Neurogenic thoracic outlet syndrome (nTOS) remains diagnostically challenging because symptoms are common, objective neurological signs are often absent, and conventional investigations may be normal or non-specific. Contemporary diagnostic frameworks remain predominantly clinical, leaving clinicians to infer the anatomical site and mechanism of compression before committing patients to injection, rehabilitation, or decompressive surgery. This opinion article argues that high-frequency point-of-care ultrasound (HF-POCUS) should be incorporated into specialist nTOS assessment as an adjunct to, not a replacement for, clinical diagnosis. HF ultrasound can directly visualise the supraclavicular brachial plexus, lower trunk deformation, fibromuscular bands, cervical rib variants, scalene anomalies, and dynamic vascular compromise that may mark costoclavicular narrowing. Evidence suggests that nerve ultrasound alone has limited sensitivity but useful specificity, while combining targeted brachial plexus neurosonography with dynamic duplex assessment substantially improves diagnostic yield and anatomical localisation. The technique is particularly valuable when it identifies surgically relevant findings such as the wedge-sickle sign, focal lower trunk distortion, distal oedematous thickening, or reproducible symptom provocation during scanning. However, HF-POCUS is operator dependent and vulnerable to over-interpretation, especially where dynamic vascular compression is present in asymptomatic individuals. Safe implementation therefore requires defined training, stored images, structured reporting, quality assurance, and explicit integration with clinical criteria, electrodiagnostic testing, MRI, and response to scalene injection where appropriate. Used within this governed framework, HF-POCUS has the potential to reduce diagnostic ambiguity, shorten time to decision-making, improve surgical planning, support more transparent patient counselling, and create a reproducible pre-operative anatomical hypothesis for clinical decision-making processes in suspected nTOS.
BACKGROUND:Astrocyte pathology is a defining feature of progressive supranuclear palsy (PSP), yet the relevance of fluid glial fibrillary acidic protein (GFAP) remains uncertain. OBJECTIVE:To determine whether mean GFAP concentrations differ between PSP and healthy controls or other parkinsonian disorders, particularly Parkinson's disease (PD) and multiple system atrophy (MSA). METHODS:PubMed and Scopus were searched from inception to 24 January 2026. Original human studies that measured GFAP in plasma, serum, or cerebrospinal fluid (CSF) and included a PSP group were eligible. Standardized mean differences were pooled using random-effects meta-analysis and interpreted as group-level separation rather than individual diagnostic accuracy. RESULTS:Of 1917 records, 1590 were screened after deduplication; 19 studies were included qualitatively and 12 quantitatively. Seven blood studies contributed to the primary PSP versus healthy-control analysis (PSP n = 283; controls n = 312). Blood GFAP was moderately higher in PSP (Hedges' g = 0.63, 95% CI 0.30 to 0.97; p = 0.003; I2 = 53.4%). The estimate persisted in leave-one-out and in a sensitivity analysis adding three studies with median-derived means (k = 10; g = 0.72, 95% CI 0.36 to 1.08). CSF GFAP was directionally concordant. Group-level separation between PSP and PD or MSA was limited and inconsistent. CONCLUSIONS:Mean blood GFAP concentrations are higher in clinically diagnosed PSP than in healthy controls, although the biological basis and disease specificity of this finding remain uncertain. However, these analyses do not establish sensitivity, specificity, or individual-level diagnostic performance, and GFAP should not be considered a stand-alone diagnostic marker.
BACKGROUND:Several idiopathic inflammatory myopathies (IIM), originally classified under polymyositis, evolved into distinct entities. Herein, we describe clinical features and treatment outcomes of a potentially novel clinico-histopathological entity: myositis with nemaline rods (MNR). METHODS:We performed retrospective chart review of the Mayo Clinic electronic medical records to identify patients with nemaline rods and muscle inflammation on biopsy, not fitting into any IIM subgroup, and extracted clinical and laboratory data. Additional immunohistochemical studies were performed on muscle biopsies. RESULTS:Eleven patients were identified, with mean age at onset 61.8 years (SD = 9.8), seven were female. MNR had a distinctive phenotype with rapidly progressive weakness, predominantly affecting swallowing, axial, and proximal limb muscles, often with prominent myalgia. No patients had monoclonal gammopathy. Creatine kinase levels were elevated in 73% of patients. Muscle histopathology revealed nemaline rods in non-atrophic and atrophic fibers. Inflammation was often endomysial, where both CD4+ and CD8+ T cells invaded nonnecrotic muscle fibers. A significant proportion of CD8+ T cells were KLRG1+. Of patients with follow-up, 6/8 responded to immunosuppressive treatment with some going into remission. Although MNR shares features with sporadic late-onset nemaline myopathy (SLONM) and inclusion body myositis (IBM), it has important distinctions. Unlike SLONM, MNR shows endomysial inflammation and no monoclonal protein; unlike IBM, MNR exhibits distinct clinical features, rapid progression, and responsiveness to immunotherapy. CONCLUSIONS:MNR is associated with a unique combination of clinical and histopathological features, responding well to treatment in most cases. Future studies are needed to explore underlying mechanisms and identify serological biomarkers.
