PracticeUpdate Neurology Best of 2018

EDITOR’S PICKS 14

Emergency Department Neuroimaging for Epileptic Seizures Epilepsia Take-home message • There is much debate regarding the yield of acute neuroimaging in patients with a known seizure disorder presenting to the emergency department (ED) with break- through seizures. In this study, the authors report findings from 822 consecutive patients presenting to the ED with breakthrough seizures. The study focused on whether ED neuroimaging led to an acute change in patient management. Of the 381 patients (46%) who received neuroimaging, only 11 imaging studies (3%) led to an acute change in patient management, and only 8 (2%) after excluding false-positive scans. ED neuroimaging was most frequently associated with acute head trauma, prolonged alteration of consciousness, and a focal neurologic examination at presentation. • This article is an insightful report revealing the high utilization trends of acute neuroimaging in the ED for patients with known epilepsy. This study is clinically useful for practitioners in the ED as well as neurologists and epilepsy experts and suggests that using clinical history and exam to guide decisions may reduce unnecessary acute neuroimaging in this specific population. Omar Khan MD

Statin- Associated Muscle Disease Neurotherapeutics Take-home message • This review discusses the recent evidence in the diagnosis and management of statin-associ- ated muscle symptoms (SAMS). • The authors concluded that better management of SAMSmay increase the number of patients able to benefit from statin therapy. Future trials are warranted to more accurately assess SAMS via a rigorous dechallenge–rechal- lenge protocol or a double-blind, placebo-controlled statin run-in study. Abstract Since the first approval of lovastatin in 1987, hydroxy-methyl-glutaryl CoA (HMG CoA) reductase inhibitors, or statins, have been effective and widely popular cho- lesterol-lowering agents with substantial benefits for the prevention and treatment of cardiovascular disease. Not all patients can tolerate these drugs, however, and sta- tin intolerance is most frequently associated with a range of side effects directed toward skeletal muscle, termed statin-associated muscle symptoms or SAMS. SAMS are par- ticularly difficult to treat because there are no validated biomarkers or tests that can be used to confirm patient self-reports of SAMS, and a number of patients who report SAMS have non-specific muscle pain not attributable to statin therapy. This review summarizes the most recent evidence related to diagnosis and management of SAMS. First, the range of skeletal muscle side effects associated with statin therapy is described. Second, data regarding the inci- dence and prevalence of SAMS, the most frequently experienced muscle side effect, are presented. Third, the most promising new techniques to confirm diagnosis of SAMS are explored. Finally, the most effec- tive strategies for the clinical management of SAMS are summarized. Better diagnos- tic and treatment strategies for SAMS will increase the number of patients using these life-saving statins, thereby increasing statin adherence and reducing the costs of avoid- able cardiovascular events. Statin-AssociatedMuscleDisease: Advances in Diagnosis and Management. Neurothera- peutics 2018 Sep 24;[EPub Ahead of Print], BA Taylor, PD Thompson. www.practiceupdate.com/c/74615

Abstract OBJECTIVE To determine the frequency and yield of neuroimaging in patients with known seizure disorders presenting to the emergency depart- ment (ED) with recurrent (nonindex) seizures. METHODS We reviewed 822 consecutive ED visits for nonindex seizures at the Oregon Health & Science University and the VA Port- land Health Care System. For each visit, we abstracted details of the clinical presentation, whether neuroimaging was obtained, the results of neuroimaging, and the results of previous neuroimaging studies, when available. We determined whether ED neuroimaging led to an acute change in patient management (yield). Clinical factors associated with obtaining ED neuroimaging, and with the yield of neuroim- aging, were evaluated by multivariate logistic regression. RESULTS A majority (78%) of ED seizure visits were for nonindex seizures. Neuroimaging was obtained in 381 of 822 nonindex seizure visits

(46%). Of these, 11 imaging studies (3%) led to an acute change in patient management, 8 (2%) after excluding false-positive scans. Acute head trauma, prolonged alteration of consciousness, and a focal neurologic examination at presenta- tion were associated with an increased yield of ED neuroimaging. Absent any of these 3 clinical factors the true positive yield of neuroimaging was zero. SIGNIFICANCE ED neuroimaging was performed in nearly half of all patients presenting with non- index seizures. A more conservative use of ED neuroimaging for nonindex seizures, based on clinical factors at presentation, could decrease imaging frequency with minimal loss of yield. Emergency Department Neuroimaging for Epileptic Seizures. Epilepsia 2018 Sep 01;59(9)1676-1683, M Salinsky, VSS Wong, P Motika, et al. www.practiceupdate.com/c/72431

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