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Reviews and Notes: Surgery: Surgical Management of Cerebrovascular Disease. RE Zierler; ed. 514 pages. New York: McGraw-Hill; 1994. $80.00. ISBN 007072792-9. Order phone 800-262-4729

This book is by 24 surgeons, 5 neurologists, 1 internist, 1 radiologist, and 1 pathologist. A more appropriate title would be Surgical Management of Extracranial Cerebrovascular Disease, because more than 450 of the well-written and illustrated pages deal with the cervical portion of the cerebral circulation. For example, the basilar artery is not indexed, the vertebral artery is given 14 lines, the vertebrobasilar system is given 24 lines, and the carotid artery is given 127 lines of indexing. Slightly more than half a page is devoted to intracranial berry aneurysms and multi-infarction dementia. This book is a must for vascular surgeons and is divided into five parts. The first part is 76 pages in length and is devoted to anatomy and pathophysiology. The section on the mechanisms of cerebral ischemia is outstanding and brings into focus the similarities between atherosclerotic plaque disruption in the coronary circulation and the carotid arteries. The next edition of this book should include the recent observations that atherosclerosis in the aortic arch is another potential source of emboli to the brain. Part two, Clinical Manifestations, is divided into four subsections. The first two cover the traditional phenomena of the carotid and vertebrobasilar arterial systems. Epidemiology and natural history come next, and the subsections that address these topics include a satisfactory portrayal of risk factors. Clinical evaluation of the patient with cerebrovascular disease is covered in the fourth subsection and is both poorly organized and incomplete. The neurovascular examination is not described. An algorithm for the diagnostic evaluation of a patient with neurologic symptoms lists electroencephalography as the second most important test (computed tomographic scanning is first), but text on the same page states that electroencephalography (EEG) is no longer routinely done. The statement is correct; the algorithm is incorrect. Part three is titled Diagnostic Evaluation and includes a description of methods of imaging the cerebral circulation and brain. Indirect noninvasive tests, duplex scanning, transcranial Doppler ultrasonography, computed tomography, and magnetic resonance imaging are thoroughly covered. Some material about cerebral angiography concludes this part of the book. A page is devoted to intravenous digital subtraction angiography, although the authors conclude that it has been largely abandoned as a substitute for preoperative selective catheter angiography. Diagnostic Evaluation does not discuss the various examinations of the heart and blood that often provide answers to the pathogenesis of a transient ischemic attack or an ischemic cerebral infarction. Part four is titled Therapeutic Approaches and Randomized Clinical Trials. Of the 103 pages in this section, 14 are about antithrombotic medical therapies to prevent stroke and 89 are about surgery. Readers who work with patients with multiple cerebrovascular problems know that fewer than 10% of all patients are candidates for vascular surgery and that this percentage will dwindle as new antithrombotic and thrombolytic therapies become available. Some of the indications for surgery will change. I have long believed that a carotid ulcerated atherosclerotic lesion actively producing emboli to the ipsilateral eye and hemisphere, even though it causes less than 70% stenosis, should be treated with endarterectomy, assuming a perioperative morbidity-mortality of less than 5%. Almost one third of part four is about carotid endarterectomy without arteriography. I suspect that the vascular surgeons' attitude toward visualizing the anatomic structure of the intracranial vasculature with arteriography has developed because the patients these surgeons treat are preselected and thus do not represent the potpourri of abnormalities present in the total population of patients with cerebrovascular problems. The last part of the book takes up 158 pages and is about surgical management. This extensive section is well done and will be technically helpful to neurovascular surgeons. To shunt or not to shunt and to patch or not to patch continue to be important questions that stir up debate. The description of the primary arteriotomy closure and patch angioplasty closure mentions that all vessels are flushed by sequential removal of all vascular clamps. This procedure should be described in detail, because the removal of all debris (potential emboli) is one of the most important parts of a carotid endarterectomy. All agree that technical perfection is mandatory. An important issue in determining the incidence of perioperative neurologic events (morbidity) is the quality of the neurologic examinations done before and after surgery. To get an accurate assessment of the patient's brain function before and after surgery, the vascular surgeon should work closely with personnel who specialize in such assessments. Minor defects in cognition or motor skills are often missed by inexperienced examiners. The book does not mention this. The last nine pages are about tumors of the carotid body. The carotid body and the carotid sinus are carefully distinguished. I was pleased that this subject was included; one seldom finds it dealt with so well. This book is about the surgery of the extracranial portion of the cerebral arterial circulation by vascular surgeons and is very well done. The potential purchaser should know that the subject is a limited one.