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The British Medical Bulletin, published quarterly, on behalf of the British Council, has a somewhat institutional ring to its title and a certain perversity in commencing, as this expert review does on page 275: “A bulletin (Italian; Bulletino) is a short official statement or periodical publication of a club.“ Professor Martin Brown, Scientific Editor, has “clubbed” together a wide choice of contributors from many disciplines though only one pathologist. The aim of this, the millennium publication, is to emphasis a British approach to cerebrovascular disorders through “the practical application of evidence based medicine combined with multidisciplinary management and rehabilitation”.
Charles Wolfe kicks off with an excellent account on the socioeconomic impact of stroke; in particular drawing attention to both current primary and secondary care service provision. Thereafter there is an abstract somewhat impenetrable account on measuring outcome followed by an excellent highly recommended review by Alastair Lammie on the pathology of small vessel disease.
Next, the complexity of different animal models are succinctly discussed before embarking on the use of modern investigative techniques. These 60 or so pages are informative, up to date, and practically relevant with the exception of the section on MR spectroscopy, which seems too experimental in emphasis.
The next section of the book, of particular value to the stroke physician, deals with the current state of therapeutics. This covers thrombolysis, neuroprotection, antithrombotic drugs, and the neglected and well described area of optimising homeostasis. Peter Langhorne then addresses authoritatively the organisation of acute stroke care, this being of particular value to any clinician in dialogue with purchasers over establishing services. Dr Langhorne addresses home versus hospital care, the effectiveness of stroke units, and how to develop a service with respect to practice, procedures, and discharge planning. The following chapters deal with the surgical management of intracerebral haemorrhage (promoting the ongoing multicentre prospective randomised control trial evaluating whether or not early clot evacuation improves outcome), swallowing, nutrition, management of spasticity, prediction of outcome and stroke prevention with respect to antiplatelet agents, carotid endarterectomy, angioplasty, and stenting (reflecting the editors' particular area of interest) and anticoagulation. These are excellently referenced and at each conclusion, draw attention to “key points for clinical practice”. The final chapter by Shah Ebrahim reviews the cost effectiveness of stroke preventions, initially introducing the non-economist to the need for and principles of economic appraisal. I found this particularly informative and table 6, summarising the cost effectiveness of a range of preventative interventions of great value.
All in all, this is an excellent publication doing justice to the importance of the millennium volume of the bulletin. It pulls together strands of current knowledge allowing informed evidence based practice The chapter format, adhered to throughout, is clear, easy to follow, and key points for clinical practice thoughtful. Professor Brown and his colleagues have achieved their objective in producing a readable, accessible series of expert reviews. Criticisms, yes; if the emphasis here is to outline the “British approach”, more attention should be directed to current haphazard practice with respect to the availability of acute stroke units, the paucity of neurologists actually involved in stroke care when compared with European and North American counterparts and the lack of proper structures and systems to triage complex, often young, patients with stroke acutely to Regional Neuroscience Centres. Also, there is nothing here that addresses the type of stroke neurologists in the United Kingdom are most often asked to review—namely, those with atypical cerebrovascular disorders. I would like to have seen more in relation to young patients with stroke, inherited cerebrovascular disorders, and vascular dementia. However, as the text stands, it is highly recommended to those who practice cerebrovascular medicine.
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