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Vital Signs

Striking back at death and disability caused by strokes

Stroke strikes someone every 45 seconds in the United States. It's the third leading cause of death, according to the American Heart Association, and the major cause of serious long-term disability. Two Dartmouth faculty members—stroke specialists who head up DHMC's multidisciplinary stroke program—hope to change those statistics.

Expanding: Neurologist Timothy Lukovits, M.D., and neurosurgeon Jonathan Friedman, M.D., joined the faculty in 2002 and 2003, respectively. They are expanding the stroke program previously run by neurologist Alex Reeves, M.D., who retired in 2002, and neurosurgeon Robert Harbaugh, M.D., who was recruited away from Dartmouth in 2003 to be the chair of neurosurgery at Penn State- Hershey Medical Center.

The newcomers' training coincided with some of the greatest advances in stroke care. Lukovits, a 1988 graduate of Dartmouth College, was nearing the end of his residency at DHMC in the 1990s just as the clot-busting drug tissue plasminogen activator (tPA) began revolutionizing the way strokes were treated. Until then, the field of stroke neurology had focused on exploring neuroanatomy and locating lesions in the brain.

"Now we had to behave more like emergency medicine physicians— quickly evaluate the patients— because you had three hours between the onset of the symptoms and the administration of the medication," Lukovits explains.

And Friedman, who recently completed a residency at the Mayo Clinic, has witnessed how surgical treatments for aneurysms, one of the main causes of hemorrhagic stroke, have improved over the past 10 years. One of the recent advances, which Friedman refers to as the "coiling of aneurysms," involves inserting a plastic catheter into a major artery in the groin and guiding it through the vascular system to the brain, where it releases tiny platinum coils into the aneurysm. The coils keep blood from entering the aneurysm. But, he points out, in the majority of cases, surgeons still perform the "gold-standard procedure" of surgically putting a clip on the aneurysm.

Jonathan Friedman, left, and Tim Lukovits are the new heads of DHMC's stroke unit.
Photo: Flying Squirrel Graphics

Smarter: Surgery isn't the only option, of course. In fact, Friedman says, "we've gotten a lot smarter . . . about picking who to operate on and who not to operate on, so that we can provide benefit to a greater number of people and spare other people the risk of surgery."

That philosophy of providing the most appropriate care to stroke patients is the underlying theme of DHMC's multidisciplinary stroke program, which is made up of specialists from neurology, neurosurgery, neuroradiology, neuroanesthesiology, stereotactic radiology, and criticalcare medicine. Together, they try to reach a consensus on what sorts of medical or surgical treatments make sense for the individual patient, no matter what condition each one has—ischemic stroke, intracranial hemorrhage, carotid artery disease, intracranial aneurysm, vascular malformation, or the ministroke known as a transient ischemic attack (TIA). Lukovits and Friedman agree that Dartmouth's collaborative environment fosters a more unified and less fragmented approach to patient care than some larger institutions are able to offer.

In fact, they believe DHMC's stroke program is well positioned to seek recognition as a nationally certified stroke center—as soon as such such certification is available. The Joint Commission of Accreditation of Healthcare Organizations is in the process of establishing criteria for designating levels of stroke centers in much the same way trauma centers are now designated. "Within the next couple of years," says Lukovits, "we're going to see certain hospitals get some kind of certification [as a] comprehensive stroke center [or a] primary stroke center."

As well as running the stroke program, the directors both do research. Lukovits is collaborating with cardiology on a multicenter clinical trial of a device to prevent recurrent TIAs and embolic strokes in patients with a particular heart defect. And Friedman does basic research on axonal regeneration after spinalcord injuries or strokes.

Focus: But, cautions Lukovits, although "these things are very glamorous and kind of exciting," delivering top-notch care is their primary focus—"good nursing care, multidisciplinary assessment, and appropriate use of rehabilitation," he explains, "all the things that a stroke unit does and [that have] been shown to improve outcomes."

"Although we've made a lot of progress, there's an awful long way to go as far as improving outcomes of patients," says Friedman of the state of the field.

Laura Stephenson Carter

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