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## Complete Summary

#### GUIDELINE TITLE

European Federation of Neurological Societies/Peripheral Nerve Society
Guideline on management of multifocal motor neuropathy. Report of a
joint task force of the European Federation of Neurological Societies
and the Peripheral Nerve Society.

#### BIBLIOGRAPHIC SOURCE(S)

Joint Task Force of the EFNS and the PNS. European Federation of
Neurological Societies/Peripheral Nerve Society Guideline on management
of multifocal motor neuropathy. Report of a joint task force of the
European Federation of Neurological Societies and the Peripheral Nerve
Society. J Peripher Nerv Syst 2006 Mar;11(1):1-8. \[59 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16519777)

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [September 11, 2008, Rituxan
    (Rituximab)](http://www.fda.gov/medwatch/safety/2008/safety08.htm#Rituxan):
    Genentech informed healthcare professionals of revisions to
    prescribing information for Rituxan regarding a case of progressive
    multifocal leukoencephalopathy (PML) leading to death in a patient
    with rheumatoid arthritis who received Rituxan in a long-term safety
    extension clinical study.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 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)

Multifocal motor neuropathy (MMN)

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Neurology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To construct guidelines for the definition, diagnosis, and treatment of
multifocal motor neuropathy (MMN) based on the available evidence and,
where adequate evidence was not available, consensus

#### TARGET POPULATION

Patients presenting with multifocal motor neuropathy (MMN)

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Evaluation**

1.  Clinical examination

2.  Electrodiagnostic tests

3.  Anti-ganglioside GM1 antibody testing

4.  Magnetic resonance imaging (MRI) of the brachial plexus

5.  Cerebrospinal fluid (CSF) examination

6.  Investigations for concomitant disease or to exclude other possible
    causes

**Treatment**

1.  Intravenous immunoglobulin (IVIg) as the first line of treatment

2.  Repeated IVIg treatment if effective

3.  Cyclosporine, azathioprine, interferon-beta 1a (IFN-beta 1a),
    cyclophosphamide, or rituximab if IVIg is not effective

#### MAJOR OUTCOMES CONSIDERED

-   Muscle strength

-   Numbers of conduction blocks (CBs)

-   Axonal degeneration

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

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

The Task Force searched MEDLINE from 1980 onwards to July 24, 2004 for
articles on multifocal motor neuropathy (MMN) and \"diagnosis\" or
\"treatment\" or \"guideline\" but found that the personal databases of
Task Force members were more useful. They also searched the Cochrane
Library in September 2004.

#### NUMBER OF SOURCE DOCUMENTS

More than 400 documents were retrieved during the literature search.

#### 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

**Evidence Classification Scheme for a Diagnostic Measure**

**Class I**: A prospective study in a broad spectrum of persons with the
suspected condition, using a \"gold standard\" for case definition,
where the test is applied in a blinded evaluation, and enabling the
assessment of appropriate tests of diagnostic accuracy

**Class II**: A prospective study of a narrow spectrum of persons with
the suspected condition, or a well-designed retrospective study of a
broad spectrum of persons with an established condition (by \"gold
standard\") compared to a broad spectrum of controls, where test is
applied in a blinded evaluation, and enabling the assessment of
appropriate tests of diagnostic accuracy

**Class III**: Evidence provided by a retrospective study where either
persons with the established condition or controls are of a narrow
spectrum, and where test is applied in a blinded evaluation

**Class IV**: Any design where test is not applied in blinded evaluation
OR evidence provided by expert opinion alone or in descriptive case
series (without controls)

**Evidence Classification Scheme for a Therapeutic Intervention**

**Class I**: An adequately powered prospective, randomized, controlled
clinical trial with masked outcome assessment in a representative
population or an adequately powered systematic review of prospective
randomized controlled clinical trials with masked outcome assessment in
representative populations. The following are required:

a.  Randomization concealment

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

c.  Exclusion/inclusion criteria are clearly defined

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

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

**Class II**: Prospective matched-group cohort study in a representative
population with masked outcome assessment that meets a--e above or a
randomized, controlled trial in a representative population that lacks
one criteria a--e

**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

Review of Published Meta-Analyses\
Systematic Review

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

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

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

This guideline has been produced by the Task Force members of the
European Federation of Neurological Societies (EFNS) who are also
members of the Peripheral Nerve Society (PNS). Additional non-European
members of the Task Force were appointed on the recommendation of the
Board of Directors of the PNS.