BACKGROUND:Public understanding about brain death/death by neurologic criteria (BD/DNC) is generally poor. With the rising popularity of utilization of large language model (LLM) chatbots to answer medical questions, we sought to determine the quality of information about BD/DNC provided by ChatGPT 4o-mini and Gemini 3 Flash (Fast). METHODS:With the assistance of a family advocate, we developed 45 open-ended questions about BD/DNC and submitted them to ChatGPT 4o-mini and Gemini 3 Flash (Fast) in January 2026. We recorded response word count, Flesch-Kincaid Readability Score and source reputability (non-reputable sources were defined as nonmedical, nongovernmental, nonlegal and not affiliated with an organ donation organization). Two authors of the 2023 BD/DNC guidelines independently assessed response accuracy relative to accepted medical standards and a third adjudicated discrepancies. RESULTS:Most responses were ≥ 10th grade level [ChatGPT 4o-mini: 44/45 (98%), Gemini 3 Flash (Fast): 39/45 (86%)]. After adjudication, 22/45 (49%) responses from Gemini 3 Flash (Fast) and 20/45 (44%) from ChatGPT 4o-mini were considered completely correct (p = 0.673). There was no relationship between accuracy and: word count; readability; or citation of at least one non-reputable source. CONCLUSION:ChatGPT 4o-mini and Gemini 3 Flash (Fast) responses to questions about BD/DNC may include inaccuracies. This could promote confusion and distrust. There is remarkable potential for integration of artificial intelligence in public education about healthcare, but there is a need for improvement to ensure responses are accurate and readable. The healthcare team should be prepared to address misconceptions about BD/DNC based on use of LLMs.
Autoimmune glial fibrillary acidic protein astrocytopathy (GFAP-A) is an immune-mediated inflammatory disorder of the central nervous system. Although delayed magnetic resonance imaging (MRI) abnormalities have been reported in patients with GFAP-A, the anatomical distribution of brain lesions that become apparent on follow-up MRI remains unclear. We retrospectively reviewed three patients with cerebrospinal fluid anti-GFAPα immunoglobulin G-positive GFAP-A who underwent serial brain MRI. The patients ranged in age from 40 to 80 years and were clinically heterogeneous: patients 1 and 2 required ventilatory support, whereas patient 3 had a milder course and improved without immunotherapy. Initial brain MRI performed 10-21 days after symptom onset showed leptomeningeal or periventricular radial linear enhancement and/or T2-weighted imaging (T2WI)/fluid-attenuated inversion recovery (FLAIR) hyperintensities in the supratentorial white matter, deep gray matter, or brainstem. Definite bilateral cerebral peduncle involvement was not evident in the corresponding initial axial midbrain images. Follow-up brain MRI performed on days 31-59 revealed bilateral cerebral peduncle T2WI/FLAIR hyperintensities in all three patients. Pathological plantar reflexes were documented during the subacute phase in two patients, although coexisting spinal cord lesions detected during follow-up may also have contributed to these signs. Previous reports have described delayed non-enhancing T2WI/FLAIR abnormalities and brainstem involvement in GFAP-A. However, whether the cerebral peduncles are involved as part of these delayed MRI abnormalities remains unclear. Thus, bilateral cerebral peduncle lesions may represent a delayed non-enhancing MRI manifestation of GFAP-A. Careful assessment of the cerebral peduncles on follow-up MRI may help characterize the evolving lesion distribution.
