Brain, Vol. 124, No. 10, 2119-2120,
October 2001
© 2001 Oxford University Press
Book reviews |
MAGNETIC RESONANCE SPECTROSCOPY IN MULTIPLE SCLEROSIS.
Edited by M. Filippi, D. L. Arnold and G. Comi. 2000. Milan: Springer. Price DM 129. Pp. 165. ISBN 88-470-0123-4.
London, UK
When asked to review this book I was surprised that an entire volume would be devoted to the topic indicated by the title. It is not: of the 150 or so pages, only 16—in chapters on magnetic resonance spectroscopy `as a measure of dynamic pathological change' in multiple sclerosis (five text pages) and correlations between magnetic resonance spectroscopy `and other magnetic resonance parameters' (six pages)—address magnetic resonance spectroscopy in multiple sclerosis. The rest of the book consists of chapters on axonal signals and myelination, axonal loss in multiple sclerosis, the theory of magnetic resonance spectroscopy, functional MRI and multiple sclerosis, magnetization transfer and diffusion-weighted imaging in white-matter diseases including multiple sclerosis and magnetic resonance spectroscopy in other brain diseases.
For the last few years, the Neuroimaging Research Unit of Milan's San Raffaele Scientific Institute has organized a meeting on various aspects of MRI in multiple sclerosis, and this hardback, well-produced volume published, remarkably, at the beginning of 2001, summarizes the meeting held in May 2000. The standard of the 12 contributions is variable. On one hand, Chapters 3 and 10, on the physics aspects of magnetic resonance spectroscopy, are written by a genuine expert and are exemplary, while Chapter 9, on new magnetic resonance spectroscopy strategies, also contains some interesting material. On the other, the reviews which close the book are distinctly sketchy; the literature on magnetic resonance spectroscopy is considerable (a very quick search for `MR spectroscopy and brain' on PubMed yields 6324 titles), but these two overviews, with ~15 pages of text between them, do little more than scratch the surface. The first of the two core chapters I identified is somewhat disappointing, but the second contains a lot of information, not all of which seems to have been unpacked; perhaps we are still at too early a stage for many things to become clear. The same may apply to the coverage of magnetization transfer and diffusion-weighted imaging, which is largely concerned with methodology. Of the 63 references in the bibliography of Chapter 11, whose topic is magnetic resonance spectroscopy in white-matter diseases other than multiple sclerosis, only about half concern magnetic resonance spectroscopy, and 12 are about multiple sclerosis. Not all the chapters are written in simple, lucid English and, as so often, the contributors from institutions in countries whose first language is not English are not necessarily the worst offenders.
As I have said, the book is well produced and has a reasonably good index. The editors have not avoided considerable repetition, which may not matter as it is unlikely that anyone is going to sit down and read it from beginning to end, short though it may be. Although an Italian pharmaceutical company aided in the `realisation and promotion' of the book, as a journal editor I would have thought the relatively small number of coloured illustrations an unnecessary extravagance.
While the programme of which this is a record may have made an interesting day's symposium, it is difficult to envisage who will want to buy it. I suppose most departments carrying out work in this field will want a copy, but it would seem rather lightweight for such people and rather too wide-ranging to attract the individual neurologist, neuroradiologist or even neuroimager. In the past, books such as this would have been a good starting point as a source of references, but with ready internet access to up-to-date databases (with which younger investigators seem actually to feel more at ease), that is clearly no longer the case.
Something long of concern to the more senior radiologists working with magnetic resonance techniques is that, without the initial expectations and subsequent disappointments of, for example, detailed analysis of CT behind them, many younger clinical neuroscientists may have been over-ambitious in drawing conclusions about tissue structure and neural function from images which essentially show the distribution of water in the brain. The recent history of radiology has essentially been one of hypotheses promoted on the basis of inadequate evidence, accepted universally, despite patent faults, and generating a great deal of industry before they are finally disproved. (Perhaps that makes it no different from many other spheres; and it may be that the academics involved would not wish it otherwise!) It remains to be seen, for example, how many of the claims for the high specificity of changes in diffusion characteristics in cerebral ischaemia will be confirmed in the longer term. However, it is evident that magnetic resonance spectroscopy provides information of a quite different kind, which, although its proponents may have a hard time demonstrating its clinical relevance, could usefully open a number of doors onto pathophysiology.
The value of these para-radiological techniques as primary research tools may indeed prove more important than any clinical role. In the recently published second edition of the BMJ publication How to Read a Paper, Trisha Greenhalgh cautions against mistaking surrogate endpoints for the outcome in which one is actually interested, defining a surrogate endpoint as `a variable which is relatively easily measured and which predicts a rare or distant outcome of . . . a therapeutic intervention . . . but which is not itself a direct measure of either harm or clinical benefit' (my emphasis). Referring to the disappointments over correlations between CD4 counts and survival in the CONCORDE trial, she goes on `If you think this is an isolated example of the world's best scientists all barking up the wrong tree in pursuit of a bogus endpoint, check out the literature on using . . . plaques on an MRI scan to chart the progression of multiple sclerosis'. I'm not sure that this particular criticism is well founded, and the only reference she cites in support of it is an anonymous 1996 article about beta interferon in the Drugs and Therapeutics Bulletin. Nevertheless, much funding of MRI research in multiple sclerosis (including the publication of this book) has derived specifically from those pharmaceutical enterprises that produce putative treatments for the condition. That does not mean, however, that information useful in other ways, including deepening our understanding of pathophysiology, will not emerge from the investigations they fund. It may not be unreasonable to hope that in, say, 5 years, a book with this title would be a large-scale, detailed study.
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