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.
Don’t routinely recommend surgery for a narrowed carotid artery (>50% stenosis) that has not caused symptoms.
Best medical therapy is generally the appropriate management of patients with asymptomatic carotid stenosis. Medical treatment has improved since trials comparing carotid endarterectomy (CEA) plus best medical treatment with best medical treatment in asymptomatic carotid stenosis were conducted. There is evidence that the annual stroke rate in patients with asymptomatic carotid stenosis receiving best medical treatment has fallen to ≤1% annually. The effectiveness of CEA compared with current best medical therapy is not established. Additionally, randomised trials suggested equivocal benefit in women and patients aged >75. It may be reasonable to consider CEA for highly selected patient aged <75 years with >70% stenosis of the internal carotid artery. Where the perioperative risk of stroke, death and myocardial infarction is <3% and the patient is estimated to have a life expectancy of more than 3 to 5 years, consultation with a physician with expertise in stroke care is recommended prior to surgery.
- MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004;363:1491-502.
- Lanzino G, Rabinstein AA, Brown RD. Treatment of carotid artery stenosis: medical therapy, surgery, or stenting? Mayo Clin Proc 2009;84(4):362–8.
- Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke 2010; 41:e11-7.
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.