![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

Practice parameter: medical treatment of infantile spasms: report of the
American Academy of Neurology and the Child Neurology Society.

#### BIBLIOGRAPHIC SOURCE(S)

Mackay MT, Weiss SK, Adams-Webber T, Ashwal S, Stephens D, Ballaban-Gill
K, Baram TZ, Duchowny M, Hirtz D, Pellock JM, Shields WD, Shinnar S,
Wyllie E, Snead OC 3rd. Practice parameter: medical treatment of
infantile spasms: report of the American Academy of Neurology and the
Child Neurology Society. Neurology 2004 May 25;62(10):1668-81. \[68
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15159460)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Infantile spasms

#### GUIDELINE CATEGORY

Assessment of Therapeutic Effectiveness\
Management\
Treatment

#### CLINICAL SPECIALTY

Neurology\
Pediatrics

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To determine the current best practice for treatment of infantile spasms
in children

#### TARGET POPULATION

Children aged 1 month to 3 years with infantile spasms

**Note**: The subcommittee did not consider studies of children with
Lennox-Gastaut syndrome, an epilepsy syndrome of early childhood that
frequently follows infantile spasms.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Management/Treatment**

1.  Adrenocorticotropic hormone (ACTH)

2.  Vigabatrin

The following treatments were considered but there was insufficient
evidence to make recommendations concerning their use:

1.  Oral corticosteroids including prednisone and prednisolone

2.  Benzodiazepines including nitrazepam

3.  Valproic acid

4.  Pyridoxine

5.  Newer antiepileptic drugs and novel therapies including zonisamide,
    intravenous immunoglobulin (IVIG), liposteroid, the ketogenic diet,
    thyrotropin-releasing hormone (TRH), and topiramate

#### MAJOR OUTCOMES CONSIDERED

-   Complete cessation of spasms

-   Resolution of hypsarrhythmia

-   Normalization of electroencephalography (EEG)

-   Relapse rate

-   Incidence of adverse effects

-   Mortality

-   Nonepileptiform electroencephalograhpy (EEG)

-   Normal development

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The OVID interface was used to search both MEDLINE (1966 to May 2002)
and EMBASE (1980 to May 2002) databases simultaneously. The search term
\"spasms, infantile\" retrieved a total of 2,616 references. A text word
search was also used to identify other potentially relevant studies.
Terms used included the following: infant: spasm, hypsarrhythmia,
hypsarrhythmi, cryptogen: infant: spasm, jackknife seizure, nodding
spasm, salaam seizure, spasmus nutans, symptomatic infant: spasm, west
syndrome:, lightning attack, salaam attack and blitznicksalaamkrampfe,
petit mal quadrette, massive myoclon: spasm, and minor motor epilepsy.
The wildcard symbol \":\" was used to truncate words, allowing retrieval
of articles that used variations in word endings. The combined MEDLINE
and EMBASE text word searches identified 1,175 articles. All search
titles and abstracts were analyzed for content. English language
articles on therapy, prognosis, and side effects were selected,
including original and review articles. There were 159 articles chosen
for detailed review.

Articles included for analysis required the following: 1) A clearly
stated diagnosis of infantile spasms. 2) An electroencephalogram (EEG)
demonstrating hypsarrhythmia or modified hypsarrhythmia. Hypsarrhythmia
is defined as very high voltage random slow waves and spikes in all
cortical areas. The spikes vary from moment to moment in duration and
location. Modified hypsarrhythmia includes variations such as
hypsarrhythmia with increased synchronization, asymmetrical
hypsarrhythmia, hypsarrhythmia with a consistent focus of abnormal
discharge, hypsarrhythmia with episodes of attenuation, and
hypsarrhythmia with little sharp wave activity or spike activity.
Articles using a routine EEG recording were acceptable for inclusion
because very few articles used video-EEG monitoring. 3) Age of 1 month
to 3 years. Infantile spasms were classified as either symptomatic or
cryptogenic as defined by the International League Against Epilepsy. The
symptomatic group is characterized by \"previous existence of brain
damage signs (psychomotor retardation, neurologic signs, radiologic
signs, or other types of seizures) or by a known etiology.\" The
symptomatic group can be further divided into prenatal, perinatal, and
postnatal groups. Prenatal causes include chromosomal abnormalities,
inborn errors of metabolism, neurocutaneous syndromes, cortical
malformations, and intrauterine infections. Perinatal causes include
hypoxic ischemic encephalopathy and birth trauma. Postnatal causes
include central nervous system (CNS) trauma, infection, and intracranial
hemorrhage. The smaller cryptogenic group is characterized by \"a lack
of previous signs of brain damage or of known etiology.\" Cases
described as idiopathic or \"doubtful\" and post immunization were
included in the cryptogenic group for analysis.

