In the 1970s, as I transitioned from neurosurgical residency to a faculty member responsible for treating patients with vascular abnormalities causing SAH, we made enormous strides in better therapies for these patients, including safe systematic arteriography, the use of the microscope for intracranial clipping, and early surgical intervention which allowed utilization of hypertensive, hypervolemic, hemodilution (HHH) therapy. Securing the aneurysm early made a world of difference in our ability to increase the mean arterial pressure (MAP) and lower the intracranial pressure (ICP) without fear of aneurysmal rupture. Since that time, other technological advances, notably endovascular therapies have enhanced less invasive intervention and this technology promises a bright future in arterial wall reconstruction, obliteration of aneurysms, and targeted delivery of molecules.

However, understanding the complex cascading pathophysiology of cerebral ischemia associated with vasospasm has been frustratingly slow, and without that knowledge, targeted medical therapy is difficult, with multiple therapeutic human clinical trials failing to result in a clear reversal or protection from the disease process. This very controversy in the research and clinical care of patients with DCI is what makes this slim reductionist volume on cerebral vasospasm by the Yale neurovascular specialists so valuable.

For the first time, under one cover you can explore the history and epidemiology of this process. Systematically, the editors have examined the rational research that defines a cascade of molecular and inflammatory events leading not to a simple reversible vasospasm phenomenon, but indeed a progressive arteriopathy. As in most human diseases, animal models are imperfect and although inhibitors of potent vasoconstrictors such as endothelin-1 (ET-1) and antagonism of inflammatory inhibitors of the natural vasodilator, nitric oxide (NO) are effective in animal models, they have fallen short in human trials.

The molecular mechanisms chapter in this volume outlines exciting and promising new molecules and one may be tempted to wait for the magic bullet. However, the editors, instead, take all the successes and failures of past therapy and provide in the appendix a carefully thought out protocol for today's SAH patient. It is detailed and represents the best of a modern neurointensive approach to quality patient care.

Even more important than the protocol is the team that designed it. Of all the advances in modern medicine over the last 20 years, the team approach to patient care vies with many of the best individual basic research discoveries in saving patients' lives. As you will note, the book is compiled by Yale School of Medicine, Yale-New Haven Hospital physicians who interact on a daily basis. The protocol, therefore, is not abstract or idealized, but is a working practical consensus of the neurologists, neurosurgeons and neuroradiologists that comprise the team.

The team approach also allows the protocol to be dynamic and therefore not strictly evidence-based. Evidence-based therapies imply homogeneous populations. Our patients are far from homogeneous, even if, as in SAH, they suffer from a similar insult they demand individualization of care. The protocol is the “checklist” of a rational approach which is partly data driven, partly empirical, and always individualized.

Despite prophylactic measures, multimodality detection monitoring and aggressive treatment interventions, the outcome for many can remain grim. There is no question that the etiologic heterogeneity of cerebral vasospasm mirrors the variability in its clinical management even amongst experienced providers.

Contemporary Understanding and Management of Cerebral Vasospasm: A Practical Guide is written by clinicians, for clinicians to provide real-world information based on our current understanding of the disorder with the hope that it will lay the foundation for optimizing treatments across the world. With that goal in mind, we embark upon this journey with you.

This book is meant to support practitioners, who are in the trenches caring for these patients. This book is also meant to serve as a practical resource for all involved in the care of subarachnoid hemorrhage patients.

We express our gratitude to M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for their patience, encouragement and professionalism during the entire process. We are especially grateful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President), and Mr Tarun Duneja (Director–Publishing), Mr Sunil Kumar Dogra (Production Executive), Mr Neelambar Pant (Production Coordinator), Mr Manoj Pahuja (Senior Graphic Designer), Mr Hemant Kumar (Typesetter), and Mr Ashutosh Pathak (Proof Reader) for their continued and tireless dedication to ensuring the production of an excellent book.1415