Tinnitus is the perception of sound without an external source. More than 50 million people in the United States have reported experiencing tinnitus, resulting in an estimated prevalence of 10% to 15% in adults. The focus of this guideline is on tinnitus that is both bothersome and persistent (lasting 6 months or longer), which often negatively affects the patient's quality of life. The target audience for the guideline is any clinician, including allied health professionals, involved in managing patients with tinnitus. The target patient population is limited to adults (18 years and older) with tinnitus that is persistent and bothersome.

Psychogenic nonepileptic seizures (PNES), also termed functional seizures, are episodes that resemble epileptic seizures but occur without the abnormal ictal electrical activity characteristic of epilepsy. PNES is frequently associated with trauma exposure, post-traumatic stress disorder (PTSD), and abnormalities in autonomic regulation. Emerging evidence suggests that altered interactions among limbic, autonomic, and motor networks may contribute to symptom generation. Cervical sympathetic blockade (CSB), including stellate ganglion block techniques, has been investigated as an intervention for PTSD through modulation of sympathetic activity; however, CSB has not been established as a treatment for PNES. This case report describes an unexpected and subsequently reproducible reduction in PNES following CSB performed for severe, treatment-refractory PTSD, and considers a possible relationship between sympathetic modulation and trauma-associated functional seizures. A 27-year-old woman with severe PTSD and approximately 30 seizure-like or syncopal episodes per day was referred for CSB because of persistent PTSD symptoms despite prior conventional treatment. PNES was not the primary indication for the procedure. Ultrasound-guided CSB was performed at the C6 and C4 cervical sympathetic chain levels using 0.5% bupivacaine. Bilateral procedures were staged 24 hours apart as a safety precaution. Following CSB, PTSD symptoms improved, while the reduction in PNES occurred on a more delayed time course. Seizure-like and syncopal episodes progressively decreased and ultimately ceased approximately two months after treatment. The patient subsequently regained functional independence. Approximately one year later, following recurrence of symptoms and repeat CSB, a similar delayed pattern of seizure reduction and elimination was observed again. No major procedural complications occurred. The delayed but reproducible reduction and cessation of PNES following two separate courses of CSB suggests a possible association between cervical sympathetic modulation and functional seizure activity in a patient with severe trauma-related autonomic dysregulation. The mechanism is unknown, and the delayed response differs from the more rapid symptomatic improvement commonly reported following sympathetic blockade for PTSD. Potential downstream autonomic or neuroimmune effects may warrant investigation. This single-patient observation does not establish causality or support CSB as an established treatment for PNES, but it is hypothesis-generating and supports further prospective study of sympathetic modulation in carefully characterized patients with trauma-associated functional seizures.

Background The surgical management of cerebral arteriovenous malformations (AVMs) requires a meticulous balance between complete nidus eradication and the preservation of adjacent normal physiological structures. While the elimination of true malformed, nidal-draining veins is mandatory to avoid intraoperative rupture, sacrificing adjacent, non-malformed, medial cortical, and deep venous channels can cause localized venous congestion, tissue infarction, and poor functional outcomes. Objective This study analyzed the clinical, radiological, and functional outcomes of a deliberate microsurgical strategy focused on preserving critical medial venous pathways during AVM resection in an early patient series. Materials and methods A retrospective study was conducted on a consecutive series of 16 adult patients (aged >18 years) who underwent micro-neurosurgical resection of cerebral AVMs (Spetzler-Martin grades I-IV) at a single private academic institution between 2018 and 2025. Preoperative baseline features, clinical presentation (hemorrhage, seizures, focal deficits), and structural profiles were documented. Microsurgical dissection emphasized circumferential nidal isolation with strict preservation of non-nidal medial veins. Long-term functional assessment was evaluated using the Patient-Reported Outcomes Measurement Information System (PROMIS) score and the modified Rankin Scale (mRS) at a minimum of six months postoperatively. Results A total of 16 patients were included in the study, of whom 10 were male (62.5%) and six were female (37.5%). Primary clinical presentations included intracranial hemorrhage in 10 patients (62.5%), seizures in eight patients (50.0%), and focal deficits in nine patients (56.3%). Complete angiographic eradication of the AVM nidus was achieved in all 16 patients. No perioperative mortality was observed. Postoperative outcome assessment demonstrated improvements or stabilization in functional capacity. Favorable neurological recovery, defined as mRS 0-2, was documented in 14 patients (87.5%), supported by increases in PROMIS physical and mental health T-scores. No delayed venous infarction or hemorrhagic transformation occurred in any patient. Conclusions In this early clinical series, prioritizing the integrity of non-malformed medial veins during cerebral AVM surgery was a safe, effective, and anatomically sound strategy. Preserving healthy venous pathways surrounding the malformation limits the incidence of secondary venous hypertension, leading to exceptional functional preservation and minimal morbidity across a range of Spetzler-Martin grades.

