|Home | About | Journals | Submit | Contact Us | Français|
(British Medical Bulletin 2000, Vol. 56, No. 2)
Editor: Martin M Brown
576 pp Price £34.95/US$57 ISBN 1-85315-457-1 (p/b)
London: RSM Press for the British Council, 2000 .
Stroke is a rotten disease. It is one of the commonest causes of death throughout the world and survivors are frequently left disabled. It is also extremely heterogeneous. The conventional division into just infarction and haemorrhage is probably too simplistic. The complexity of the aetiology and of the clinical manifestations of stroke makes prevention, acute treatment and rehabilitation difficult to individualize. However, led by campaigning enthusiasts, the management of stroke has undergone considerable change. When I started as a consultant in geriatric medicine it was regarded as quite acceptable to adopt a conservative approach to the management of acute stroke and only to intervene, even with intravenous fluids, once it was clear that the patient had survived the initial insult. That has all changed. With the increasing evidence base on the effectiveness of preventive and therapeutic interventions, coupled with a humanistic imperative, such neglect is now totally unacceptable. My own post, funded in part by the Stroke Association, was created to provide local impetus for change. UK researchers have contributed greatly to the improvements in practice. Most hospitals now have a stroke service of some sort although there are few where all stroke patients undergo their complete hospital stay within designated stroke beds.
It is with this background that Martin Brown has assembled a galaxy of medical stars of the stroke world for a British Medical Bulletin that offers both a summary of knowledge and a clear agenda for future work. Each chapter is extensively referenced with up-to-date citations. Medical, surgical and neuroimaging aspects of stroke are all covered. Even so, it is not comprehensive: readers who wish to learn about important aspects such as nursing and therapy, or about the experiences of patients and carers, will have to look elsewhere.
Martin Brown's contention is that stroke should be regarded as a `brain attack'—an acute medical emergency akin to myocardial infarction. Chapters on thrombolytic treatment, neuroprotective agents (both by Kennedy Lees) and homoeostasis (Philip Bath) summarize the evidence for acute pharmacological interventions and for intensive physiological monitoring in the acute phase. The most convincing evidence comes from a meta-analysis of the results of the thrombolytic agent alteplase. This drug, not yet licensed for this indication in the UK, has been shown in clinical trials to reduce death and disability in ischaemic stroke (the number needed-to-treat is said to be as low as 10.7). There are two major drawbacks to its use. The first is the very short time window, less than 3 hours following the stroke, before the risk/benefit ratio starts to deteriorate. The second is that, to rule out cerebral haemorrhage, a computed tomographic (CT) scan of the brain needs to be done before the drug is given. There is also uncertainty that the benefits seen in highly selected groups of patients recruited from specialist centres will be observed when the drug is used on a wider scale. Lees also summarizes the evidence for neuroprotective agents that are designed to protect the ischaemic penumbra around areas of actual infarction. Results here have been universally disappointing, although he believes that further work may reveal subgroups in which these drugs are of value. The maintenance of homoeostasis in the immediate post-stroke period, with intensive monitoring in an acute stroke unit, may also be regarded as analogous to treatment in a coronary care unit. However, as summarized by Philip Bath, there is scant evidence on how best to treat the known poor prognostic factors such as hypertension, hyperglycaemia and hyperpyrexia. If some of these acute strategies prove worthwhile, they will call for heightened public and primary-care awareness of the need for immediate action. The admissions ward, CT scanner and stroke unit will need to be in close proximity to each other—in our hospital these services are provided in different buildings and patients have to be transferred from one to another by ambulance. Immediate access to neuroimaging will also demand substantial investment. This may be the way ahead but I do not think that the case has yet been established.
What has been clearly established is that organized care systems such as those provided in stroke units improve survival and the likelihood of the patient returning to an independent life. Continued development of such models of service delivery will be given further impetus by the forthcoming National Service Framework for stroke. It is left to Shah Ebrahim, in the last chapter, to remind us that the disease costs the NHS in Britain about £2 billion a year and that there exist effective and cheap interventions such as aspirin, bendrofluazide for hypertension and smoking cessation advice. Even if new drugs for acute stroke become available, these proven cost-effective interventions must not be neglected.