Brain, Vol. 123, No. 9, 1970-1971,
September 2000
© 2000 Oxford University Press
Book reviews |
NEUROLOGIC CATASTROPHES IN THE EMERGENCY DEPARTMENT.
.
Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
Judging by the contents page of a typical issue of Brain, one could easily come away with the impression that the clinical practice of neurology gives much opportunity for reflection. How meticulously are patients studied! How detailed their baseline characteristics! How long the follow-up! A very civilized business. But many neurological management decisions that ultimately have the greatest impact on outcome are those taken immediately upon presentation of common emergencies. So where can one turn to find clear instructions on what to do in the `golden hour' when patients present with neurological catastrophes? Existing monographs that are sufficiently detailed to explain the rationale for management decisions generally do not deal with the immediate presentation of a neurological condition as a special case. And although some excellent books on neurocritical care have appeared, they generally do not address the triage of the patient in the casualty department.
This monograph by Wijdicks attempts to fill that gap. As implied by the rather alarmist title, the book restricts itself to the very early management of emergencies even before patients get to the ward. Wijdicks has already considered critical care neurology separately (E. F. M. Wijdicks, The clinical practice of critical care neurology. Philadelphia: Lippincott-Raven; 1997), and thereby avoids some temptation to digress from the subject in the present tome. So how helpful is this book? It is divided into two sections: `Evaluation and management of evolving catastrophes in the neuraxis' and `Catastrophic neurological disorders due to specific causes'. Each of these is further divided rather broadly into chapters such as `Brain edema' in the first section, and `Intracerebral hematomas' in the second. The breadth of coverage of common emergencies is reasonable, and about one-quarter of the book is devoted to neurosurgical conditions, including traumatic head and spine injury. Missing from the book is a third section on evaluation of individual presenting syndromes. For instance, the reader will look in vain for instructions on what to do with the patient presenting with acute 3rd nerve palsy. This is an unfortunate omission for a book that claims to deal with triage in the Emergency Department. (By way of compensation, though, the book does contain instructions for performing an emergency ventriculostomy in the Emergency Department theatre.)
The unity of style that comes from avoiding contributions from many authors is certainly pleasing, as are the illustrations. There are some useful drawings showing, for instance, the mechanisms of herniation syndromes, and there are plentiful good-quality reproductions of CT and MR (including FLAIR and diffusion-weighted) scans. Inevitably, some of the colour plates are somewhat idiosyncratic, with four out of 21 inexplicably devoted to inherited collagen disorders. The references are plentiful and up to date.
But what about the instructions for management? The problem is the same as that which limits the coverage of emergency neurology in Brain: we suffer from a lack of data. This is where advanced monographs become of questionable usefulness. Unless every statement can be justified on the basis of adequately randomized and controlled trials, there is always a risk of perpetuating false beliefs or advocating sub-optimal management. By and large, Wijdicks does a good job of avoiding an over-dogmatic approach, although potentially risky procedures are still advocated. Thus, for instance, decompressive hemicraniectomy in major ischaemic stroke `may be indicated for survival', and the reader is referred to a box summarizing what little is known of the risks and benefits of this procedure. However, in the absence of randomized trials, it is quasi-impossible to know how to translate this information into good clinical practice. And even where randomized trial data are available, it is not always clear how to proceed. Remaining on the subject of stroke, Wijdicks deals with the available data on thrombolysis by suggesting that intravenous `tPa can be started if symptoms have not abated within 3 hours after onset', following this with the contradictory statement `Intravenous thrombolysis with tPa within 3 and 6 hours is not successful'. This falls short of the clear instructions that the Emergency Department physician wants to read when faced with a patient with an ischaemic stroke in the middle of the night.
One can quibble about a few other statements. For instance, we are told that spinothalamic sensory loss occurs with `anterior horn' (instead of anterior spinal cord) lesions. And ethosuximide is advocated as first-line treatment for recurrent absence seizures, whereas most would agree that sodium valproate is a better choice.
Overall, this is a well-written and balanced book, which will be of considerable interest to Emergency Department physicians, neurologists, neurosurgeons and intensivists. It also contains a wealth of data that will be useful to the trainee, although its hard-back format does not allow it to be slipped into the pocket of the white coat. Perhaps that is fortunate, because it is not the emergency handbook that many would like to have in their possession.
Notes
By Eelco F. M. Wijdicks. 2000. Oxford: Butterworth-Heinemann. Price £42.50. Pp. 266. ISBN 0-7506-7055-X.
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