Objective: To explore journal quality as perceived by clinicians and researchers in clinical neurology.

Methods: A survey was conducted from August 2003 to January 2004. Ratings for 41 selected clinical neurology journals were obtained from 254 members of the World Federation of Neurology (1,500 solicited; response rate 17%). Participants provided demographic information and rated each journal on a 5-point Likert scale. Average ratings for all journals were compared with the ISI's journal impact factors. Ratings for each journal were also compared across geographic regions and respondent publication productivity.

Results: The top 5 journals were rated much more highly than the others, with mean ratings greater than 4. Mean journal ratings were highly correlated with journal impact factors (r = 0.67). Most of the top 10 journal ratings were consistent across the subgroups of geographic regions and journal paper productivity. However, significant differences among the different geographical regions and respondent productivity groups were also found for a few journals.

Conclusions: The results provide valuable insight on how neurological experts perceive journals in clinical neurology. These results will likely aid researchers and clinicians in identifying potentially desirable research outlets and indicate journal status for editors. Likewise, biomedical librarians may use these results for serials collection development.

OBJECTIVES—To estimate the incidence rate of Guillain-Barré syndrome variants in an unselected population and to describe their clinical features and prognosis.
METHODS—A two year prospective multicentre study on the incidence and prognosis of Guillain-Barré syndrome was performed in Emilia-Romagna, northern Italy (3 909 512 inhabitants). A surveillance system was instituted within the study area, which comprised all the neurological departments, private and public general hospitals, and practising neurologists. The international classification of diseases (ICD) codes 357.XX (any peripheral neuropathy) of hospital discharges were also reviewed.
RESULTS—Data were separately analysed for Miller Fisher syndrome and other Guillain-Barré syndrome variants. During the study period 18 patients with Guillain-Barré syndrome variants including seven with Miller Fisher syndrome were recruited; the incidence rates were 0.14/100 000/year (95% confidence interval (95% CI) 0.07-0.25) for Guillain-Barré syndrome variants (excluding Miller Fisher syndrome) and 0.09/100 000/year (95% CI 0.04-0.18) for Miller Fisher syndrome. Guillain-Barré syndrome variants alone (excluding Miller Fisher syndrome) accounted for 10.5% of total cases. Death and relapses were not found. Details of clinical, electrophysiological, and CSF findings of Guillain-Barré syndrome variants are provided.
CONCLUSIONS—Guillain-Barré syndrome variants other than Miller Fisher syndrome, as obtained through a population based study, account for about 10% of total cases of Guillain-Barré syndrome and, as a whole, have a good prognosis. Their clinical features are heterogeneous; bifacial weakness (associated with other signs, mainly sensory disturbances) represents the most frequent finding.



Background:

The details about the research productivity in the neurology specialty from India is lacking. We analyzed the publishing trends and the research productivity of neurology-related articles in the Journal of the Association of Physicians of India (JAPI).

Materials and Methods:

We carried the bibliometric analysis of articles related to neurology specialty from JAPI published between 2000 and 2011. Data were derived from the journal's website and the articles were analyzed for type (original article, case reports, etc.), disease (infection, vascular, etc.), place, and timelines for publication.

Results:

Out of total 2977 articles published, 256 articles belong to neurology. Neurology contributed to 7--20% of the published articles per year in JAPI. Case reports (52%) constitute the majority type of articles followed by Original Articles (20%), Correspondence and Images (15% each). Infections (27%), structural disorders (19%), cerebrovascular and peripheral nervous system disorders (16% each) contribute the majority of research articles in Neurology. Mumbai (15%), Delhi (13%), and Chennai (9%) are the top three contributors followed by Lucknow and Varanasi. All types of articles took about 9--10 months for acceptance and another 4--5 months for publication. Letters to the Editor were published faster when compared to other articles (P=0.0035).

Conclusion:

Neurology specialty contributes an average 14% of articles per annum in JAPI. Infections, vascular, structural, and peripheral nervous system disorders together account for 80% of published literature with a small representation from other diseases. Mumbai and Delhi are the leading contributors toward research productivity in neurology.

To illustrate the extent of time lags from manuscript submission to journal publication certain “core” journals in neurology and general medicine have been surveyed. The clinical journals experience less time lag, but more of a problem with backlogs of manuscripts, than basic research journals. Most editors of the journals surveyed cited the following as the major causes for publication delay: failure of authors to follow journal requirements, slowness of editorial and referee reviews, and author revisions.