For the purposes of this practice parameter, the subcommittee did not
consider studies of children with Lennox-Gastaut syndrome, an epilepsy
syndrome of early childhood that frequently follows infantile spasms.
Studies were excluded if the patient\'s age was \<1 or \>36 months at
the time of entry into the study or if an EEG was not performed to
confirm the diagnosis of hypsarrhythmia or modified hypsarrhythmia.
Retrospective studies were excluded if they were single case reports or
case series with fewer than four infants. Studies on long-term prognosis
that were uncontrolled for treatment, letters, abstracts, and
unpublished data were also excluded.

#### NUMBER OF SOURCE DOCUMENTS

159 articles were selected for detailed review

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**American Academy of Neurology Evidence Classification Scheme for a
Therapeutic Article**

**Class I**: evidence provided by a prospective, randomized, controlled
clinical trial with masked outcome assessment, in a representative
population. The following are required:

a.  Primary outcome(s) is/are clearly defined.

b.  Exclusion/inclusion criteria are clearly defined.

c.  Adequate accounting for dropouts and crossovers with numbers
    sufficiently low to have minimal potential for bias.

d.  Relevant baseline characteristics are presented and substantially
    equivalent among treatment groups or there is appropriate
    statistical adjustment for differences.

**Class II**: evidence provided by a prospective matched group cohort
study in a representative population with masked outcome assessment that
meets a--d above *or* a randomized control trial in a representative
population that lacks one criteria of a--d.

**Class III**: all other controlled trials (including well-defined
natural history controls or patients serving as own controls) in a
representative population, where outcome assessment is independent of
patient treatment.

**Class IV**: evidence from uncontrolled studies, case series, case
reports, or expert opinion.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Individual committee members reviewed, abstracted, and classified the
selected articles to assess the quality of evidence-based data related
to study design and treatment effect. Outcome measures included short-
and long-term measures. Short-term outcome measures were defined as 1)
complete cessation of spasms, 2) resolution of hypsarrhythmia and, where
documented, normalization of electroencephalography (EEG), and 3)
relapse rate. Adverse effects and mortality were documented. In studies
with a mean follow-up of \>2 years, long-term outcome measures were 1)
nonepileptiform EEG, 2) absence of seizures, and 3) normal development.
Stringent criteria were not used in the analysis of the developmental
outcome data because the results of developmental assessments were often
based on clinical impression, developmental screening tools, and school
placement rather than standardized, age-appropriate psychometric
testing. There are very limited natural history data on infantile
spasms. Thus, it is impossible to accurately quantify, but at least some
children do spontaneously remit, approximately in the order of 10 to 25%
according to older and uncontrolled reports. Data recorded included
description of the number of patients entering and completing the trial,
age at onset of spasms, age at entry into the study, sex, etiology, drug
dosage, duration of therapy, co-interventions, and duration of
follow-up.

A four-tiered classification scheme for diagnostic evidence recently
approved by the Quality Standards Subcommittee was utilized as part of
this assessment (see \"Rating Scheme for the Strength of the Evidence\"
field). Depending on the strength of this evidence, it was decided
whether specific recommendations could be made and, if so, the strength
of these recommendations (see below \"Rating Scheme for the Strength of
the Recommendations\" field). Evidence pertinent to each treatment
together with the committee\'s evidence-based recommendations is
presented.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Other

