40th T S Srinivasan Oration

 Every decade of TS Srinivasan orations, marks yet another significant milestone in the global neuroscience arena.

Prof. Ralph L. Sacco

Ralph L. Sacco, MD, MS, is the Chairman of Neurology, Olemberg Family Chair in Neurological Disorders, Miller Professor of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Executive Director of the Evelyn McKnight Brain Institute, Senior Associate Dean for Clinical and Translational Science, Director of the Clinical and Translational Science Institute at the Miller School of Medicine, University of Miami, and Chief of the Neurology Service at Jackson Memorial Hospital.  He was previously Professor of Neurology, Chief of Stroke and Critical Care Division, and Associate Chairman at Columbia University before taking his current position.

Prof. Sacco has been a member of the World Stroke Organization since 2008 and past chair of the WSO Research Committee, and is on the Board of Directors. He has published extensively with over 600 peer-reviewed articles and 250 invited articles in the areas of stroke prevention, disparities, treatment, epidemiology, risk factors, vascular cognitive impairment, and human genetics. He has been the recipient of numerous awards including the AAN Wartenberg Lecture.  He is the founding Principal Investigator of the NINDS-funded Northern Manhattan Study among several other NIH – funded research projects. He is the immediate past-President of the American Academy of Neurology and was the first neurologist to serve as the President of the American Heart Association, 2010-2011. Fifty years ago, the American Heart Association’s journal Stroke was conceived, and now it is the premier journal in the field. Ralph L. Sacco, will take the reins as Stroke’s editor-in-chief beginning with the July 2020 issue.

 Preventing Stroke and Maintaining Brain Health in 2020

Prof. Ralph L. Sacco, the 40th TS Srinivasan orator observed that the impact of the Srinivasan lectures was felt not only in India but the world over. Looking at the impressive list of 39 orators before him, he elaborated on how nine among them had touched his life in varied capacities. To mention the role of two, Prof JP Mohr (the 2004 orator) was his mentor in Stroke, and he took over as the third Chair in Neurology at University of Miami from WG Bradley (the 1996 orator). He acknowledged the vision of the TS Srinivasan family, the significant contribution of the programme distinguished mentors and the amazing hospitality and  meticulous organisation that went into the success of the mammoth event that marked the neuroscientific calendar year after year.  

Prof. Sacco outlined the global burden of stroke and dementia, and the alarming projected figures for 1. Stroke, a major cause of mortality and the second highest cause of disability and for 2. cognitive  decline and dementia with the progressive increase in the greying population. The urgency to deal with ‘Brain Health’ globally and to adopt preventive strategies was the focus of Prof. Sacco’s oration. He dwelt on the interplay between vascular disease, stroke and dementia and on the convergence of the pathogenic mechanisms in vascular and neurodegenerative processes. He had devoted much effort and thought to this concept and as the first neurologist to be elected President of the American Heart Association (AHA) 2010-2011, his Presidential address was ‘Achieving Ideal Cardiovascular and Brain Health – Opportunity Amid Crisis’ bringing the two vital organs under a common lens to establish the link between factors leading to carotid artery stenosis due to atheromatous plaques, atrial fibrillation releasing embedded clots, and heart failure with brain health and cerebrovascular events. 

The multidimensional stroke disability burden (Global Burden of Disability 2016) risk factors for stroke are hypertension, high blood sugar and cholesterol levels, and kidney disease- 72% ; smoking, poor diet control and poor physical activity – 66.3 % and  air pollution 28.1 %, risk factors total – near 90%. Stroke and cognitive decline/dementia being life–course illnesses, preventive steps must be taken before midlife and not later, when adverse consequences result. A Presidential Advisory from ASA/American Stroke Association, 2017, is ‘AHA’s Life simple 7 ‘ (which the professor believes are not so simple and the average score falls short by 2-3  of the ideal ). The 7 metrics to define optimal brain health in adults are ideal health behaviors (nonsmoking, physical activity at goal levels, healthy diet consistent with current guideline levels, and body mass index <25 kg/m2) and 3 ideal health factors (untreated blood pressure <120/<80 mm Hg, untreated total cholesterol <200 mg/dL, and fasting blood glucose <100 mg/dL).  The professor shared the large cohort study stretching over 27 years -the Northern Manhattan Study (NOMAS), where his team established that timely intervention in behaviours and control of other health factors could prevent stroke and slow cognitive decline when compared with those in the study who did not adhere to lifestyle modifications in diet, physical activity, etc. NOMAS studies moved on to include baseline values of cognitive performance with follow up records after 5 years, conducted subtle cognitive neuropsychiatric test based on executive function, semantic memory, episodic memory and processing speed, where the cognitive decline was less in those who took preventive measures early to alter the course. The study of novel determinants, namely inflammatory and infectious markers,  MRI  markers of subclinical brain ageing –small vessel disease, white matter hyperintensities, microbleeds, silent infarcts and brain atrophy, and predisposing candidate genes were other advanced aspects of the study, yielding promising research data, toward  speeding up early risk prediction and prevention.

The professor discussed the ethnic variations, and socio-economic factors influencing the course of stroke and cognitive decline. There was an urgent need for setting population health goals and policies towards preventive measures for non-communicable diseases, lifestyle changes, healthcare of the elderly, and government advocacy measures to improve these areas of health policy, more so for LMIC countries with mounting public health concerns. He stressed the need for effective communication to the public on preventive measures and on recognition of early symptom of stroke to hasten hospitalization within the stipulated golden  period. The scope of research in the branches of this field are phenomenal and must be exploited effectively with adequate funding. Moving closer to equitable global healthcare should be the goal and  national and international collaboration is the key, he observed