Brain, Vol. 123, No. 1, 192-193,
January 2000
© 2000 Oxford University Press
Book reviews |
ACUTE STROKE TREATMENT.
.
University Hospital of Wales, Cardiff, UK
The use of thrombolysis as a treatment for acute ischaemic stroke is changing the nature of stroke medicine. A disease which used to be managed with relatively modest facilities and without a perceived need for urgent assessment may now require a senior clinical and radiological opinion within a few hours of the onset of relevant symptoms if a potentially hazardous treatment is to be administered. The consensus in the UK is that the routine use of thrombolysis is not justified and that further trials are required; to take part in such trials requires a change in the infrastructure of paramedical and hospital services to ensure that new treatments are given to the right patients in optimal conditions. In this regard the development of thrombolysis and other potentially useful pharmacological interventions for stroke has outstripped the development of appropriate clinical services.
Such developments justify the title of this book. Acute Stroke Treatment was published in 1997. It contains 17 chapters (from a total of 35 authors) covering major issues regarding the diagnosis and treatment of acute stroke, and also useful overviews of relevant radiological and pharmacological research. The text is enhanced by excellent illustrations and figures, and tables and algorithms summarize important information in a concise and helpful way.
The opening chapter may be the most important in relation to conducting rigorous trials of treatment as it addresses the issues of transportation of patients to hospital, competent triage and the role of dedicated stroke units. Whilst professional nihilism may have been a barrier to the development of appropriate stroke services in the past, there now seems to be a consensus that stroke units adopting a multidisciplinary approach are well placed to provide adequate rehabilitation for stroke victims. The variation in practice between different countries is described and we are reminded of the very small contribution that neurologists make to the diagnosis of stroke in the United Kingdom.
Although magnetic resonance imaging may prove to be the only reliable method for establishing whether ischaemic brain tissue is structurally intact (but functionally silent), a sound knowledge of the stroke syndromes and those diseases which may mimic them will be crucial to the successful triage of patients presenting with acute neurological deficits. In Chapter 2, Professor Bogousslavsky describes the different cortical and lacunar stroke syndromes, and in doing so highlights the limitations of more pragmatic classifications of stroke. Having the adequate clinical skills to detect the different types of aphasia, alexia, agraphia, dysarthria, visual field defect, neglect and inattention must improve the precision of the clinical diagnosis and allow the patient (and carers) to start making sense of the neurological deficit. What is less clear is whether an appreciation of the clinical subtleties of the different stroke syndromes informs the decision regarding the use of potentially dangerous treatments in the first few hours after presentation, a time at which MRI imaging alone seems destined to determine management.
Later chapters on MRI and ultrasound research methods provide introductions to the place of these techniques in the assessment of stroke patients. Although the views of the authors appear to be prejudiced by their research interests, the reader is guided through principles underlying the techniques as well as their clinical applications. A chapter devoted to heart–brain relations highlights the limitations of inferring the cause of an embolic stroke without adequate investigation of the donor heart and the recipient cerebral artery. The authors advocate a diagnosis of cardioembolic stroke on three levels of evidence—possible, probable and clinically definite—with the need for cerebral arteriography for a definite diagnosis. In the same chapter there is a discussion of the merits of transoesophageal and transthoracic echocardiography and an intriguing description of the role of the insular cortex in cardiac chronotropic organization; the latter includes details of the different ECG abnormalities which may occur as a result of strokes involving the insular cortex.
Chapters describing the intensive care management of stroke patients and special interventions to which they may be exposed reflect a style of practice which is not common in the United Kingdom. Potentially more relevant are chapters which include in tabulated form the results of thrombolysis trials and clear descriptions of how they have been administered. The discussion of subarachnoid haemorrhage is a valuable reminder of the many (non surgical) complications which may plague patients after the acute event, particularly the devastating effects of vasospasm. Chapters describing the developments in neuroprotective agents and the potential for gene therapy complement the more clinically based chapters and a chapter devoted to trial design provides a very readable account of the complexity of multi-centre trials in acute stroke.
I would recommend this book as an introduction to stroke medicine as practised in some centres outside the United Kingdom. The narrative style of the chapters will offend those who seek only systematic reviews, there is some repetition between chapters, and undoubtedly there are more exhaustive and up to date reviews of the available evidence in more recently published work. However, for those seeking to appreciate the spectrum of practice in this burgeoning area of medicine, it is a worthwhile read.
Notes
Edited by Julien Bogousslavsky. 1997. Pp. 304. London: Martin Dunitz. Price £65.00. ISBN 1-85317-413-0.
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