Managing patients with myasthenia gravis who get acutely worse is often done with supportive treatment and intravenous immunoglobulin (IVIG). However, we are often told by some of our more senior colleagues that plasma exchange (PE) is better under such circumstances. The article by Sivakumar Sathasivam in this issue of ACNR reviews these two immune therapies in myasthenia and concludes that the two therapies appear equal in terms of their efficacy under such circumstances. Indeed he recommends that “As IVIG is easier to administer and associated with fewer adverse events than PE, and the efficacy of the two treatments are similar, the former is commonly preferred to the latter”.

In the second of our Neuroradiology series, Justin Cross takes us through the principles of MRI. This extremely well illustrated review summarises the physics underlying this scanning modality before discussing its clinical applications and limitations. This, as with the other article in this series on CT by Justin (ACNR 8.5), is a very helpful guide to those involved with MRI at whatever level, and is especially useful if you and your neuroradiology colleagues are seeing different things on the same scan!

In the neurosurgical series, Andrew Strong reports on spreading depolarisation, a concept developed by Leao in the 1940s and perhaps most commonly thought of in the context of migraine. However, in his article (with exciting video links) he discusses the significance and relevance of this phenomena in the injured brain and a better understanding of it may have clinical implications for the management of patients with brain injuries in the future.

Nicholas Shenker and colleagues explore the mechanisms underlying abnormal pain states in the Complex Regional Pain Syndrome. This involves sensorimotor “incongruence and neuroplasticity” within frontoparietal cortical areas with a particular emphasis on the role of the anterior cingulate cortex in this process. Furthermore they discuss the different pathways that mediate aspects of nociception and pain and how this may be exploited in the treatment of this condition.

Sabahat Wasti in the first of a new series of Neurology from around the world discusses some of the observations he has made whilst serving the people of the United Arab Emirates (UAE). In his article, he presents “new ways of analysing the needs of patients requiring rehabilitation” and that “This analysis should lead to defining the cultural and social constructs of the communities patients originate from, and allow the treating teams to develop Culturally Adjusted Rehabilitation Models (CARM)”. A stimulating personal account that raises many interesting questions on how and why we practice medicine, in the way that we do.

In the last issue of ACNR we discussed a common problem for refractory epilepsy, non-compliance. In this issue we discuss a very rare cause for it, namely the Ring 20 Chromosome [r(20)] epilepsy syndrome. This uncommon condition is presented in great depth by Dr Syed Hosain, and throws up many questions as to how this condition causes epilepsy and whether it may be more common than we suspect as it can only be diagnosed by chromosomal testing.

“Recent experiences of surgery for NLPE (Non-lesional Partial Epilepsy) suggests that undertaking an invasive presurgical evaluation in carefully selected patients is worthwhile and gives a reasonable chance of surgical success.” So writes Dr Lee and colleagues in an article on the role for surgery in NLPE, and how this can be optimally developed using an array of clinical, imaging and neurophysiological approaches. They show that by carefully selecting the right patient and studying them with a range of state-of-the-art techniques, one can identify some epileptic individuals who will do very well with surgery.

Finally, in his commentary “Living well with Dementia: A National Dementia Strategy”, Andrew Larner discusses this new initiative and how well it will or will not be implemented in the years to come. He concludes that “Formulation of policy (top-down) is relatively easy, whereas implementation (bottom-up) is rather more difficult. Only time will tell whether this policy can be meaningfully delivered.”

We also have our usual collection of reviews for you to enjoy, and we are always keen to have more help in this task – so if you are interested in becoming a reviewer for us then do let us know.

Roger Barker
Roger@acnr.co.uk