Background: Multiple sclerosis (MS) is a chronic neuroinflammatory disease that significantly impairs quality of life. Spasticity is one of the most frequent and highly disabling features of MS, often accompanied by cramps, pain, bladder dysfunction, sleep disturbances, fatigue, and tremor. Recently, the concept of ‘spasticity-plus syndrome’ (SPS) has emerged to reflect the interplay among these symptoms. This work aims to update the Spanish clinical guideline for managing MS-related spasticity (MSS) by adopting this evolving concept. Methods: A panel of 14 Spanish neurologists assessed the available evidence using a two-level literature review strategy, combining a systematic review focused on SPS with a rapid review of MSS management. Building on the previous guideline, the panel formulated updated recommendations with the scientific endorsement of the Spanish Society of Neurology (SEN). To support a structured and transparent development process, an adapted GRADE-informed framework was used to guide the appraisal of the evidence and formulation of recommendations. Results: A total of nine publications addressing the SPS concept were identified. Based on the evidence and expert consensus, the panel developed 13 recommendations covering triggering and aggravating factors, the diagnosis and evaluation of spasticity, and therapeutic strategies for patient management. In addition, a comprehensive treatment algorithm was proposed to guide therapeutic decision-making according to patients’ clinical profiles. Conclusions: This work provides updated recommendations for the management of patients with MSS, integrating the SPS concept into clinical practice. The panel highlights the importance of a symptom-oriented approach that considers the full spectrum of clinical manifestations to individualize treatment, simplify the therapeutic approach, and minimize the risk of polypharmacy.
Attention deficit hyperactivity disorder (ADHD) is a comorbidity affecting 12%–29% of individuals with epilepsy, significantly impacting learning, psychosocial development, behaviour, and quality of life. Moreover, ADHD and epilepsy share a bidirectional relationship. Although methylphenidate has been proven effective in alleviating ADHD symptoms, its use remains limited in individuals with epilepsy due to outdated concerns—dating back over 20 years—that psychostimulants could increase seizure frequency. This manuscript presents a narrative review of the scientific literature published between January 2000 and May 2026 regarding the use of methylphenidate in patients with epilepsy and ADHD. Based on the available evidence, a panel of paediatric neurologists from five Spanish tertiary hospitals with expertise in epilepsy and neurodevelopmental disorders reached an expert consensus and developed a series of practical recommendations for the assessment and management of these patients. This expert group issued several recommendations, including the proactive screening of ADHD symptoms in all children and adults with epilepsy from the onset of the condition. Current evidence has not consistently demonstrated an increased seizure risk associated with methylphenidate in patients with epilepsy, although available data remain limited for some epilepsy subgroups. Furthermore, undertreatment of ADHD is associated with poorer patient outcomes. Methylphenidate may be considered in children and adults with epilepsy when clinically indicated, following optimization of epilepsy management, associated comorbidities, and behavioural and psychosocial interventions. Treatment decisions should be individualized, particularly in patients with active epilepsy, drug-resistant epilepsy, recent seizure worsening, or developmental and epileptic encephalopathies.
Background: Acute ischemic stroke (AIS) resulting from carotid artery occlusion (CAO) represents a significant clinical challenge because conventional imaging modalities often lead to inaccuracies in occlusion length assessment, potentially compromising therapeutic decision-making. We aimed to analyze the distribution patterns of contrast agents using computational fluid dynamics (CFD) simulations in AIS caused by CAO and to mitigate errors in estimating occlusion length. Methods: Data from four patients with AIS caused by CAO were analyzed. CFD simulations were conducted using postoperative computed tomography angiography (CTA) data to model contrast agent flow, and the results were compared with those of preoperative CTA and intraoperative digital subtraction angiography (DSA). Results: CTA/DSA demonstrated a flame sign at the ICA origin in Patients 1–3. Patients 1 and 2 had carotid dissection, whereas Patient 3 had a C4-segment embolic occlusion. In Patient 3, DSA showed C1-origin vortices, a horizontal contrast–blood interface, and no distal C1 opacification, features distinct from those in Patients 1 and 2. CFD simulations using the post-recanalization CTA model replicated this contrast distribution, including the vortices and interface; proximal C1 vortex ranges, velocities, pressures, and wall shear stress were comparable, but the mass-weighted average velocity varied over time. Conclusions: CFD simulations recreated contrast agent distribution during C4 segment occlusion, revealing a high-pressure dead space in the distal C1 segment. This study generated preliminary evidence for understanding contrast agent distribution in CAOs, offering valuable insights for clinical imaging assessments.
