Book Review

Stroke Therapy

N Engl J Med 1995; 333:1651December 14, 1995

Article

Stroke Therapy
Edited by Marc Fisher, with contributions by 33 others. 490 pp., illustrated. Boston, Butterworth–Heinemann, 1995. $90. ISBN: 0-7506-9575-7

An early chapter of this book begins with a scenario that is played out every day in emergency rooms throughout the country:

A patient has arrived who had a sudden onset of aphasia and right hemiparesis three hours before. A CT scan of the brain is performed; perhaps an MRI scan is done if that is fortuitously available on short notice. The scans are normal. Since normal scans are consistent with the diagnosis of acute ischemic infarction at three hours, this clinical diagnosis is made. The patient is admitted to the hospital, the lesion is allowed to ripen for several days, the scan is repeated. . . .

Therapy is not immediately available, and irreversible neuronal injury is assumed to have already occurred.

As the reader explores the 19 chapters in this book, it becomes clear that cases such as this may be handled very differently in the near future. A chapter on the pathophysiology of stroke describes the recently identified biochemical features of the ischemic cascade of neuronal injury and relates recent experimental findings indicating that patients with a stroke that began only three hours earlier may still have a large rim of viable tissue, the ischemic penumbra. The chapter on animal models of stroke therapy reveals that a myriad of new compounds can be administered to “rescue” neurons in the ischemic penumbra and restore function in drug-treated animals.

A chapter on cytoprotective therapy for ischemic stroke chronicles the preclinical and early clinical development of these new neuroprotective medications. A similar chapter on thrombolytic therapy succinctly summarizes the recent clinical experience with both intraarterial and intravenous thrombolytic agents to treat patients within the first few hours after the onset of stroke.

But which of these therapies should be offered to the patient described above, who had negative neuroimaging studies three hours after the onset of symptoms? The answer may be facilitated by the use of new techniques of magnetic resonance imaging that immediately allow the identification of areas of brain ischemia at presentation, as well as the status of brain perfusion. With these techniques, known as diffusion-weighted imaging and perfusion imaging, the ischemic penumbra may be imaged as an area of delayed or decreased perfusion that extends beyond the region of the diffusion abnormality. These techniques are described in a well-written chapter in terms understandable to the nonradiologist. Impressive examples of their use in patients with acute stroke are also provided.

Besides the chapters described above, which provide a road map into the future of stroke therapy, there are numerous other chapters that are useful for the clinician caring for patients with stroke. These include a nice description of risk factors for stroke, medical therapies (anticoagulant and antiplatelet agents) for stroke prevention, intensive care of cerebrovascular disorders, and a summary of the recent trials of carotid endarterectomy.

The book is not limited to the discussion of ischemic stroke; concise summaries of the diagnosis and treatment of subarachnoid hemorrhage and intracranial hemorrhage are also included. New neurointerventional approaches to the treatment and diagnosis of stroke, including endovascular treatments for intracranial aneurysms and vascular malformations, as well as the emerging field of cerebral angioplasty, are summarized and accompanied by numerous excellent figures.

One of the final chapters describes therapy for unusual causes of stroke, such as the antiphospholipid-antibody syndrome, patent foramen ovale, arterial dissection, and cerebral venous thrombosis. Although studies have not provided definitive therapeutic guidelines for most of these, the chapter provides an excellent overview of the data currently available.

The chapters in this book are brief, but generally well referenced and almost uniformly well written. This is not a comprehensive textbook about the diagnosis and management of stroke. It is, however, a book that conveys tremendous optimism, documenting the substantial advances in the diagnosis and therapy of stroke that have occurred over the past decade and promising even more remarkable progress in the years to come.

Gregory W. Albers, M.D.
Stanford University Medical Center, Stanford, CA 94305