After reviewing the results of the journal survey and articles concerning information dissemination, it seems that the role of the journal is changing. Publication speed in a journal is not of vital importance to members within an “invisible college” but is important to those conducting research in fields outside of their “invisible college” contacts. Distinctions will have to be made between the archival function and the rapid dissemination function if efficient and effective modes of information dissemination are to be developed.

Objective: To review the current status and recent trends in the American Board of Psychiatry and Neurology (ABPN) specialties and neurologic subspecialties and discuss the implications of those trends for subspecialty viability.

Methods: Data on numbers of residency and fellowship programs and graduates and ABPN certification candidates and diplomates were drawn from several sources, including ABPN records, Web sites of the Accreditation Council for Graduate Medical Education and the American Medical Association, and the annual medical education issues of the Journal of the American Medical Association.

Results: About four-fifths of neurology graduates pursue fellowship training. While most recent neurology and child neurology graduates attempt to become certified by the ABPN, many clinical neurophysiologists elect not to do so. There appears to have been little interest in establishing fellowships in neurodevelopmental disabilities. The pass rate for fellowship graduates is equivalent to that for the “grandfathers” in clinical neurophysiology. Lower percentages of clinical neurophysiologists than specialists participate in maintenance of certification, and maintenance of certification pass rates are high.

Conclusion: The initial enthusiastic interest in training and certification in some of the ABPN neurologic subspecialties appears to have slowed, and the long-term viability of those subspecialties will depend upon the answers to a number of complicated social, economic, and political questions in the new health care era.

The latest revision of the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) was available in booklet format in June 2011, and is published in this issue of the Journal of Spinal Cord Medicine. The ISNCSCI were initially developed in 1982 to provide guidelines for the consistent classification of the neurological level and extent of the injury to achieve reliable data for clinical care and research studies. This revision was generated from the Standards Committee of the American Spinal Injury Association in collaboration with the International Spinal Cord Society's Education Committee. This article details and explains the updates and serves as a reference for these revisions and clarifications.

The National Institute of Neurological Diseases and Blindness (NINDB) has the responsibility of trying to alleviate the morbid and mortal effects of all the diseases of the nervous system and the special senses including speech, hearing, and vision. The information problem facing the NINDB is only a fraction of the total information problem of the biomedical community, but it is probably representative. The NINDB information audience has a core of about 19,000 persons, 10 percent of whom are nonclinical research scientists; 10 percent of whom are engaged in patient care, teaching, and some research; 12 percent in training (post doctoral); and 68 percent chiefly involved in the care of patients. In addition, there is an unknown number of other interested scientists. Fifty to eighty thousand journal articles, an unknown number of technical reports, and other items produced each year are potentially valuable to this group. The exact needs of each subgroup must be identified and ways developed to deliver the required information quickly, accurately, and in an easily useable form. NINDB has undertaken a large information program as a service to the biomedical community to help cope with these information problems. This program is to serve the needs of the practicing physician, the research scientist, and NINDB program analysis and planning. The Neurological Information Network is the core effort of the program.

The Neurological Information Network envisions large units incorporating both information storage and retrieval and information analysis. These will be in universities with strong biomedical libraries where there are ongoing research programs in some area relevant to NINDB responsibilities. These units are to be integrated and will interact with each other and with the National Library of Medicine to avoid duplication of work. In addition to their own information analysis activities, the major documentation centers will be able to support information analysis satellites at other research centers where specific categorical research programs are underway.

The principles of peer reviewed scientific publications date back two and one-half centuries to the origins of Medical Essays and Observations published by the Royal Society of Edinburgh (1731). This year (2012) is notable in that perhaps the most prestigious and best-known medical journal, the New England Journal of Medicine, crossed the second century mark. The methodologies of peer review have undeniably served medicine well and helped to usher in unimaginable advances in human health. Despite such illustrious history, the winds of change are in the air.

This paper describes a departmental database created on an ongoing basis by the output of a regular educational activity: the weekly Current Literature Review Conference or Journal Club. Four core neurology journals are reviewed monthly by a team of an attending and a resident. Neurology papers appearing in widely-read medical journals are read bimonthly. A handout containing a summary of each article published in the journal to be reviewed is distributed at the time of the conference and facilitates discussion. After 11 months of use, the database (2.4 megabytes in size) contains 1,327 articles. Information on the articles in the database can be obtained by text search or by specifying a numeric range in the appropriate fields. It is used by the residents and faculty for patient care and to prepare conferences and papers.