**Methods for Reaching Consensus**

Pairs of Task Force members prepared draft statements about definition,
diagnosis, and treatment, which were considered at a meeting in
September 2004. Evidence was classified as class I to IV and
recommendations as level A to C according to the scheme agreed for EFNS
guidelines (see the \"Rating Scheme for the Strength of the Evidence\"
and the \"Rating Scheme for the Strength of the Recommendations\"
fields). When only class IV evidence was available but consensus could
be reached, the Task Force offered advice as good practice points. The
statements were revised and collated into a single document, which was
then revised iteratively until consensus was reached.

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

**Rating of Recommendations for a Diagnostic Measure**

**Level A rating** (established as useful/predictive or not
useful/predictive) requires at least one convincing class I study or at
least two consistent, convincing class II studies.

**Level B rating** (established as probably useful/predictive or not
useful/predictive) requires at least one convincing class II study or
overwhelming class III evidence.

**Level C rating** (established as possibly useful/predictive or not
useful/predictive) requires at least two convincing class III studies.

**Rating of Recommendations for a Therapeutic Intervention**

**Level A rating** (established as effective, ineffective, or harmful)
requires at least one convincing class I study or at least two
consistent, convincing class II studies.

**Level B rating** (probably effective, ineffective, or harmful)
requires at least one convincing class II study or overwhelming class
III evidence.

**Level C rating** (possibly effective, ineffective, or harmful)
requires at least two convincing class III studies.

**Good Practice Point (GPP)** When only class IV evidence was available
but consensus could be reached, the Task Force offered advice as good
practice points.

#### COST ANALYSIS

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

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines were validated according to the European Federation of
Neurological Societies (EFNS) criteria (Hughes RAC, Barnes MP, Baron J,
Brainin M \[2001\]. Guidance for the preparation of neurological
management guidelines by EFNS scientific task forces. *Eur J Neurol*
8:549-550).

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The levels of evidence (class I-IV) supporting the recommendations and
ratings of recommendations (A-C, Good Practice Point \[GPP\]) are
defined at the end of the \"Major Recommendations\" field.

**Diagnostic Criteria (Good Practice Points)**

1.  Clinical: the two core criteria and all exclusion criteria should be
    met (see Table 1, below)

2.  Electrodiagnostic: definite or probable conduction block (CB) in at
    least two nerves (see Table 2, below)

3.  Supportive: anti-GM1 antibody testing, magnetic resonance imaging
    (MRI), cerebrospinal fluid (CSF) examination, and treatment response
    (see Table 3, below)

4.  Categories: definite and probable multifocal motor neuropathy (MMN)
    (see Table 4, below)

+-----------------------------------------------------------------------+
| **Table 1. Clinical Criteria for Multifocal Motor Neuropathy (MMN)**  |
+=======================================================================+
| Core criteria (both must be present)                                  |
|                                                                       |
| 1.  Slowly progressive or stepwise progressive, asymmetric limb       |
|     weakness, or motor involvement having a motor nerve distribution  |
|     in at least two nerves, for more than 1 month\*                   |
|                                                                       |
| 2.  No objective sensory abnormalities except for minor vibration     |
|     sense abnormalities in the lower limbs                            |
+-----------------------------------------------------------------------+
| Supportive clinical criteria                                          |
|                                                                       |
| 3.  Predominant upper limb involvement\*\*                            |
|                                                                       |
| 4.  Decreased or absent tendon reflexes in the affected limb\*\*\*    |
|                                                                       |
| 5.  Absence of cranial nerve involvement\^                            |
|                                                                       |
| 6.  Cramps and fasciculations in the affected limb                    |
+-----------------------------------------------------------------------+
| Exclusion criteria                                                    |
|                                                                       |
| 7.  Upper motor neuron signs                                          |
|                                                                       |
| 8.  Marked bulbar involvement                                         |
|                                                                       |
| 9.  Sensory impairment more marked than minor vibration loss in the   |
|     lower limbs                                                       |
|                                                                       |
| 10. Diffuse symmetric weakness during the initial weeks               |
|                                                                       |
| 11. Laboratory: cerebrospinal fluid protein \>1g/L                    |
+-----------------------------------------------------------------------+

\*Usually more than 6 months.

