books book reviews

neurology books

reviewed by T. Nelson

book review

Neurologic Complications of Critical Illness, 3e
EFM Wijdicks
Oxford, 2009, 464 pages

Reviewed by T. Nelson

This single-author textbook is a compendium of all the terrible things that can happen to your brain when you visit the ER.

It discusses neurologic complications in ICUs and transplantation units, surgery, CNS catastrophes, and clinical practice. Much of the text discusses problems resulting from bacterial and viral infections, cardiac arrest, acute renal disease and hepatic failure, coagulopathies, environmental injuries, drug overdose, trauma, and transplantation.

A surprising number of the problems patients encounter are not caused by the disease, but by the treatment. For example, 25% of the patients who die within six months of vascular catheterization are found to have cholesterol embolization. Insertion of a catheter can traumatize arteries by dislodging cholesterol “crystals” from atheromatous ulcerated plaques. This creates massive showers of embolic material, producing cerebro­vascular occlusion and stroke. One sign of this, says the author, is ‘blue toe syndrome’ in which the patients' toes show distinctive blue marks. Other signs include spinal cord injury, renal failure, and muscle weakness that resembles polymyositis.

Cardiac surgery, arterial surgery, and cardiac arrest are important contributors to brain injury, but many people might not know that electrical and thermal burns also cause serious neurological morbidity. Burn patients lose serum albumin and other drug-binding proteins, which can turn standard drug treatments into overdoses. Patients struck by lightning get an elaborate dendritic red pattern on their skin called a Lichtenberg figure. High voltage electrical shock victims can have delayed onset spinal cord injury starting months or years after the injury.

Lymphoma of the brain occurs in 7% of all transplant recipients. (Not brain transplants of course, any kind of transplants).

Cyclosporine and tacrolimus, which are used to suppress the immune system after a transplant, are neurotoxic and can cause hallucinations, tremors, speech apraxia, or even coma, possibly due to their effect on calcineurin.

Perhaps most interesting is the chapter on neurological sequelae of viruses. Influenza can cause toxic shock and hypoxemia, but it can also cause acute necrotizing hemorrhagic enceph­al­opathy, which leads rapidly to coma. The 1989 epidemic in Japan found multiple cases in children, which left them with psychiatric and parkinsonian disabilities. An H5N1 epidemic will be even more concerning: in past outbreaks between 8 and 50% of patients experienced impaired consciousness and seizures as well as myositis and rhabdomyolysis decreasing ventricular function to such an extent that extracorporeal membrane oxygenation—a high-risk procedure often used in hypothermia and cardiac surgery—was required. About two thirds of H5N1 infections resulted in death.

The book is a bit old but has many CT and MRI images. Its focus is exclusively clinical, with little science. The index is inadequate. The pages are so glossy I had to use polarizing sunglasses to cut down on the glare before I could read it. But at only 464 pages it's incredibly concise and fascinating. If there's ever a time to learn about horrible diseases, it's now.

A more complete treatment of how influenza and other viruses affect the brain can be found in Infections of the Central Nervous System, reviewed here.

apr 16, 2020

book review

Case Files: Neurology, 3e (Lange)
Toy, Simpson, Mancias, Stimming
McGraw-Hill 2018, 488 pages

Reviewed by T. Nelson

This one, written for medical students, provides 54 case histories of patients with various neurological problems. The goal is to help med students diagnose patients and prescribe the appropriate treatment. It's a page-turner compared to a normal neurology textbook. Even laymen can benefit from it, though it assumes you know some neuroanatomy and pharmacology.

Example: in Case #9, we're told that a recovered alcoholic was disoriented and had ‘flapping’ hand motions (called asterixis) and difficulty focusing which fluctuated over time. What is the most likely diagnosis? Delirium caused by hepatic encephal­opathy, where the liver is damaged and ammonia and manganese aren't removed from the blood.

The authors say that 40% of patients in an ICU have delirium. Between 10 and 24% of all patients admitted to hospitals are delirious, and 26% of them die. The most common medications would be neuroleptics like haloperidol, quetiapine, or risperidone. Elderly patients often become disoriented and are prone to delirium, and it's important to distinguish it from dementia.

There are new diseases like anti-NMDA receptor encephalitis and spinal muscular atrophy (floppy baby); and old ones like concussion, stroke, multiple sclerosis, migraine, Lewy body dementia, CJD, spinocerebellar ataxias, traumatic spinal cord injury, autism, and infantile botulism. What you actually see, though, are the symptoms: paralysis, pain, memory loss, seizures, rash, muscle weakness, confusion, lip-smacking, hallucinations, or psychosis. The task is to identify the cause. The cases aren't challenging but intended to teach the classic symptoms. It's also useful to remind specialists what the intern who calls you at three AM is thinking.

Reading this book is like watching House M.D. except that the author doesn't OD on vicodin or go nuts and start having sex with the Dean of Medicine.

You'll also learn a great new word: encephalo­duro­arterio­synangi­osis, which is another word for dura­encephalo­synangi­osis (a surgical procedure used for moyamoya syndrome).

But mostly if you're the resident it will help you pass your USMLE exam. If you're a patient you'll get enough of an idea about neurological diseases so you can nod your head knowingly and ask for a second opinion when they misdiagnose you.

apr 20, 2020