Towards prevention and personalised care

Why is it important?

Stroke and dementia are two major causes of disability, loss of independence and reduced quality of life.

Although significant progress has been made in managing these conditions over the last two decades, prevention remains the key to healthy ageing.

Vascular brain diseases, such as cerebral small vessel disease, may be asymptomatic before the onset of stroke or dementia. However, they can be identified during cerebral imaging, particularly magnetic resonance imaging (MRI). Identifying these conditions offers a major opportunity to identify patients at increased risk of stroke and dementia, and to propose preventive treatments aimed at reducing this risk.

The major risk factors for stroke and dementia are hypertension, diabetes, obesity, a sedentary lifestyle and smoking. In addition to general recommendations on their overall management, it is also possible to undertake more effective personalised prevention by identifying specific characteristics in each patient, such as:

• emerging risk factors (new lipid markers),
• genetic susceptibility factors conditioning the risk of developing cerebral small vessel disease, and
• response to drug treatments.

The development of new, individualised care pathways is essential in reducing the risk of stroke and dementia.

The Institute’s priorities in prevention and care

We now know that lesions caused by cerebral small vessel disease are very common and are associated with an increased risk of stroke and dementia, as well as vascular diseases of the heart, retina and kidneys.

Our institute has two major objectives:

• to facilitate early identification of patients with cerebral small vessel disease,
• to optimise the prevention of complications associated with this disease.

At present, cerebral MRI and, to a lesser extent, CT scans are the complementary tests used to identify cerebral small vessel disease, but access to them is limited due to a limited number of machines, the cost associated with running them, and potential radiation exposure in the case of CT scans. This limits large-scale diagnosis as well as capacity to carry out effective follow-up.

Therefore, our priority is to develop and validate new tools for identifying and monitoring the progression of this disease using less complex MRI scans or the evaluation of markers of retinal vascularisation , i.e. specific signs or elements which make it possible to describe the state of the blood vessels in the retina. To meet our objective of personalising prevention, we are developing a number of aspects, including:

• a care pathway enabling a global assessment of risk factors, including some that are currently underestimated like addictions or new dyslipidemias (abnormalities in blood fat levels (cholesterol and triglycerides)),
• screening methods such as polygenic risk scores,
• pharmacogenomic analyses to assess individual response to proposed treatments,
• digital monitoring of vascular risk factors to adapt their management in real time and, multi-organ assessment (heart, retina, kidney) enabling broader prevention.

However, the effectiveness of systematically using such techniques has not yet been proven. The VBHI, through the BrainVasc cohort and its prevention clinic, will study the added clinical added value of such precision procedures in the fight against stroke and dementia.

The VBHI will rethink the care pathways of patients living with one or more neurovascular diseases in order to establish earlier, more effective and more equitable prevention. To achieve this, the institute will draw on :

• the cerebral small vessel disease Prevention Clinic , a new concept that will involve patients living with the disease, radiologists and general practitioners, to enable personalised assessments of risk factors and individualised plans.
• The Living Lab on brain resiliency, which will test and evaluate real-life preventive measures, assessing the impact of specific preventive measures at a population level, in collaboration with patient associations and regional networks of healthcare professionals.

An ecosystem dedicated to prevention

Avoid 45,000 deaths in France through targeted prevention

The Neurovascular Unit at Bordeaux University Hospital currently treats patients with acute neurological symptoms, whether transient (Transient Ischaemic Attack Clinic) or persistent (Neurovascular Unit Intensive Care).

The Neurovascular Unit works closely with rehabilitation services to reduce post-stroke disability and with cardiovascular disease prevention services to optimise control of post-stroke vascular risk factors.

The Bordeaux Neurodegenerative Diseases Institute contributes to the management of patients with cognitive problems suggestive of dementia, making it possible to clarify the respective roles of vascular and neurodegenerative lesions.

With its Prevention Clinic and Living Lab, the VBHI aims to position itself upstream of these various structures by fuelling research which will foster early prevention.