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Neuroanesthesia and Cerebrospinal Protection

Himmelseher, Sabine MD; Kochs, Eberhard F. MD PhD

doi: 10.1213/ANE.0000000000001494
Books, Multimedia, and Meeting Reviews: Book Review

Department of Anesthesiology, Technische Universitaet Muenchen, Klinikum rechts der Isar, Munich, Germany,

Our quest for the “holy grail” of brain protection and regeneration in neuro, cardiac, and major vascular surgery continues. Areas of interest include safe and effective anesthesiologic management and provision of patient comfort because they form the basis of neuroprotection and clinical outcome in these settings. If our care is guided by outcome-based evidence to prevent (further) injury to the brain, results can be encouraging. We also anticipate improving treatment options by better use of advanced brain imaging, neuromonitoring, and surgical and neuroradiologic techniques. Besides, there is increased awareness of the meaning of preclinical and translational neuroscientific research, which may support rational clinical decisions to overcome obstacles to progress in neuroprotection. Against this background, the textbook, Neuroanesthesia and Cerebrospinal Protection, meets the increasing demand for aggregate presentation of complex know ledge to all caregivers who are faced with the challenge of providing state-of-the-art, comprehensive patient-centered care in areas of anesthesiology where the brain or the spinal cord has been injured and/or is at high risk of injury.

Neuroanesthesia and Cerebrospinal Protection covers numerous topics related to neuroprotection and neuroanesthesia. The first section covers neuroanatomy, neurophysiology, neuropharmacology, and neuromonitoring. Fundamental knowledge of the healthy brain, consequences of cerebral ischemia, and the potential of stem cells are highlighted. The role of anesthetics and other adjuvant drugs for central nervous system protection and possible neurotoxicity of anesthesia are reported. Then, all clinically established neuromonitoring techniques are described. The main sections on anesthetic management strategies start with a part on diverse issues typical for central neurosurgical anesthesia, such as preoperative assessment or patient positioning. The book continues with chapters on anesthesia care for carotid and intracranial vascular procedures, brain tumor surgery, and traumatic brain and spinal cord injury. The next section outlines the anesthetic approach to specific situations including epilepsy surgery, interventional radiology, stereotactic surgery, and deep brain stimulation. A section exclusively dedicated to pediatric anesthesia, which includes such topics as anesthesia for meningomyelocele, cardiac surgery, or diagnostic magnetic resonance imaging, follows. In addition, a section on anesthetic management regarding neuroprotective issues in the field of cardiac and major vascular surgery ensues. It touches, for example, on the effects of cardiopulmonary bypass on the brain and deals with postoperative neurocognitive dysfunction after heart and noncardiac surgery. The last section discusses the management of perioperative challenges and complications, and finally reflects on miscellaneous topics such as hypothermia for neuroprotection, or the handling of brain death and organ donation. This impressive content is laid out in 12 parts with 61 chapters of different length, more than 140 illustrations, and 70 tables spread over more than 700 pages. Including the editors, there are more than 120 contributors to the book. Each chapter is preceded by an abstract and key words. Unfavorably, the book’s size approximates a DIN a 5 format (approximately 5.89 × 9.06 in.), which causes many color figures to be small in size and sometimes hard to decipher.

It is a merit of Neuroanesthesia and Cerebrospinal Protection to encompass a tremendous amount of information in one entity. Although it is rather unlikely that a neuroanesthesiologist will also deliver anesthesiology in cardiac surgery, the discussion of neuroprotective issues in brain, cardiac, and major vascular surgery united in one book points to the fact that there are common pathophysiologic principles underlying all neuroprotective measures such as maintenance of adequate cerebral perfusion. Unfortunately, chapters on neurointensive care are lacking. This is an absolute shortcoming of the book because neuroinjuring mechanisms from all kinds of insults extend way into the postoperative period and may nullify prior treatment with neuroprotective efficacy. Nevertheless, there is, for example, a good chapter on microdialysis, a neuromonitoring tool of the neurocritical care unit. In contrast, a bit exotic chapters such as one on the physiology of mitochondria or routine use of extracorporeal circulation after cardiopulmonary resuscitation have been included.

In the preclinical part, chapters are well written and offer some nice illustrations to depict the current view on (patho)physiologic conditions and mechanistic explanation of processes. In the clinical part, there are excellent chapters that convey the most clinically relevant information and conclusions from the literature, while not forgetting to mention deficiencies in knowledge on the covered topics. These include, for example, the chapters on transcranial Doppler ultrasonography in neuroanesthesia, anesthesia for posterior fossa tumor surgery, anesthesia for spinal surgery, anesthesia for adult vascular surgery and cerebrospinal protection, and cardiovascular surgical technique under cardiopulmonary bypass. However, there are also chapters that offer no or little concrete advice or recommendations for everyday practice or present decision algorithms. Some chapters also appear not to be in real command of the literature, and only repeat published opinions. In these instances, it would have been of much benefit to the reader if more precise expert- and/or evidence-based conclusions or guidance in a more approachable manner would have been provided. For example, addition of concise standard operating procedures would have been of great value, especially because we have come to know the positive impact treatment protocols may have in complex situations, such as with managing raised intracranial pressure in traumatic brain injury. In addition, contents could sometimes benefit from using more recent literature, and some citations could have been more precise and informative. If the references are cited rather shallow, a distorted view is produced. It is also a pity that contributions do not refer to each other, which leads to (unnecessary) overlap and, unfortunately, even some contradictory statements.

Apart from the outstanding chapter on the pressure reactivity index written by authors from Cambridge and Porto, all parts have been authored by colleagues from Japan. Nevertheless, the information presented is generalizable to non-Japanese practice, with the exception of the chapter on brain death and organ donation. Here, it is interesting to learn about the different perspective on brain death in Japan, a view that the chapter clearly delineates from other concepts around the world.

In summary, Neuroanesthesia and Cerebrospinal Protection may serve as a broad overview for academicians, anesthesiology trainees, and all practitioners who regularly or less often encounter patients with neuronal injury and/or with high risk of that in neuro, cardiac, and vascular anesthesiology. Certainly, the book will find its place on the book shelves because such a starting point is indispensable to stimulate more widespread search for in-depth review of current literature on knowledge and research in central nervous system protection.

Sabine Himmelseher, MD

Eberhard F. Kochs, MD PhD

Department of Anesthesiology

Technische Universitaet Muenchen

Klinikum rechts der Isar

Munich, Germany

© 2016 International Anesthesia Research Society