Over the last 10-15 years it has become increasingly clear that the problem with MS is more than just one of areas of inflammation, demyelination and then repair. The early loss of axons coupled to the widespread pathology consequent on early inflammation has challenged those working in the field as to how best to treat this condition and then how best to measure any effect from such therapies. Declan Chard and David Miller, in their beautifully succinct article, discuss the power of MRI in this process, both in terms of what it has been able to show and what it may be used for in the future. This article highlights how technical developments for research can translate into more mainstream clinical practice.

Our other major review article is the second in his series on the Neurological Sleep Clinic by Paul Reading and tackles the insomnias and parasomnias. He discusses, again from a personal perspective, the therapeutic options and useful discriminators in distinguishing the causes of these types of sleep disorder.

There are some articles which we publish that cause me to stop and think about greater questions than just treatments in patients with neurological problems. One such article by Joanna Collicut does just this, as it engages with the ethical challenges posed by acquired brain injury. Whilst we have discussed the problems in patients in a vegetative state in other issues of ACNR, this article takes the debate to a wider remit. It is a fascinating read about some of the current dilemmas and problems that face medical practitioners dealing with such patients and I strongly urge you to read this article given its thought provoking content.

This article in our Neuropathology series by Tibor Hortobagyi and Safa Al-Sarraj, discusses the best ways to stain for axonal injury and how this can be used to ascertain the cause of that pathology. In particular, APP immunohistochemistry seems an especially sensitive tool for detecting damaged axons and its use is becoming more mainstream and, with this, its utility in establishing the cause of diffuse axonal injury.

One of the major problems in those surviving their initial subarachnoid haemorrhage is subsequent vasospasm that occurs in most cases and which has a significant effect on outcome. In their article in the Neurosurgery series Rueben Johnson and Hilary Madder discuss the optimal management of this aspect of subarachnoid haemorrhage and the challenges that such management presents.

In our series from India, Uday Muthane describes the causes of the different types of movement disorders seen in this part of the world. He also discusses the challenges of managing such cases, in terms of the availability of diagnostic tests and therapeutic options and the problem that the vast majority of individuals have no means of paying for such treatments.

Andrew Larner, after four excellent articles on headache, takes us into the world of cognition and literature. As usual this is a highly entertaining account with plenty to reflect on.

Nick Kane, in his contribution to the Neurophysiology series, edited by Andrew Michell, discusses the role of evoked potentials and other neurophysiological tests in the evaluation of comatosed patient and their utility as tools for prognosis. He concludes that they are probably underused, as are all neurophysiological tests, probably underused in the ITU setting with patients who have prolonged coma states. The ease with which such neurophysiological tests could be used does make them attractive tools of assessment with the caveat that it requires experience and expertise to interpret them accurately.

In our ENS supplement, Steven Laureys and colleagues gives us another article on the challenge in accurately assessing patients with prolonged abnormalities in consciousness and awareness. The critical importance of diagnosing the vegetative state over a minimally conscious state or locked in syndrome cannot be over emphasised and in their review Laureys et al demonstrate how this field has progressed using functional imaging and neurophysiology.

Also don’t forget our case reports which this month features a fascinating case of a spontaneous anterior intracranial artery dissection by Gina Kennedy and colleagues, along with a new case of CNS vasculitis from Nick Gutowski et al. We also have our usual series of reviews, including a wonderful update on Muscular Dystrophies by Rajith de Silva in the conference report section which also features a picture of our very own Dr Alasdair Coles. So I hope you continue to enjoy ACNR and do let us know how we can do things better.

Roger Barker
Roger@acnr.co.uk