Hemorrhagic and Ischemic Stroke is a multidisciplinary, 584-page hardcover textbook which discusses the medical, radiological, surgical, and image-guided interventional aspects of this topic. It is co-edited by 2 neurosurgeons (Drs. Bendok and Batjer), a neurologist (Dr. Naidech), and a neuroradiologist (Dr. Walker). The imaging input into this text is substantial, and radiology abounds throughout the book, even in areas where imaging is not the primary topic of the section. A significant portion of the text is devoted to Radiology—Section II: Imaging Considerations. Authors include many prominent in neuroradiology so the reader is assured of up-to-date and relevant information.

One is immediately struck by the fanciful cover, apparently drawn by the artist Jennifer Pryll. It is enticing and attempts to summarize (a picture in this instance is worth many more than a thousand words) all sorts of aspects of surgery, imaging, and interventions. You gotta see it.

There are 4 major sections, each section with multiple chapters: Medical and Critical Care Considerations (6 chapters); Imaging Considerations (6 chapters); Open Surgical Approach (17 chapters); Neurointerventional Approaches (11 chapters). While all chapters should be of interest to a neuroradiologists, Chapter II commands most of our attention. Here, separate areas deal with Hemorrhagic and Ischemic Stroke relative to (1) CT, (2), MR (3) PET, (4) Ultrasound, and (5) Neuroangiography. There is a sixth chapter on Promising Developments in Stroke Imaging.

These chapters contain high quality imaging with up-to-date protocols in advanced stroke imaging. Tables abound throughout these chapters, so one gets for example a quick summary of perfusion weighted imaging parameters (CBV, CBF, etc., along with an adequate examples), MRA, the time evaluation of blood on MR, parameters for assessing carotid disease by ultrasound—again with abundant examples, guidelines for TCD, along with many more. The section ends with a short but beautiful chapter on the future of imaging in stroke by Drs. Rowley, Turski, and Strother. Besides the authors perspective on where stroke imaging/analysis is heading, we are shown new entities (or at least new to this reviewer) such as time resolved MRA using HYPR-highly constrained projection reconstruction. [“Y” fits into that acronym by the end of word highly]. We also see the result of phase contrast MRA yielding hemodynamic date.

For the neurointerventionalist there will be great interest in the chapters on Open Surgical approaches and also, obviously, in the 155-page section on neurointervention. In this latter section, the whole gamut of procedures is covered, including thrombolysis/thrombectomy, angioplasty/stenting, aneurysm coiling, management of dissections, embolization of intracranial AVMs and DAVFs, and Spinal AVMs and DAVFs. These chapters nicely complement and add to material that appears earlier in the text on open surgical perspectives of these abnormalities.

Please note that added to all of this written and illustrative material is a registration and code which allows the reader to access surgical/interventional videos of 10 different operative procedures such as AVM surgery, ECA-ICA bypass, aneurysm coiling, spinal dural fistula embolization, and more. These extra features enhance significantly the value of this textbook.

As a final note, one has to admire the many artist drawings which are so helpful to the reader’s understanding, particularly with issues related to surgery.

To this reviewer, Hemorrhagic and Ischemic Stroke is the best single publication on this topic produced to date. It is recommended in the highest terms to all neuroradiologists; in fact, it should be part of the personal library of anyone who deals with stroke (and what neuroradiologists doesn’t?).

]]> http://www.ajnrblog.org/2012/02/01/hemorrhagic-and-ischemic-stroke-medical-imaging-surgical-and-interventional-approaches/feed/ 0 http://www.ajnrblog.org/2012/01/30/fighting-for-our-health/ http://www.ajnrblog.org/2012/01/30/fighting-for-our-health/#comments Mon, 30 Jan 2012 20:20:02 +0000 bookreviews http://www.ajnrblog.org/?p=5765 Kirsch R.  Fighting For Our Health.  The Rockefeller Institute Press 2012, 416 pages, $19.95.

Fighting For Our Health provides a left-sided perspective on the processes and powers that led to the passage of the Patient Protection and Affordable Care Act in March of 2010.  The author is neither an academic nor a health care provider.  He has spent much of his recent career working with an advocacy organization called Health Care for America Now that is headquartered on K street in Washington, D.C., backed by a coalition which includes grass roots support, powerful unions, and wealthy backers.

