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Observation is essential in neurology. But not just passive looking: we must search for particular things, looking in an informed way but not being so directed as to miss other things. In the famous ‘invisible gorilla’ experiment, a man in a gorilla suit walks across a basketball game unnoticed by many observers busy looking for other things (counting the passes the players make)1—but the gorilla is readily seen by those who know to look for it. Such inattentional blindness has been repeatedly demonstrated in different settings from radiology to data analysis. Effective observation must strike a fine balance: knowing what to look for, yet looking without prior hypothesis. Achieving this is a recurring challenge in clinical neurology.
Localising the onset of focal seizures provides an excellent illustration of how knowing what to look for can enhance observation. Those familiar with the diversity of seizure phenotypes will more likely pick up details that can be very informative—for example, the ictal pout (‘chapeau de gendarme’) might pass unrecognised, yet points to a specific location. Fahmida Chowdhury and colleagues (page 481) use their extensive experience of presurgical evaluation of patients with epilepsy—the highest stakes arena for accurate localisation—to provide an excellent framework for the clinical localisation of focal epilepsy.
Unsurprisingly, patients with migraine concentrate on their headaches, but there are many other associated phenomena. Appreciating the full range of symptoms in the premonitory phase to the resolution phase—knowing what to listen for—will help our understanding of a patient’s description of symptoms. Some commonly accepted apparent triggers, for example, strong perfumes, can be re-understood as reflecting increased sensitivity to olfactory stimuli during the premonitory phase. Nazia Karsan and Peter Goadsby explore ‘Migraine: beyond pain’ on page 475.
Awareness of frailty is increasing. Lucy Pollock and Matthew Smith provide a guide for neurologists (page 468) on what to look for—recognising that its major manifestations are neurological (falls, cognitive decline, reduced hearing and vision)—and how it might influence the management of additional neurological disorders. Tom Hughes sets frailty in its neurological clinical context in his editorial (page 464) and provides a striking visual metaphor. Alexandra Daneasa and Josef Heckmann (page 522) present a real-world case of stroke in a centenarian.
Sometimes just observing allows us to see something different in the everyday. Jorik Nonnekes and Maarten Nijkrake (page 552) describe the ‘face-mask sign’, where using a face mask markedly impaired the gait of a patient with an ataxic syndrome. This is a specific instance of a more general problem; Rajith da Silva discusses a range of other everyday factors can make life difficult for patients with ataxia and how low-tech solutions can help to tackle them (page 466). Other simple low-tech observations include the use of a simple paper and pen test to document epilepsia partialis continua (page 543) and a simple drawing test to reveal creative exuberance in a patient with Parkinson’s disease on dopamine agonist (page 468).
Many people with neurological disease have urinary catheters. Calum Clark and colleagues review what neurologists need to know about catheters and the options available (page 504). Catheter blockage is the most important of several causes of autonomic dysreflexia, a major emergency in people with established spinal injury, as clearly explained and illustrated by Celine Lakra and colleagues on page 532.
Managing patients with peripheral neuropathies who are found to have a paraprotein can be challenging. Is the paraprotein relevant? What should we do about it? What are the treatment options? Antonia Carroll and Michael Lunn (page 493) come to our aid with a comprehensive review of what to look for and what to do.
We have several cases to test your neurology—from Apurva Sharma et al (page 553) and Keng Lam and Navdeep Sangha (page 557)—and a CPC from Saranya Gomathy and colleagues (page 523). We also highlight a dramatic but benign radiological change that can follow shunt insertion (corpus callosum impingement syndrome) (page 546).
We have articles that revisit classical neurology—the dorsal midbrain (Parinaud) syndrome (page 550) and superficial abdominal reflexes (page 541), and A Fo Ben rounds off the year with another excellent collection of papers you might have missed—but will probably tell your colleagues about.
The Practical Neurology Twitter feed is becoming more active and we now aim to tweet a brief summary of each published article. Twitter is also useful as a teaching tool. In their unusual article—comprising a series of tweets—Catherine Albin and Aaron Berkowitz provide a Tweetorial on how to produce a Tweetorial, as a vehicle for online teaching (page 539).
Finally, in place of our usual book club report, we offer a starter kit for any new neurology book clubs. The clubs who have previously submitted reports offer reports of their most successful books (page 559). This list, along with the Invisible Gorilla,1 provides unrivalled suggestions of Christmas gifts for the’ hard to buy for’ neurologist; and everyone knows one. Don’t they?