\*\*At onset, predominant lower limb involvement accounts for nearly 10%
of the cases.

\*\*\*Slightly increased tendon reflexes, in particular in the affected
arm, have been reported and do not exclude the diagnosis of MMN provided
criterion 7 is met.

\^12th nerve palsy has been reported.

+-----------------------------------------------------------------------+
| **Table 2. Electrophysiological Criteria for Conduction Block (CB)\*  |
| (Good Practice Points)**                                              |
+=======================================================================+
| 1.  Definite motor CB\*\                                              |
|     Negative compound muscle action potential (CMAP) area reduction   |
|     on proximal versus distal stimulation of at least 50% whatever    |
|     the nerve segment length (median, ulnar, and peroneal). Negative  |
|     CMAP amplitude on stimulation of the distal part of the segment   |
|     with motor CB must be \>20% of the lower limit of normal and      |
|     \>1mV (baseline negative peak) and an increase of proximal        |
|     negative peak CMAP duration must be [\<]{.underline}30%.          |
+-----------------------------------------------------------------------+
| 2.  Probable motor CB\*\                                              |
|     Negative CMAP area reduction of at least 30% over a long segment  |
|     of an upper limb nerve with an increase of proximal negative peak |
|     CMAP duration [\<]{.underline}30%, *or*\                          |
|     Negative CMAP area reduction of at least 50% (same as definite)   |
|     with an increase of proximal negative peak CMAP duration \>30%    |
+-----------------------------------------------------------------------+
| 3.  Normal sensory nerve conduction in upper limb segments with CB    |
|     and normal sensory nerve action potential (SNAP) amplitudes (see  |
|     exclusion criteria)                                               |
+-----------------------------------------------------------------------+

\*Evidence for CB must be found at sites distinct from common entrapment
or compression syndromes.

+-----------------------------------------------------------------------+
| **Table 3. Supportive Criteria**                                      |
+=======================================================================+
| 1.  Elevated immunoglobulin M anti-ganglioside GM1antibodies (**level |
|     A recommendation**)                                               |
|                                                                       |
| 2.  Magnetic resonance imaging showing gadolinium enhancement and/or  |
|     hypertrophy of the brachial plexuses (**good practice point**)    |
|                                                                       |
| 3.  Clinical improvement following intravenous immunoglobulin         |
|     treatment (**good practice point**)                               |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Table 4. Diagnostic Categories**                                    |
+=======================================================================+
| Definite MMN                                                          |
|                                                                       |
| Clinical criteria 1, 2, and 7 to 11 and electrophysiological criteria |
| 1 and 3 in one nerve                                                  |
+-----------------------------------------------------------------------+
| Probable MMN                                                          |
|                                                                       |
| Clinical criteria 1, 2, and 7 to 11 and electrophysiological criteria |
| 2 and 3 in two nerves                                                 |
|                                                                       |
| Clinical criteria 1, 2, and 7 to 11and electrophysiological criteria  |
| 2 and 3 in one nerve and at least one supportive criterion 1 to 3     |
| (see Table 3 above)                                                   |
+-----------------------------------------------------------------------+

**Diagnostic Tests (Good Practice Points)**

1.  Clinical examination and electrodiagnostic tests should be
    considered in all patients.

2.  Anti-ganglioside GM1 antibody testing, MRI of the brachial plexus,
    and CSF examination should be considered in selected patients.

3.  Investigations to discover concomitant disease or exclude other
    possible causes should be considered, but the choice of tests will
    depend on the individual circumstances.

