Book Review

Stroke: Practical Management

N Engl J Med 2008; 359:1188-1189September 11, 2008

Article

Stroke: Practical Management
Third edition. By Charles Warlow, Jan van Gijn, and Martin Dennis, with eight others. 995 pp., illustrated. Malden, MA, Blackwell, 2008. $299.95. ISBN: 978-1-4051-2766-0

Stroke is the third leading cause of death worldwide. In industrialized countries it accounts for 10 to 12% of all deaths, but two thirds of deaths from stroke now occur in nonindustrialized countries. About half of stroke survivors must depend on others to carry out the activities of daily living, and more than one third are depressed. The burden of stroke also affects caregivers, who often have to limit their professional and leisure activities. Stroke is thus a huge health problem worldwide, and its burden is likely to increase further with the aging of the population.

Many books — either encyclopedic or highly specialized, multiauthored or by a single author — have been published on the topic of stroke. Like its predecessors, the third edition of Stroke is unique in having all the advantages of a multiauthored book but none of the disadvantages; it is comprehensive, covering all areas of stroke management, and yet it is as homogeneous and coherent as a book written by a single author. This coherence may be due in part to the fact that all the authors, including four new contributors, have worked with lead author Charles Warlow in Edinburgh.

The book is also unique in its deliberate orientation toward practice and its use of a problem-solving approach. After a short historical chapter, readers are confronted with the first question they ask themselves when they see a patient in the emergency room: Is it a stroke, and where is the lesion? The authors then review the main symptoms and signs of transient ischemic attacks and of stroke and address the many conditions that can mimic them. All readers of this book would agree that “Is it a stroke?” is indeed the first question that needs to be asked, but in the era of neuroimaging, the second question would probably be, “Is it an ischemia or a hemorrhage?” rather than “Which arterial territory is involved?” — a question that applies only to ischemic stroke. This order of questioning allows the authors to describe clinical syndromes before discussing neuroimaging, which corresponds with their maxim that “one should not presume that the results of investigations will necessarily be any more sensitive or specific than the clinical findings.” The next questions addressed in the book are clear-cut: What caused this ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage? How does one manage the care of a stroke patient and specifically treat each variety of stroke? How can stroke be prevented? How can services for stroke be organized and the overall impact of stroke on the patient be reduced?

Color-Enhanced Magnetic Resonance Image of the Brain of a 75-Year-Old Man, Showing a Cerebral Infarction.

All the chapters are excellent, but the nearly 100-page chapter on the general management of stroke is a masterpiece, dealing at the highest scientific level with daily practical problems that are often neglected in other books. It has long been established that the benefit of stroke units, in terms of decreased mortality and dependence, is due to the kind of day-to-day care that is described in this chapter. Some readers — particularly American readers — will probably be astonished to find only about 10 pages on thrombolysis and other reperfusion methods, as well as minimal discussion of improving awareness of stroke, reducing delays in travel time to hospitals, and telemedicine. These are indeed important steps in improving care for patients with stroke, but the perspective of the authors is clearly the bedside treatment of patients. Unlike patients with myocardial infarction, who are treated mainly by cardiologists, patients with stroke receive care from a variety of physicians, including general internal physicians, stroke physicians, neurologists, neurosurgeons, and geriatricians. This book is clearly for physicians in all these areas of practice, as well as for nurses, therapists, and social workers. As the authors emphasize, it is not a book to be read from cover to cover but rather a friendly companion to keep at hand and to open whenever a question about stroke management arises, be it for an individual patient or for patients in general: Why is this patient's condition worsening? What should I do about her blood pressure? How should I treat his hiccup? Can my patient drive or travel by air? Should the general population be checked regularly for the presence of carotid stenosis? How many beds should there be in a stroke unit? What kind of public health measures should we recommend?

In the introduction, the authors wonder whether there will be a fourth edition, as two of its senior authors, Warlow and van Gijn, are retiring. I urge their younger coauthors to continue, because the field of stroke is growing rapidly and, more important, because medicine needs people who are both scientists and practicing physicians and who have — like Warlow and van Gijn — an independent way of thinking. But whether or not there is a fourth edition of this book, this current edition is a must for all those who deal with patients with stroke.

Marie-Germaine Bousser, M.D.
Lariboisière Hospital, 75010 Paris, France