The … Continue reading >>

With the ever-increasing availability of high-field strength MRI scanners, the demand for clinical functional MRI studies is outstripping the supply of formally trained individuals to fill this need.  fMRI: Basics and Clinical Applications seeks to address this critical need by providing the interested novice with the tools necessary to develop such a program.

The 181-page book is organized into two large sections that first review the basics of fMRI and then discuss various clinical applications.  The contributing authors are internationally distinguished experts in the fields of radiology, neurology, and neurosurgery.  The chapter topics are well organized and begin with an introductory overview of the challenges intrinsic to building a clinical fMRI program followed by a well-illustrated chapter reviewing neuroanatomy and cortical landmarks.   The neuroanatomy chapter is important, since fMRI interpretation requires a more in depth understanding of neural function and structure than radiologic interpretation of structural MRI. Missing from this chapter, however, is the inclusion of 3-D renderings that are now widely available.  Other topics reviewed in the Basics section include spatial resolution of fMRI techniques, a discussion on perfusion vs. blood oxygen level dependent (BOLD) imaging, the electrophysiologic basis underlying fMRI, and the pros and cons of high-field and ultra-high field MRI.  The Basics section ends with a chapter called “Press Button Solutions” that provides an incomplete review of various commercially available fMRI hardware and software tools.  The authors then compare these commercial solutions to spm2, a research-grade software solution, to determine how well each tool can reliably detect fMRI activations.  The author’s findings are not surprising, though one topic missing from the discussion involves regulatory issues that may restrict the ability to use more powerful research applications for clinical studies.

The Clinical Applications section is organized based on the type of indication for fMRI and includes standard clinical methodologies for pre-surgical brain mapping, as well as research-based applications and combining fMRI with other physiological tools.  Readers interested in getting a clinical fMRI program off the ground will find the chapters discussing sensorimotor and language mapping for epilepsy and tumor resections most informative and practical.  A full chapter is devoted to “Special Issues in fMRI-studies involving Children.”  The remaining chapters discuss more research-based applications, including mapping brain rehabilitation following stroke, and combining fMRI with direct cortical stimulation, transcranial magnetic stimulation, and magnetoencephalography.

This book accomplishes its goal of providing an overview of how fMRI can be applied to clinical applications.  The daunting challenges of conducting clinical fMRI studies are softened, and the reader gains focus on the various areas within their own program that they must strengthen.  While some editors may exclude valuable details that can shorten a text’s shelf-life, it is these pearls that make this title a must-have for the novice neuroimager.  While informative, this book does feed into the modern “fast and easy” philosophy and generally understates the challenges and limitations of push-button fMRI solutions that further separate the clinician from their data.  There were also a number of important issues the book did not cover, including how to properly use statistics in single subject studies, the role of functional connectivity in brain mapping, standardization of experimental paradigms, and quality control.  With these caveats in mind, I strongly recommend this book to anyone interested in learning more about the field of clinical fMRI.

It was a pleasure to review this book, which is very comprehensive in its coverage on the diagnosis, management, and prognosis of diseases of the posterior fossa. This book has described extensively and accurately the anatomical aspects of posterior fossa through skull base and intraoperative images, with apt correlation to the radiological imaging. This correlation enables the reader to understand and remember better the normal anatomy of posterior fossa.

Further, the author has covered all the important and commonly encountered topics of posterior fossa:  trauma, congenital abnormalities, vascular malformations, and tumors. There are detailed descriptions of the molecular basis of the disease, appearance on imaging, and intra-operative aspects of the disease. The images have accurate figure legends and are appropriately placed, giving a good visual description of the text. For example, the chapter “Hemagiomas and Dural Fistulas” begins with microscopic pathology, followed by imaging studies, followed by a series of illustrations describing the various approaches to the brain stem, and then finally ends with endovascular imaging and treatment. This clinico-pathological-radiological understanding is the key to accurate diagnosis and management of any disease.

In addition, I find that the topics covered are very up-to-date and relevant to the title of the book. The references are rightly chosen to include not only landmark papers on the topic but also latest developments in the management.

