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Cerebral death, 3rd Edition
BOOK REVIEWS
463
This reviewer was especially pleased that certain points were emphasized by the author. Included are that the aura itself 'is nothing more than a simple partial seizure,' seizures longer than 18 sec have a 95% chance of associated automatisms, prolonged fugue states are rarely epileptic (principle 40) and violence is extremely uncommon during epileptic seizures (principle 42). One more point is Dr. Porter's emphasis on the simple and obvious matter, misunderstood by too many neurologists, that 'many brief absence attacks go unnoticed clinically and the EEG is the best way to identify such seizures.' This book is simple to read, as all books should be, and it contains a wealth of information for all neurologists who will be treating patients with epilepsy. Even for the experienced epileptologists, some new data and many old reminders will be useful. Therefore, the reviewer heartily recommends Dr. Porter's book, especially at a price which all can afford. JOHN R. H U G H E S
Unioersity of Illinois Medical Center, Chicago, IL 60612 (U.S.A.)
Cerebral death, 3rd e d i t i o n . - A.E. Walker (Urban and Scbwarzenberg, Baltimore, MD, 1985, 206 p., U.S. $34.50) Dr. Walker's book on brain death has been and will likely be the most complete and authoritative volume in print on this important topic. This third edition has been further updated and represents a general improvement, compared to the prior two editions. One major publication has appeared since the printing of the second edition and this document was the publishing of the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Defining Death. Dr. Walker has incorporated into his third edition the details of this Report. Other than a streamlining and a rewriting of much of the second edition, the present book shows a reorganization of various sections and also presents new data. For example, the new Ch. I on Death and Burial Practices appropriately introduces the topic of death to the reader, while Ch. IV and V on Cerebral Circulation and Biochemical Findings are gone as chapters, finding their way into the discussion under Confirming Tests of Brain Death. The old chapter on Criteria of Cerebral Death can be found under the new heading of Criteria of Brain Death in the chapter on Status of Brain Death in the Nations of the World. The reader will note the important difference in the two adjectives, cerebral and brain, and the author just before Ch. I tries to make clear this difference in a two-page introduction entitled 'What's in a Name?' Dr. Walker has, of course, kept the same name of this book, but makes clear that the term, cerebral, has not recently been used to refer to the whole brain, but instead only to the part rostral to the mesencephalon. The older and present title has been and still may be somewhat confusing to the reader, since this book is clearly on death of the entire brain and any criteria found therein refer to the whole brain, not only to the diencephalon
and cortex, but also to the brain-stem. Dr. Walker has tried to make clear these points and has often replaced the adjective, cerebral, by the term, brain. This reviewer is somewhat concerned whether the reader will completely understand the role of the EEG in the context of the criteria for brain death. By spelling out the findings of the President's Commission, Dr. Walker does try to clarify the role, but occasionally refers to the EEG as a confirmatory test. For example, on page 178 the author states, 'Because the clinical examination may be inconclusive, a confirmatory test for brain function (EEG) or cerebral circulation (angiography) is desirable.' The reader may be left with the impression that these latter two tests are looking at the same kind of phenomena as the clinical exam evaluates and when the latter is inconclusive, the former may be used as a confirmation. However, the President's Commission did make clear that the clinical examination assesses the brain-stem and the EEG deals with the cerebrum. The clinical exam essentially can say nothing about the cerebrum in a comatose patient and the EEG can make no statement about the brain-stem. Thus, the EEG cannot confirm an inconclusive clinical exam since these two tests look at different parts of the brain. This reviewer wishes to stress this point because some neurologists may not understand that a clear absence of brain-stem reflexes, needing no confirmation of brain-stem viability, still requires a separate test of cerebral viability, like the EEG. The present edition of this book is more clear about this point than the prior editions, but the reader could still misunderstand that the American criteria are similar to the British who deal only with brain-stem death, as long as EEG and blood flow studies are viewed only as confirmatory. In this regard, the data of Bennett on the 50% chance that the EEG may demonstrate some cerebral activity when the brain-stem reflexes are all absent were not included in the book, but Dr. Walker's Table IV-7 shows this value to be 26%. One useful addition to this edition is the discussion of rhombencephalectomized animals, leaving a cerveau isol6 preparation with a well developed EEG and evoked responses. This excellent work, spearheaded by Dr. Walker himself, was inspired by the well-known controversy over the British brainstem criteria of brain death. These new data show how much activity remains when the brain-stem is (surgically) gone, therefore further questioning whether brain-stem death could ever be considered brain death. Dr. Walker has a clearly improved product in this third edition and should be highly complimented for the most complete and authoritative treatise on brain death in existence. In this reviewer's opinion, there is no more excellent text on this topic, likely the result of nearly a fulltime effort on brain death on the part of the author for the last 15 years. Therefore, this reviewer highly recommends Dr. Walker's third edition to all neurologists. JOHN R. H U G H E S
University of Illinois Medical Center, Chicago, IL 60612 (U.S.A.)