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

When formulating the recommendations the guideline developers considered
the *magnitude* of the effect (benefit or harm of therapy, accuracy of
tests, yield of studies) and the relative *value* of various outcomes.
Under most circumstances, there is a direct link between the level of
evidence used to formulate conclusions and the strength of the
recommendation. This linkage is illustrated in Appendix 9 of the 2004
AAN Guideline Process Manual (see Companion Documents field). Thus, an
\"established as\" (two class I) conclusion supports a \"should be
done\" (level A) recommendation; a \"probably effective\" (two class II)
conclusion supports a \"should be considered\" (level B) recommendation;
a \"possibly effective\" (two class III) conclusion supports a \"may be
considered\" recommendation. In those circumstances where the evidence
indicates that the intervention is not effective or useful, wording was
modified. For example, if multiple adequately powered class I studies
demonstrated that an intervention is not effective, the recommendation
read, \"should not be done.\"

There are important exceptions to the rule of having a direct linkage
between the level of evidence and the strength of recommendations. Some
situations where it may be necessary to break this linkage are listed
below:

-   A statistically significant but marginally important benefit of the
    intervention is observed

-   The intervention is exorbitantly costly

-   Superior and established alternative interventions are available

-   There are competing outcomes (both beneficial and harmful) that
    cannot be reconciled

Under such circumstances the guideline developers may have downgraded
the level of the recommendation.

Edlund W, Gronseth G, So Y, Franklin G. Clinical practice guideline
process manual. St. Paul (MN): American Academy of Neurology (AAN);
2004. 49 p.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**[American Academy of Neurology System for Translation of Evidence to
Recommendations]{.underline}**

**Rating of Recommendation**

**A** = established as effective, ineffective, or harmful for the given
condition in the specified population.

**B** = probably effective, ineffective, or harmful (or probably
useful/predictive or not useful/predictive) for the given condition in
the specified population.

**C** = possibly effective, ineffective, or harmful (or possibly
useful/predictive or not useful/predictive) for the given condition in
the specified population.

**U** = data inadequate or conflicting. Given current knowledge,
treatment is unproven.

**Translation of Evidence to Recommendations**

**Level A** rating requires at least one convincing class I study or at
least two consistent, convincing class II studies.

**Level B** rating requires at least one convincing class II study or at
least three consistent class III studies.

**Level C** rating requires at least two convincing and consistent class
III studies.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Guidelines were approved by the Quality Standards Subcommittee (QSS) on
July 26, 2003, the American Academy of Neurology (AAN) Practice
Committee on November 16, 2003, and the AAN Board of Directors in
January 2004.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions of the strength of the recommendations (A, B, C, U) and
classification of the evidence (Class I through Class IV) are provided
at the end of the \"Major Recommendations\" field.

**Effectiveness of Adrenocorticotropic Hormone (ACTH) and Oral
Corticosteroids in the Treatment of Infantile Spasms**

1.  ACTH is probably effective for the short-term treatment of infantile
    spasms and in resolution of hypsarrhythmia (**level B**).

2.  There is insufficient evidence to recommend the optimum dosage and
    duration of treatment with ACTH for the treatment of infantile
    spasms (**level U**).

3.  There is insufficient evidence that oral corticosteroids are
    effective in the treatment of infantile spasms (**level U**).

**Effectiveness of Vigabatrin in the Treatment of Infantile Spasms**

1.  Vigabatrin is possibly effective for the short-term treatment of
    infantile spasms (**level C, class III and IV evidence**).

2.  Vigabatrin is also possibly effective for the short-term treatment
    of infantile spasms in the majority of children with tuberous
    sclerosis (**level C, class III and IV evidence**).

3.  Serious concerns about retinal toxicity in adults suggest that
    serial ophthalmologic screening is required in patients on
    vigabatrin. However, data are insufficient to make recommendations
    regarding the frequency or type of screening that would be of value
    in reducing the prevalence of this complication in children (**level
    U, class IV studies**).

**Other Agents Evaluated for the Treatment of Infantile Spasms**

1.  There is insufficient evidence to recommend other treatments
    (valproic acid, benzodiazepines, pyridoxine, newer antiepileptic
    drugs, or other or novel therapies) for the treatment of infantile
    spasms (**level U, class III and IV evidence**).