This book is essential to every neurosurgery resident or attending and is definitely a good study for beginners of radiology and neuroradiology who are in the process of understanding of posterior fossa anatomy and diseases. It also serves as a reference for practicing neuroradiologists for descriptions of radiological images and their appearance intraoperatively. The surgical approaches may not be of direct relevance, but the book does explain significantly the postoperative changes noted on radiological imaging.

Essentials of Pain Management by Drs. Nalini Vadivelu, Richard D. Urman, and Roberta L. Hines is a 834-page detailed text on this subject.  The authors are anesthesiologists dealing with the management of the commonest of all symptoms that practitioners deal with on a day-to-day basis.  The book is divided into nine parts covering all aspects of a pain management.  The book covers the subject broadly and chapters touch on alternative forms of treatment such as acupuncture as well as the psychosocial and psychological aspects of pain. Pharmacology of commonly used drugs is detailed. Their use is explained with diagrams, charts, and tables. These are clear and easy to follow.  Most of the chapters will be of particular interests to those in the clinical disciplines, especially in pain management practice. In this regard, the text is detailed, and the authors cover the subject comprehensively. Clear diagrams and photographs are used to show pertinent anatomical detail. These clearly demonstrate the target site/s of the various treatments. Each area of intervention is described under subheadings.  These are divided into the anatomy pertinent to the intervention and the technique.  These sections are kept short and succinct, but are in enough detail to be comprehensive. Section 6 deals with regional anesthesia techniques and is described in detail.  Surface anatomy (with photographs /diagrams) and surface anatomical landmarks relevant to the particular site are shown.  Technique and recommended pharmacologic agents are described. Further sections deal with labor pain and its management. Suggested strategies in cancer-related pain is covered.  The armamentarium of drugs, blocks, and pain pumps gives the reader a detailed overview of this subject.

Where necessary, radiographic images are provided to illustrate a particular point. A drug formulary of agents used in pain management is provided. Included is a pediatric section, which would prove valuable to those in this field.  Rehabilitation of the chronic pain sufferer is included, and the role of a multidisciplinary approach in this task is discussed.  Chapters include occupational therapy assessment and nursing perspectives in its arrangement.  Many of the chapters end with case scenarios and suggested approaches to their management. Of interest to the Neuroradiology audience would be Chapter 21 which details Principles of ultrasound techniques. This chapter gives a fairly detailed overview of ultrasound techniques in general, but especially in reference to needle guidance.  It is, of course, specifically aimed at the technique used in peripheral nerve interventions. Chapter 6 gives a very brief description of diagnostic imaging techniques used in pain management. It is very short and hence not of much value to the Neuroradiology audience.

Generally, the images and diagrams are labeled clearly and legends are suitably descriptive.  Compared to other books dealing with this subject it covers this topic broadly but in sections not as comprehensively.  Its breadth rather than its depth of detail is what impresses. References are up to date and comprehensive.  Overall an excellent book for those contemplating going into or already performing the practice of pain management.

The second edition of Differential Diagnosis in Computed Tomography, written by Drs. Burgener, Herzog, Meyers, Zaunbauer, is an 854-page hardcover text which covers the field of CT imaging. Included are six separate sections: Intracranial Lesions, Head and Neck, Spine, MSK, Thorax, Abdomen and Pelvis. Considering the parts of the book concerned with neurology (which includes a short segment on spine fractures in the MSK section), neuroradiology consumes well over half of this book (480 pages).

In the chapters on intracranial CT, the brain and extra-axial lesions, ventricles and cisterns, meninges and skull, and vascular lesions are discussed. Recognizing that, for most part, MR is the preferred imaging modality for the brain, Dr. Meyers has with some cases integrated CT and MR.  At a glance one quickly can appreciate the advantages of one over the other in different clinical settings. The same holds true when discussing spine lesions where it is clearly recognized that, besides trauma, potentially calcified lesions, and purely bony pathology, MR is vastly preferred. With the ratcheting down of imaging because of overall costs, it is worthwhile to consider the pros and cons of these modalities.

