Book Reviews


 

Concussion and Traumatic Encephalopathy: Causes, Diagnosis and Management 1st Edition

by Jeff Victoroff (Editor), Erin D. Bigler (Editor)  Cambridge University Press; 1 edition (April 18, 2019)


[The reviewer is an adult neurologist who has treated brain injuries since the early 1980s and is certified in brain injury medicine. I have no connections to any of the authors but did attend an excellent presentation in Toronto by Dr. Bigler. This enthusiastic review is based exclusively on the extraordinary merits of this remarkable work. I have bought more than one copy and will be buying more.]


This work is a collaborative effort of some rather heavy hitters in the field. Despite the impressive pedigree, sometimes this tome reads like a monologue. Other writers surface from the deep on occasion with worthy information but at its soul, this is Wunderkind and adult neurologist Jeff Victoroff’s brainchild. At first, I was puzzled that as we approach November 2019 no review has been posted on Amazon. On reflection, that is probably related to the nature and presentation of some rather anti-mainstream sentiment. Don’t let the lack of reviews divert you from an incredibly important work. 

The only other book loosely within my domain that I would give 5 stars is The Psychopathology of Everyday Life.  There is much to like in Concussion and Traumatic Encephalopathy but there is even more to love. Stay with me, you are going to agree.

To properly grasp the importance of this book one needs to understand the sad and pathetic scholarship, attitudes, suspicion, axiomatic thinking that bedevil the mild traumatic brain injury (concussion) field. The word on the street (and in the journals) is that these patients all get better except for a few miserable folks who are lying or have pre-existing problems. As noted in my disclaimer, I have treated traumatic brain injury for a long time. My personal experience does not comport well with the “official story.”  Many of these patients do not get better. They lose their jobs, get divorced, endure a type of frustration hard to imagine, live in pain, are ostracized and suffer perhaps the supreme indignity of not being believed. Not by friends or family but also by the very person who really should know better. Their physician. Friends and family members might get a pass but not the MD. These folks, mostly men, represent an invisible and bewildered army of inexplicably failing humans. Although they are hard to find, you could look in bars, divorce courts, unemployment lines, ER’s with another TBI, ED clinics, AA meetings, detox/tox centers, and if we are to believe our polymath interlocutor, on death row. Some of these injured souls take their own lives. How long after? Sometimes two decades according to a Finnish study.

It is with all this in mind that we really have to appreciate the sterilizing sunshine and anti-miasma spray that this book brings to our unique dungeon.

Not slow to warm to his subject, Dr. V doesn’t even wait for chapter one. Already in Acknowledgments, he sets upon us. The crime scene is rapidly demarcated with yellow tape, and we learn quite early on which side of the divide he and Dr. Bigler stand.  Speaking of his and Dr. Bigler’s conviction that concussive brain injury (CBI) was serious and inadequately addressed:


(We), by evolutionary convergence or serendipity, arrived at pretty much the same conclusion at the same time: the problem with truly understanding the human consequences of CBI transcended the combined effects of low-quality research and puritanical suspicion of patients with persistent distress.


OK, battle lines drawn. The first tactical nuke is launched at the “central dogma” i.e. that except for the “miserable 15%” everyone is all OK and better again after 3 months. There were no survivors of this attack. Exhaustive argumentation drawn from epidemiology, static imaging, dynamic imaging including functional magnetic resonance imaging (fMRI), PET scans, genetic studies, pathology, electrophysiology, and animal studies are collated and marshaled definitively against the belief that a concussion is trivial or short-lived. Dr. Victoroff proposes a more realistic figure for permanent post-TBI problems at approximately 40%. Thousands of references are provided and an excellent historical review is included. Plenty of heroes and villains! Actually more villains than heroes. The words of Niels Bohr came to mind, “ Science advances one funeral at a time.”

And another thing that needs to be beaten into the head of physicians is driven home in the intro. It makes no sense to attempt to distinguish between “organic” and “psychological” illness. Anxiety, depression and other “psychological” are rooted in brain dysfunction of one type or another. These symptoms are likely to be part of the injury rather than a reaction to it. Depression, for example, is seen in just about every brain disorder. 

The individuality of a brain injury is discussed frequently, especially in chapter five. Even the brains of identical twins are significantly different.  A description of the uniquely vexing nature of studying TBI is provided in this chapter:

Since the effects of a concussion are never the same in two people, testing the victim’s frequency of headaches or mental efficiency compared with the average human is fruitless. The only meaningful comparison is between that victim and his pre-injury self.

Oh, Dr. Victoroff is not above good-natured dishing on the various specialties involved in TBI. We neurologists really got clubbed (rightly so) but despite the navy blue jacket and fragile appearing bow ties, we’re pretty resilient. Not so sure about the psychiatrists though.

Who really was roundhoused were the neuropsychologists. Their tools which are ancient and were never intended for use in head injuries were heavily criticized specifically due to validity and specificity failings. That is not to say that in the proper setting these techniques are not valuable.

There is much more to this book. The language is beautiful and there is plenty of unexpected humor. This book is not going to tell you how to manage seizures or elevated intracranial pressure in the ICU. It is not intended for that. Other TBI books that I like are Hovda’s and Zasler’s.

Some will find this book too long. And it might be for some but I found the historical and philosophical contextualization useful if not immediately practical. TBI may be the most complex clinical syndrome known to medicine. This book is a major step in the right direction. Amazon should only ship this book with a dictionary. I know I needed mine.  Does anyone know what “bedizen” means?

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