Author: Louis R. Caplan, MD
Publisher:  Cambridge University Press – 594 pages
Book Review by: Nano Khilnani

In his Foreword to this detailed second edition of this book by Dr. Louis R. Caplan on posterior circulation disease, Dr. C. Miller Fisher that in the 1950s, “there was no therapy for the stroke patient. A stroke was a stroke was a stroke.” 

What happened after that? Anticoagulants were introduced, and vascular surgery followed.  As a consequence, Dr. Miller continues: “medicine was for the first time faced with the task of investigating the pathology and pathophysiology of the many types of cerebrovascular disease and laying down rules for diagnosis and management.”

Then, many diagnostic machines and tools were developed, including angiography, computed tomography (CT), magnetic resonance angiography (MRA), MR diffusion, magnetic resonance imaging (MRI), and neurosonography. Dr. Fisher informs us that in the new specialty of stroke neurology, it is now possible to intricately study strokes in the vertebra-basilar territory.

This book by Dr. Caplan is as extensive as it is intensive in coverage. It contains a very lengthy list of topics (that we have outlined by letters a,b,c, etc) that he discusses within 15 chapters organized around three broad Sections, as shown below:

  1. Section I – General Features of Cerebrovascular Disease in the Posterior Circulation
  2. Historical Background
  3. Early history
  4. Anatomy and pathology: the sixteenth, seventeenth, and eighteenth centuries
  5. The nineteenth and early twentieth centuries Basic Anatomy and Physiology
  6. Development of knowledge about the causes of stroke
  7. The modern era
  8. Acute reperfusion using thrombolytic drugs, thrombus removal with devices, and direct angioplasty and stenting
  9. Posterior circulation strokes
  10. Basic anatomy and pathology
  11. Brain anatomy
  12. Vascular pathology
  13. Signs and symptoms and their clinical localization
  14. Visual perception and related deficits
  15. Other cognitive and behavioral abnormalities including agnosia, alexia, and aphasia
  16. Reduced level of consciousness
  17. Moto abnormalities
  18. Vestibular and oculomotor abnormalities
  19. Sensory abnormalities
  20. Pupillary size and reactivity
  21. Automatic dysfunctions including abnormalities of cardiac and respiratory control and micturition
  22. Diagnosis: clinical, imaging, and laboratory
  23. Method of clinical diagnosis
  24. The frequency of various findings in the new England Medical Center Posterior Circulation Registry (NEMC-PCR)
  25. Common patterns of ischemia / infarction
  26. Diagnosis in the emergency room
  27. Question-driven imaging and laboratory evaluation
  28. Treatment
  29. Introduction
  30. Acute Ischemic stroke
  31. Stroke prevention
  32. Section II – Posterior Circulation Ischemia: Specific Vascular Sites and Conditions
  33. Extracranial occlusive disease: innominate, subclavian, and vertebral arteries
  34. The development of ideas and information
  35. Causes, frequency, and epidemiology of arterial lesions at various neck sites
  36. Symptoms, signs, and stroke mechanisms
  37. Diagnostic evaluation
  38. Treatment
  39. Intracranial vertebral arteries and the proximal intracranial territory
  40. Background and development of ideas
  41. Clinical findings in patients with proximal posterior circulation territory infarcts
  42. Findings in the New England Medical Center Posterior Circulation Registry
  43. Diagnosis and Treatment
  44. Basilar Artery
  45. Development of ideas
  46. Pathology, pathophysiology, and frequency of vascular lesions
  47. Other less common causes
  48. Symptoms and signs
  49. Reports of outcomes  in patients with basilar artery disease before the NEMC-PCR and the BASICS studies
  50. Basilar artery lesions in the NEMC Posterior Circulation Registry
  51. The Basilar Artery International Cooperative Study (BASICS)
  52. Clinical and laboratory diagnosis
  53. Treatment
  54. Posterior cerebral arteries(PCA)
  55. Background and development of ideas
  56. Pathology and frequency of vascular lesions and stroke mechanisms
  57. Clinical symptoms and signs
  58. PCA and PCA territory vascular lesions in the New England Medical Center Posterior Circulation Registry
  59. Diagnosis
  60. Treatment
  61. Penetrating Arteries
  62. Development of ideas about the pathology that causes small deep infatcts
  63. Development of knowledge about the anatomy of posterior circulation branches
  64. Signs, symptoms, syndromes in penetrating artery disease at various brainstem sites
  65. The New England Medical Center Posterior Circulation Registry experience
  66. Diagnosis
  67. Treatment of patients with branch artery occlusive disease
  68. Cerebral Infarcts
  69. Essential cerebellar brain and vascular anatomy and physiology
  70. Development of ideas about cerebellar lesions and infarcts
  71. Cerebellar infarcts: distribution, general clinical signs, outcome, and etiologies
  72. Posterior inferior cerebellar artery (PICA) territory cerebellar infarcts
  73. Anterior inferior cerebellar artery (AICA) territory cerebellar infarcts
  74. Superior cerebellar artery (SCA) territory cerebellar infarcts
  75. Multiple cerebellar artery (MCA) territory cerebellar infarct
  76. Small, non-territorial cerebral infarcts
  77. Pseudo-tumoral space-occupying cerebellar infarcts
  78. Hemorrhagic cerebellar infarcts
  79. Concluding comments
  80. Migrane
  81. Background information about migraine
  82. Migraine ‘auras’ and accompaniments
  83. Basilar artery migraine
  84. Vascular and hematological abnormalities
  85. Migraine-like conditions
  86. Differentiation of migrainous accompaniments from atherostenous-related brain ischemia
  87. Migrainous strokes
  88. Summary and conclusions
  89. Venous and dural sinus thrombosis
  90. Anatomy
  91. Development of ideas
  92. Etiologies
  93. Distribution of the venous structures involved
  94. General clinical features
  95. Thrombosis of venous structures that drain the structures within the posterior circulation
  96. Diagnosis
  97. Treatment
  98. Section III – Posterior Circulation Hemorrhage
  99. Parenchymatous hemorrhage
  100. General considerations
  101. Historical background
  102. Hemorrhage at various posterior circulation sites
  103. Subarachnoid Hemorrhage, Aneurysms, and Vascular Malformations
  104. Subarachnoid hemorrhage and intracranial aneurysms
  105. Vascular malformations

This is truly an excellent book on the growing neurological specialty of vertebra-basilar ischemia and hemorrhage. It is probably the one o the best one available in the medical book market on this subject because of its broad yet detailed analysis of the many aspects it covers.



Louis R. Caplan, MD is Senior Neurologist at Beth Israel Deaconess Medical Center (BIDMC) and Professor of Neurology at Harvard Medical School in Boston, Massachusetts.