PracticeUpdate Neurology Best of 2018

EDITOR’S PICKS 11

Differentiating Myelitis FromVascular and Other Causes of Myelopathy Neurology Take-home message • Transverse myelitis (TM) is a diagnostic challenge, with impor- tant implications given the balance between effectiveness and risk of available therapies. This is a retrospective analysis of patients with presumptive TM, using logistic regression to determine characteristics that can help establish the diagnosis. The final diagnosis distribution included 54% inflammatory TM, 20% vascular myelopathy, 8% spondylotic, and 18%other mye- lopathy. The best individual classifier for diagnostic category was the temporal profile of symptoms, with a correct classifi- cation rate of 77%. When adding temporal profile, initial motor examination, andMRI lesion distribution toCSF pleocytosis and MRI gadolinium enhancement, the multinomial AUC was 0.67. • The results suggest that using this multifactorial algorithm, weighted toward the clinical presentation characteristics, can improve TM diagnostic accuracy. Codrin Lungu MD Abstract OBJECTIVE To assess the predictive value of the initial clinical and para- clinical features in the differentiation of inflammatory myelopathies from other causes of myelopathy in patients with initial diagnosis of transverse myelitis (TM). METHODS We analyzed the clinical presentation, spinal cord MRI, and CSF features in a cohort of 457 patients referred to a specialized myelopathy center with the presumptive diagnosis of TM. After evaluation, the mye- lopathies were classified as inflammatory, ischemic/stroke, arteriovenous malformations/fistulas, spondylotic, or other. A multivariable logistic regres- sion model was used to determine characteristics associated with the final diagnosis and predictors that would improve classification accuracy. RESULTS Out of 457 patients referred as TM, only 247 (54%) were con- firmed as inflammatory; the remaining 46% were diagnosed as vascular (20%), spondylotic (8%), or other myelopathy (18%). Our predictive model identified the temporal profile of symptom presentation (hyperacute <6 hours, acute 6-48 hours, subacute 48 hours-21 days, chronic >21 days), initial motor examination, and MRI lesion distribution as characteristics that improve the correct classification rate of myelopathies from 67% to 87% (multinomial area under the curve increased from 0.32 to 0.67), compared to only considering CSF pleocytosis and MRI gadolinium enhancement. Of all predictors, the temporal profile of symptoms contributed the most to the increased discriminatory power. CONCLUSIONS The temporal profile of symptoms serves as a clinical bio- marker in the differential diagnosis of TM. The establishment of a definite diagnosis in TM requires a critical analysis of the MRI and CSF character- istics to rule out non-inflammatory causes of myelopathy. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients presenting with myelopathy, temporal profile of symptoms, ini- tial motor examination, and MRI lesion distribution distinguish those with inflammatory myelopathies from those with other causes of myelopathy. Clinical Biomarkers Differentiate Myelitis From Vascular and Other Causes of Myelopathy. Neurology 2018 Jan 02;90(1)e12-e21, P Barreras,

Restarting Antiplatelet TherapyAfter Spontaneous Intracerebral Hemorrhage Take-home message • The decision to restart antiplatelet therapy (APT) after an intracranial hemorrhage (ICH) and balancing the risks of ischemic vascular events with those of ICH recurrence are difficult and frequent dilemmas for the neurologist. This multicenter, retrospective, matched cohort study compared functional outcomes and health-related quality of life (HRQoL) associated with restarting vs not restarting APT in patients with ICH. After propensity matching, a modified Rankin Scale score (mRS) of 0–2 was achieved in 35.5% of patients resuming APT and 43.9% of patients not resuming APT, not reaching statistical significance. The other outcome measures were also non-significantly different between the groups. • The results suggest that, in patients already on APT before presenting with spontaneous ICH, restarting the APT after the acute hospitalization is not associated with worse functional outcomes. Codrin Lungu MD Abstract OBJECTIVE To compare the functional outcomes and health-related quality of life metrics of restarting vs not restarting antiplatelet therapy (APT) in patients presenting with intracerebral hemorrhage (ICH) in the ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) study. METHODS Adult patients aged 18 years and older who were on APT before ICH and were alive at hospital discharge were included. Patients were dichotomized based on whether or not APT was restarted after hospital discharge. The primary outcome was a modified Rankin Scale score of 0-2 at 90 days. Secondary outcomes were excellent outcome (modified Rankin Scale score 0-1), mortality, Barthel Index, and health status (EuroQol-5 dimensions [EQ-5D] and EQ-5D visual analog scale scores) at 90 days. RESULTS The APT and no APT cohorts comprised 127 and 732 patients, respectively. Restarting APT was associated with lower rates of good functional outcome (36.5% vs 40.8%; p = 0.021) and lower Barthel Index scores at 90 days (p = 0.041). The 2 cohorts were then matched in a 1:1 ratio, and the matched cohorts each comprised 107 patients. No dif- ference in primary outcome was observed between restarting vs not restarting APT (35.5% vs 43.9%; p = 0.105). There were also no differ- ences between the secondary outcomes of the 2 cohorts. CONCLUSION Restarting APT in patients with ICH of mild to moderate severity after acute hospitalization is not associated with worse func- tional outcomes or health-related quality of life at 90 days. In patients with significant cardiovascular risk factors who experience an ICH, restarting APT remains the decision of the treating practitioner. Restarting Antiplatelet Therapy After Spontaneous Intracerebral Hemorrhage: Functional Outcomes. Neurology 2018 Jul 03;91(1)e26- e36, CJ Chen, D Ding, TJ Buell, et al. www.practiceupdate.com/c/70538 Neurology

KC Fitzgerald, MA Mealy, et al. www.practiceupdate.com/c/62703

VOL. 3 • NO. 4 • 2018