Australian and New Zealand Association of Neurologists
Recommendations from the Australian and New Zealand Association of Neurologists on faints, headache disorders, low back pain, migraine & narrowed carotid arteries. ANZAN aims to ensure that high standards of clinical neurology are practised in Australia and New Zealand by playing an active role in training, continuing education and encouragement of teaching and research.
1.
Don’t perform imaging of the carotid arteries for simple faints.
Syncope is common, with a lifetime prevalence of 40%. Carotid imaging studies such as carotid duplex are commonly performed in patients presenting with syncope. When symptomatic, occlusive carotid artery disease causes focal neurologic symptoms such as weakness, altered sensation or speech, and not syncope. In addition, studies demonstrate that even elderly patients with syncope are unlikely to have carotid occlusive disease. Therefore, performing carotid imaging studies in patients with syncope increases cost without adding benefit. Furthermore, carotid imaging may identify incidental asymptomatic occlusive carotid artery disease that may be inappropriately assumed to be the cause of the syncope. This can delay the identification of the true cause of syncope and may subject the patient to additional risk-associated procedures such as catheter angiography, carotid endarterectomy (CEA), or carotid stenting.
Supporting evidence
- Kadian-Dodov D, Papolos A, Olin JW. Diagnostic utility of carotid artery duplex ultrasonography in the evaluation of syncope: a good test ordered for the wrong reason. Eur Heart J Cardiovasc Imaging 2015;16(6):621-5.
- Maung AA, Kaplan LJ, Schuster KM, et al. Routine or protocol evaluation of trauma patients with suspected syncope is unnecessary. J Trauma 2011;70(2):428-32.
- Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF Scientific Statement on the Evaluation of Syncope. J Am Coll Cardiol 2006;47:473-84.
How this list was made
The ANZAN Council considered 12 clinical practices in neurology which may be overused, inappropriate or of limited effectiveness in a given clinical context. After choosing the top 5 items to prioritise, these were passed on to the appropriate subspecialty committees within ANZAN for comment and additional suggestions. The final list of the top 5 items chosen was compiled following a review of the evidence and the formulation of suitable recommendations and endorsed by the Council on 7th January 2016.
- 1 Don’t perform imaging of the carotid arteries for simple faints.
- 2 Don’t perform imaging of the brain for non-acute primary headache disorders.
- 3 Don’t perform epidural steroid injections to treat patients with low back pain who do not have radicular symptoms in the legs originating from the nerve roots.
- 4 Don’t use opioids for the treatment of migraine, except in rare circumstances.
- 5 Don’t routinely recommend surgery for a narrowed carotid artery (>50% stenosis) that has not caused symptoms.