Neurologic and Neurosurgical Emergencies.

Abstract

Bingham and Women’s HospitalInstructorAssociate ProfessorDepartment of AnesthesiologyHarvard Medical SchoolBrigham and Women’s HospitalBoston, Massachusettsgcrosby@zeus.bwh.harvard.eduNeurologic and Neurosurgical Emergencies.Edited by Julio Cruz. Philadelphia, WB Saunders, 1998. Pages: 569. Cost: $145.00. This multiauthored, first-edition text is published under the auspices of the International Society for Neuroemergencies. According to the editor, a neurosurgeon, the goal was to integrate into a single volume the current basic and clinical sciences that guide the treatment of patients with neurologic or neurosurgical emergencies. The book is generally successful in this regard. The publication’s single greatest strength is that it is a multidisciplinary treatment of the topic and, as such, it reflects the different but complementary perspectives of various specialists. The book’s 20 chapters are written by 54 authors from specialties such as neurology, neurosurgery, radiology, anesthesiology, internal medicine, critical care, emergency medicine, pediatrics, rehabilitation medicine, and nursing. The chapters are generally well illustrated with useful tables, charts, and radiographs, and successfully place clinical management in the context of the available basic science. All of the chapters have a practical orientation, and whereas most are directed toward neurologists or neurosurgeons, anyone with an interest in neurologic emergencies will find an abundance of useful information.The first few chapters regarding the evaluation of the patient with neurologic injuries and the cardiac and respiratory complications that are associated with acute neurologic diseases are thorough and well referenced. These are followed by 15 chapters that are devoted to specific acute neurologic disorders, nursing care, predictors of long term prognosis, and rehabilitation. The chapters about the pediatric patient, neuroemergencies during pregnancy, subarachnoid and intracranial hemorrhage, intracranial and pituitary tumors, neuromuscular diseases, brain trauma, and acute spinal cord disorders are well written and will be of particular interest to anesthesiologists. As with any multiauthored text, there is some inevitable variation in writing style between chapters; however, the editor does a good job of minimizing redundancy and maintaining consistency. The majority of the references are current, and many references of historical importance are included. Chapter 14, which does not contain a single reference published within the last 10 years, is an exception to this generalization.A problem encountered when attempting to systematize the clinical management of patients who are severely ill is that the science, basic or clinical, that supports certain practices is often incomplete, conflicting, or is rapidly changing. This is certainly the case here. Statements about clinical management based on extrapolation of nonhuman data and clinical experience are common. To the book’s credit, however, these statements are frequently accompanied by the admonition that such extrapolations are suspect and that proper studies are lacking. This is exemplified in Chapter 9, in which the authors discuss and advocate use of “triple H therapy” for the management of cerebral vasospasm based on clinical experience, despite the lack of controlled, randomized studies to prove the treatment’s effectiveness. One area of much-current controversy and research that receives relatively superficial and anecdotal discussion is the use of moderate hypothermia in the setting of acute brain trauma. This is unfortunate, but not the rule; other timely topics (e.g. , thrombolytics for acute ischemic stroke, hyperventilation in the management of head trauma) receive more balanced and complete treatment.Clearly, this book is not is a replacement for a text about neurosurgical anesthesia or the anesthetic treatment of patients with neurologic disease. In fact, the discussion of anesthetic management tends to be superficial, of the “cook book” variety, or is frankly wrong. There are, for example, statements that etomidate should be given slowly for a rapid-sequence induction, that a nonrebreather mask delivers 100% oxygen, and that the hallmark of a good neuroanesthetic is “…deep anesthesia with neuromuscular blockade during intracranial micro-dissection…” Similarly, statements that a patient undergoing aneurysm clipping requires volume loading with albumin, placement of a central line, topical administration of lidocaine to the airway, and the use of a low-dose opioid technique reflect, at best, local biases that are not shared by the reviewers. Overall, Neurologic and Neurosurgical Emergencies is a scientifically grounded, thorough, and practical compendium of the issues surrounding the medical and surgical management of acute neurologic and neurosurgical conditions. The book is neither intended nor suited to be a stand-alone text for the anesthesiologist. It is, therefore, best viewed as a reference or resource for the anesthesiology trainee or the practicing anesthesiologist seeking a comprehensive review of the rationale for the clinical management of a broad range of neurologic and neurosurgical emergencies. In this regard, the book succeeds in achieving its stated purpose and will be a welcome addition to the departmental library.