Evidence-based Management of Stroke

I'm certainly not going to spend $99 for this book that the reviewer also agrees is out of date. But anything that gets the medical staff at least closer to current thinking is worth while. Better than my doctor who obviously had not cracked a research paper in the 30 years since college. I can't look inside the book on Amazon to see if they have a chapter on where stroke research should be going.
http://www.ajnrblog.org/2011/10/21/evidence-based-management-of-stroke/

Over the last two decades, advances in the treatment of stroke have occurred at a seemingly breakneck pace. It was not so long ago that the National Institute of Neurologic Disorders and Stroke published its landmark rt-PA Stroke Study, which was the first large randomized controlled trial demonstrating the efficacy of intravenous rt-PA for treating patients with acute strokes. Now, intravenous rt-PA is standard treatment for patients presenting within 4.5 hours of ictus of an ischemic stroke. In addition, over the last decade, a number of newer tools, including intraarterial thrombolytic therapy, mechanical thrombectomy devices, and vascular stents, have become viable and relatively widely used options for the treatment and prevention of stroke.

Given this rapidly changing landscape, trying to keep abreast of current trends and treatment guidelines can be a daunting task, particularly for clinicians working in busy practices outside of the walls of academia. Compounding this problem are the increasing tendency toward subspecialization as well as the influence of various potentially competing interests, both from the commercial sector and from within the medical community itself—issues which tend to muddy the waters when it comes to deciding how best to care for our patients. Nevertheless, in this era of skyrocketing medical costs and increasing public scrutiny of the medical community, the use of evidence-based practices is now, as it should be, the mandate for all medical practitioners.

It is with this backdrop in mind that Evidence-based Management of Stroke was written. The authors of this book set out to create a self-contained resource which attempts to answer the most widely asked clinical questions related to the management of stroke, using the most compelling evidence currently available. Each chapter was written to be an up-to-date review of both medical and surgical therapies for stroke, as well as preventative strategies, and attempts to clarify those issues for which there is widespread consensus on best practice and those for which the evidence remains inconclusive.

The book is broken up into fifteen chapters with the first seven chapters devoted primarily to issues relating to ischemic strokes, including thrombolysis in acute stroke, management of stroke risk factors and stroke prevention, surgical and endovascular interventions for acute stroke, managing carotid artery disease, and surgery for malignant cerebral infarctions. The latter half of the book covers miscellaneous topics including management of hemorrhagic causes of stroke, cerebral venous thrombosis, and stroke in specific patient populations, such as children, pregnant women, and patients with cerebrovascular complications from cardiac procedures.

It should be noted that neuroradiologists are clearly not the primary intended audience for this textbook. In fact, very few pages are actually devoted to neuroimaging, and, surprisingly, advanced stroke imaging techniques, such as perfusion imaging, receive only cursory mention. The book is written primarily by and for neurologists and neurosurgeons, but there are several sections, including those on acute stroke intervention, management of carotid and intracranial stenoses, aneurysmal subarachnoid hemorrhage, and vascular malformations, which should appeal to those neuroradiologists involved in endovascular interventions.

The chapters are generally well written and well researched, some more rigorously so than others. Among the best features of the book are highlighted lists of “Key Points” included at the end of each chapter, which cover specific recommendations and the levels (I-IV) and grades (A, B, or C) of evidence supporting each recommendation. Unfortunately, the Key Points are not referenced, leaving it to the reader to search through the text to identify the specific source(s) for each recommendation, if he or she is so inclined.

Ironically, one of the primary shortcomings of this book derives the problem which it is attempting to address, namely the difficulties of staying abreast of a vast and constantly evolving body of literature. Without spanning several volumes, it would be impossible to cover every important published study related to stroke, leaving a number of questions unasked and unanswered. For example, topics such as primary stenting versus combined angioplasty and stenting, cerebral protection devices, and bioactive versus bare metal coils receive little or no attention in the book. Furthermore, as is the case with most medical textbooks, it is more than likely that the individual contributions were each completed well before the book’s release. As a result, its contents were probably at least a year old before it even hit bookshelves, which in the realm of medical research can seem an eternity. Notably omitted, for instance, were results from the International Carotid Stenting Study (ICSS) published in 2010, which found significantly higher rates of stroke and all causes of death associated with carotid stenting compared to endarterectomy and also called into question the efficacy of cerebral protection devices used during stenting.

Despite its relative shortcomings, Evidence-based Management of Stroke does a very good job of condensing a wealth of information into several concise and easily digested chapters and at highlighting the most important and most current (at least for now) best practice recommendations for stroke management. It is certainly not at as comprehensive a text as the most recent edition of Stroke : pathophysiology, diagnosis, and management, edited by Mohr et al. (also published this year), but at just a shade under 350 pages, it is a much more manageable read and makes it quite easy to locate specific practice recommendations. While this information may not directly affect most neuroradiologists in our day to day dealings in the reading room, it is certainly knowledge that makes us better attuned to the inner workings of our referrers, which in turn makes us better colleagues and practitioners.