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Toole's Cerebrovascular Disorders


  • 156 b/w illus. 79 colour illus. 80 tables
  • Page extent: 422 pages
  • Size: 279 x 215 mm
  • Weight: 1.63 kg

Library of Congress

  • Dewey number: 616.8/1
  • Dewey version: 22
  • LC Classification: RC388.5 .T6 2010
  • LC Subject headings:
    • Cerebrovascular disease
    • Cerebrovascular Disorders

Library of Congress Record


 (ISBN-13: 9780521866224)

TOOLE’S Cerebrovascular Disorders, Sixth Edition
Cambridge University Press
9780521866224 - TOOLE’S Cerebrovascular Disorders, Sixth Edition - By E. STEVE ROACH, KERSTIN BETTERMANN and JOSÉ BILLER

Toole’s Cerebrovascular Disorders, Sixth Edition

Toole’s Cerebrovascular Disorders was the first modern book devoted to the care of stroke, originally published more than 40 years ago. Drs. E. Steve Roach, Kerstin Bettermann, and José Biller have completely revised and updated this sixth edition of the highly respected standard for stroke diagnosis and treatment, adding chapters on genetics, pregnancy-related stroke, and acute treatment. The practical focus of the book has not changed, retaining its emphasis on bedside diagnosis and treatment. Easily accessible for both stroke specialists and residents, this sixth edition has been modernized to keep pace with the rapid expansion of knowledge in stroke care and includes evidence-based recommendations, the latest technology and imaging, and risk factors. The text is supplemented with more than 200 images, many in color.

E. Steve Roach, MD, FAAN, FAHA, is Professor of Pediatrics and Neurology and Director of the Division of Child Neurology at The Ohio State University College of Medicine, Columbus, Ohio.

Kerstin Bettermann, MD, PhD, is Assistant Professor of Neurology at Penn State College of Medicine, Hershey, Pennsylvania.

José Biller, MD, FACP, FAAN, FAHA, is Professor of Neurology and Neurosurgery and Chairman of the Department of Neurology at Loyola University Chicago Stritch School of Medicine, Maywood, Illinois.

Image not available in HTML version

What is the hardest of all? What you as easiest would deem

To see with your eyes, what lies before your eyes.

Johann Wolfgang von Goethe

TOOLE’S Cerebrovascular Disorders, Sixth Edition


The Ohio State University College of Medicine, Columbus, Ohio


Penn State College of Medicine, Hershey, Pennsylvania


Loyola University Chicago Stritch School of Medicine, Maywood, Illinois

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Information on this title:

© Cambridge University Press 2010

This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press.

First published 2010

Printed in the United States of America

A catalog record for this publication is available from the British Library.

Library of Congress Cataloging in Publication DataRoach, E. S. (Ewell Steve)Toole’s cerebrovascular disorders. – 6th ed. / E. Steve Roach, Kerstin Bettermann, José Biller.p. ; cm.Rev. ed. of: Cerebrovascular disorders / James F. Toole. 5th ed. c1999.Includes bibliographical references and index.ISBN 978-0-521-86622-4 (hardback)1. Cerebrovascular disease. I. Bettermann, Kerstin. II. Biller, José. III. Toole, James F., 1925– Cerebrovascular disorders. IV. Title. V. Title: Cerebrovascular disorders.[DNLM: 1. Cerebrovascular Disorders. WL 355 R628t 2009]RC388.5.T6 2009616.8′1–dc22 2009013065

ISBN 978-0-521-86622-4 Hardback

Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party Internet Web sites referred to in this publication and does not guarantee that any content on such Web sites is, or will remain, accurate or appropriate.

We dedicate this book to

Lisa Hyde Roach

Wolfram, Katherine, and Sebastian Bettermann

Rhonda T. Biller


Contributor Affiliations
Foreword by James F. Toole
1     A History of Cerebrovascular Disease since the Renaissance
James F. Toole
2     Interview and Examination
3     Syndromes of Vascular Dysfunction
4     Pathophysiology of Ischemic Stroke
5     Diagnostic Evaluation of Stroke
6     Transient Ischemic Attacks
7     Atherosclerosis of the Cervicocranial Arteries
8     Embolism and Stroke
9     Lacunar Strokes and Hypertensive Encephalopathy
10    Inflammatory Angiopathies and Stroke
11    Hematological Disorders and Hypercoagulable States
12    Arterial Dissection
13    Moyamoya and Other Vasculopathies
14    Migraine and Related Disorders
15    Vascular Dementia
16    Intracerebral Hemorrhage
17    Subarachnoid Hemorrhage and Aneurysms
18    Intracranial Vascular Malformations
19    Subdural and Epidural Hematomas
20    Sinovenous Occlusion
21    Genetics of Cerebrovascular Disease
22    Stroke in Children
23    Stroke in Pregnancy
24    Vascular Diseases of the Spinal Cord
25    Management of Acute Ischemic Infarction
26    Neurorehabilitation Following Stroke
David C. Good and Lumy Sawaki

Contributor Affiliations

David C. Good, MD

Department of Neurology
Penn State University
College of Medicine
Hershey, Pennsylvania

