Principles of Cerebrovascular Disease
Harold P. Adams, Jr, MD
564 pages. New York, NY: McGraw-Hill; 2006. $159.00. ISBN 0071416536
In the decade since the US Food and Drug Administration approved intravenous thrombolysis, the use of evidence-based therapy in the treatment of stroke patients has become increasingly prevalent. This has occurred because of the growing weight of evidence-based medicine in general and the increased availability of clinical studies in stroke outcomes in particular. As a consequence, guidelines set by the American Heart Association influence modern stroke management more than at any time in the past. Emphasis continues to shift from an understanding of the underlying concepts of cerebrovascular pathology to the delivery of care to the patient.
Published studies that show that dedicated stroke units improve patient outcomes have led the American Heart Association to encourage the integration of different disciplines of health care into independent stroke centers. The comprehensive stroke center as a distinct service, physically separate within the hospital, has arisen as the model for modern stroke treatment. As multidisciplinary entities, the efficacy of these centers depends not on whether they are staffed by neurologists or internists, but on whether the attending physicians have a broad knowledge of all facets of stroke management. To oversee such a program requires training in rehabilitation and prevention as well as emergency management and intensive care. The recent Accreditation Council for Graduate Medical Education accreditation of stroke training programs and board certification in stroke is designed to facilitate the production of comprehensive stroke physicians.
Principles of Cerebrovascular Disease is a textbook aimed at the training of physicians in this new style of stroke management. Author Harold P. Adams, Jr, Professor of Neurology at the University of Iowa, has provided a text that stresses delivery of care. As a clinician with 30 years of experience in the field, Dr. Adams is an ideal author for such a text. He is a member of the Stroke Systems Task Force of the American Academy of Neurology as well as the executive committee of the American Heart Association and the International Stroke Society.
The organization of Principles of Cerebrovascular Disease is more like a textbook than other standard texts in neurology or stroke. Rather than present information in an encyclopedic style, the book provides clinically relevant material in logically structured chapters, each beginning with general comments and, where appropriate, ending with specific guidelines for treatment. This format lends itself to a straightforward basis for a curriculum. A year-long lecture series in stroke could easily be founded on this text.
The book was specifically organized, as the author states in his preface, to “run parallel with the course of evaluation and treatment of a hypothetical patient with cerebrovascular disease.” It has 25 chapters, beginning with “Classification of Stroke” and ending with “Rehabilitation and Return to Society.” The chapters in between cover epidemiology, clinical presentation, diagnostic studies, and management. There are 12 chapters on risk factors and diseases associated with stroke, 2 chapters on medical and surgical measures to prevent stroke, and 4 chapters on acute management. It includes a brief outline of how the advent of guidelines, evidence-based medicine, and public opinion has shaped the formation of stroke centers. An early chapter focuses on resources for stroke care. There is an extended discussion of the major conditions associated with stroke, such as atrial fibrillation, hypertension, and diabetes. Topics as recently appreciated as metabolic syndrome are also covered. The section on hypercholesterolemia is up to date as is the book’s discussion of transient ischemic attack, which reflects current thinking on the short-term risk of stroke.
The chapters on clinical manifestations are broad, though sometimes they lack in detail. Clinical syndromes are presented in outline form, sometimes in tables. This organization will appeal to the physician who wishes to quickly remind herself of the major features of lesions within the different vascular territories. The sections on medical conditions associated with stroke are also quite inclusive. Although some topics such as lymphatoid granulomatosis and Susac syndrome are not covered in depth, extensive references provided at the end of each chapter will facilitate readers looking for supplementary information.
The chapter on emergency management of stroke is detailed and comprehensive. The subsequent chapters on treatment are weighted toward care of patients admitted to a ward rather than an intensive care unit. Thus, there is discussion of the initial presentation of subarachnoid hemorrhage, but not on treatment of vasospasm.
Other than 4 pages of color plates, the illustrations are in black and white. This does not detract from the imaging examples given, but the clarity of the histological specimens shown would have benefited from colored graphics. There are copious tables and graphs that are helpful in illustration of the points made in the text. This is particularly true of chapters that discuss stroke prevention trials, in which, for example, tables adapted from trials that study anticoagulation or aspirin in patients with atrial fibrillation are presented. This direct comparison of data for differing treatments will be thought provoking for any physician who plans secondary prevention. One criticism is the frequent lack of axis labels, which hinders interpretation by the cursory reader.
The entire book has been rigorously edited. The only error noticed was a table in chapter 19 that compares antiplatelet medications that incorrectly associates clopidogrel with the Ticlopidine Aspirin Stroke Study (TASS) and European Stroke Prevention Study 2 (ESPS-2).
The text will be accessible to any clinician who works with stroke patients. Unlike other texts aimed toward stroke specialists, Principles of Cerebrovascular Disease defines the common terminology of basic concepts (eg, transient ischemic attack, watershed) and how usage of these terms has changed in recent years. The use of tables and large headings simplifies any search for those who look for specific answers to questions. For example, to answer the question, “What are the clinical features of an anterior choroidal artery territory stroke?” there is a clearly marked section called “Occlusion of the Anterior Choroidal Artery” in the chapter “Clinical Manifestations of Ischemic Stroke.”
This text’s intended audience is clinicians who encounter patients and thus will be particularly useful to neurovascular fellows and neurology residents interested in stroke. This book is not for readers looking for in-depth treatment of the biochemical and physiological basis of stroke. Nor is it a guide for intensive care therapy for stroke. However, as a clinical reference for any physician who encounters stroke patients and seeks guidance, it will prove indispensable. I would also like to note that the book is a single-author text, which is rare. The thoughts of a prominent neurologist with decades of experience in stroke treatment make it a valuable resource as well.
In summary, this book is a concise treatise on the presentation, evaluation, and management of stroke. It is well organized and clinically relevant, and thus suitable as the basis for a course curriculum. There are helpful tables, though some figures and graphics were disappointing. The book is reliable and accessible to a wide audience. Most importantly, it fills a need previously unmet to inform the new generation of physicians who care for patients with stroke.