Book Review

The Comatose Patient

N Engl J Med 2008; 358:2653-2654June 12, 2008

Article

The Comatose Patient
By Eelco F.M. Wijdicks. 584 pp., illustrated, with DVD. New York, Oxford University Press, 2008. $125. ISBN: 978-0-19-532626-0

The venerable neurologist Charles Miller Fisher once said, “Coma is a continuum rather than a single state.” Eelco Wijdicks's book justifies and expands on that idea. Although the term “coma” is derived from the Greek word koma, meaning a deep (presumably unarousable) sleep, a tremendous range of anatomical sites, causes, and mechanisms may be at work in cases of coma. The severity and reversibility of states of impaired alertness also vary widely.

The book's chapters are organized into two parts. Part I deals with the anatomy, physiology, and neurochemistry of consciousness and coma. The first chapter is a thorough review of how the historical study of coma has led to current concepts. It includes reproductions of landmark papers from such giants as Harvey Cushing, John Cheyne, and Jean-Martin Charcot, and from famous experiments in animals that still serve as the foundation for clinical localization in comatose patients. In discussing anatomical correlates, Wijdicks emphasizes the important and underappreciated concept that displacement and compression of thalamic structures may play a key initial role in impaired consciousness. The clinical approach of localizing the site or sites of derangement that produce impaired consciousness is supplemented by the grading of coma using Wijdicks's Full Outline of Unresponsiveness (FOUR) Score technique, which does not seem to have the limitations of some of the more commonly used coma scales.

The role of ancillary tests, including neuroimaging, is discussed, along with a review of the neuropathology of various causes of coma. The clinician's role goes beyond diagnosis; it includes the vital step of formulating a prognosis before treatment decisions are made. Determination of brain death, ethical principles, a practical exploration of interactions between the family and the physician, and a thought-provoking discussion of coma in the media are also included in the first part of the book.

Part II of the book comprises 75 vignettes, each about five pages in length, of isolated clinical problems involving coma states — including metabolic and endocrine disturbances, trauma, overdoses, inflammatory disorders, neoplasms, status epilepticus, pregnancy, and psychiatric disturbances. A DVD that covers the clinical assessment of the comatose patient, determination of brain death, selected demonstration of clinical signs, and an illustration of pseudoseizures, supplements the book.

The book has an attractive uniformity of style and organization; there is little redundancy. Concepts are well presented, and the illustrations, many of which are in color, are numerous and clear. Wijdicks's many contributions to the field of critical care neurology, including the areas of determination of brain death, clinical examination, prognostic determination, and hepatic encephalopathy, are emphasized, but the book also covers a wide range of conditions that cause coma. The approach is clinical and practical, and even though some aspects are dealt with only briefly as illustrative cases, the terse discussion is supplemented by up-to-date references.

Deficiencies are inevitable in a book that covers such a wide range of disorders. Trauma and aneurysmal subarachnoid hemorrhage, although among the most common causes of coma, are each dealt with in only a few pages, with few recommendations for the management and monitoring of patients with these conditions. Seizures in the intensive care unit are not sufficiently emphasized. However, the technique of using illustrative cases with brief, practical discussions and excellent references is a clever way to introduce these topics to the reader. This book is therefore well suited for use as either an introduction to the history, basic science, and clinical approach to coma, or as a quick reference for clinicians encountering a difficult case, since the critical points surrounding each vignette are efficiently covered. A more detailed review of commonly encountered problems in the neurologic critical care unit would provide the reader with a more thorough understanding of this emerging field.

G. Bryan Young, M.D.
University of Western Ontario, London, ON N6A 5A5, Canada
bryan.young@lhsc.on.ca

Gary Hunter, M.D.
University of Saskatchewan, Saskatoon, SK S7V 1J1, Canada