**Treatment**

1.  Intravenous immunoglobulin (IVIg) (2 g/kg given over 2 to 5 days)
    should be considered as the first line of treatment (**level A
    recommendation**) when disability is sufficiently severe to warrant
    treatment

2.  Corticosteroids are not recommended (**good practice point**)

3.  If an initial treatment with IVIg is effective, repeated IVIg
    treatment should be considered in selected patients (**level C
    recommendation**). The frequency of IVIg maintenance therapy should
    be guided by the response (**good practice point**). Typical
    treatment regimen is 1 g/kg every 2 to 4 weeks or 2 g/kg every 1 to
    2 months (**good practice point**)

4.  If IVIg is not (or not sufficiently) effective, then
    immunosuppressive treatment may be considered. Cyclophosphamide,
    cyclosporine, azathioprine, interferon-beta 1a (IFNb1a), or
    rituximab are possible agents (**good practice point**)

5.  Toxicity makes cyclophosphamide a less desirable option (**good
    practice point**).

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

**Evidence Classification Scheme for a Diagnostic Measure**

**Class I**: A prospective study in a broad spectrum of persons with the
suspected condition, using a \"gold standard\" for case definition,
where the test is applied in a blinded evaluation, and enabling the
assessment of appropriate tests of diagnostic accuracy

**Class II**: A prospective study of a narrow spectrum of persons with
the suspected condition, or a well-designed retrospective study of a
broad spectrum of persons with an established condition (by \"gold
standard\") compared to a broad spectrum of controls, where test is
applied in a blinded evaluation, and enabling the assessment of
appropriate tests of diagnostic accuracy

**Class III**: Evidence provided by a retrospective study where either
persons with the established condition or controls are of a narrow
spectrum, and where test is applied in a blinded evaluation

**Class IV**: Any design where test is not applied in blinded evaluation
OR evidence provided by expert opinion alone or in descriptive case
series (without controls)

**Evidence Classification Scheme for a Therapeutic Intervention**

**Class I**: An adequately powered prospective, randomized, controlled
clinical trial with masked outcome assessment in a representative
population or an adequately powered systematic review of prospective
randomized controlled clinical trials with masked outcome assessment in
representative populations. The following are required:

a.  Randomization concealment

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

c.  Exclusion/inclusion criteria are clearly defined

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

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

**Class II**: Prospective matched-group cohort study in a representative
population with masked outcome assessment that meets a--e above or a
randomized, controlled trial in a representative population that lacks
one criteria a--e

**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

**Rating of Recommendations for a Diagnostic Measure**

**Level A rating** (established as useful/predictive or not
useful/predictive) requires at least one convincing class I study or at
least two consistent, convincing class II studies.

**Level B rating** (established as probably useful/predictive or not
useful/predictive) requires at least one convincing class II study or
overwhelming class III evidence.

**Level C rating** (established as possibly useful/predictive or not
useful/predictive) requires at least two convincing class III studies.

**Rating of Recommendations for a Therapeutic Intervention**

**Level A rating** (established as effective, ineffective, or harmful)
requires at least one convincing class I study or at least two
consistent, convincing class II studies.

**Level B rating** (probably effective, ineffective, or harmful)
requires at least one convincing class II study or overwhelming class
III evidence.

**Level C rating** (possibly effective, ineffective, or harmful)
requires at least two convincing class III studies.

**Good Practice Point (GPP)** When only class IV evidence was available
but consensus could be reached, the Task Force offered advice as good
practice points.

#### 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 selected
recommendations (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate diagnosis and treatment of multifocal motor neuropathy (MMN)
resulting in improved disability

#### POTENTIAL HARMS

-   Cyclophosphamide is associated with toxicity which makes it less
    desirable option than other immunosuppressants.

-   Patients taking interferon beta-1a have been reported rarely to
    experience severe hepatic injury, including cases of hepatic
    failure.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guideline provides the view of an expert task force appointed by
the Scientific Committee of the European Federation of Neurological
Societies (EFNS). It represents a peer-reviewed statement of minimum
desirable standards for the guidance of practice based on the best
available evidence. It is not intended to have legally binding
implications in individual cases. This guideline is not intended to have
implications regarding reimbursement.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The European Federation of Neurological Societies has a mailing list and
all guideline papers go to national societies, national ministries of
health, World Health Organisation, European Union, and a number of other
destinations. Corporate support is recruited to buy large numbers of
reprints of the guideline papers and permission is given to sponsoring
companies to distribute the guideline papers from their commercial
channels, provided there is no advertising attached.

