Book Review

Acute Stroke Treatment

N Engl J Med 1998; 339:484-485August 13, 1998

Article

Acute Stroke Treatment
Edited by Julien Bogousslavsky. 304 pp., illustrated. London, Martin Dunitz, 1997. (Distributed by Mosby, St. Louis.) $120. ISBN: 1-85317-413-0

Not long ago, I overheard a distinguished cardiologist lamenting in private that brain infarcts would be a far less serious problem if neurologists could only get out of bed at a moment's notice to insert an arterial catheter into a patient. Alas, the solution is not as simple as that. The window of time for salvaging brain tissue is much narrower than that for heart muscle, and the danger of intracerebral hemorrhage lurks around the corner, even with the intravenous administration of thrombolytic agents. However, stroke treatment was released from its Cinderella status among treatments for arterial disorders after two trials (one in the United States and the other in Europe) demonstrated in 1995 that intravenous tissue plasminogen activator given within a few hours after ischemic stroke reduces the risk of death or disability from 73 percent to 60 percent.

Acute Stroke Treatment, with contributors from four continents, rides the wave of enthusiasm that followed those two encouraging studies. Thrombolysis after ischemic stroke is the theme around which most of the chapters revolve. The longest and perhaps most helpful chapter, by Brott, is devoted to the reopening of occluded brain arteries. However, Brott's review of the relevant clinical trials, including trials of streptokinase with or without aspirin, is conventional and narrative. Readers would have been better informed by a systematic, integrated analysis of the evidence, such as is now available in the data base of the Cochrane Collaboration, which is updated quarterly. What is also missing is the recognition that it is premature to introduce thrombolysis as a blanket treatment for all ischemic strokes. Many centers still lack the diagnostic skill and facilities to identify patients who stand to lose from thrombolysis (by intracerebral bleeding) rather than gain from it. In addition, current knowledge of the benefits and risks of this therapy in individual patients, according to cause and type of stroke, is far from complete.

This book's contributors address brain ischemia from many other angles as well. There is a sound chapter about clinical syndromes, three chapters dealing with biochemical changes (predictably overlapping in content), and three chapters about diagnostic techniques (divided rather awkwardly). The contribution concerning cardiac tests strays into an incomplete review of anticoagulant treatment and even into stroke-induced tachycardia in mice and humans. Some investigations are mentioned only in the chapter on intensive care treatment of ischemic stroke. That approach explores the borderlands of evidence-based medicine; unwary readers will be surprised to learn that in some centers, treatment may be so intensive that acoustic evoked potentials are necessary to assess brain-stem function. Two good but forlorn contributions review the management of intracerebral and subarachnoid hemorrhages. The chapter by Brass, on methods of clinical trials, offers good instruction, although it reviews the rather sterile topic of bias introduced by the exclusion of patients from the randomization process. In addition, pragmatists may find his discussion too lenient on surrogate end points and impairment scales.

The production time of this book was admirably short, allowing citation of references from late 1996 and even 1997. Only the International Stroke Trial could not be incorporated into Koudstaal's closing chapter, which focuses on prevention of early recurrences of stroke. Inevitably, speed is achieved at the expense of cohesion. Perhaps editorial whips should be cracking more loudly, now that books about stroke are turned out faster than ordinary mortals can read them. Fortunately, Acute Stroke Treatment includes a thorough index to guide the novice who prefers a monograph to the original reports.

J. van Gijn, M.D.
Utrecht University, 3584 GA Utrecht, the Netherlands