Joseph Broderick, professor of neurology and director of the Neuroscience Institute at the University of Cincinnati, Cincinnati, USA, has focused much of his career on the treatment and underlying causes of stroke. He speaks to NeuroNews about the future of neurology and his research, in particular, his role as principal investigator for NIH StrokeNet—a network slated to be the engine for all new US National Institute of Neurological Disorders and Stroke-funded trials for stroke prevention, acute therapy, and recovery.
How did you come to choose medicine as a career and, in particular, what drew you to neurology and stroke treatment?
My father is a wonderful role model as a person and physician, but I thought strongly about psychology and pastoral counselling in college where my major was classical studies and my minor was philosophy. I did not decide to pursue medicine until the end of junior year and I had to take organic chemistry across summer to make requirements for my medical school application. I planned to be a psychiatrist when I entered medical school but found that psychiatrists in those days rarely laid hands on patients which did not fit my vision of a physician. I then considered internal medicine like my father, but my first rotation in internal medicine at the beginning of third year was painful. I finally came to consider neurology, which combined the thought processes and patient care of internal medicine with my fascination of how the brain works. In residency, I considered many potential subspecialties, but was drawn to stroke because of several role models: one who was a tremendous teacher and one who was a thoughtful clinical researcher.
Who were your mentors in the field and what do you still remember from their wisdom?
Burt Sandok was the chair of Neurology at the Mayo Clinic and ran a wonderful cerebrovascular teaching conference. He became a role model for me as a stroke physician and educator. Jack Whisnant, the former chair of Neurology at Mayo, was another important role model from whom I learnt the tools of clinical research, research writing, and a critical approach to data that set me on my path as a clinical researcher.
What was your most memorable case and why?
The most memorable patient is from my earliest days as a senior neurology resident. I admitted a 19-year-old college student who had progressive language problems and confusion over several weeks. She had aphasia and apraxia upon examination and had a history of a hospitalisation for aseptic meningitis, bilateral facial weakness and possible rash at the age of 13 which resolved completely with prednisone. Her cerebrospinal fluid showed 15 white cells (lymphocytic) and normal glucose. At that time, neurological presentations for Lyme disease had just been described (CDC first monitored the disease in 1985), but her classic presentation was six years earlier. I empirically treated her with intravenous penicillin for what I thought could be the first reported case of tertiary Lyme disease, although my attending physician was sceptical. She continued to worsen over two weeks despite antibiotics and was discharged to her home town. Two months later, I got a call from the neurologic attending to come quickly to his office because he wanted to show me something. To my surprise, there was the young woman who now had a normal neurological exam. Her serology (Lyme serology was just being developed at that time) eventually confirmed Lyme disease, and she returned to college. I had a heck of time getting my case of tertiary Lyme disease published because reviewers would not accept the concept without an actual spirochete. Changing lives is what we do with acute stroke therapy and this was my first taste of this experience which I saw again and again while treating stroke patients with t-PA for the first time in the 1980s.
What innovations have changed neurology and in particular, stroke care, in the last 10 years?
I think that the standardisation and expansion of neurocritical care units and training have improved neurological outcomes, although this is hard to measure. I think that this is one reason underlying the decrease in mortality due to SAH over the past 20 years. The aggressive approach to medical stroke prevention—better blood pressure control, statins, smoking cessation, diet, antithrombotic medications, etc—has proven to be a match for interventional approaches to reduce stroke in patients with major extracranial and intracranial atherosclerosis. We have some excellent options instead of warfarin for patients with atrial fibrillation. Endovascular technology is changing the treatment of both ischaemic and haemorrhagic stroke, but demonstrating the subgroups of patients most likely to benefit from its use requires much more study.
As chair of the American Heart Association Stroke Council, what would you say are the benefits of becoming a member? How do members help to shape the future of stroke care?