Objectives To assess the extent to which funding and study design are associated with high reprint orders.

Design Case-control study.

Setting Top articles by size of reprint orders in seven journals, 2002-09.

Participants Lancet, Lancet Neurology, Lancet Oncology (Lancet Group), BMJ, Gut, Heart, and Journal of Neurology, Neurosurgery & Psychiatry (BMJ Group) matched to contemporaneous articles not in the list of high reprint orders.

Main outcome measures Funding and design of randomised controlled trials or other study designs.

Results Median reprint orders for the seven journals ranged from 3000 to 126 350. Papers with high reprint orders were more likely to be funded by the pharmaceutical industry than were control papers (industry funding versus other or none: odds ratio 8.64, 95% confidence interval 5.09 to 14.68, and mixed funding versus other or none: 3.72, 2.43 to 5.70).

Conclusions Funding by the pharmaceutical industry is associated with high numbers of reprint orders.

Welcome to the Journal of Neuroinflammation, an open-access, peer-reviewed, online journal that focuses on innate immunological responses of the central nervous system, involving microglia, astrocytes, cytokines, chemokines, and related molecular processes. 'Neuroinflammation' is an encapsulization of the idea that microglial and astrocytic responses and actions in the central nervous system have a fundamentally inflammation-like character, and that these responses are central to the pathogenesis and progression of a wide variety of neurological disorders. This concept has its roots in the discoveries of inflammatory cytokines and proteins in the plaques of Alzheimer disease, and these ideas have been extended to other neurodegenerative diseases, to ischemic/toxic diseases, to tumor biology and even to normal brain development. The Journal of Neuroinflammation, published by BioMed Central, will bring together work focusing on microglia, astrocytes, cytokines, chemokines, and related molecular processes in the central nervous system. All articles published in the Journal of Neuroinflammation will be immediately listed in PubMed, and access to published articles will be universal and free through the internet.

Objective To estimate the degree of scatter of reports of randomised trials and systematic reviews, and how the scatter differs among medical specialties and subspecialties.

Design Cross sectional analysis.

Data source PubMed for all disease relevant randomised trials and systematic reviews published in 2009.

Study selection Randomised trials and systematic reviews of the nine diseases or disorders with the highest burden of disease, and the broader category of disease to which each belonged.

Results The scatter across journals varied considerably among specialties and subspecialties: otolaryngology had the least scatter (363 trials across 167 journals) and neurology the most (2770 trials across 896 journals). In only three subspecialties (lung cancer, chronic obstructive pulmonary disease, hearing loss) were 10 or fewer journals needed to locate 50% of trials. The scatter was less for systematic reviews: hearing loss had the least scatter (10 reviews across nine journals) and cancer the most (670 reviews across 279 journals). For some specialties and subspecialties the papers were concentrated in specialty journals; whereas for others, few of the top 10 journals were a specialty journal for that area. Generally, little overlap occurred between the top 10 journals publishing trials and those publishing systematic reviews. The number of journals required to find all trials or reviews was highly correlated (r=0.97) with the number of papers for each specialty/subspecialty.

Conclusions Publication rates of speciality relevant trials vary widely, from one to seven trials per day, and are scattered across hundreds of general and specialty journals. Although systematic reviews reduce the extent of scatter, they are still widely scattered and mostly in different journals to those of randomised trials. Personal subscriptions to journals, which are insufficient for keeping up to date with knowledge, need to be supplemented by other methods such as journal scanning services or systems that cover sufficient journals and filter articles for quality and relevance. Few current systems seem adequate.

