Book Review

Stroke: A practical guide to management

N Engl J Med 1997; 336:1395-1396May 8, 1997

Article

Stroke: A practical guide to management
By C.P. Warlow, with six others. 694 pp., illustrated. Cambridge, Mass., Blackwell Science, 1996. $199.95. ISBN: 0-86542-874-3

Do we need another book on stroke? Two decades ago there were only a few small books of mainly anecdotal value, but in recent years a variety of works have appeared ranging from weighty encyclopedias to slim “do-it-yourself” books. The arena is quite crowded. However, as the introduction points out, this book is not just a collection of old-fashioned chapters on “ologies,” it is problem-based, and for stroke at least, this represents a unique approach. The seven authors are young, enthusiastic, and well informed and have somehow managed to avoid the familiar uneven style of a multiauthored textbook.

Some of the 18 chapters answer clinical questions, such as “Where is the lesion?” and “What are this person's problems?” Some reflect the practice bias of the authors, such as the one on the organization of stroke services, which includes such controversial statements as “the main reason for referral to hospital in the United Kingdom is for nursing care rather than diagnosis and treatment,” a sentiment unlikely to find much favor outside the United Kingdom.

I liked the layout, the generous but clear illustrations, the refreshing digressions into general neurology, the little observations highlighted in gray, and the general tempo of the prose. I did not like the way references were cited by author and year, an approach that interrupts the flow of the book; the blurred quality of some of the computed tomographic scans; and the lack of color in the photographs of the fundus. I thought that some of the clinical vignettes were frankly wrong, such as the one describing a 55-year-old man with no previous history of migraine who had a transient attack and was given a diagnosis of “migraine without headache” with no further investigations and was “quite well four years later.”

The main problem of any medical textbook today is both the rapidly expanding data base (often more than the human mind can digest) and the rapid obsolescence of recent advances. This book, published just last year, anticipates the results of the International Stroke Trial (which are now available), which compared aspirin with low-dose and high-dose heparin, and refers to a systematic review of thrombolysis published in 1992 that is already outdated. The list of neuroprotective agents (current as of 1995) contains several compounds (such as eliprodil) that have already been discarded. In a year or two, many of the treatment paradigms will be obsolete. The principles of common-sense management, well described in this book, are essentially ageless, but published details of treatments and forms of technology often lag years behind their actual discovery. Galen's works lasted a millennium; today, the equivalent may be obsolete within a year or two. The days of the format of textbooks as we know it are numbered, and the statement in the introduction that this is a book “to be used on stroke units and in clinics” and “to be kept handy and referred to when a problem crops up” cannot be justified on this account alone.

Any textbook published now needs some form of complementary or equivalent work in an electronic format. The authors are intimately acquainted with the huge data bank of the Cochrane Collaboration, which is now available on the Internet and is constantly updated. Other data bases are being assembled. Making these data bases an integral part of the next edition would produce a formidable, scholarly, and original contribution to stroke literature.

John W. Norris, M.D.
University of Toronto, Toronto, ON M4N 3M5, Canada