Lumy Sawaki, MD, PhD

Departments of Physical Medicine and Rehabilitation and Neurology
University of Kentucky College of Medicine
Lexington, Kentucky

James F. Toole, MD

Walter C. Teagle Professor of Neurology
Wake Forest University School of Medicine
Winston-Salem, North Carolina


I am honored that three such highly authoritative stroke neurologists have produced the sixth English edition of what began at Wake Forest in 1964 as a collaboration with my research Fellow, Aneel Patel. Our goal was to summarize the nascent field by writing the first textbook devoted solely to the prevention, diagnosis, management, and rehabilitation of stroke, emphasizing transient ischemic attacks – then a new concept. At that time there were no stroke journals or texts devoted solely to the topic even though stroke was already becoming recognized as a leading cause of disability and death worldwide.

We reviewed anatomy, physiology, patient presentation and examination, differential diagnosis, management, and rehabilitation. In those days our equipment was a detailed history, a reflex hammer, a tuning fork, a wisp of cotton, and a pin. We adopted the stethoscope as well as ophthalmoscope for neurologic use. There were few useful neurodiagnostic tests. Before ultrasound, computed tomography, computed tomography angiography, magnetic resonance imaging, and SPECT, we used skull X-rays to determine displacement of the calcified pineal gland because it was thought too daring to do an arteriogram. The prevailing attitude was “There is no treatment for stroke, so what purpose do dangerous studies serve?” I took the opposite view – that severe carotid stenosis, even if still asymptomatic, deserved medical and perhaps surgical intervention and that atherosclerosis could be stabilized and in some cases even reversed. At that time these were bold theories and actions. Gradually, of course, attitudes about stroke care have changed, and we have evolved from a largely intuitive approach to a more evidence-based mentality that is made possible by years of study and painstakingly completed multicenter clinical trials.

Dr. Richard L. Masland, previously at Wake Forest University and subsequently Director of the National Institute of Neurologic Diseases, along with Dr. Murray Goldstein designed and implemented the stroke portion of President Lyndon Johnson’s so-called War on Heart Disease, Cancer, and Stroke. Our medical center subsequently became the third in the nation to be designated a stroke center. Over time we attracted a number of extraordinarily talented people, including Dr. Lawrence McHenry, a medical historian who helped to develop cerebral blood flow measurement; Dr. William M. McKinney, who led the charge in developing and promoting ultrasound as a noninvasive neurovascular imaging tool; Dr. Richard Janeway, who rose to become dean of our medical college; and Dr. David Good, a neurorehabilitation specialist who has contributed to the last several editions of this book. Assisted by Diane C. Vernon and Ralph Hicks, we participated in the formation of national and international stroke societies and the editing of journals and texts, which have resulted in worldwide attention to this dread disorder – stroke.

We also attracted exceptional people for training, among them all three authors of this sixth edition of Cerebrovascular Disorders: E. Steve Roach, MD, a child neurologist specializing in stroke and genetics; Dr. José Biller, MD, a superb clinician and educator who focuses on stroke and cerebrovascular disorders; and most recently Kerstin Bettermann, MD, PhD, an expert in stroke and neurocirculatory physiology. I am proud to have influenced these and other outstanding colleagues, and as I leave the bedside for a more research-oriented life, I enthusiastically pass the baton to them as a team akin to that of Olympian Roger Bannister, neurocirculatory physiologist and neurologist, who electrified the world by doing the impossible – breaking the track barrier of the four-minute mile.1 Of course, Bannister’s hard-earned track record was quickly surpassed, as will be, one hopes, our current achievements in the study of stroke.

The six editions of Cerebrovascular Disorders mirror to a large extent the changes in our understanding of stroke and its diagnosis, prevention, management, and rehabilitation over the last four decades. Each succeeding edition incorporated an increasing array of new diagnostic techniques and reflected a progressively more sophisticated understanding of stroke in all its forms and presentations, increasingly supported by experimental models and patient-centered clinical trials. As evidenced by the numerous new pathological specimens that illustrate this sixth edition, it retains the firm grounding in neuroanatomy and pathology that characterized the previous editions. Like the earlier editions, this one strives to make the concepts that underlie stroke prevention, diagnosis, and management understandable to both clinicians and students. Moreover, this edition includes new developments in the prevention, diagnosis, and treatment of stroke, with new considerations of arterial dissection, genetic aspects, acute therapy, and vasculopathies as well as major updates of endovascular treatment, pathophysiology, technology, and primary and secondary stroke prevention. In the future, new concepts and methods will continue to accumulate, and so I applaud my author colleagues for providing a comprehensive, readable, and authoritative picture of what stroke care has become.


Bascomb N. The Perfect Mile: Three Athletes, One Goal, and Less than Four Minutes to Achieve It. Boston: Houghton Mifflin; 2004.

James F. Toole, MD
The Walter C. Teagle Professor of Neurology and Public Health Sciences
Wake Forest University Baptist Medical Center
Past President of the American Neurological Association
Past President of the World Federation of Neurology
Past President of the International Stroke Society

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