Book Review

Surgery for Stroke

N Engl J Med 1994; 330:1465May 19, 1994

Article

Surgery for Stroke
Edited by R.M. Greenhalgh and L.H. Hollier. 420 pp., illustrated. Philadelphia, W.B. Saunders, 1993. $135. ISBN: 0-7020-1759-0

With the recent publication of several well-designed, prospective, randomized, multicenter studies demonstrating the benefit of carotid endarterectomy for symptomatic high-grade carotid-artery disease, this book is both timely and thought-provoking. The title is slightly misleading, since the book discusses only carotid-artery surgery and fails to mention vertebral-artery surgery, extracranial-intracranial bypass surgery, or other intracranial revascularization procedures for cerebral ischemia. However, the editors have done an excellent job of exploring the important issues concerning the selection and preoperative evaluation of patients and the timing, techniques, and efficacy of carotid endarterectomy.

The book is divided into nine sections dealing with the history of carotid surgery, pathophysiologic aspects of carotid-artery disease, preoperative investigation of carotid disease, indications for carotid surgery, timing of carotid surgery, techniques of carotid surgery, intraoperative monitoring, natural-history and observational studies, and clinical trials. Most of the authors are vascular surgeons, but some are neurologists, radiologists, and other scientists. Most of the authors are from the United Kingdom or continental Europe, with a few articles from North American centers. In general, the individual chapters are well written and concise, although there is some variability both in the writing style and in the authors' adherence to rigorous criteria when formulating conclusions. Some chapters are short reviews of their topics, whereas others contain primary data from a single center.

Although Surgery for Stroke is heavily weighted toward the surgical aspects of treating carotid-artery disease, I found the chapters on the pathophysiologic aspects and clinical trials especially comprehensive, informative, and well balanced. Unequivocal scientific data regarding mechanisms of carotid-plaque formation, the pathophysiology of cerebral ischemia, and the efficacy of carotid endarterectomy for selected groups are nicely integrated with unresolved questions on these and other topics.

The information provided is generally complete and unbiased, and the chapters include up-to-date references. I found the historical review of carotid-artery surgery quite interesting and entertaining. The chapters on preoperative investigations, indications for surgery, techniques, and intraoperative monitoring were detailed, lucid, and focused on important controversies such as the need for contrast angiography before surgery, combining carotid endarterectomy and coronary-artery bypass grafting at one stage, and the benefit and limitations of intraoperative monitoring techniques or shunting.

In summary, I enjoyed reading this book for its wealth of contemporary information, thoughtful approach, and clarity of writing. I highly recommend it to surgeons and physicians who have an interest in the treatment of carotid-artery disease.

Gary Steinberg, M.D., Ph.D.
Stanford University Medical Center, Stanford, CA 94305