#### IMPLEMENTATION TOOLS

Staff Training/Competency Material

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

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Joint Task Force of the EFNS and the PNS. European Federation of
Neurological Societies/Peripheral Nerve Society Guideline on management
of multifocal motor neuropathy. Report of a joint task force of the
European Federation of Neurological Societies and the Peripheral Nerve
Society. J Peripher Nerv Syst 2006 Mar;11(1):1-8. \[59 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16519777)

#### ADAPTATION

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

#### DATE RELEASED

2006 Mar

#### GUIDELINE DEVELOPER(S)

European Federation of Neurological Societies - Medical Specialty
Society\
Peripheral Nerve Society - Disease Specific Society

#### SOURCE(S) OF FUNDING

European Federation of Neurological Societies

#### GUIDELINE COMMITTEE

Joint Task Force European Federation of Neurological Societies and the
Peripheral Nerve Society

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Task Force Members*: Ivo N. van Schaik, Netherlands; Pierre Bouche,
France; Isabel Illa, Spain; Jean- Marc Leger, France; Peter Van den
Bergh, Belgium; David R. Cornblath, USA; Eileen Evers, UK; Robert D.
Hadden, UK; Richard A. C. Hughes (*Chair*), UK; Carol L. Koski, USA;
Eduardo Nobile-Orazio, Italy; John D. Pollard, Australia; Claudia
Sommer, Germany; Pieter A. van Doorn, Netherlands

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The following authors have reported conflicts of interest:

R. Hughes, personal none, departmental research grants or honoraria from
Bayer, Biogen-Idec, Schering-Laboratoire Francais du Biofractionnement
(LFB), and Kedrion

D. Cornblath, personal honoraria from Aventis Behring and Baxter

C. Koski, personal honoraria from American Red Cross, Baxter, Bayer, and
ZLB-Behring

J. M. Leger, personal none, departmental research grants or honoraria
from Biogen-Idec, Baxter, LFB, and Octapharma

E. Nobile-Orazio, personal honoraria from Kedrion, Grifols, Baxter, and
LFB (and he has been commissioned by Kedrion and Baxter to give expert
opinions to the Italian Ministry of Health on the use of IVIg in
dysimmune neuropathies)

J. Pollard, personal none, departmental research grants from Biogen-Idec
and Schering

P. van Doorn, personal none, departmental research grants or honoraria
from Baxter and Bayer

The other authors have nothing to declare.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available to registered users from the [European
Federation of Neurological Societies Web
site](http://www.efns.org/content.php?pid=142).

Print copies: Available from Richard A. C. Hughes, Department of
Clinical Neuroscience, King\'s College London School of Medicine, Guy\'s
Hospital, London SE1 1UL, UK; E-mail: <richard.a.hughes@kcl.ac.uk>

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Brainin M, Barnes M, Baron JC, Gilhus NE, Hughes R, Selmaj K,
    Waldemar G; Guideline Standards Subcommittee of the EFNS Scientific
    Committee. Guidance for the preparation of neurological management
    guidelines by EFNS scientific task forces -- revised
    recommendations 2004. Eur J Neurol. 2004 Sep;11(9):577-81.
    Electronic copies: Available in Portable Document Format (PDF) from
    the [European Federation of Neurological Societies Web
    site](http://www.efns.org/files/guideline_23.pdf).

-   Guideline papers. European Federation of Neurological Societies.
    Electronic copies: Available from the [European Federation of
    Neurological Societies Web
    site](http://www.efns.org/content.php?pid=141).

-   Continuing Medical Education questions available from the [European
    Journal of Neurology Web
    site](http://www.blackwellpublishing.com/products/journals/ene/mcqs/).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on December 8, 2006. The
information was verified by the guideline developer on January 2, 2007.
This summary was updated by ECRI Institute on May 17, 2007 following the
U.S. Food and Drug Administration (FDA) advisory on Gadolinium-based
contrast agents. This summary was updated by ECRI Institute on June 20,
2007 following the U.S. Food and Drug Administration (FDA) advisory on
gadolinium-based contrast agents. This summary was updated by ECRI
Institute on October 8, 2008 following the U.S. Food and Drug
Administration advisory on Rituxan (rituximab).

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the Blackwell-Synergy copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008