The medical profession in its training as well as in everyday practice takes a fundamentally therapeutic attitude to its patients [2]. The aim is perceived to be the diagnosis and assessment of injury or illness; and its restitution to the maximum extent possible. However, in the medico-legal context the role of the medical expert is quite different. He is seeing the "patient" in order to evaluate the effect that injury has caused and to provide a prognosis which will allow the court to come to a decision about the magnitude of compensation. By the time most claims come to settlement therapeutic aspects are generally long past. The practical therapeutic approach of medicine therefore may lead to conflicts which should be perceived by the doctor.

In the assessment of any patient complaining of neurological symptoms some general principles must be borne in mind. Neurological symptoms may be associated with objective abnormality demonstrable on examination. But the objective signs may be disproportionate, that is, they may be less than the symptoms would lead you to expect so that wilful or subconscious exaggeration is suspected. Or the signs may seem unrelated to the symptom, for example, a complaint of paralysis when the signs indicate sensory loss. Or finally the neurological symptoms may have no corresponding sign or abnormality on examination. A lack of objective support for the organic basis of a complaint is relatively common in neurology. It occurs, for example, in many pain syndromes, especially those where the pain is associated with damage to peripheral nerve, the spinal cord or central nervous system. Migraine, epilepsy, irritability and personality change are all common post-traumatic phenomena where there is usually no associated objective abnormality. Compensation gives a motive to perpetuate symptoms previously experienced or to claim symptoms that have either recovered or never been sufficiently severe to cause disability. 

The doctor must be able to recognise patterns of symptomatology associated with organic disorder of the CNS and to be able to distinguish these from symptoms that are exaggerated or feigned. Where there are abnormalities demonstrable on examination the case may appear straightforward and convincing but there should be an "appropriateness" between history, present symptoms and objective abnormality.

Despite the large numbers of individuals affected, members of the generalpublic often have little insight into the consequences of a neurological condition until they have direct personal experience [3]. Levels of awareness are low even about relatively common conditions such as epilepsy and head injury. Conditionsthat are less common, such as Friedreich’s ataxia, are largely unheard of and poorly understood by both the general public and health and social care professionals alike. Research commissioned to underpin the National Service Framework (NSF) for Long-term Conditions demonstrates the fear felt by patients who perceive that the professionals organising and delivering their care have little understanding of their particular needs. Individuals with conditions affecting their ability to communicate are particularly vulnerable and often disadvantaged by the failure of staff to recognise the extent to which this problem affects care. Similarly, busy staff may wrongly interpret cognitiveand behavioural problems and attribute any difficulties to personality defects,failure to adjust or obstinacy. These labels once acquired are often difficult to shake off, becoming accepted and perpetuated by other health professionals without further investigation or assessment. In this way the ignorance and attitudes of others can compound the difficulties people with neurological conditions experience, often causing them to feel stigmatised and misunderstood, which can, in turn, lead to further social, emotional and economic disadvantage.

Many neurosurgical disease states such as intracerebral hemorrhage, ischemic neurological injury, and carotid artery disease are affected by the blood pressure [4]. Finding an optimal level of blood pressure depends on many factors including severity of chronic hypertension, patient age, and impairment of intracranial compliance (e.g., patients with elevated ICP). Blood pressure control may be particularly critical in patients with (or at risk for) hemorrhage in areas that place neurologic tissue at risk for further injury (e.g., brain or spinal cord). 

For individual patients with neurologic injury, the optimal blood pressure range is often difficult to establish. Ideally, the blood pressure range would allow for optimal cerebral perfusion without placing the patient at risk for cerebral hemorrhage or edema. This can be difficult to demonstrate since CT and MRI – the usual scanning methods – are static exams and are impractical for providing information over time. More advanced studies such as PET scanning can give more insight but are not readily available. One study in stroke patients shows a U-shaped blood pressure curve with increased mortality for patients presenting with blood pressures greater than 220/111 or less than 100/61. Hypotension is rare in patients in the acute setting of stroke. When hypotension is observed in this population, potential etiologies include aortic dissection, dehydration, blood loss, sepsis, and decreased cardiac output. If hypotension is noted, immediate steps should be taken to correct the hypotension and to identify and treat the underlying cause.