Neurological and Neurosurgical Intensive Care, Third Edition. A.H. Ropper (Editor). Raven Press, NY, 1993. Pages: 505. Price: $99.00.
This is the third edition of this multiauthor text, the last edition having been written in 1988. The editor's intention was to describe the general principles of intensive care, as they apply to disorders of the central nervous system, and to cover specific neurological and neurosurgical clinical entities that are managed in a neuro-intensive care unit (ICU). The book reflects the training and orientation of the editor, who is a clinical neurologist specializing in critical care. As in any multiauthor book, the different chapters are written by various clinicians and vary substantially in quality from barely adequate to superb.
The book is divided into two sections. The first addresses general principles of neurological intensive care. This section includes chapters on physiology, monitoring, and management of intracranial hypertension, respiratory support, cardiopulmonary aspects, infections, and metabolic disorders. The chapters dealing with intracranial hypertension are excellent and provide a thorough review of the standard clinical principles. The chapter on airway management and respiratory support is thorough and excellent. The chapter on cardiopulmonary aspects of acute neurological diseases discusses almost exclusively neurogenic pulmonary edema and neurogenic cardiac damage. I was disappointed to find little discussion of the techniques for monitoring systemic hemodynamic status or for the therapeutic manipulation of cardiovascular parameters in patients with disordered brain physiology. There was little or no discussion of the management of arrhythmias or the selection and administration of vasoactive drugs (vasodilators, vasoconstrictors, inotropic agents). The chapter on nosocomial infections is so general as to be almost useless. There is little or no discussion of the selection of antimicrobial agents for the treatment of the infections that commonly complicate the management of patients in a neuro-ICU. Recommendations regarding acute pharmacological therapy (particularly before the results of cultures and sensitivities are available) of sepsis, pneumonitis, and post-traumatic and postoperative meningitis would have been very helpful. The chapter on metabolic derangements in acutely ill neurological patients is one of the better chapters in this section. A significant shortcoming of this first section is the lack of discussion of the physiology, monitoring, and management of cerebral blood flow and metabolism.
The second section covers specific problems in neurological intensive care. This section begins with a superb review of the techniques and results of electrophysiological monitoring in the ICU. This is one of the most thorough and well-researched chapters in the book. The interest and orientation of the editor is reflected in the selection of topics for this section. Fully half of the topics cover critical care aspects of medical or nonsurgical neurological disease. The chapters on the management of critically ill patients with myasthenia gravis, Guillain-Barre syndrome, and status epilepticus are excellent. The chapters on occlusive cerebrovascular disease are well written and comprehensive, but they do not define clearly the role of intensive care unit monitoring and management for patients with acute ischemic stroke.
The chapters on the management of neurosurgical disorders were, by and large, a bit disappointing for two reasons. First, the space delegated to these disorders was inadequate and disproportionate to the prevalence of neurosurgical cases in virtually all neuro-ICUs. Second, the chapters on neurosurgical disorders (with the exception of the chapter on head injury, which was excellent) are rather broad, general reviews of individual topics (spontaneous intracerebral hemorrhage, subarachnoid hemorrhage) and do not include detailed discussions of the specific techniques of contemporary ICU monitoring and management of patients with these disorders. The discussion of the management of vasospasm in the chapter on subarachnoid hemorrhage was not detailed enough in its coverage of new techniques for detecting vasospasm, such as transcranial Doppler, the fine points of “triple-H” therapy, or the role of new techniques such as balloon dilatation angioplasty. The chapter on postoperative care of intracranial tumors is the most thorough of those regarding neurosurgical topics. There is an appropriately brief overview of the topic, followed by a comprehensive discussion of prevention and treatment of the various postoperative complications. This chapter included several very useful tables, including a list of routine postoperative orders for brain tumor patients and an excellent table on postoperative neurological decompensation. The book concludes with three excellent chapters on the diagnosis of brain death and the legal and ethical aspects of decision making.
In summary, this book provides excellent coverage of the neurological disorders that require management in the ICU, and for this reason alone, it should find a place in the personal library of neurologists, intensivists, and neurosurgeons with a particular interest in critical care. For the most part, the chapters on neurosurgical disorders do not provide adequate depth or detail regarding pathophysiology or monitoring and do not provide sufficiently well-developed management guidelines to be optimally useful for most neurosurgeons. Other texts on neurosurgical critical care and other monographs on the topics of intracranial hemorrhage and head trauma provide the comprehensive coverage of these areas that is required by the practicing neurosurgeon.