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Highlights from this issue
  1. Phil Smith,
  2. Geraint N Fuller

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There is an increasing vogue for fast access disease-based clinics—TIA clinics or first fit clinics—where a major role is to make the diagnosis. It is easy to see the potential benefits of organising clinics in this way: ensuring speedy access for patients to expertise and as a way to streamline the organisation of investigations. However, in their article on TIA mimics and chameleons (see page 23), David Werring and colleagues explore presentations that are transient, vascular and frequently not TIAs, once again highlighting the importance of careful history in neurological evaluation. Perhaps, given the high proportion of patients with alternative diagnoses, we should rename them ‘Possible TIA clinics’ or ‘Suspected first seizure clinics’ to maintain diagnostic equipoise? The theme of cerebrovascular differential diagnosis is further developed by Anisha Doshi describing an unusual stroke mimic (see page 39), Negar Ashaghi reporting a stroke chameleon (see page 42) (or seizure mimic) and Muhammad Rafiq's case of cerebral hypoperfusion syndrome (see page 64).

We often use ‘rules’ to help in clinical assessment—for example, to distinguish upper from lower motor neurone facial weakness—but do we know our ‘Rules of Tongue?’ The tongue is rarely the centre of neurological attention, but a couple of cases, one by Pedro Cruz (see page 57) and another by Thiego Vale (see page 59), make clear that the tongue's motor control is actually quite complicated. Tom Hughes, who reviewed both cases, steps in to bring some order to lingual neurology (see page 62).

Neurology is not just about diagnosis. Not so long ago that there were no widely used disease-modifying treatments for multiple sclerosis and the budget for neurology treatments was minimal. Yet now, the cost on these disease-modifying treatments places them towards to top of the list of neurology expenditure. They tend to be prescribed in MS specialist clinics by increasingly specialised neurologists. With so many new drugs, and many with new adverse effects and new precautions, we asked Claire Rice to review the range of disease-modifying drugs, to help to bring general, non-‘MS-ologists’, up to speed (see page 6).

With the growing treatment options in neurology, selecting the best management increasingly requires the patient to weigh up conflicting information—for example, how the risks of an operation compare to the risks of conservative management. Rob Seal and colleagues explore using an ‘Option Grid’ to inform these shared decision-making discussions (see page 54). Mark Manford, who reviewed the paper for us, provides his views on this formalisation of a core skill (see page 4).

We have a thoughtful review of the neurology of Sjögren's syndrome from Aaron Berkowitz and Marty Samuels (see page 14), highlighting an important overlap between neurology and rheumatology. We have a clinical conundrums from Martin Turner (see page 45) and new presentations of anti-Ma encephalopathy (see page 36), broadening its range of clinical phenotypes and associations, and we have an international neurology perspective from Iran (see page 50).

Catherine Pearce, a medical student, provides her brief answer to an important clinical question—is botulinum toxin safe in a pregnant woman?—and comes up with an interesting proposal to address the difficulties in answering the question (see page 32). We would encourage medical students or junior doctors interested in answering similar focused questions to get in touch with their suggestions.

Derrick Wade discusses new guidelines on the management of prolonged disorders of consciousness (see page 2). He highlights the important skills neurologists need in approaching such patients: “a combination of expertise, attention to detail and humility”.

In the last issue we introduced the ‘Neurology Book Club’ and now Katharine Harding reviews her first club book (see page 67) while Eelco Wijdicks shares the wealth of experience from the Mayo Clinic book and film club, and includes titles of books and films you might wish to consider (see page 68).

Practical Neurology is expanding into the spoken word and you can now listen to a fascinating podcast via the website where Andrew Lees, Oliver Sacks, Peter Gautier-Smith and Chris Goetz discuss the recent article on Neurology and Detective Writing ( Also be warned that a PN Twitter account is coming soon.

Finally, as ever, Carphology (see page 70), picks out highlights from the literature to pique your interest.

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