Abstract
Recent advances in acute stroke therapy have revolutionized the care of people suffering strokes, and with the increasing deployment of organized stroke units, the time is ripe for well-organized summaries of various strategies aimed at stroke prevention.
The introduction and conclusion of the first chapter of this useful text helpfully place the remaining chapters in the proper context by demonstrating the overall global burden of stroke and the importance of an ‘urgent amelioration in primary and secondary prevention and treatment’. It is in this way that this text is timely and helpful.
The overall organization of the book is straightforward, with a clear table of contents and an index that is easy to work through when searching for a particular subject. One particularly impressive aspect of the text is the faculty who collaborated to write it. The authors of the various chapters include many respected international authorities in the area of stroke. The chapters themselves are brief and well laid out, the font is easy to read and the tables are concise. The chapters are generally well-referenced.
In less than 300 pages, the editors have assembled a collection of many of the common topics in primary and secondary stroke prevention, including the assessment of future stroke risk with respect to major risk factors, and the use of antiplatelet and anticoagulant agents in primary and secondary stroke prevention. Separate chapters deal with heart disease and stroke, and asymptomatic carotid stenosis (an annoying typographical error at the top of each page in this chapter suggests that it concerns itself with symptomatic stenosis, but this is not the case). Unfortunately, the editors have not included a chapter on the evaluation and management of symptomatic carotid stenosis, which seems rather a strange oversight. Instead, there is an academically interesting, but not practically useful chapter on the pathobiology of the carotid plaque. Also included are chapters dealing with less common (but nonetheless important) entities such as hypercoagulable disorders and migrainous stroke, as well as vascular dementia.
In the final chapter, the editors offer a brief editorial about the historical role of the neurologist in the care of the patient with stroke, and provide insights about what the future may hold. Indeed, one strength of this book is that it is of potential interest not only for neurologists, but or all health professionals with an interest in preventing stroke in their patient populations. Many of the chapters include specific references to recent relevant randomized controlled clinical trials, and will therefore be of interest to those wishing to understand some of the current evidence underlying the use of specific preventative therapies.
One problem with textbooks in general is that they can be out of date by the time they have been published, especially in areas of active research, such as is increasingly the case with stroke. In addition, the use of individual chapter authors, while allowing a breadth of international experience, can result in an emphasis of individual preferences and biases, especially if the opinion of an individual author is not strictly based on all of the available evidence. Both of these observations are true of this textbook; readers familiar with the stroke prevention literature will recognize important omissions from several chapters of the text, and in some cases, a lack of discussion of controversial treatment areas and alternate points of view. Two specific examples include the controversial suggestion that heparin be used in progressing stroke, and the lack of mention of ongoing research into endarterectomy for asymptomatic carotid stenosis.
Perhaps the most important omission, and one that is consistent throughout the text, is that the individual chapters related to specific therapies do not describe the methods by which they chose the data to discuss (i.e their search strategies). There is a consistent lack of reference to systematic reviews of randomized controlled trials with respect to the prevention of stroke. Specifically, mention of relevant Cochrane Collaboration Systematic Reviews (published quarterly on the Cochrane Library) are nowhere to be found. In this age of evidence-based medicine, such oversights cannot be ignored. Indeed, long after this text-book becomes obsolete, the specific relevant Cochrane Systematic Reviews will continue to provide regularly updated summaries (and where indicated, statistical meta-analyses) of the literature.