Cardiac disease and stroke remain the leading causes of death and disability in the United States. For most of my career, I have treated stroke patients and studied the associated risks. We have come a long way in treatment; we can now open brain arteries with clot-dissolving drugs or use devices to retrieve a clot before the damage is irreversible.
However, many of these approaches must begin within hours of a stroke. But many people do not recognize the stroke warning signs and fail to get medical attention quickly enough to benefit from the most effective therapies. Public education such as the widespread “brain attack” campaigns and slogans such as “time lost is brain lost” have certainly helped, but more needs to be done. Fortunately, new therapies are in the pipeline that may expand the time for treatment, but we still have a long way to go.
Prevention is key to avoiding a disabling stroke, yet getting our patients to lead a healthy lifestyle is not easy. As often too busy clinicians, we are not always best at taking the time to counsel our patients to eat right, exercise, and effectively control risk factors such as high blood pressure and diabetes with the proper medications. There are many new preventive medicines and evidence-based recommendations to help reduce stroke risk. While practicing the best medicine at the Miller School, one of our missions is to lead the way in education about these advances among our young physicians-in-training and other health care providers.
Besides stroke, vascular disease of the brain can also lead to a decrease in cognitive function sometimes called “vascular cognitive impairment.” What we so casually have attributed to getting older may be preventable. Just as control of vascular risk factors can reduce stroke risk, we may be able to reduce the chance of cognitive decline. New research shows vascular conditions are more frequent even among patients diagnosed with Alzheimer’s disease. Through brain imaging, we can find early changes such as “silent strokes” and evidence of “white matter hyperintensities” that may not be evident to doctor or patient without very sensitive testing. The study of sub-clinical or pre-clinical disease is presenting new possibilities for earlier detection and treatment. Should we treat silent stroke just as clinical strokes? Should people with early changes on MRI be given preventive vascular medicines? These are questions we need to address in new clinical trials.
The future of stroke prevention and reduction in vascular cognitive impairment will be greatly aided by advances in genetics. We know our environment has an impact on vascular risk, but we have also learned many of our vascular risk factors are controlled by our genes. Understanding the impact of genetic determinants on early changes in the brain, arteries, or on cognitive function will revolutionize our approaches to risk prediction and treatments. New genetic markers will help us more precisely quantify and predict global vascular risk. Moreover, identifying novel disease pathways will lead to potential new drug discoveries. Tailoring the use of medicines using genomic approaches will help improve efficacy and minimize side effects.
At the Miller School we have the opportunity to attack these problems and find future pathways to brain health. I am excited about building partnerships between neurology, radiology, epide-miology, cardiology, behavioral medicine, and the new genetics strength on campus. If we put our minds together, we can make a difference for our patients and reduce the future threats of stroke and vascular cognitive impairment.
Ralph L. Sacco, M.D., M.S., Miller Professor of Neurology, Epidemiology, and Human Genetics and chairman of the Department of Neurology, is an internationally renowned expert on stroke.