Introduction Epilepsy is a common neurological disorder. Despite being on anti-epileptic drug therapy, a subset of patients continue to experience seizures. In such patients with drug-resistant epilepsy, surgery remains a viable treatment option. Patient-reported satisfaction provides an important perspective on post-epilepsy surgery outcomes. This study aimed to descriptively assess postoperative patient satisfaction using the validated Epilepsy Surgery Satisfaction Questionnaire-19 (ESSQ-19). Materials and methods This was a retrospective observational study conducted at a tertiary care centre in India. This study enrolled a total of 45 patients who underwent epilepsy surgery between 2017 and 2025. Details such as clinical and demographic information were obtained from the medical records. Patient satisfaction was assessed through telephone interviews using the ESSQ-19 questionnaire. Descriptive analyses were performed to evaluate the questionnaire responses. Result In the subset of patients who underwent epilepsy surgery between 2017 and 2025 (27 males, 60%, and 18 females, 40%), the mean age at the time of questionnaire administration was 30.73 ± 9.40 years. A major subset of patients had undergone temporal lobe surgery (n=35, 77.8%), and at the time of questionnaire administration were not on any anti-epileptic drugs (n=25, 55.5%). The Epilepsy Surgery Satisfaction Questionnaire-19 (ESSQ-19) demonstrated favourable patient satisfaction (Summary Score 84.1±21.7). Out of the four domains assessed, a high mean score was reported in the surgical complication domain (89.2±21.1) and the seizure control domain (85.0±27.6). Additionally, comparatively lower scores were observed in the psychosocial domain (79.9±24.1). Most patients expressed being extremely satisfied (N=15, 33.3%), or very satisfied (N=13, 28.9%) with their surgery. Conclusion In this single-centre retrospective study, patients reported favourable postoperative satisfaction following epilepsy surgery, with favourable mean scores observed in the surgical complication and seizure control domains. The Epilepsy Surgery Satisfaction Questionnaire-19 (ESSQ-19) may provide a useful patient-centred tool for assessing patient satisfaction following epilepsy surgery.

Meningiomas represent the most common benign primary intracranial tumors. However, multiple meningiomas (MMs) are relatively rare and can be challenging to manage, often requiring repeated surgical interventions and long-term follow-up. Here, we present the case of a 28-year-old woman who was operated on in 2019 for a right parasagittal MM, WHO grade 1. Her initial presentation was characterized by seizures and left-sided hemiplegia. Seven years later, she presented with recurrent seizures that were resistant to medical treatment. Neurological examination revealed residual left-sided spastic pyramidal syndrome. Brain MRI revealed multiple extra-axial dural-based lesions, including a large right frontal parasagittal mass. Subtotal resection of the largest lesion was performed. Histopathology confirmed the diagnosis of WHO grade 1 mixed meningothelial and fibroblastic MM. The postoperative course was uneventful. This case highlights the challenges associated with sporadic MMs, particularly long-term surveillance, tumor recurrence, and the potential need for repeated surgical interventions.

Cerebral cavernous malformations (CCMs) are cerebrovascular diseases characterized by vascular lesions of the central nervous system (CNS) that can result in epileptic seizures, headaches, focal neurologic deficits (FNDs), and hemorrhagic stroke. Germline and somatic loss-of-function (LOF) mutations in one of the three established CCM-associated genes, namely CCM1 (or krev interaction trapped protein 1, KRIT1), CCM2, and CCM3 (or programmed cell death 10, PDCD10), which have been validated as core drivers of CCM pathogenesis and progression. Over the past few decades, a substantially improved understanding of the hallmarks and molecular basis of CCMs has been achieved. Key pathological hallmarks include but are not limited to excessive angiogenesis, vascular leakage, endothelial-mesenchymal transition (EndMT), defective autophagy, inflammation and immune response, oxidative stress, influenced gut microbiome and altered brain vascular microenvironment. These hallmarks are orchestrated by dysregulated signaling cascades, notably MEKK3-KLF2/4, PI3K-mTOR, and RhoA-ROCK, which integrate genetic, inflammatory, and hemodynamic cues. Concurrently, sophisticated neuroimaging (MRI with SWI/QSM) and genetic testing now enable precise diagnosis and risk stratification. Although surgical resection remains the mainstay for accessible symptomatic lesions, a wave of mechanism‑based pharmacological candidates has shown promising efficacy in preclinical models, and several have advanced to early‑phase clinical trials. This review summarizes the current understanding of CCM epidemiology, molecular pathogenesis, diagnosis and therapy, highlighting how the evolving multi‑hit concept and the dissection of downstream signaling are paving the way towards personalized management of this complicated vascular disease.