**Long-term Outcome**

1.  The data are insufficient to make any recommendations regarding the
    use of ACTH, corticosteroids, vigabatrin, valproic acid, and
    pyridoxine to improve the long-term outcomes (seizure freedom and
    normal development) of children with infantile spasms (**level U,
    class III and IV evidence**).

2.  The data are insufficient to conclude that early initiation of
    treatment should be used to improve the long-term outcome of
    children with infantile spasms (**level U, class III and IV
    evidence**).

**[Definitions]{.underline}**:

**Rating of Recommendation**

**A** = established as effective, ineffective, or harmful for the given
condition in the specified population.

**B** = probably effective, ineffective, or harmful (or probably
useful/predictive or not useful/predictive) for the given condition in
the specified population.

**C** = possibly effective, ineffective, or harmful (or possibly
useful/predictive or not useful/predictive) for the given condition in
the specified population.

**U** = data inadequate or conflicting. Given current knowledge,
treatment is unproven.

**Translation of Evidence to Recommendations**

**Level A** rating requires at least one convincing class I study or at
least two consistent, convincing class II studies.

**Level B** rating requires at least one convincing class II study or at
least three consistent class III studies.

**Level C** rating requires at least two convincing and consistent class
III studies.

**American Academy of Neurology Evidence Classification Scheme for a
Therapeutic Article**

**Class I**: evidence provided by a prospective, randomized, controlled
clinical trial with masked outcome assessment, in a representative
population. The following are required:

a.  Primary outcome(s) is/are clearly defined.

b.  Exclusion/inclusion criteria are clearly defined.

c.  Adequate accounting for dropouts and crossovers with numbers
    sufficiently low to have minimal potential for bias.

d.  Relevant baseline characteristics are presented and substantially
    equivalent among treatment groups or there is appropriate
    statistical adjustment for differences.

**Class II**: evidence provided by a prospective matched group cohort
study in a representative population with masked outcome assessment that
meets a--d above *or* a randomized control trial in a representative
population that lacks one criteria of a--d.

**Class III**: all other controlled trials (including well-defined
natural history controls or patients serving as own controls) in a
representative population, where outcome assessment is independent of
patient treatment.

**Class IV**: evidence from uncontrolled studies, case series, case
reports, or expert opinion.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate treatment of infantile spasms

#### POTENTIAL HARMS

-   Adverse effects of the various treatments

-   Serious concerns about retinal toxicity suggest that serial
    ophthalmologic screening is required in patients on vigabatrin.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This statement is provided as an educational service of the American
Academy of Neurology (AAN). It is based on an assessment of current
scientific and clinical information. It is not intended to include all
possible proper methods of care for a particular neurologic problem or
all legitimate criteria for choosing to use a specific procedure.
Neither is it intended to exclude any reasonable alternative
methodologies. The AAN recognizes that specific patient care decisions
are the prerogative of the patient and the physician caring for the
patient, based on all of the circumstances involved.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources\
Quick Reference Guides/Physician Guides\
Slide Presentation

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Mackay MT, Weiss SK, Adams-Webber T, Ashwal S, Stephens D, Ballaban-Gill
K, Baram TZ, Duchowny M, Hirtz D, Pellock JM, Shields WD, Shinnar S,
Wyllie E, Snead OC 3rd. Practice parameter: medical treatment of
infantile spasms: report of the American Academy of Neurology and the
Child Neurology Society. Neurology 2004 May 25;62(10):1668-81. \[68
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15159460)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 May 25

#### GUIDELINE DEVELOPER(S)

American Academy of Neurology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Neurology (AAN)

#### GUIDELINE COMMITTEE

Quality Standards Subcommittee of the American Academy of Neurology

Practice Committee of the Child Neurology Society

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*American Academy of Neurology (AAN) Quality Standards Subcommittee
Members*: Gary Franklin, MD, MPH (*co-chair*); Gary Gronseth, MD
(*co-chair*); Charles E. Argoff, MD; Stephen Ashwal, MD (*ex-officio*);
Christopher Bever, Jr., MD; Jody Corey-Bloom, MD, PhD; John D. England,
MD; Jacqueline French, MD (*ex-officio*); Gary H. Friday, MD; Michael
Glantz, MD; Deborah Hirtz, MD; Donald J. Iverson, MD; Samuel Wiebe, MD;
William J. Weiner, MD; Catherine Zahn, MD (*ex-officio*)