The purpose of this article was to provide a literature review of occupational neurological disorders and related research in Korea, focusing on chemical hazards. We reviewed occupational neurological disorders investigated by the Occupational Safety and Health Research Institute of Korean Occupational Safety and Health Agency between 1992 and 2009, categorizing them as neurological disorders of the central nervous system (CNS), of the peripheral nervous system (PNS) or as neurodegenerative disorders. We also examined peer-reviewed journal articles related to neurotoxicology, published from 1984 to 2009. Outbreaks of occupational neurological disorder of the CNS due to inorganic mercury and carbon disulfide poisoning had helped prompt the development of the occupational safety and health system of Korea. Other major neurological disorders of the CNS included methyl bromide intoxication and chronic toxic encephalopathy. Most of the PNS disorders were n-hexane-induced peripheral neuritis, reported from the electronics industry. Reports of manganese-induced Parkinsonism resulted in the introduction of neuroimaging techniques to occupational medicine. Since the late 1990s, the direction of research has been moving toward degenerative disorder and early effect of neurotoxicity. To understand the early effects of neurotoxic chemicals in the preclinical stage, more follow-up studies of a longer duration are necessary.

Clinical neurological abnormalities in patients with schizophrenia have been generally called “Neurological Soft Signs” (NSS). Studies have consistently shown increased NSS in patients with schizophrenia as compared to healthy persons. Early studies were limited by possible confounds of prior neuroleptic medications and illness chronicity. Studies in first episode never treated schizophrenia patients have addressed these confounds. The clinical significance of these findings and the correlation with cognitive dysmetria is the focus of the current review. Relevant literature was obtained using PUBMED and MEDLINE search (1980–2008) and a direct search of reference list of pertinent journal articles. In a 2003 study, neuroleptic-naive schizophrenia patients had significantly more NSS than controls. Patients who were more neurologically impaired had more negative symptoms. Higher NSS scores in treatment-naive schizophrenia patients and the absence of correlation between NSS and illness duration lends support to a neurodevelopmental pathogenesis for schizophrenia. The finding of incoordination and cerebellar signs in most studies also supports the “cognitive dysmetria” explanatory model for schizophrenia. A significant subgroup of patients with schizophrenia may have more neuropathological abnormalities, which predisposes them for a more severe and chronic course of illness. These patients may potentially be identified by clinical neurological examination, which might be very important for prognostication and evolving better methods of treatment for these patients. NSS, by themselves or as a composite index with other neurobiological parameters, hold potential as a candidate endophenotype for schizophrenia.

A reliable disease model mimicking Enterovirus 71 (EV71) infection in humans is essential for understanding pathogenesis and for developing a safe and effective vaccine. Commonly used rodent models including mouse or rat models are not suitable for vaccine evaluation because the rodents are resistant to EV71 infection after they reach the age of 6 days. In this study, 21-day-old gerbils inoculated intraperitoneally (IP) with a non mouse-adapted EV71 strain developed neurological lesion-related signs including hind limb paralysis, slowness, ataxia and lethargy similar to those of central nervous system (CNS) infection of EV71 in humans. The infected gerbils eventually died of the neurological lesions and EV71 could be isolated from lung, liver, spleen, kidney, heart, spinal cord, brain cortex, brainstem and skeletal muscle. Significantly high virus replication was detected in spinal cord, brainstem and skeletal muscle by cellular analysis, real-time quantitative PCR (RT-PCR) and immunohistochemical staining. Histopathologic changes such as neuronal degeneration, neuronal loss and neuronophagia were observed in spinal cord, brain cortex, brainstem, and skeletal muscle along with necrotizing myositis and splenic atrophy. Gerbils that received two doses of inactive whole-virus vaccine showed no EV71-specific symptoms after challenged with EV71. In contrast, gerbils that received mock vaccination died of EV71-induced neuropathology after challenged with EV71. The result indicates that gerbils can serve as a reliable disease model for evaluating safety and efficacy of EV71 vaccine.

Objective:

To review the presentation, evaluation, treatment, and prognosis of various nerve injuries about the shoulder in the athletic population. Included are injuries to the axillary, suprascapular, musculocutaneous, long thoracic, and spinal accessory nerves.

Data Sources:

This article represents a review of the literature regarding incidence, presentation, and results of treatment of these various nerve injuries. The clinically pertinent anatomy is also presented to better relate mechanism of injury to the occurrence of nerve injury. I searched MEDLINE from 1966 through 1999 and the Journal of Shoulder and Elbow Surgery from 1992 through 1999 for the key words “nerve” and “shoulder.”

Data Synthesis:

A historical review of treatment results is presented as well as a review of treatment options and the results of studies using modern techniques in the management of nerve injuries.

Conclusions/Recommendations:

Nerve injuries about the shoulder present as distinct clinical syndromes, although signs and symptoms can be subtle. The athletic trainer and team physician must be able to recognize the presentation of these injuries so that adequate evaluation and prompt treatment can be instituted to maximize the athlete's chance for early return to sport.

