Vascular Neurology
Stroke is the third leading cause of death in the industrialized world, following heart disease and all cancer deaths. It is the leading cause of neurologic disability. About 500,000 new strokes still occur annually in the United States despite advances in prevention through risk factor management and surgical intervention. The challenge of stroke will remain for all medical practitioners as the proportion of older Americans continues to rise into the next century.
Overview
The Baylor Department of Neurology provides care for acute ischemic stroke at four major general hospitals: St. Luke’s Episcopal Hospital, The Methodist Hospital, The Ben Taub Hospital, and the Michael E. DeBakey VA Hospital. Each setting is equipped with the resources for comprehensive stroke care, including endovascular care and urgent neurosurgical intervention.
St. Lukes' Episcopal Hospital
Stenting of the basilar artery in the setting of acute brainstem ischemia.
St. Lukes' Episcopal Hospital (SLEH), including the Texas Heart Institute, is a 900 bed private, general adult hospital that serves as the primary hospital affiliate of Baylor College of Medicine. There is an active Brain Attack program for rapid evaluation of inpatient acute ischemic stroke as well as patients presenting to the emergency ward. The Brain Attack Program is build around thrombolytic therapy, delivered intravenously, intra-arterially, or by a combination of the routes. Endovascular techniques such as stenting acute carotid dissections further extend the range of our acute therapies. A 20 bed Neurocritical care unit is staffed by Baylor Neurologists trained in intensive care. A powerful array of patient care resources are available, include transcranial Doppler and a portable CT scanner in the unit. Neurological expertise is complemented by a large and highly skilled endovascular service, based in Neuroradiology.
Restoration of cerebral blood flow after intra-arterial administration
of a thrombolytic agent.
Dr. Jose Suarez directs the Vascular Neurology service at St. Luke’s, and is actively studying the use of human serum albumin in the context of acute ischemic stroke. Other clinical investigations focus on the use of hypothermia after cardiopulmonary arrest, and the benefits of close control of glucose concentration during the early phases of acute ischemic stroke.
The Texas Heart Institute at St. Luke’s is one of the largest cardiovascular programs in the world. There are exceptional opportunities for clinical investigation and cooperative care in patients with severe atheromatous disorders.
The Methodist Hospital
The Methodist Hospital is licensed for 1200 adult beds. The Department of Neurology at Baylor College of Medicine provides two patterns of care: general inpatient consultation, and an acute stroke service. The hospital has superb imaging and patient care resources, and the sheer number of patients provides an excellent training environment. The Methodist Hospital ranked 9th in the nation for Neurology and Neurosurgery in the 2007 US News and World Report Survey.
Ben Taub General Hospital
MR imaging of a stroke caused by occlusion of a small penetrating artery.
The Ben Taub General Hospital (BTGH) is an important teaching and education site for Baylor College of Medicine, and is one of the busiest public hospitals in the country. Somchai Laowattana, M.D., Ph.D. has recently joined BTGH and directs the stroke service. Dr. Laowattana’s clinical and research interest is in the interaction between stroke, the autonomic nervous system, and the heart. BTGH has approved the establishment of a dedicated stroke unit that will evolve over the next few years. Also available are CT and MRI based imaging support and interventional neuroradiological procedures both for stroke management and prevention. Dr. Laowattana has established a weekly stroke clinic.
Michael E. DeBakey Veterans Affairs Medical Center
Care for cerebrovascular disease has attained remarkable clinical and clinical research excellence at the Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC). Dr. Thomas A. Kent directs the Neurology service, and has developed a Brain Attack program that regularly provides thrombolytic care in the first three hours after the onset of stroke. This is nearly unique across the VA hospitals in the nation.
Roderic Fabian, M.D. and Pitchaiah Mandava, M.D., Ph.D. are stroke specialists with extensive clinical and research experience who work closely with Dr. Kent. Jane Anderson, NP, is Associate Director of the Stroke Program and has a major interest in decision support systems to aid in the development and maintenance of high quality clinical stroke care. There are two fellow positions funded through the MEDVAMC. All of the excellent attending physicians in the Neurology Care Line participate in the care of stroke patients, providing an outstanding interactive environment for our patients, fellows, residents and students.
The clinical research program in cerebrovascular disease has special expertise in the role of platelet aggregation in acute ischemic stroke. They are testing the potential therapeutic roles of low dose abciximab plus short term heparin as an alternative to intra-arterial delivery of thrombolytic agents. There is an extensive research program on the interaction between diabetes, hyperglycemia and acute stroke. Intensive insulin therapy, through an NIH funded grant, is being investigated both clinically and in the laboratory. Hyperglycemia is the second most important predictor of outcome in acute stroke and the focus of our research is the deleterious effects of hyperglycemia on vascular function
Basic research at the MEDVAMC is focused on both the vasculature and on factors that influence neuronal plasticity after stroke. Drs. Kent and Fabian, with an NIH-funded project part of a larger Program Project Grant, are investigating the role of endothelial dysfunction, specifically “uncoupling” in brain injury following hypoxic/ischemic injury. The same mechanism, by which endothelium produce superoxide in lieu of the important vasodilator, nitric oxide, is being studied in hyperglycemia.
Recovery after stroke is extensively studied in the laboratory, supervised by William Dalmeida. Dr. Kent and colleagues have discovered that the important class of transcriptional regulators, the CEBP’s, are expressed in specific cell types following ischemic injury and when overexpressed in neuronal culture, influence neurite extension. Dr. Kent is studying the development of a high throughput assay that will investigate small molecules that can improve neuroplastic responses. There is a clinical project in stroke recovery, using magnetoencephalography in collaboration with Dr. Andrew Papanicolaou at the Texas Institute of Research in Rehabilitation (TIRR), funded through an NIH Program Project Grant, examining neuroplastic responses in the brains of patients as they recover from stroke.
BCM Department of Neurology
Educational Activities related to stroke include a monthly stroke journal club. There is a weekly neurovascular conference at St. Luke’s that emphasizes recent clinical experience with endovascular care. The St. Luke’s program also conducts weekly didactic conferences and weekly case review conferences. In addition, there are numerous opportunities for joint clinical and research activities with the other institutions represented at the Texas Medical Center.