The AHA/ASA has been my entree into the world of stroke and cardiovascular science and education. My career may have been quite different without it. My very first grant was an American Heart Association Grant-in-Aid award that eventually led to our longstanding population-based study of stroke in Greater Cincinnati/Northern Kentucky. The ISC meetings are where I have been witness to the many major advances in stroke research over the past 25+years and where I have developed some of my best collaborations and friendships within medicine, not just in North America but around the world. Members of the AHA/ASA get to help shape the strategic direction of science, education and advocacy to decrease the burden of stroke and heart disease.
How do you see the field of neurology and stroke care developing in the future?
We must do a much better job with transitions of care in both neurology and stroke. Our current systems are too fragmented and not as patient/family-centred as they need to be. I believe that the great advances in the next century will be in the area of neuro-recovery and rehabilitation and that future advances in acute stroke therapy will ultimately be limited by the constraints of time and biology within the next 25 years or so. This has already happened for the most part in the treatment of acute myocardial infarction.
What are your current areas of research focused on?
My current research areas include new medical and interventional approaches to acute ischaemic stroke; triage of acute stroke patients; the improved design, organisation and delivery of clinical trials; and the genetics of intracranial aneurysm. One of my most exciting areas of research is my role as principal investigator of the national coordinating centre for the new NIH StrokeNet. This network will be the engine for all new NINDS-funded stroke trials for prevention, acute therapy, and recovery. We hope that this infrastructure will allow us to make progress in the prevention and treatment of stroke more rapidly and are planning to link this network with other national stroke networks to do stroke trials that are too big for one country in a reasonable time frame.
What recent publications have caught your eye?
The publications in New England Journal of Medicine (NEJM) this year regarding increased detection of atrial fibrillation with more prolonged monitoring are interesting and probably will change practice, although their true impact on stroke prevention requires longer term study. I am looking forward to the results of the MR CLEAN trial which tests endovascular therapy as compared to standard care in acute ischaemic stroke. And finally as a neurologist, I was delighted to see that a British-American scientist and a pair of Norwegian researchers were awarded this year’s Nobel Prize in Physiology or Medicine for discovering “an inner GPS in the brain” that enables virtually all creatures, including humans, to navigate their surroundings. Still left unsolved is why men do not like to ask for directions.
What are your interests outside of medicine?
My wife and four children, and a very large extended and close-knit family are the centre of my personal life. I am an avid college basketball fan and sports fan in general; I have very eclectic musical tastes and play the piano, and read broadly and often. And sometimes sleep.
Professor of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine and director of the University of Cincinnati Neuroscience Institute, Cincinnati, USA
1978 Honours Bachelor of the Arts, summa cum laude with distinction
1982 Medical doctor
1987 Fellow in cerebrovascular disease
1986–1987 Instructor, Mayo Clinic
1987–1993 Assistant professor of Neurology, University of Cincinnati
1987–1993 Staff Attending Physician, Veterans Administration Medical Center
1988–1994 Director of Neurology Residency Training Program
1993–1996 Associate professor of Neurology
1997–2007 Director, Vascular Neurology Fellowship
1996–2010 Tertiary Neurosurgery Appointment
2000–2013 Chairman, Department of Neurology University of Cincinnati
2006–2013 Academic/Research Director of University of Cincinnati Neuroscience Institute
1987–present Staff attending physician, University of Cincinnati
1989–present Courtesy staff, 15 Community Hospitals
1996–present Professor of Neurology
2014–present Director, UC Neuroscience Institute
2000 Samuel Kaplan Visionary Research Award—American Heart Association
2003 William B Feinberg Award for Excellence in Clinical Stroke—Stroke Council of the American Heart Association
2007 University of Cincinnati Distinguished Research Professorship award
2010 Daniel Drake award for outstanding achievements in biomedical science as evidenced by major significant contributions to medical research
2011 American Heart Association Clinical Research Prize
- Principal investigator, National Clinical Coordinating Center for NIH StrokeNet
- Principal investigator, SPOTRIAS
- Principal investigator, IMS III
- Co-investigator, THERAPY