*Child Neurology Society Practice Committee Members*: Carmela Tardo, MD
(*chair*); Bruce Cohen, MD (*vice-chair*); Elias Chalhub, MD; Roy
Elterman, MD; Murray Engel, MD; Bhuwan Garg, MD; Brian Grabert, MD;
Annette Grefe, MD; Michael Goldstein, MD; David Griesemer, MD; Betty
Koo, MD; Edward Kovnar, MD; Leslie Ann Morrison, MD; Colette Parker, MD;
Ben Renfroe, MD; Michael Shevell, MD; Shlomo Shinnar, MD; Gerald
Silverboard, MD; Russell Snyder, MD; Dean Timmons, MD; Greg Yim, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Dr. Mackay has received honoraria from GlaxoSmithKline, and Janssen
Cilag. Dr. Mackay has no equity, stock, or any other ownership interests
in these companies. Dr. Pellock has received grants/research support in
excess of \$10,000 and is a paid consultant for Abbott Laboratories,
Aventis, Carter Wallace (MedPointe), Elan Pharmaceuticals,
GlaxoSmithKline, Ortho McNeil/Johnson & Johnson, and UCB
Pharmaceuticals. Dr. Shinnar has received grants/ research support from
Abbott Laboratories, Elan Pharmaceuticals, and Xcel Pharmaceuticals. He
is a paid consultant for Abbott Laboratories, Cephalon, Inc., Elan
Pharmaceuticals, Ovation, Pfizer Laboratories, and Xcel Pharmaceuticals.
He also has received honoraria from Abbott Laboratories, Cephalon, Inc.,
Elan Pharmaceuticals, Pfizer Inc., the R.W. Johnson Pharmaceutical
Research Institute, UCB Pharmaceuticals, Inc., and Xcel Pharmaceuticals.
Dr. Shinnar has no equity, stock, or any other ownership interest in any
of these companies. Dr. Shields participated in a study of vigabatrin
that was partially supported by an unrestricted grant from Aventis.

#### ENDORSER(S)

American Epilepsy Society - Disease Specific Society

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: A list of American Academy of Neurology (AAN)
guidelines, along with a link to a Portable Document Format (PDF) file
for this guideline, is available at the [AAN Web
site](http://aan.com/go/practice/guidelines).

Print copies: Available from the AAN Member Services Center, (800)
879-1960, or from AAN, 1080 Montreal Avenue, St. Paul, MN 55116.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Practice parameter: Medical treatment of infantile spasms. AAN
    summary of evidence-based guidelines for clinicians. St. Paul (MN):
    American Academy of Neurology. 2. p. Available in Portable Document
    Format (PDF) from the [American Academy of Neurology (AAN) Web
    site](http://aan.com/professionals/practice/pdfs/infantile_spasms_clinicians.pdf).

-   Slide presentation: practice parameter: medical treatment of
    infantile spasms. St. Paul (MN): American Academy of
    Neurology. 2004. Available in Power Point from the [AAN Web
    site](http://www.aan.com/professionals/practice/guidelines/pwr_pnt/is.ppt).

-   AAN guideline development process \[online\]. St. Paul (MN):
    American Academy of Neurology (AAN). Available from the [AAN Web
    site](http://aan.com/go/practice/guidelines/development).

-   Edlund W, Gronseth G, So Y, Franklin G. Clinical practice guideline
    process manual. St. Paul (MN): American Academy of Neurology
    (AAN); 2004. 49 p. Electronic copies available in Portable Document
    Format (PDF) from the [AAN Web
    site](http://aan.com/globals/axon/assets/2535.pdf).

#### PATIENT RESOURCES

The following is available:

-   Medical treatment of infantile spasms. AAN guideline summary for
    parents and caregivers. St. Paul (MN): American Academy of Neurology
    (AAN). 2 p.

Electronic copies: Available in Portable Document Format (PDF) from the
[AAN Web
site](http://aan.com/professionals/practice/pdfs/infantile_spasms_patient.pdf).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on August 17, 2004. The
information was verified by the guideline developer on September 9,
2004.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the American Academy of Neurology.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008