Chemical profiling of illicit drugs has traditionally relied on laboratory-based techniques such as gas chromatography-mass spectrometry (GC-MS). Recent developments in portable drug testing devices have facilitated the decentralization of forensic capabilities, enabling field users to obtain rapid results. In this study, portable near-infrared (NIR) spectroscopy was evaluated for the chemical profiling of ecstasy tablets. A total of 668 tablets from 393 seizures made by Swiss law enforcement agencies were analyzed. Intra- and inter-seizure spectral variability was assessed using Euclidean distance, and a threshold value was defined to identify pairs of samples exhibiting sufficiently similar NIR profiles to be considered potentially linked. The results showed that NIR spectroscopy successfully distinguished intra- and inter-variability, with only 1.14% of inter-seizure comparisons falling below the selected threshold. Most NIR-based groupings were consistent with GC-MS chemical profiles, supporting the technique's ability to highlight spectral similarities and generate hypotheses of potential links between seizures for forensic intelligence purposes. As a further application, this study evaluates the use of NIR-based chemical profiling for early response in a drug checking context. Through a case study of eleven tablets that the drug checking service's NIR classification model failed to identify, we demonstrate the ability to link similar tablets of concern without prior knowledge of their composition. Comparing the spectra of newly analyzed specimens with previously flagged hazardous samples could enable the timely dissemination of alerts to consumers and public health authorities. The use of such rapid, non-destructive analytical methods could support more efficient decision making and contribute to harm-reduction efforts. Overall, this study supports portable NIR spectroscopy as a rapid screening approach for highlighting potential links at the pre-tableting formulation level in forensic intelligence and early-response applications.

Epilepsy is a complex neurological disorder with diverse underlying causes. Growing evidence suggests that gut dysbiosis may promote epileptogenesis by disrupting short-chain fatty acids, tryptophan-kynurenine metabolism, immune signaling, and neuronal excitability. In this review, we combine findings from human and animal studies to explain how gut dysbiosis may influence seizures through the gut-brain axis. We highlight emerging and less-discussed mechanisms, including vagus nerve signaling, microbial amyloids, bacterial extracellular vesicles (BEVs), the queuosine salvage pathway, and multi-kingdom microbiota interactions. We also summarize microbiota profiling studies and describe dysbiosis patterns linked to seizure. To support translation, we propose a peri-ictal multi-omics strategy for biomarker discovery. This includes standardized sampling and integration of metagenomics, metabolomics, and host transcriptomics. In addition, our bibliometric analysis further shows rapidly growing global interest in this topic. Recent studies increasingly focus on the gut-brain axis, ketogenic diet, and inflammation-driven mechanisms. Finally, we outline both established approaches and emerging next-generation microbiome-based therapeutic strategies, including SCFA-restoring synbiotics, engineered psychobiotics, bacteriophage therapy, and AI-guided personalization. These advances highlight the microbiota as modifiable target for adjunctive epilepsy management and provide a translational roadmap for future mechanistically informed research and clinical interventions.

Despite advances in EEG, neuroimaging, and other diagnostic technologies, a carefully obtained clinical history remains the cornerstone of diagnosis, classification, and treatment planning. However, structured guidance on history-taking that integrates state-of-the-art evidence and the updated 2025 International League Against Epilepsy (ILAE) seizure classification is limited. We performed a review of evidence published between January 2000 and April 2026, supplemented by landmark earlier studies, ILAE position papers, and National Institute for Health and Care Excellence (NICE) guidelines. Evidence was synthesized to develop a practical framework for obtaining and interpreting the clinical history in adolescents and adults presenting with a first seizure, recurrent seizures, or established epilepsy. We present a structured approach that follows the sequence of a clinical consultation, encompassing the presenting complaint, detailed event reconstruction, semiology, collateral witness accounts, smartphone video recordings, seizure triggers and temporal patterns, past medical history, medication review, family history, social factors, and safety issues. We discuss the diagnostic value of individual history elements, practical strategies for distinguishing epileptic seizures from functional/dissociative seizures and syncope, and the contribution of history-taking to seizure classification under the updated 2025 ILAE framework. We also summarize clinically relevant risk factors, comorbidities, and management implications that influence diagnostic accuracy and individualized care. Practical diagnostic questionnaires are provided to facilitate differential diagnosis and seizure classification, particularly for clinicians without specialist epilepsy expertise. A systematic clinical history, obtained from the individual and eyewitnesses and complemented by video recordings when available, remains the single most important diagnostic tool in epilepsy. Structured history-taking improves diagnostic accuracy, reduces misdiagnosis, supports accurate seizure classification, guides appropriate investigations, and provides the foundation for personalized management. This practical framework offers an evidence-based approach that can be readily incorporated into routine clinical practice and education across diverse healthcare settings.