Book Review

The Clinical Practice of Critical Care Neurology

N Engl J Med 1998; 338:628February 26, 1998

Article

The Clinical Practice of Critical Care Neurology
By Eelco F.M. Wijdicks. 419 pp., illustrated. Philadelphia, Lippincott–Raven, 1997. $99. ISBN: 0-316-94759-8

For years, the stereotype of the neurologist was that of an academic recluse who concentrated on diagnosing disease and was then preoccupied with admiring it rather than effectively treating it. This image has changed dramatically in recent years, a change that has been formalized by the establishment of the subspecialty of critical care neurology. The neurologist is now seen as an aggressive interventionalist who manages life-threatening disorders of the nervous system. Critical care neurology is practiced in emergency rooms, in consultations in general medical and surgical intensive care units, in intermediary care units such as stroke units, and in specialized neurointensive care units where patients are frequently on life-support systems involving ventilators, intravascular lines, and monitoring and treatment devices.

It is for the neurologist working in, or directing, a specialized neurointensive care unit that Wijdicks has written this book. Wijdicks had a thorough grounding in both intensive care medicine and neurointensive care while training in the Netherlands and later with Ropper's group in Boston. He is now codirector of the neurologic–neurosurgical intensive care unit at Saint Mary's Hospital, Mayo Medical Center, Rochester, Minnesota. His intent has been to produce a book that is readable and emphasizes the clinical and practical aspects of management in the neurointensive care unit. In this hardcover, single-author edition of some 400 pages, he has succeeded admirably. The various chapters cover all aspects of the subject. The opening chapter contains an excellent table outlining specific criteria for admission and then provides clear descriptions of general nursing care, physiotherapy, and isolation and infection precautions and, most important, a sensitive discussion of how to communicate with the patient's family. An appendix provides a list of commonly used numerical values — gas-exchange formulas, dosages of hemodynamic drugs, and so forth. There is an effective, uncluttered chapter on airway management and mechanical ventilation, with helpful illustrations of the application of the resuscitative mask and the technique of endotracheal intubation, and there are even photographs of the instrument panels of several mechanical ventilators in current use. Wijdicks has wisely avoided long and complex discussions of controversial topics. Nonetheless, in the chapter on the management of anticoagulation and thrombolytic therapy, there is a well-organized discussion of the pertinent literature; helpful tables summarize the experience at several centers of thrombolytic therapy and detail the contraindications for intraarterial administration. The references to the literature are not exhaustive but are up to date, with citations as recent as 1996. There is a welcome absence of acronyms.

In the author's attempt to bridge the disciplines of neurology and general intensive care, members of each may feel that their discipline has been shortchanged. With the book's restricted scope, the reader will not find, for example, systematic coverage of neurologic emergencies or conditions encountered in general intensive care units, such as the nervous system complications of sepsis or encephalopathy after cardiac arrest, which often require neurologic consultation. A separate chapter on prognosis, with clear guidelines for deciding about immediate and long-term care of neurologic conditions, would have been helpful. Nonetheless, the book will clearly be of great value not only to critical care neurologists working in neurointensive care units but also to intensivists who may be entirely responsible for the care of neurologically ill and injured patients in general intensive care units. All such workers, nurses, surgeons, and other physicians should have ready access to this book.

Thus, let us hope this book, in addition to providing an important new addition to the emerging literature of critical care neurology, will spur the further development of this subspecialty and heighten the recognition by general medical and surgical intensivists of the importance, and complexities, of nervous system dysfunction in critically ill and injured patients.

Charles F. Bolton, M.D.
University of Western Ontario, London, ON N6A 4G5, Canada