Images

Literature on sleep disorders from our country, India, can mainly be found in the Indian journal of Sleep medicine, Indian Journal of psychiatry, The Annals of Indian Academy of Neurology and certain other journals and books. The article highlights the contribution of various Indian doctors in the field of sleep disorders, which includes review articles, prevalence studies, studies on etiology and treatment options, case reports and a couple of case control studies. Also included are studies on various sleep related syndromes as well as studies about awareness and knowledge of sleep disorders amongst the medical fraternity. This is a humble attempt to compile the rich data available in the country on sleep disorders in order to aid further research in the field.

Section Editor note

The appearance in The Journal of Headache and Pain of this paper on an important document of the history of brain anatomy could seem of marginal interest for a journal devoted to clinical and basic research on headache and pain. On the contrary, the knowledge of the remote development of our understanding of the nervous system can throw light on the development which followed in all the fields of neurologic interest [1–3]. In other terms, and just to give an example, modern neurology, and particularly neurophysiopathology and neuropharmacology, would be simply inconceivable without the notion of the neuron and of the synapses, and, before those, of the macroscopic morphology of the nervous system. To rationally modify the software, in this case a clinical condition such as headache, in the favourable terms we desire, would not be possible without a scientific knowledge of the structure of the hardware, the nervous system, which today we are able to manipulate at a very subtle cellular, or even molecular, level. Therefore, a glimpse into this fascinating moment of the Renaissance in which an outstanding advancement of neurological knowledge took place, documented by a pictorial representation – actually a true brain imaging – of exceptional beauty and scientific value, will not only please our eyes, but will also stimulate our interest in a better understanding of the present through the path of the past.

Giorgio Zanchin

References

1. Zanchin G (2004) New additions to the History of Headache Section. J Headache Pain 5:260

2. Zanchin G (2004) Sources. J Headache Pain 5:261–264

3. Zanchin G (2006) Section Editor note. J Headache Pain 7:149–150

Abstract

Girolamo Fabrici d’Acquapendente (ca.1533–1619), in his olograph will donated to the Signoria of Venice a rich collection of anatomical paintings, which are today preserved in the Marciana Library. The third volume of these tabulae pictae, entitled De Anatomia Capitis Cerebri Nervorum, deals with the nervous system and contains the only known illustrations by Fabrici regarding neuroanatomy. Despite the realisation of this splendid collection of 21 coloured paintings, neither a systematic description nor an iconographic record regarding nervous structures were found to be published by Fabrici. For this reason, a thorough study of these plates is pivotal to a better understanding of the contribution made by d’Acquapendente to the knowledge of the nervous system. Besides their aesthetic quality, Fabrici’s tabulae pictae appear as a unique document of exceptional scientific value, thanks to the unprecedented realism given to the anatomical structures by the innovative use of colours. These pictures represent the highest point reached by the 16th-century Paduan Medical School well demonstrating its aim for a sound naturalistic approach.

The Neuroscience Peer Review Consortium (NPRC) was conceived in the summer of 2007 at a meeting of editors and publishers of neuroscience journals. One of the working groups addressed whether it was possible to construct a system for permitting authors whose manuscript received supportive reviews at one journal but was not accepted to send a revised manuscript together with its first round of reviews to a new journal for the second round. This would speed up the review process and reduce the work for reviewers and editors. The working group not only designed a framework for transferring reviews among journals, but also implemented it as the NPRC. By the fall of 2007, more than a dozen major journals had signed onto the NPRC, sufficient to launch the experiment in January, 2008. We invite authors who have not yet used the NPRC to try this method for appropriate manuscripts.

In order to encourage dissemination of the details outlined in this Editorial, it will also be published in other journals in the Neuroscience Peer Review Consortium.

Background:

In India, the majority of individuals with neurological disorders are rural based and cannot even afford the cost of rehabilitation. At the same time, we do not have barrier free environment in India.

Aim:

This study attempts to find out the neurological disorders and barriers for neurological rehabilitation in rural areas in Uttar Pradesh, India.

Setting:

Rural areas in Uttar Pradesh, India.

Design:

It is a cross-sectional study.

Materials and Methods:

The study was done by means of an interview method using a questionnaire. The rural areas in Uttar Pradesh were visited personally and a data from 201 individuals was collected.

