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Coma from severe spontaneous intracranial hypotension due to a CSF-venous fistula

BMJ Practical Neurology - Current Issue· Published 21 Sep 2026 Relevancy: 89%

Spontaneous intracranial hypotension (SIH) is a debilitating condition characterised by orthostatic symptoms resulting from cerebrospinal fluid (CSF) depletion. It is caused by leakage at the spinal level, causing gravitationally dependent downward displacement of intracranial structures. Rarely, severe brain sagging due to SIH can compromise brainstem function to the point of coma and even death. Effective management of such patients requires awareness about SIH as a possible cause of coma and multidisciplinary collaboration between neurocritical care, neurosurgical and neurointerventional services. The management aims to optimise supportive medical management, with early implementation of emergency treatment by placing the patient in a head-down position, and rapid detection and treatment of the CSF leak. We present a rare case of severe SIH resulting in coma from a spinal CSF–venous fistula and review the status of knowledge on this clinical scenario, emphasising current diagnostic techniques, multidisciplinary management and curative interventions.

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Non-motor symptoms in Parkinsons disease: a practical approach

BMJ Practical Neurology - Current Issue· Published 21 Sep 2026 Relevancy: 58%

Non-motor symptoms of Parkinson’s disease (PD) drive disability, reduce quality of life and increase healthcare resource use. Yet, they are often under-recognised in time-limited clinics. We outline an evidence-informed approach for everyday neurology. We propose brief previsit process followed by in-visit prioritisation of one or two high-impact symptoms and simple education/resources for the rest. Psychosis requires clinicians to address triggers, simplify dopaminergic therapy and use PD-safe antipsychotics when required. Mood and anxiety benefit from optimised dopaminergic regimens, selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors, counselling, exercise and online cognitive-behavioural programmes. Cognitive impairment warrants regular screening and medication review; cholinesterase inhibitors are indicated for dementia. Sleep management includes treating contributing factors, hygiene measures and cautious hypnotic use. Pain and autonomic dysfunction require pragmatic, stepwise strategies tailored to real-world practice. We include special considerations for atypical Parkinsonism and caregiver needs. Integrating these steps into routine visits improves safety, function and patient–carer well-being.

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Low back pain, with or without sciatica

BMJ Practical Neurology - Current Issue· Published 21 Sep 2026 Relevancy: 57%

According to the Global Burden of Disease Project (2021), back pain affects over half a billion people worldwide and is responsible for the most years lived with disability of any condition. Only a small fraction of these will ever see a neurologist, but those that do pose a range of difficulties, from attempting an accurate diagnosis to estimating prognosis and providing advice as to whether any interventions, particularly surgery, are likely to be better than the effect of time alone. There are many guidelines, mainly aimed at primary care practitioners. This article tries to provide succinct evidence-based messages for neurologists (and others in secondary care) to use with patients at different stages of back pain duration—from acute to chronic—to help in navigating some of these difficulties.

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The 2024 McDonald criteria for the diagnosis of multiple sclerosis: implications for clinical practice

BMJ Practical Neurology - Current Issue· Published 21 Sep 2026 Relevancy: 94%

The 2024 revisions to the McDonald criteria mark a major shift in the diagnosis of multiple sclerosis (MS), reflecting advances in imaging and biomarker science. The updated framework adopts a more biologically anchored approach, integrating radiological and cerebrospinal fluid evidence to enable earlier and more accurate diagnosis. Key changes include recognition of the optic nerve as a fifth anatomical site for dissemination in space, incorporation of advanced MR imaging markers such as the central vein sign and paramagnetic rim lesions to improve specificity, and acceptance of the kappa free light chain index as a quantitative alternative to oligoclonal bands. In selected patients with highly characteristic clinical and imaging features, MS may now be diagnosed without demonstration of dissemination in time, reducing diagnostic delay. A unified pathway across relapsing and progressive phenotypes, including children, promotes consistency, while defined pathways also allow diagnosis in certain asymptomatic individuals, including those with radiologically isolated syndrome, when supported by biomarkers. Implementation will require access to advanced imaging, standardised laboratory testing, multidisciplinary expertise and careful clinical judgement to minimise misdiagnosis and ensure equitable access.

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Suspected encephalitis in adults

BMJ Practical Neurology - Current Issue· Published 21 Sep 2026 Relevancy: 91%

‘Query encephalitis’ is one of the most common reasons for inpatient neurology referral in the context of an acutely confused patient. Growing evidence suggests that time to treatment is a key determinant of outcome in both infectious and autoimmune encephalitis; hence, these two causes should be considered simultaneously at presentation. However, under-recognition and the existence of several mimics make a rapid diagnosis of encephalitis challenging. Appreciation of clinical syndromes can guide aetiological investigation and consequent treatment. In this article, we discuss clinical phenotypes associated with both infectious and autoimmune encephalitis, as well as a systematic approach to their investigation and up-to-date treatment strategies. We also highlight ongoing areas of research, such as metagenomics and therapeutic trials.

