Cerebrovascular Disease & Preventive Neurology


 

As a Neurologist I have a singular goal – to avert cerebrovascular events like Transient Ischemic Attacks (TIAs), strokes and other related neuro-degenerative Disorders. At first blush this may seem to be an easy task. After all, everyone knows the major risks for vascular disease – smoking, diabetes, high blood pressure, elevated cholesterol, unfavorable genetics, age, and gender. Understanding and identifying the causes of cerebrovascular disease should make the mission of prevention rather effortless. For example, a patient presents to my office with high risk factors. All I have to do is inform her that unless we get her risk factors under control she will continued to be at risk for another event. She accepts the recommendations and lives happily ever after. Sadly, this storybook fantasy is just that – pure fiction. Rarely is the task of modifying a patient’s risk factors so seamless. Let’s first, define the modern day usage of “prevention.”

Prevention now comes in three flavors: primary, secondary and tertiary.

Primary prevention:

Refers to helping people avoid dangerous habits. As it relates to Neurology, the avoidance of smoking, Alcohol and drug abuse would be the best example. Other non-neurologic modes of primary prevention include changing life style by adopting preventive care focused on body repair system, including diet, nutrition, proper supplement, exercise and relaxations techniques. Also to improve sleep hygiene, avoiding head trauma by wearing helmets and seat belts, where necessary and practicing safe sex.

Secondary prevention:

Refers to a method whereby we physicians try to prevent an already established disease process from reaching its undesired culmination. For cerebrovascular diseases this would mean halting the progression of established but “subclinical” (asymptomatic) disease so that a patient will never experience a “hard outcome” such as heart attack, stroke or sudden cardiac death. In the world of non-neurologic medicine, screening tests such as mammograms and bone densitometries are excellent illustrations of secondary prevention.

Tertiary prevention:

Tertiary prevention comes into play when we see patients who have already experienced a hard outcome; now we must preempt another event. The practice of cerebrovascular disease prevention is built upon a foundation of solid risk assessment at all three levels, with subsequent strategic correction of these risks.

The neurologic risks, can be quantified. They all are built upon the same premise – multiple risks are generally far worse than a solitary one. For example, an isolated but substantially elevated LDL- C (the amount of cholesterol carried in our LDL particles) is generally not as ominous as the combination of mildly elevated blood pressure, central obesity, and slightly elevated triglycerides. In other words, risk factors act synergistically; their whole is definitely greater than the sum of their parts. We use this information to risk stratify our patients. They are seen as low, moderately high, high, or very high risk depending on their risk factors. With this knowledge in hand, we can then help our patients by appropriately chiseling away at their risk factors in order to lower their risk. The concept is sound, but as with everything in life, it’s not perfect.

The great news is that there are many opportunities available to you and your physician to have a substantive impact on minimizing or even preventing serious neurologic disease sequelae. Family history, gender, and age are the only risks set in stone, but all other risk factors can be modified. I have often used the analogy of a bicycle wheel in discussing risk modification with my patients. The wheel represents neurologic disease while each spoke of the wheel represents a modifiable risk factor. Our mission is to attack the spokes and in this manner destabilize the wheel. We must render the “bicycle of neurologic disease” “un-ridable”. Be proactive; don’t wait for the wake up call. Become educated and partner with your doctor. In so doing you will have a considerable impact on preventing disease and thereby enjoying excellent health.