The book reviewed here is ‘Stroke. Epidemiology, evidence and clinical practice’ by Shah Ebrahim, a professor of epidemiology of Aging and Rowan Harwood, a consultant in geriatric medicine. The authors have accumulated a vast knowledge in this area and this shows in the detailed evidence based discussions that occur in the clearly structured sections of the book.
The book starts with an introduction to economics and epidemiology giving the reader an overview of some of the discussion that follows. They consider risk factors, looking at causality including the Kock postulate and Hill’s criteria before looking at different aspects of individual and population risk as well as confounding factors. Variation in disease patterns across places and times are examined next and various risk factors for occlusive and hamorhagic stroke are discussed including the intriguing association of stroke with ‘febrile illness’ and the season of the year. The authors then go on to the issue of diagnosis looking at various diagnostic measures such as specificity and senstivity and also covering vascular dementia. Here they not that that
‘From the pointof view of stroke epidemiology it is reasonable to consider vascular dementia as a presentation of stroke and where technically feasible and clinically appropriate to reduce remediable vascular risk factors‘.
There is quite an interesting look at some of the literature on diagnostic accuracy which considers the influence of clinical setting and physician characteristics amongst other factors. They also look at the closely related area of clinical disagreement. Certain symptoms, from their review, seem to improve agreement such as dysphagia and deviation of eyes. They look at investigtions covering some of the difficulties in interpreting CT scans as well as some disagreements that have occurred with reporting particularly with lesions location. They also look at attempts at standardising the reporting procedure and decision-making trees for CT scan diagnosis and MRI as well as investigation of the carotid arteries.
In the third part, the authors cover management of stroke with prevention, acute treamtents, rehabilitation and preventing recurrence. In keeping with the general theme of the book, the authors provide a structured evidence-based approach to prevention and along the way pose the question of whether a patent foramen ovale should be closed? The authors then consider acute management the domain of the hospital specialist. The authors then cover rehabilitation with inpatient rehabilitation, early discharge and domiciliary rehabiliation again examing the supporting evidence in some detail. The authors then look at preventing occurrence including long term anticoagulation as well as carotid endarterectomy.In terms of prognosis the chapter on mortality usefully considered the value of prediction highlighting important factors such as urinary incontinence and disability which may however represent stroke severity. Recurrence. The authors also look at the effects of stroke including psychiatric and physical consequences followed by prognosis and carers.
This is a clearly structured examination of the many aspects of stroke, from epidemiology through to diagnosis and treatment which looks closely at the supporting literature.
Shah Ebrahim and Rowan Harwood. Stroke. Epidemiology, evidence and clinical practice. Second Edition. Oxford University Press. 1999 (2001 Reprint).
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