LOUISVILLE If you ask Alex Abou-Chebl, MD, interventional neurologist with Baptist Neuroscience Associates, part of Baptist Health Louisville, the secret to changing the status quo in medicine, his answer will probably be stubbornness and the refusal to accept “no treatment available” as an answer. Five minutes into a conversation with him and his passion and persistence about stroke care are immediately evident. “I actually think stroke is the most important disease known to mankind because it affects the very organ that makes us who we are, that makes us human,” he says. Stroke is the fourth leading cause of death and the leading cause of adult disability in the United States. “The reality is that the majority of patients in the stroke belt, where Kentucky is, do not get adequate stroke care. I want to solve that,” he contends.
A Diagnosis without Treatments
It was the complexity of the brain and the lack of effective treatments for stroke while he was in medical school in the 1990s that drew Abou-Chebl to the field of neurology. But the road from education to stroke intervention was an uphill climb. In addition to the lack of therapies, neurologists also faced a misconception about their role. “I refused the notion because I was a neurologist I could not intervene,” says Abou-Chebl. “We could diagnose where the problem was but we were viewed as not being able to offer treatment to patients.” He persevered because he believed the clinically trained neurologist is the best person to manage patients through all phases of care.
In 1999, Abou-Chebl began a fellowship in interventional neurology at Cleveland Clinic, a training program he helped create. He completed that fellowship and two others, in stroke and critical care neurology, concurrently at Cleveland Clinic over the next three years. In 2002, he became the first interventional neurologist on staff at Cleveland Clinic and “one of the first interventional neurologists in the world,” he says.
Fortuitously for Abou-Chebl, his pursuit of comprehensive stroke care overlapped with the advent of effective stroke treatments, such as thrombolysis and mechanical embolectomy, in the late 1990s and early 2000s. “The development of the field of neurology really coincided with the availability of new treatments,” he says.
By 2006 there were 14 interventional neurologists in the world, and they formed the Society of Vascular and Interventional Neurology, of which Abou-Chebl was the founding vice president and is still a board member.
Building a Better Program
Abou-Chebl joined Baptist Health Louisville in August 2014 after seven-and-a-half years as director of Interventional Neurology at the University of Louisville. Because of Baptist Health’s large patient population and gap in comprehensive stroke services, he says, “I saw an opportunity here to help build a world-class stroke program.”
He is quick to note that interventional neurologists are not the only physicians who can treat stroke and that building a better program necessitates a team approach. “The ideal program, which is what I think we have here at Baptist, is where neurologists, neurosurgeons, and neuroradiologists work together to deliver the best possible care.” Each of these specialties can perform stroke interventions and each brings different tools and skills to the table, he posits.
With the right team in place, the next part of Abou-Chebl’s mission is to continue to expand effective stroke treatments. “Every stroke patient has to be given a chance to receive some treatment, and this means we cannot stop until we prove that there’s no brain tissue worth saving, for every individual,” he says.
For example, Abou-Chebl refused to accept there were no treatment options for the acute stroke patient who presents beyond six hours after onset. After doing a few anecdotal cases, he set about creating the scientific evidence to back his position. “One way we can garner that evidence is by doing advanced multimodal imaging – scans that look at how much brain tissue is dead, how much brain tissue is at risk of dying, and what brain tissue is not at risk of dying,” he says. By working with neuroradiologists to do CT and MRI perfusion scans, they established a protocol for screening patients. The neuroradiologists then interpret the scans to identify patients with large penumbras, brain tissue that is at risk of dying, to see who could benefit most from mechanical embolectomy, removal of the clot, or thrombolysis, clot-busting medication. Abou-Chebl then performs the procedure. In the case that the procedure is not successful or there is already too much damage, a neurosurgeon may be called in to consult.
Because acute stroke treatments are still relatively new, they are still being tested and fine-tuned. Intravenous tissue plasminogen activator (IV tPA) is still the gold standard for ischemic stroke, the most common type of stroke, when administered within three to four hours of stroke onset. However, Abou-Chebl says, “Generally across the country, only five percent of patients are being treated with IV tPA. We have to do better.”
National guidelines for door-to-tPA time are under 60 minutes. Abou-Chebl says Baptist Health Louisville’s quickest door-to-tPA time has been 15 minutes, and they do a “substantial amount” under 30 minutes because of the protocols they have in place.
Beyond tPA, the good news is that in mid-November 2014, two randomized clinical trials showed mechanical embolectomy to be effective at improving stroke outcomes for the first time. “I think now the standard of care is going to shift so that within 12 hours of stroke onset, if a person has major stroke, and a CT scan doesn’t show a lot of dead brain, they should be offered mechanical embolectomy,” says Abou-Chebl. The success rate for opening an artery with this procedure is 80 to 90 percent, and Abou-Chebl says up to 60 percent of patients walk home from the hospital.
In hemorrhagic stroke, there is a new Pipeline stent for subarachnoid hemorrhages, available at Baptist, which is employed in the normal artery to block blood flow to the aneurysm.
Regardless of stroke presentation, for Abou-Chebl the path is clear: “The days of therapeutic nihilism are gone. We’ve got to get rid of this notion that you can’t treat stroke patients … and we’ve got to do better at educating our patients on the symptoms of stroke. If they don’t come in, we can’t treat them.”