Statistical Analysis Used:

Data analysis was done by using descriptive statistics.

Results:

Out of 201 individuals, 76.6% (n=154) individuals were with polio, 12.9% (n=26) were with cerebral palsy, 7.9% (n=16) were with stroke and 2.4% (n=5) were with spinal cord injury. Reasons for not taking the treatment/discontinuation of treatment were financial problem (44%), lack of awareness (43%), family negligence (6%), transportation problem (3.5%) and other environmental barriers (1%).

Conclusion:

In our study, we found polio to be the most prevalent disorder followed by Cerebral Palsy, Stroke and Spinal Cord Injury. Financial problem was the major barrier for neurological rehabilitation followed by lack of awareness, family negligence and transportation problem.

Objective

Anti-Hu antibodies (Hu-Ab) and anti-CV2/CRMP5 antibodies (CV2/CRMP5-Ab) have been identified in association with paraneoplastic neurological disorders. However, it is not clear whether these antibodies are associated with specific neurological symptoms or are only markers of anti-cancer immune reaction.

Methods

To address this question, we compared 37 patients with CV2/CRMP5-Ab and 324 patients with Hu-Ab.

Results

Whereas the age and sex ratio were the same between the two groups, the distribution of neurological symptoms was not. Patients with CV2/CRMP5-Ab presented more frequently cerebellar ataxia, chorea, uveo/retinal symptoms and myasthenic syndrome (Lambert-Eaton myasthenic syndrome LEMS or myasthenia gravis). They also had better Rankin score. On the opposite, dysautonomia, brainstem encephalitis and peripheral neuropathy were more frequent in patients with Hu-Ab. Limbic encephalitis occurred similarly in both groups. Small cell lung cancer (SCLC) was the most frequently associated tumor in both groups of patients while malignant thymoma was observed only in patients with CV2/CRMP5-Ab. In particular, patients with CV2/CRMP5-Ab and thymoma developed more frequently myasthenic syndrome while patients with SCLC developed more frequently neuropathies. Chorea and myasthenic syndrome were only seen in patients with CV2/CRMP5-Ab. The median survival time was significantly longer in patients with CV2/CRMP5-Ab and this effect was not dependent on the type of tumor.

Interpretation

Our data demonstrate that in patients with paraneoplastic neurological syndromes, the neurological symptoms and survival vary with both the type of associated onco-neural antibody and the type of tumor.

Neurologic dysfunction complicates the course of 10–40% of left-side infective endocarditis (IE). In right-sided IE, instead, when systemic emboli occur, paradoxical embolism should be considered. The spectrum of neurologic events includes embolic cerebrovascular complication (CVC), intracranial haemorrhage, ruptured mycotic aneurysm, transient ischaemic attack (TIA), meningitis, encephalopathy and brain abscess. Cardiopulmonary bypass might exacerbate neurological deficits due to: heparinization and secondary cerebral haemorrhage; hypotension and cerebral oedema in areas of the disrupted blood brain barrier. A best evidence topic was written according to a structured protocol. The question addressed was, whether there is an optimal timing for surgery in IE with CVCs. One hundred papers were found using the reported search criteria, and out of these 20 papers, provided the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results were tabulated. We found that evidence is conflicting because of lack of controlled studies. The optimal timing for the valve replacement depends on the type of neurological complication and the urgency of the operation. The new 2009 Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (IE) recommend a multidisciplinary approach and to wait for 1–2 weeks of antibiotics treatment before performing cardiac surgery. However, early surgery is indicated in: heart failure (class 1 B), uncontrolled infection (class 1 B) and prevention of embolic events (class 1B/C). After a stroke, surgery should not be delayed as long as coma is absent and cerebral haemorrhage has been excluded by cranial CT (class IIa level B). After a TIA or a silent cerebral embolism, surgery is recommended without delay (class 1 level B). In intracranial haemorrhage (ICH), surgery must be postponed for at least 1 month (class 1 level C). Surgery for prosthetic valve endocarditis (PVE) follows the general principles outlined for native valve IE. Every patient should have a repeated head CT scan immediately before the operation to rule out a preoperative haemorrhagic transformation of a brain infarction. The presence of a haematoma warrants neurosurgical consultation and consideration of cerebral angiography to rule out a mycotic aneurysm.