THE VEGETATIVE STATE: MEDICAL FACTS, ETHICAL AND LEGAL DILEMMAS

Publicised as the first textbook to deal with imaging of pathology of the entire visual system, the book is aimed at radiologists, ophthalmologists, neurologists, neurosurgeons, and ENT specialists. There are chapters on imaging methods, specifically colour Doppler ultrasonography, computed tomography and magnetic resonance imaging, on anatomy with imaging correlates, and on functional magnetic resonance imaging. There is a “Short Primer” of neuro-ophthalmology, a special section on optic pathway pathology in children, a chapter on orbital pathology comprising almost 200 pages and a chapter on intracranial pathology comprising about 90 pages. The text is organised according to pathology with generally an easy to read style. The book’s most remarkable characteristic, a great testament to the editor, is the immense collection of high quality CT and MRI scans. It is a wonderful reference for busy clinicians, ophthalmologists, neurologists, neurosurgeons, and ENT specialists who need to confirm whether imaging is consistent with the clinical diagnosis. They will also appreciate the early chapters on imaging methods and anatomy. The organisation of the text may make it less immediately helpful but still highly useful to radiologists, both neuro-radiologists but more especially those not regularly reporting orbital or head scans, trying to make a diagnosis from the imaging, The value of the section on neuro-ophthalmology is somewhat unclear. The idea is good but most readers will be overwhelmed by the detailed discussion of the organisation of the visual and ocular motor systems. A more thorough scheme of topographical diagnosis would have been helpful. There is no mention of the pattern of visual field loss specific to lateral geniculate lesions or lesions of visual cortical area V2. The discussion of nystagmus only mentions jerk nystagmus without any reference to the acquired pendular nystagmus of brainstem infarction or demyelination. In other chapters there are superfluous discussions of disease pathogenesis, such as for multiple sclerosis. The reader needs to be wary of the advice on clinical management. Optic nerve compression in dysthyroid eye disease is not “a conclusive indicator for surgical intervention”. Systemic steroids and radiotherapy also play important roles. To state that in idiopathic intracranial hypertension “conservative therapy consists of medication with acetazolamide and/or prednisolone” misrepresents the role of steroid therapy which is infrequently used. Many readers will find the terminology and phraseology irritating at times. The terms hypomochilon and phlegmon are not in regular use. Optomotor is unfamiliar and clumsy compared to ocular motor. “Drusen of the optic head consists of a primarily autosomal-dominant preliminary mucoprotein matrix deposit with blurred papilla, but only subclinical visual field deficits, a differential diagnosis to papilledema in idiopathic cerebral hypertension, and demonstrates calcification of the optic head” will send many a head spinning! There are also a number of factual errors, for example Parinaud’s syndrome is characterised by vertical not horizontal gaze paralysis. The ultimate reference book in neuro-ophthalmology remains Walsh and Hoyt’s Clinical Neuro-Ophthalmology, now consisting of 5 enormous volumes and full to the brim with similar quality scans but not necessarily available to most neurologists. In comparison this book’s emphasis on orbital pathology will reduce its appeal to neurologists, even those with a particular interest in neuro-ophthalmology, but it would be a useful addition to neurology department libraries. Paul O’Riordan-Eva, King’s College Hospital, London Imaging of Orbital and Visual Pathway Pathology