Background Endovascular therapy (EVT) is an established treatment for basilar artery occlusion (BAO) with severe deficits, but its benefit in patients with mild-to-moderate symptoms (National Institutes of Health Stroke Scale [NIHSS] <10) remains unclear due to limited randomized controlled trial (RCT) evidence. We performed a systematic review and meta-analysis to evaluate EVT efficacy and safety in this subgroup. Methods We searched PubMed, Embase, and the Cochrane Library for RCTs and observational studies published between January 1, 2014, and July 1, 2026, comparing EVT plus best medical treatment (BMT) versus BMT in BAO with NIHSS <10. The primary outcome was 90-day good functional status (modified Rankin Scale [mRS] 0–2). Secondary outcomes were favorable (mRS 0–3) and excellent (mRS 0–1) functional status. Safety outcomes included 90-day mortality, any intracerebral hemorrhage (ICH) and symptomatic ICH. Results Fifteen studies comprising 3981 patients (1812 EVT; 2169 BMT) were included. No significant differences were observed in good (OR = 1.51; 95% CI 0.89–2.54; p = 0.12) or favorable functional status (OR = 0.99; 95% CI 0.75–1.30; p = 0.92), while EVT increased the odds of excellent status (OR = 2.01; 95% CI 1.33–3.05; p < 0.001). Mortality (OR = 0.94; 95% CI 0.55–1.59), any ICH (OR = 1.23; 95% CI 0.69–2.19) and symptomatic ICH (OR = 0.98; 95% CI 0.61–1.57) were comparable. Conclusion Although no difference emerged for the primary outcome, EVT increased the likelihood of excellent recovery without compromising safety. These findings highlight the need for RCTs targeting this population.
BACKGROUND:Defining viral serology in multiple sclerosis (MS) patients has become increasingly more relevant, given the potential association between viruses and MS, along with the recent introduction of new immunosuppressive treatments. OBJECTIVES:To describe the frequency of viral seropositivity in a Brazilian cohort of patients with MS and to explore the association of disease-modifying therapies (DMTs) and intravenous pulse therapy (IVPT) with viral serological status. METHODS:This retrospective descriptive study evaluated the seropositivity of ten viral markers in 70 patients with MS followed by a specialist at a neurological center in Brazil. Serological testing was performed according to routine clinical practice; therefore, not all patients were tested for every viral marker. RESULTS:High frequence of IgG seropositivity was observed for Epstein-Barr virus (95.1%), rubella (95.7%), varicella-zoster virus (87.5%), and cytomegalovirus (87.2%). Anti-HBs positivity was detected in 45.2% of patients, whereas no cases of HBsAg, HIV, HCV, or HTLV-I/II were identified. IgM positivity was uncommon. No statistically significant differences in viral seropositivity were detected according to DMT or recent IVPT exposure. CONCLUSIONS:This study describes the viral serological profile of a Brazilian cohort of patients with MS and supports the clinical value of baseline viral screening for vaccination planning and treatment evaluation. The analyses according to DMT and a recent IVPT exposure should be considered exploratory, and prospective studies with standardized viral screening are needed to better define the impact of these therapies on viral serological status.
BACKGROUND:CADMUS is an MRI-based classification for small vessel disease (SVD) related intracerebral hemorrhage (ICH), providing distinct SVD phenotypes: cerebral amyloid angiopathy (CAA), deep perforator arteriopathy (DPA), Mixed CAA-DPA, and Undetermined SVD. We evaluated construct validity in an external cohort by examining whether CADMUS subtypes demonstrate biologically coherent anatomical distributions, and whether lobar hematoma location is associated with probable CAA within the mixed ICH subtypes: Mixed CAA-DPA and Undetermined SVD. METHODS:Cross-sectional analysis of patients with first-ever spontaneous ICH admitted to a tertiary hospital (2008-2024). Location was classified as lobar supratentorial, deep/non-lobar supratentorial, or infratentorial. Differences in hematoma location across CADMUS subtypes were assessed by chi-square with Bonferroni-corrected pairwise comparisons. Within the mixed ICH subtypes, we assessed whether lobar hemorrhage location was associated with Probable CAA according to the Boston Criteria 2.0. RESULTS:There were 843 patients with sufficient neuroimaging for CADMUS classification: 164 (19.5%) with CAA, 185 (18%) with DPA and 495 (62.5%) with one of the mixed ICH subtypes Location differed markedly across subtypes (χ2 = 394.2, p < 0.001): CAA was exclusively lobar and DPA exclusively deep or infratentorial. Among patients with a mixed ICH subtype, those with lobar hemorrhage location were more likely to have Probable CAA criteria than those with a non-lobar hemorrhage: 63/262 (24.0%) of lobar patients were Boston-probable compared with 1/232 (0.4%) of non-lobar patients OR 73.1 (95% CI 10-534, p < 0.001). CONCLUSIONS:CADMUS subtypes demonstrate near-complete anatomical segregation in an independent external cohort. Among patients with a mixed ICH subtype, lobar hemorrhage location was strongly associated with Probable CAA, supporting its use as a potential marker of CAA in this population.