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CAR-T cells in the treatment of neurological autoimmune diseases

BMJ Practical Neurology - Current Issue· Published 21 Sep 2026 Relevancy: 59%

Chimeric antigen receptor T cells (CAR-T cells) have revolutionised cancer treatment by offering personalised therapy of unprecedented efficacy to patients with relapsed B-cell malignancies and myeloma. CAR-T cells are designed selectively to target CD19 or other B-cell antigens with high affinity, leading to a potent immune response and effective killing of malignant B cells. More recently, CAR-T treatment has been shown to be safe and effective in a very limited number of patients with severe, refractory autoimmune conditions such as systemic lupus erythematosus, systemic sclerosis and myositis. This paper describes the early use and feasibility of CAR-T therapies in the treatment of refractory autoimmune neurological diseases.

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Editors commentary

BMJ Practical Neurology - Current Issue· Published 21 Sep 2026 Relevancy: 22%

The actress Ellen Terry (1847–1928) attributed her success to the three I’s, ‘Industry, intelligence and imagination’. This is a tricolon—a useful rhetorical device that brings together ideas with a rhythm and places emphasis on the last element. What might be the neurological equivalent? Curiosity must be one element. Curiosity about patients’ stories, the diseases causing their symptoms, the investigations and treatments available, and how colleagues have approached similar clinical problems. But this exploration needs to be combined with reflection; what do we know and how can we be sure that what we think that we know is true? This leads to a recognition of what we do not know, identifying our ignorance, and thinking about how to address that ignorance through research. But how do we best manage our patients in the meantime? The approach to encephalitis has evolved considerably over the 14 years since the last guidelines were...

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Cramps as the initial presentation of CANVAS/RFC1-related disorder

PubMed - small fiber neuropathy· Published 18 Sep 2026 Relevancy: 80%

Biallelic mutations in the RFC1 gene are associated with CANVAS syndrome (cerebellar ataxia, neuropathy and vestibular areflexia). Peripheral nerve involvement in the form of sensory neuronopathy and small fiber autonomic axonopathy is a core feature of its presentation. Motor manifestations, in the other hand, remain poorly understood and incompletely characterized.We present two cases referred for evaluation of muscle cramps as the main clinical symptom, who were ultimately diagnosed with...

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Bilateral pulmonary embolism in anti-NMDA receptor encephalitis presenting as acute psychosis

PubMed - autoimmune encephalitis AND misdiagnosis· Published 17 Sep 2026 Relevancy: 86%

CONCLUSION: This case underscores the importance of considering autoimmune encephalitis in young patients presenting with new-onset psychosis, in the apparent absence of malignancy. A high index of suspicion and early CSF evaluation can prevent diagnostic delay and improve patient outcomes.

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MRI activity in pre-symptomatic multiple sclerosis: the role of paramagnetic rim lesions beyond the 2024 McDonald diagnostic criteria

Journal of Neurology, Neurosurgery & Psychiatry - Online First· Published 15 Sep 2026 Relevancy: 88%

Background The 2024 McDonald criteria allow multiple sclerosis (MS) diagnosis in pre-symptomatic individuals but their association with MRI activity remains uncertain. We assessed whether paramagnetic rim lesions (PRL) predict future MRI activity beyond the 2024 McDonald criteria. Methods We retrospectively included individuals with incidental MRI findings suggestive of MS, ≥6 months of radiological follow-up, 3D T2*-weighted echo-planar-imaging MRI. Clinico-radiological data included PRL, central vein sign (CVS) Select-6, cerebrospinal fluid positivity, optic nerve, spinal cord involvement and disease-modifying treatment. Time to first MRI activity and annualised lesion rate (ALR) were analysed using multivariable-penalised Cox and mixed-effects Poisson models. Results Among 68 patients (mean age 38 years; 79.4% female; mean follow-up 55.7 months), 21 showed MRI activity. PRL were associated with shorter time to first MRI activity (HR 5.66, 95% CI 1.33 to 28.39, p=0.019). PRL (RR 3.45, 95% CI 1.40 to 8.47, p=0.007) and CVS positivity (RR 4.09, 95% CI 1.17 to 14.27, p=0.027) predicted higher ALR. Fulfilment of the 2024 McDonald criteria associated with increased risk of future MRI activity (HR=11.95, 95% CI 2.77 to 51.51, p=0.001; Cox regression). Adding PRL presence to the criteria changed classification performance (2=18, p<0.001; McNemar’s test), improving specificity and accuracy while reducing sensitivity. Conclusions PRL are associated with subsequent radiological activity in pre-symptomatic MS, featuring complementary predictive value beyond biomarkers currently included in the 2024 McDonald criteria.

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