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Neurology
5th Nov, 2025
The Lancet
Intracranial aneurysms are detected in about 3% of adults who undergo brain vascular imaging.1,2 About 7 million people in the US alone have an intracranial aneurysm, which are being detected more frequently due to the increasing use and sensitivity of brain vascular imaging. The most important manifestation of an intracranial aneurysm is subarachnoid haemorrhage, but its incidence is only 6 per 100 000 population per year.3 This discrepancy between the prevalence of intracranial aneurysms and the incidence of subarachnoid haemorrhage means that most intracranial aneurysms never rupture.
Treatment with anti-amyloid β antibodies is becoming standard therapy for early Alzheimer's disease, as lecanemab and donanemab received full approval in the USA, Japan, and other countries between 2023 and 2024. However, only about ten autopsy cases involving passive immunisation with these treatments have been reported so far. These reports include three cases involving aducanumab treatment;1,2 two cases after lecanemab treatment that experienced severe amyloid-related imaging abnormalities (ARIA),3,4 an adverse event specific to this therapy; one case of lecanemab treatment without ARIA;5 and four cases of gantenerumab or solanezumab treatment from the Dominantly Inherited Alzheimer Network Trials Unit (DIAN-TU; table).
Stroke risk evolves across the lifespan, with distinct sex-specific differences that remain underappreciated in both research and clinical practice.1 One of these differences is the higher incidence of ischaemic stroke in women younger than 35 years compared with men of the same age, attributed to reproductive and hormonal factors such as oestrogen exposure, pregnancy complications, and, possibly, migraine with aura.2 In contrast, men's stroke risk accelerates more rapidly in midlife, whereas in older age (typically 75 years and older), the risk in women again surpasses that in men—driven by longer life expectancy and a higher prevalence of specific risk factors, such as atrial fibrillation.
The acute management of central retinal artery occlusion (CRAO) has shifted from eye-care providers (eg, optometrists and ophthalmologists) to stroke neurologists, with emphasis on hyperacute management, expedited diagnostic tests, and aggressive secondary prevention.1,2 Revascularisation of the ischaemic retina with thrombolysis is supported by anecdotal cases, open-label studies, and meta-analyses of observational data, suggesting that intravenous thrombolysis is a low-risk therapy in patients with acute CRAO.
Several updates relevant to neurologists and health-care professionals involved in the prevention and treatment of neurological diseases have been added to the WHO Model List of Essential Medicines (EML). The inclusion of drugs into “the world's most influential list of medicines” is a necessary step towards equitable access. WHO's aspiration is for most countries to have access to all essential medicines for neurological disorders by 2031, and more drugs need to be added to the list in upcoming revisions if this goal is to be fulfilled.
Rheumatology
A 36-year-old woman had dyspnoea on exertion with intermittent chest tightness that occurred during and outside of exertion. She did not disclose any systemic diseases and there was no family history of cardiovascular or pulmonary conditions. An electrocardiogram done during a treadmill test showed ST segment depression without atypical serum concentrations of creatinine kinase or troponin I. A coronary CT angiography showed a so-called rosary-bead appearance and luminal irregularity with ectatic changes over the coronary arteries (figure A–C).
Although psoriatic arthritis and rheumatoid arthritis are both common types of inflammatory arthritis characterised by synovial inflammation, there are distinct molecular and cellular landscapes between these conditions. Recent advances in synovial research in psoriatic arthritis have begun to unlock important insights into disease pathogenesis and potential clinical applications. For example, studies using high-dimensional technologies have identified psoriatic arthritis-specific macrophage, fibroblast, and mast cell subsets, as well as specific cytokines, such as IL-36 and IL-41, that drive pathogenesis.
Treatment sessions of CFT produced sustained effects at 3 years for people with chronic disabling low back pain. These long-term effects are novel and provide the opportunity to markedly reduce the effect of chronic back pain if the intervention can be widely implemented. Implementation requires scaling up of clinician training to increase accessibility and replication studies in diverse health-care systems.
Both interventions led to improved disease activity in patients with early, untreated psoriatic arthritis, without a clinically or statistically significant difference in PASDAS between treatment groups at week 24. Participants in the placebo and methotrexate group required more rescue corticosteroids. Sustained results were observed at week 52 in both groups, without serious or unexpected adverse events.
Sharon Dowell, a native of Barbados, had wanted a medical career since age 12, when her uncle was diagnosed with brain cancer. He ultimately succumbed to the cancer, but she had lasting memories of the doctors, who impressed her as “confident” and “knowledgeable” at a time when she and her family did not know what to do. “They brought hope”, she remembers. “I wanted to be able to do that for my family, for my mom, who seemed so lost and uncertain.” Dowell would later attend medical school at the University of the West Indies (Kingston, Jamaica).
Qian Wang and colleagues assessed the feasibility of HN2301, an engineered CD8 T-cell-targeted lipid nanoparticle encapsulating CD19 chimeric antigen receptor (CAR) messenger RNA, in five patients with refractory systemic lupus erythematosus (SLE). Patients received an infusion of HN2301 at a dose of 2 mg or 4 mg. CD8+ CD19 CAR T cells and CAR mRNA peaked at 6 h after infusion, decreasing to baseline levels within 2–3 days. Within 6 h after infusion, circulating B cells were substantially decreased in the two patients who received the 2 mg dose and were completely depleted for 7–10 days after administration in the three patients who received the 4 mg dose.
Benjamin S, Vi L, Chatterjee D, et al. Maternal autoantibodies to the sodium potassium pump α1 subunit AT1A1 and fetal autoimmune congenital heart block: a case-control study. Lancet Rheumatology 2025; 7: e554–64—In this Article, the last sentence of the Summary Findings should read “Anti-AT1A1 autoantibodies were absent in all unaffected pregnancies of women with no history of fetal heart block (autoimmune congenital heart block-naive, 54 [100%] of 54) and in 61 (94%) of 65 of unaffected pregnancies”.
I read with interest the Article by Dennis A Ton and colleagues1 comparing MRI findings in patients with rheumatoid arthritis, at-risk populations, and healthy individuals. Using well defined cohorts, the authors provide valuable insights into the specificity of MRI findings in rheumatoid arthritis. However, the findings also highlight the need for caution in how MRI results are interpreted across different clinical contexts.
Aikeremujiang Muheremu and Kan Jiang raise insightful and thought-provoking points on our recent paper1 on CNS activation in patients with rheumatoid arthritis. We are pleased to hear that the key thesis of the study—that the CNS is a key determinant of therapeutic responses to TNF inhibitors in patients with rheumatoid arthritis—has been recognised by Muheremu and Jiang. Indeed, these findings challenge the conventional, peripherally focused view of rheumatoid arthritis by providing evidence for a crucial joint–brain axis that might influence therapeutic responses to cytokine inhibition.
The landmark study by Hess and colleagues1 represents a paradigm shift in rheumatoid arthritis therapeutics by positioning the CNS as a key predictor of TNF inhibitor response. The authors' randomised trial compellingly shows that patients with high baseline functional MRI (fMRI)-measured CNS pain activation have substantially better clinical outcomes with certolizumab pegol than individuals with low activation. This work challenges the peripheral–centric view of rheumatoid arthritis, reframing subjective symptoms such as pain as active therapeutic targets rather than mere byproducts of joint inflammation.
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