Book Review

Stroke: A Clinical Approach

N Engl J Med 1993; 329:1050-1051September 30, 1993

Article

Stroke: A Clinical Approach
Second edition. By Louis R. Caplan. 562 pp., illustrated. Boston, Butterworth-Heinemann, 1993. $90. ISBN: 0-7506-9181-6

Most treatises on stroke begin with a familiar refrain: stroke is the third leading cause of death in the United States, affects about 500,000 patients each year, and costs over $10 billion annually. This is the stuff that multiple-choice examinations are made of, but it is so much less compelling than the image Caplan conjures up in his introductory chapter: Roosevelt, Churchill, and Stalin at Yalta, each suffering from cerebrovascular disease, with Roosevelt to succumb in two months. What follows -- in 19 chapters organized into sections titled “General Principles,” “Stroke Syndromes,” and “Prevention, Complications, and Rehabilitation” -- is a highly personal but undogmatic book that emphasizes data derived from stroke registries, illustrative case histories, practical advice on management, and mindfulness of the patient's perspective. It is difficult not to like a book whose author owns up to “armchair theorizing” and characterizes the odious acronym CVA as “a pseudoscientific set of meaningless initials.”

The unique strength of this book is the section on general principles. The opening chapter provides a historical account of stroke from the time of Hippocrates through the development of modern diagnostic techniques. Chapter 3 offers an insightful analysis of the diagnostic process, describing how the author thinks as he proceeds from the patient's presentation to a presumptive etiologic and anatomical diagnosis. Chapter 4 discusses laboratory investigations in relation to the questions they can help to answer. It lists the indications for echocardiography, explains how angiographic strategy is tailored to the individual patient, and compares the merits of computed tomography and magnetic resonance imaging. Chapter 5, on treatment, depreciates the value of classifying cerebral ischemia as transient ischemic attack, reversible ischemic neurologic deficit, stroke-in-evolution, or completed stroke. The author offers guidelines for the use of anticoagulants and platelet antiaggregants and reviews the status of experimental drugs. His therapeutic recommendations are reasoned and conservative: he opposes carotid endarterectomy for asymptomatic stenosis in patients who undergo heart surgery and for ulcerated plaques on nonstenotic vessels, and he advocates aneurysm surgery only for patients in Hunt and Hess grades I and II.

The section on stroke syndromes is less detailed and, paradoxically, less accessible than that in the encyclopedic second edition of Stroke: Pathophysiology, Diagnosis, and Management edited by H.J.M. Barnett, J.P. Mohr, B.M. Stein, and E.M. Yatsu (New York: Churchill Livingstone, 1992). It should be possible to consult this section to determine the localizing value of specific findings, but it was difficult to find reference to macular sparing, peduncular hallucinosis, wrong-way eyes, ocular bobbing, thalamic pain syndrome, or hemiballismus, which are not listed in the index. These chapters, and the chapter on stroke prevention and risk factors, could benefit from more subheadings and tables, which are used to greater effect elsewhere.

In a book written as carefully as this one, it is disappointing that many of the line drawings are of such poor quality. It is also possible to quibble with the emphasis on using stroke-registry data to deduce the mechanisms of stroke. Ischemia and hemorrhage can be distinguished definitively (by computed tomography), but thrombosis and embolism typically cannot. It is therefore impossible to confirm the validity of proposed correlations between particular clinical features and mechanisms of ischemic stroke.

According to the preface, this book is directed at medical students, house officers, and nonspecialist physicians who care for patients with stroke. All these groups will find it useful. Its greatest value, however, will be to neurologists in training, who can learn from the section on general principles how to approach the problem of stroke in a logical fashion. Alfred North Whitehead wrote that “civilization advances by extending the number of important operations which we can perform without thinking about them.” Caplan clearly does not agree.

David A. Greenberg, M.D., Ph.D.
University of California, San Francisco, CA 94110