463
This reviewer was especially pleased that certain points were emphasized by the author. Included are that the aura itself 'is nothing more than a simple partial seizure,' seizures longer than 18 sec have a 95% chance of associated automatisms, prolonged fugue states are rarely epileptic (principle 40) and violence is extremely uncommon during epileptic seizures (principle 42). One more point is Dr. Porter's emphasis on the simple and obvious matter, misunderstood by too many neurologists, that 'many brief absence attacks go unnoticed clinically and the EEG is the best way to identify such seizures.' This book is simple to read, as all books should be, and it contains a wealth of information for all neurologists who will be treating patients with epilepsy. Even for the experienced epileptologists, some new data and many old reminders will be useful. Therefore, the reviewer heartily recommends Dr. Porter's book, especially at a price which all can afford. JOHN R. H U G H E S
Unioersity of Illinois Medical Center, Chicago, IL 60612 (U.S.A.)
Cerebral death, 3rd e d i t i o n . - A.E. Walker (Urban and Scbwarzenberg, Baltimore, MD, 1985, 206 p., U.S. $34.50) Dr. Walker's book on brain death has been and will likely be the most complete and authoritative volume in print on this important topic. This third edition has been further updated and represents a general improvement, compared to the prior two editions. One major publication has appeared since the printing of the second edition and this document was the publishing of the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Defining Death. Dr. Walker has incorporated into his third edition the details of this Report. Other than a streamlining and a rewriting of much of the second edition, the present book shows a reorganization of various sections and also presents new data. For example, the new Ch. I on Death and Burial Practices appropriately introduces the topic of death to the reader, while Ch. IV and V on Cerebral Circulation and Biochemical Findings are gone as chapters, finding their way into the discussion under Confirming Tests of Brain Death. The old chapter on Criteria of Cerebral Death can be found under the new heading of Criteria of Brain Death in the chapter on Status of Brain Death in the Nations of the World. The reader will note the important difference in the two adjectives, cerebral and brain, and the author just before Ch. I tries to make clear this difference in a two-page introduction entitled 'What's in a Name?' Dr. Walker has, of course, kept the same name of this book, but makes clear that the term, cerebral, has not recently been used to refer to the whole brain, but instead only to the part rostral to the mesencephalon. The older and present title has been and still may be somewhat confusing to the reader, since this book is clearly on death of the entire brain and any criteria found therein refer to the whole brain, not only to the diencephalon
and cortex, but also to the brain-stem. Dr. Walker has tried to make clear these points and has often replaced the adjective, cerebral, by the term, brain. This reviewer is somewhat concerned whether the reader will completely understand the role of the EEG in the context of the criteria for brain death. By spelling out the findings of the President's Commission, Dr. Walker does try to clarify the role, but occasionally refers to the EEG as a confirmatory test. For example, on page 178 the author states, 'Because the clinical examination may be inconclusive, a confirmatory test for brain function (EEG) or cerebral circulation (angiography) is desirable.' The reader may be left with the impression that these latter two tests are looking at the same kind of phenomena as the clinical exam evaluates and when the latter is inconclusive, the former may be used as a confirmation. However, the President's Commission did make clear that the clinical examination assesses the brain-stem and the EEG deals with the cerebrum. The clinical exam essentially can say nothing about the cerebrum in a comatose patient and the EEG can make no statement about the brain-stem. Thus, the EEG cannot confirm an inconclusive clinical exam since these two tests look at different parts of the brain. This reviewer wishes to stress this point because some neurologists may not understand that a clear absence of brain-stem reflexes, needing no confirmation of brain-stem viability, still requires a separate test of cerebral viability, like the EEG. The present edition of this book is more clear about this point than the prior editions, but the reader could still misunderstand that the American criteria are similar to the British who deal only with brain-stem death, as long as EEG and blood flow studies are viewed only as confirmatory. In this regard, the data of Bennett on the 50% chance that the EEG may demonstrate some cerebral activity when the brain-stem reflexes are all absent were not included in the book, but Dr. Walker's Table IV-7 shows this value to be 26%. One useful addition to this edition is the discussion of rhombencephalectomized animals, leaving a cerveau isol6 preparation with a well developed EEG and evoked responses. This excellent work, spearheaded by Dr. Walker himself, was inspired by the well-known controversy over the British brainstem criteria of brain death. These new data show how much activity remains when the brain-stem is (surgically) gone, therefore further questioning whether brain-stem death could ever be considered brain death. Dr. Walker has a clearly improved product in this third edition and should be highly complimented for the most complete and authoritative treatise on brain death in existence. In this reviewer's opinion, there is no more excellent text on this topic, likely the result of nearly a fulltime effort on brain death on the part of the author for the last 15 years. Therefore, this reviewer highly recommends Dr. Walker's third edition to all neurologists. JOHN R. H U G H E S
University of Illinois Medical Center, Chicago, IL 60612 (U.S.A.)