It is well recognized that the story changes when speaking of head and neck imaging:  the value of CT is unmistakably better in a number of circumstances and, most often, the only imaging needed. Nonetheless, correlative MR/CT should have been more emphasized.

The setup throughout the book is generally uniform, and the bulk of each section and chapter, aside from a couple of pages of introductory material, consists of well designed Tables which categorize and enumerate the diseases, summarize the CT findings, and comments of value concerning the disease entity itself. These tables are, of course, complimented by imaging (predominately but not exclusively CT). The neuro images are well described and appropriately labeled.

If we take the orbit chapter as an example, there would have been vast improvement in the material had the authors (Drs. Zaunbauer and Burgener) included some MR imaging and if they would have used more up-to-date, higher quality CT images. There are many advantages and important additional information gained by using MR in the orbit for ON lesions and space occupying mass. That chapter is a disappointment because, again, a reader wants to know the pluses and minuses of different imaging modalities. The authors needed, for example, to have shown the CT and MR of an optic neuritis or of optic nerve ischemia in order to demonstrate the clear-cut benefit of MR. Other examples of this could be mentioned in this review, such as in lymphomas or abscesses, and in fact in other areas of head and neck imaging.

This book is packed with information, but for the neuroradiologist the material is considered uneven—good in the brain and spine but less so in chapters in head and neck. If, in the future, the authors intend to publish a third edition of this book, they should tightly compare CT and MR. That would make for a more worthwhile publication.

In summary, this book is dated for neuroimaging. It does not address (for the most part) images with which we most commonly deal. Many other works in neuroradiology surpass this book, and therefore, anyone looking for a publication in the brain, spine, and head/neck, other purchases would be wiser.

The latest issue of the Neuroimaging Clinics of North America is entitled Neuroimaging Tropical Disease, and Dr. Rakesh K. Gupta was wisely chosen as the guest editor. Dr. Gupta is widely recognized as a leading authority in neuroradiology, particularly in advanced MR techniques. He has chosen 27 authors to write chapters on 14 subjects, most of which are germane to and specifically deal with tropical disease affecting the CNS. Most of this, of course, involves infections such as TB, fungal disease, parasitic disease, and viral infections, but some chapters and the material within them, although well written, do not exclusively pertain to tropical diseases. For example, in the chapter on craniovertebral anomalies the descriptions and illustrations of the anatomy and pathological conditions shown are standard fare, and there is no reason to suspect these abnormalities are more common in the tropics. Similar comments can be made relative to the chapter on Vascular Brain Pathologies:  here we see diseases which those involved in neuroimaging often encounter. Another instance is the chapter or Hirayana Disease, which is certainly interesting, with the background of the disease and current concepts well explained along with good imaging, but again  there is little here which suggests any preference to the tropics.

Those relatively minor considerations aside, the book is very effective in providing the pathology, clinical scenarios, and imaging of diseases less frequently encountered in the Northern Hemisphere. The first chapter correlates imaging with pathology (gross and histologic) in many of these diseases such as malaria, amebiasis, neurocysticercosis, TB, pyogenic infections, Toxoplasmosis, and a number of viral encephalitides such as the Nipah virus. These are just a few that are included.

Subsequent chapters then delve more deeply into each of these subjects. The chapter which deals with just pathology of tropical disease forms a basis for the imaging which follows in subsequent chapters.  Here we read, among other entities, about tuberculosis explanations concerning the terminology/pathophysiology for granulomas, tuberculomas with solid caseation and liquefaction of caseation, and the non-granulomatous tuberculosis abscess. This chapter takes the reader through fungal infections (aspergillosis, Cryptococcosis, mucromycosis, blastomycosis, histoplasmosis), parasitic diseases, viral diseases, and nutritional deficiency states. While all entities are described and illustrated, particular emphasis is placed on the most frequent and important of the infections, such as Japaneses encephalitis, CNS tuberculosis, fungal infections, and parasitic infections. The book wanders a bit from its intended emphasis when we read the chapter on neuroimaging in postinfectious demyelination and nutritional disorders of the CNS. The material covers ADEM tumefactive demyelination, CMP/osmotic demyelination Wernicke’s, B₁₂ deficiency. These are well summarized, but again the material is not exclusive to the tropics. As an aside, Dr. Mukherji (the consulting editor) noted in his Foreword that this publication is now known as “Neuroimaging Clinics” to reflect a worldwide interest and expertise in neuroimaging. Perhaps it was a mix up in communication, but the cover of this issue still carries the title of Neuroimaging Clinics of North America.

