Neurology is the specialty that went from only diagnosing diseases to treating them.
For most of its history, a neurologist could find a lesion, name the disease and explain what would happen next, and could do very little to change it. Multiple sclerosis was the clearest case. In 1993 a trial in 372 patients with relapsing-remitting disease tested injections of interferon beta-1b every other day against placebo. After two years the yearly relapse rate was 1.27 on placebo and 0.84 on the higher dose, and twice as many patients on that dose had gone the whole two years without a relapse, 36 against 18. The scans agreed. It became the first drug approved to treat the disease. Whether it slowed disability, the trial could not tell.
Stroke was the same story. Clot-dissolving drugs had been approached cautiously, because early trials had seen high rates of bleeding into the brain. In 1995 the New England Journal of Medicine published a trial of 624 patients given t-PA or placebo within three hours of the stroke starting. The drug did cause harm: symptomatic brain haemorrhage in 6.4% of treated patients, against 0.6% on placebo. And yet treated patients were at least 30% more likely to be left with minimal or no disability three months later. A stroke had become something to treat, and the clock had become part of the treatment.
Twenty years later the field went further. A Dutch trial randomised 500 patients at 16 centres with one of the main arteries of the brain blocked, most of whom had already been given the clot-dissolving drug, to have the clot pulled out through a catheter within six hours or to usual care alone. At 90 days, 32.6% of those treated were living independently, against 19.1%, with no rise in deaths or bleeding. A treatment that had only ever been shown to open the artery had now been shown to help the patient.
These are three of the thousands of studies that shaped modern neurology. They turned multiple sclerosis into a disease with treatments and stroke into an emergency measured in hours, and each time the answer was in a paper years before it was in a textbook.
It is still happening. Recently, in May 2025, the New England Journal of Medicine published a trial in the form of multiple sclerosis that no longer relapses but keeps getting worse. No drug was approved for it. The trial gave 1,131 people a daily pill, tolebrutinib, or placebo, and followed them for a median of 133 weeks. Disability progressed in 22.6% on the pill, against 30.7% on placebo. The cost was real: serious adverse events in 15.0% against 10.4%, and raised liver enzymes in 4.0% against 1.6%. A form of the disease with no treatment now had a first one. Practice follows the literature as it goes. It is a good culture. It has exactly one cost.
The literature grows faster than anyone can read it.
Across the medical topics a neurologist needs to stay up to date on, from Alzheimer’s disease and stroke prevention to epilepsy and peripheral neuropathy, around 470 full-text papers now arrive every week. That is about 2,000 a month, and more than 20,000 a year. Alzheimer’s disease treatment alone is 73 of each week’s 470. Peripheral neuropathy is 60. These are not press releases or opinion pieces. They are the same kind of paper as the two stroke trials above, and somewhere in each week’s 470 are the handful that will change a prescription.
It is tempting to believe that experience closes the gap, that twenty years of clinic teach what the papers teach. The evidence points the other way. A systematic review of 62 studies found that in most of them, more years in practice went with lower adherence to current standards of care. Experience is not what keeps a neurologist current. Reading is. And reading is the one thing the week does not have room for.
So we built the tool you need to stay up to date.
We summarise the latest research for you and send it directly to your email inbox, every week, or whenever you choose.
Tolebrutinib slowed disability in progressive MS that had stopped relapsing
TakeawayIn 1,131 people with nonrelapsing secondary progressive multiple sclerosis, daily tolebrutinib cut confirmed disability progression to 22.6%, against 30.7% on placebo. No treatment is approved for this form of the disease.
Current disease-modifying therapies for multiple sclerosis do little for the disability that builds up without relapses, which is thought to come partly from smouldering inflammation inside the brain. There are no approved treatments for nonrelapsing secondary progressive disease.
- •Confirmed disability progression sustained for at least 6 months: 22.6% vs 30.7% (hazard ratio 0.69, 95% CI 0.55 to 0.88, P = 0.003).