Highlights from this issue
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* Phil E M Smith
* Geraint N Fuller

COVID-19 has profoundly disrupted the normal rhythms of life. It is hard to anticipate the full impact of the pandemic as we write this in March 2020, with almost daily changes in advice for both the population and medical staff. The disease is flooding normal acute medical services. From a neurological perspective, there is concern for the collateral damage caused to patients with neurological disorders. We must try to ensure we can provide the services that neurological patients need while not exposing them to unnecessary risk. We have to identify and protect those patients who are particularly vulnerable, for example, those taking immunosuppression. One early change has been a switch to remote consultations by either telephone or video. This is an extension of the usual clinical consultation but poses particular issues. Arani Nitkunan and Dominic Paviour provide us with some practical advice on how to carry out these consultations (page 220), and the Association of British Neurologists’ (ABN) website also has regularly updated information (https://www.theabn.org/). It seems quite likely that what we learn in this extraordinary time will change our practice when times become more ordinary once again.

What we prescribe and the way that we prescribe it is already changing. Exercise is a modifiable risk factor for dementia, and increased exercise can improve outcomes in patients with other neurological disorders. Jane Alty and colleagues make the case for exercise in dementia (page 226), and Monica Busse and Gita Ramdharry provide a broader perspective across other degenerative disorders (page 187).

Symptoms that persist after a mild traumatic brain injury are common and can be challenging. Anne van Gils and colleagues consider how to approach patients who have had a mild traumatic brain injury and how they can be helped (page 211). A neurological approach, a detailed history and dissection of the issues can lead to a number of helpful treatments. Again, the proposed interventions are for the most part not dispensed from a pharmacy, but a prescription in a broader sense.

Patent foramen ovale (PFO) is both common and rare—common as it exists in a quarter of the population and yet rare as the cause of clinical problems, particularly stroke. Simply finding a PFO is not enough to indicate it is important, and we must work out whether it is relevant to the clinical problem. Deciding when to intervene and when to ignore a PFO can be difficult; Vafa Alakbarzade and colleagues walk us through what to do (page 219). And for people who do need an intervention, again it is not dispensed from a pharmacy.

Patients with drug-resistant epilepsy should be considered for epilepsy surgery—but what to do if there is no resectable focus? At that point, vagus nerve stimulation is one option, although one that offers not a cure but improved seizure control. Laura Pérez-Carbonell and colleagues discuss what it can do, and what problems we might encounter (page 189), while John Duncan sets this treatment into its practical context (page 186).

Sarcoidosis has been labelled the ‘great imitator’—though a disputed title, with syphilis, lupus and HIV each having their supporters—reflecting its protean manifestations. Neurosarcoidosis provides particular challenges in its diagnosis and management. Desmond Kidd shares his extensive experience of this condition on page 198.

We have a series of instructive clinical cases: someone with an unusual clue to their genetic diagnosis from Clara Camelo and colleagues (page 243), a dramatic illustration of Hirayama’s disease, the well-known mimic of motor neurone disease, from Tun Hing Lui (page 232) and a ‘Test Yourself’ from Miguel Pereira and colleagues (page 239). Checkpoint inhibitors, used increasingly to treat malignancies, can provoke several immune-mediated neurological disorders; Shane Lyons and colleagues describe such a case with an unusual autoimmune encephalitis (page 246). Sometimes diagnosis requires practical rather than metaphorical detective work as illustrated by Soon Tjin Lim and colleagues who uncover a surprising drug adverse effect (page 234). Heather Angus-Leppan provides a moving and insightful account of her father’s illness, progressive supranuclear palsy.

Inevitably, the COVID-19 pandemic has dominated the news and most of our thoughts. This has displaced other issues we might once have worried about, such as whether to refer to fasciculation or fasciculations, singular or plural? Mark Baker, Tim Williams and James Bashford offer two sides to this debate (page 249 and 251) as a reminder of happier, simpler times. Keep safe.