This book is another in a long line of solid contributions to the neuroradiology literature.

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.

The 4^th edition of Dr. Castillo’s highly successful Neuroradiology Companion: Methods, Guidelines, and Imaging Fundamentals is now available. It contains basic information which should be known by every trainee, whether fellow or resident. It provides a reasonable summary of major diseases that can be reviewed by all those involved in the interpretation of neuroimaging studies.

This softcover, 605-page book is 178 pages longer than its predecessor and contains a number of new features. It is divided into 2 major sections the first of which is entitled “Imaging Protocols and Guidelines” and contains specifics on CT, MR, myelographic, and DSA protocols—each with its own CPT code. There is valuable material on sedation, management of contrast reactions and other medications used in radiology, and a series of sample (templates/macros) dictations recommended for all commonly performed procedures. The second section involves the description and major points involved in over 260 different diseases. This represents an increase over and above the material present in 3^rd edition (2005): in the brain (85 more pages), spine (18 more pages) and head and neck (33 more pages). There are many new areas and subjects described, such as craniostenosis, increased cases on brachial plexus abnormalities, and a section of color imaging which primarily enables one to evaluate CT and MR perfusion maps, PET, and CTA/MRA. These are just 3 examples where there has been an increase in material. Along with more cases we see the inclusion of infrequently used terms such as hematohygroma, and the inclusion of more diffusion weighted imaging.

The reading of this companion is made straightforward and easy by the inclusion key facts for every case. This is information everyone training in neuroradiology or actively practicing neuroradiology should know. There are, at the conclusion of each case, one or two citations for suggested readings. A  good exercise is to look at each case, think of 6 or 7 of your own key points (i.e. what you would list), and then read what Dr. Castillo has considered as his key points.

Dr. Castillo has added a 10-page section entitled “Sample Dictations,” which are his recommendations of approximately 40 common, normal dictations in neuroimaging. These are what could be called standardized reports, which are different from the evolution toward the structure or itemized reports that are now becoming increasingly popular with the use of voice recognition.

Just as in life, as “companions” age they tend to get larger. Such is the situation with this new edition. When a 5^th edition appears, which will certainly occur, one would hope that a slimmer companion would be the result. That could easily happen even if new material is added, because the current edition has an abundant amount of wasted space:  there are some pages where 50-90% of the page is blank (this reviewer doubts this huge amount of space would be used to write notes as Dr. Castillo suggests in his preface). These pages could be subject to a weight reduction diet, and we’d end up with a svelte companion. A very positive by-product of this could be a book which would neatly fit into one’s lab coat (which is not possible now).  Then you’d have a real companion.

This is a highly recommended text; in fact, it is one which should be on a required list for all housestaff. They might even stump their attendings by remembering some of the many pearls which Dr. Castillo has given us.

]]> http://www.ajnrblog.org/2011/10/18/neuroradiology-companion-methods-guidelines-and-imaging-fundamentals/feed/ 1 http://www.ajnrblog.org/2011/09/16/problem-solving-in-neuroradiology/ http://www.ajnrblog.org/2011/09/16/problem-solving-in-neuroradiology/#comments Fri, 16 Sep 2011 22:01:11 +0000 bookreviews http://www.ajnrblog.org/?p=5326 Law M, Som PM, Naidich TP.  Problem Solving in Neuroradiology. Mosby Elsevier, 2011, 655 pages, $149.00.

To instill the Socratic method of teaching in a neuroradiology textbook is an interesting approach to education. Drs. Law, Som and Naidich—along with 35 co-authors—have put together a “problem solving” textbook, with questions embedded in many, but not all, chapters. When used, it focuses the reader’s attention to the material in the chapters. As with many books these days, the entire text is searchable online when you activate your account with a code unique to each book.

The book is divided into 4 sections: … Continue reading >>