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Book Reviews

Posted in Book Reviews on 12th Nov 2012

Cavernous Malformations of the Nervous System

Editors:  Daniele Rigamonti, Professor of Neurosurgery and Radiation Oncology at John Hopkins University Hospital, USA.
Published by: Cambridge University Press, 2011.
Price: £75.00.
ISBN: 978-0521764278.
Reviewed by:  Ranjith K Menon, Clinical Fellow Vascular Neurology, Division of Adult Neurology, Sunnybrook Health Sciences Centre, University of Toronto.

Cavernous malformations (CM) are problematic for neurologists in day-to-day practice because they are common and often, but not always, harmless: their morbidity is uncomfortably similar to that of the means by which they may be treated. CM are vascular anomalies lacking shunt, major feeding artery or draining vein, their walls not possessing either smooth muscle or elastic fibres. They are known variously as cavernomas, cavernous haemangiomas and cavernous angiomas.

This book, ‘Cavernous Malformations of the Nervous System’ edited by Professor Daniele Rigamonti is a well researched and comprehensive text. There are 40 contributing authors from numerous international centres, providing an array of research and clinical experience. They cover current concepts in CM practice. The volume is presented very systematically in four sections with 19 chapters.

In Section 1 the authors focus on the structural pathology, epidemiology and molecular genetics of CM. They describe mutations in three genes which are linked to familial CM, inherited as autosomal dominant traits. One criticism is that these genetics subsections sometimes strayed from comprehensive to repetitive.

In Section 2, the authors detail the clinical presentations of CM and the most sensitive diagnostic imaging modalities to be used for initial assessment and for follow-up. The authors provide insights into the safety of various drugs that may be used in the presence of CM. They also give well-reasoned recommendations about activity restriction in CM. This is very practical information, potentially of great utility in advising patients with CM.

Section 3 discusses the management of CM including, both conservative and surgical, while the final section provides an update on genetic counselling in CM.

Cavernous malformations, from basic structure to diagnosis and management, are both intriguing and challenging to clinicians. With the advent of precise neuroimaging, patients asymptomatic from CM are being identified more frequently. This book attractively and effectively provides an update on current research and clinical practice as to the best approaches with both symptomatic and asymptomatic CM. It also has sufficient scientific rigour to be a reminder of how little we know of the subject. Vascular neurologists in particular will find this book very valuable.

The Medicalization of Cannabis

Wellcome Witnesses to Twentieth-Century Medicine. Volume 40.
Editors: Crowther SM, Reynolds LA and Tansey EM
Published by: The Wellcome Trust Centre for the History of Medicine at UCL (2010)
Price: £6.00
ISBN: 978-0854841295
Reviewed by: Dr Colin Mumford DM FRCP, Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU

Somewhere in the East of England thousands of cannabis plants are growing within a high-security secret site. Their destiny is to become a component of medical treatments for a range of conditions, and specifically for the treatment of multiple sclerosis. Medical practitioners have differing views on the likely benefits of this novel therapy: some are highly enthusiastic, whereas others remain sceptical and consider the drug to lack legitimacy in a clinical environment. Perhaps even the word “novel” is inappropriate in this setting, since cannabis has been used as a drug from the 1800s, but understanding of its potential only blossomed three decades ago when cerebral cannabinoid receptors were first identified.

Volume 40 of the “Wellcome Witnesses to Twentieth-Century Medicine” series represents a collection of transcripts of testimony provided by a diverse group of individuals – clinicians, scientists and patients –  invited to contribute to a conference held in London, the topic being the medical use of cannabis over the centuries. The volume is not really a book at all, but is more of a verbatim record of what was said “on the day”, with some commentary, by way of annotation. It reads like a stenographer’s transcript of legal proceedings, in which the evidence in favour of and against the use of cannabis for medical purposes has been advanced and rebutted. But that is not to be critical of the style, rather the presentation tends to draw the reader in, as though they themselves were party to the debate at the time, albeit at the expense of some continuity of content.

It is clear that some of the speakers whose words are recorded in the volume are passionate advocates of the cannabinoids, whereas others express doubt. The early reluctance of “mainstream” pharmaceutical companies to embark on cannabis-related research because of the perceived stigma is stressed. Very reasonably, many contributors draw attention to the plethora of self-reports of benefit of cannabis in treating the symptoms of diverse conditions, with inevitable emphasis on MS. The exacting reader may find it disappointing that the proponents speaking strongly in favour of cannabis are not forced to scrutinise their statements with greater scientific ruthlessness, to ensure that their assertions can truly be backed up by an evidence base. The scientists whose thoughts are presented certainly make valiant efforts to maintain perspective. But overall we are still given too much anecdote, methinks, with one enthusiast noting that her experience of smoking cannabis didn’t just relieve the pain and ease the spasticity imposed by her MS, but also helped her to sleep and to eat. Meanwhile another MS sufferer notes simply “Cannabis has changed my life. It really has.”  Quite some claims! They go largely unchallenged in the debate.

This volume will certainly be of interest to those who have coordinated research into the benefits of cannabis in neurology. However, for others, it may be rather heavy-going despite its brevity, in part because of the format. Many will find the lack of intellectual rigour in some parts disappointing. All, however, will be interested in the historical perspective offered by early sections of the book. These give insight into a potential therapeutic agent which has found favour, not just in recent years, but which in reality has a pedigree stretching back many thousands of years in the history of medical practice.

If you don’t have a special interest in this area, this is one to glance at, perhaps, if it catches your eye from a top shelf in the library.


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