Brain, Vol. 123, No. 5, 1065-1066,
May 2000
© 2000 Oxford University Press
Book reviews |
PREVENTION OF ISCHEMIC STROKE.
.
Royal Perth Hospital, The University of Western Australia, Perth, Australia
The editors of this book aim to provide `both the specialist and primary care physician with an up-to-date review of the emerging opportunities for management and prevention of stroke.' Together with 39 other contributors they have assembled 19 chapters (290 pages) that do not appear to be organized in any coherent structure.
The book begins appropriately with a good chapter describing the burden of stroke, which sets the scene for the need for effective stroke prevention. The following chapter is also very good and describes the major risk factors for stroke and their role in primary stroke prevention. However, from there on, the book seems to lose its direction. Whilst the third and fourth chapters, which are devoted to the role of heart disease and haematological disease in stroke, are also excellent in content and a very interesting and informative read, they are not accompanied by a preceding chapter discussing the major cause of ischaemic stroke, which is atherothrombosis. This is discussed eventually, but not until Chapter 14, which is entitled: `Carotid plaques and stenosis: molecular mechanisms affecting the development of symptomatic lesions'. Instead the fifth chapter describes the epidemiology and etiology of stroke in the young, and contains several pages (p. 90–5) on hypercoagulable disorders that repeat the more detailed contents of the preceding chapter (p. 58–71).
Chapter 6 is the first chapter to discuss a specific risk factor and is entitled `Cholesterol-lowering and strokes: a heart/brain comparison'. Instead of being a chapter about the most important risk factor for stroke, which is high blood pressure (and for which there is no chapter in this book), or cigarette smoking (which is also another important and modifiable risk factor for stroke, and for which there is no chapter in this book), this is a chapter devoted to cholesterol (which is not a definite risk factor for stroke) and concentrates on the relationship between cholesterol and coronary heart disease, without reference to the epidemiological associations between cholesterol and stroke, or a systematic review of the trials evaluating the effect of cholesterol-lowering on stroke prevention.
The seventh and eight chapters discuss the role of antiplatelet and anticoagulant drugs respectively in acute stroke treatment and in stroke prevention, and are followed by another good chapter on atrial fibrillation, which concentrates on the results of primary prevention trials but also describes some of the risk factor and diagnostic information presented earlier in Chapters 2 and 4.
Chapter 10 returns to antiplatelet therapy, concentrating on the risk of haemorrhage, but this should have accompanied or followed Chapter 7.
The eleventh chapter focuses on risk factors for, and stroke recurrence after, a particular subtype of ischaemic stroke (lacunar infarction), but there are no accompanying chapters dedicated to risk factors and stroke recurrence after other aetiogical subtypes of ischaemic stroke, except for a rare form (migrainous stroke) in Chapter 18.
Chapter 12 describes the aetiology, prognosis and therapy for silent infarcts, which is a doubtful priority in stroke prevention, and the thirteenth chapter, on neuroprotection, which reviews the pathophysiology of acute ischaemic stroke and negative trials of neuroprotection in the treatment of acute ischaemic stroke, is even further from the subject of this book.
Finally, in Chapter 14, carotid stenosis is addressed, which is relevant to the prevention of ischaemic stroke, and it describes nicely the pathogenesis of atherothrombosis but repeats the section on thrombosis so well described in Chapter 4.
Chapter 15 discusses the treatment of asymptomatic carotid stenosis, but there is no mention any where in this book on the effective treatment of symptomatic carotid stenosis by carotid endarterectomy, which is far more important and less controversial, and for which large trials have recently established its role in arguably the major advance in the prevention of ischaemic stroke in the last decade. Instead, Chapter 16 is devoted to an unproven treatment for symptomatic carotid stenosis: `Stenting and angioplasty for cerebrovascular disease'.
Chapter 17 describes the diagnosis and treatment of migrainous stroke, which is an uncommon aetiological subtype of stroke, and Chapter 18 discusses vascular dementia, which shares some risk factors (and thus prevention strategies) with ischaemic stroke, but is not really a major part of the subject of this book.
The book concludes with a chapter on `the role of the neurologist', almost discounting the role of other specialists and primary care physicians who were mentioned in the editors' preface to the book that `this volume provides both the specialist and primary care physician with an up-to-date review of the emerging opportunities for management and prevention of stroke'.
The strengths of this book are that the chapters have been written by experts in their fields and the content of each chapter is very good. The major weakness of this book, however, is that it is poorly planned and structured. Instead of presenting a book that discusses the size of the problem of ischaemic stroke, the major causal risk factors, the potential strategies of primary and secondary stroke prevention, the evidence for each prevention strategy based on systematic reviews of randomized trials (or otherwise the best available non-trial evidence), the potential impact of each strategy on the burden of stroke, and the role of government, public health physicians, primary care physicians and specialists, this book is an eclectic collection of chapters of varying relevance to the prevention of ischaemic stroke. There is very little about the two major modifiable risk factors for ischaemic stroke (treatment of hypertension and smoking) in either primary or secondary prevention (where they have major roles), and nothing about carotid endarterectomy for symptomatic carotid stenosis—the only surgical treatment proven to have a role. Instead, chapters that should have been devoted to these crucial areas have been filled with far less appropriate chapters on neuroprotection, silent infarcts, migrainous stroke and vascular dementia.
Notes
Edited by Cesare Fieschi and Marc Fisher. 1999. London: Martin Dunitz. Price £65. Pp. 304. ISBN 1-85317-738-5.
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