Stroke and Microcirculation

Japanese neurosurgery in general and Sano's group in particular has made a formidable contribution to the development of acute aneurysm surgery and challenging the con- ventional wisdom about timing ofoperation.In a delightful preface, Professor Sano describes how the first Shogun probably died on 13 January 1199 of a rebleed following an initial subarachnoid haemorrhage on 31 December 1198, when he fell from his horse during the opening ceremony for a new bridge.Following a brief introductory chapter that places the various problems in context, there follows a most useful review of the pathophysiology of both immediate and delayed ischaemic neurological deficits.The authors are clearly wedded to the concept of proliferative vasculopathy as the basis for "cerebral vasospasm" and do not quote all the contradictory literature.Chapter 4 is an authoratitive review of the possible rele- vance of the metabolism of membrane lipids and eiconsanoids to cerebral vasospasm and ischaemic brain damage based both on the literature and Asano's very substantial personal contribution to this subject.Tamura reviews the problems of clinical grading of patients with some useful new data com- paring aspects of the Glasgow coma scale with the Japanese scale.There now appears to be a consensus with publication soon of the World Federation of Neurosurgical Societies' clinical grading system.There is an interesting subsection on recurrent haemorrhage during angiography together with a detailed review of the prognostic value of CT scanning.The authors recommend, from a review of over a thousand cases, that, if the patient presents within the first forty-eight hours after subarachnoid haemorrhage, micro- surgical exclusion of the aneurysm with removal of subarachnoid blood clots is indicated for good grade patients but to be avoided in poor grades and in patients over 60 years of age.Post operatively, treatment with induced hypertension, volume expansion and a variety ofcerebral protectors may be required.After 48 hours, their policy is to operate on good grade patients at any time, but to defer surgery in the poorer grades until they improve.Any deterioration leads to further postponement.They would recommend aggressive surgery for intra- cerebral haematomas with clipping of the aneurysm at the same sitting-such a policy resulted in a useful social life for forty-eight per cent of their cases.