluid samples (identified by cytology and flow (see Item 76). cytometry) may obviate the need for biopsy (see Item 67). xii