UCLA neuros: Let imaging be the birthing, raising ground for cerebrovascular health

The HHS department, collaborating with various private-sector partners, launched the Million Hearts initiative to fight heart attacks and strokes back in 2011. The Precision Medicine Initiative and BRAIN Initiative followed, both with stroke as a key target. Well and good, but the concerted stroke-busting efforts to date have mostly stressed genomics, novel biomarkers and innovative data. Where’s the imaging?

In fact, come to think of it, where’s the cerebrovascular focus?

Or, as put in an opinion piece penned by three UCLA stroke specialists and published online Jan. 3 in JAMA Neurology:

“Other data types are undoubtedly informative, yet the multidimensional array of data stems from imaging as the nidus. It would be an egregious oversight for the Precision Medicine Initiative (PMI) and BRAIN Initiative to neglect neurovascular imaging rather than promote key goals in precision cerebrovascular health and leverage an emerging, tremendous opportunity for patient-centered big data.”

In issuing their call for a million brains initiative to advance the cause of cerebrovascular health, David Liebeskind, MD, Konark Malhotra, MD, and Jason Hinman, MD, PhD, note that cerebrovascular medicine begins with imaging.

They set out three key goals for advancing precision cerebrovascular health:  

1. Introduce and promote the concept of cerebrovascular health.
2. Modernize stroke epidemiology with routine imaging.
3. Create a Million Brains Initiative of real world data for precision medicine in stroke.

Liebeskind and co-authors point out that, as a field unto itself, cerebrovascular health has been cited only 10 times in the literature. The dearth is especially striking, they suggest, when compared against the reams of literature of cardiovascular health.

“Cerebrovascular health cannot be ascertained by focusing solely on the heart,” they write. “Imaging of the brain is the mainstay in the management of individuals with vascular disorders of the brain, yet long-term management of such patients often relies on the surveillance of discrete clinical symptoms heralding another stroke rather than implementing bona fide prevention efforts.”

The authors posit that, if enough stakeholders will buy in, collective efforts to amass the data on a million brains would not be as daunting a task as it may sound.  

“Real-world data on cerebrovascular health are readily available in the public domain,” they write, adding that the problem has been a lack of leadership and organization.

In their vision of the way things could be, routine brain imaging “may be the backbone, but numerous other dimensions such as future biomarker or genomic data and mobile health technologies may be subsequently layered on top of this hierarchical model to characterize cerebrovascular health status,” they write.

“Failure to utilize imaging as the nidus for precision medicine in stroke,” they add, “runs the inherent risk of jeopardizing the validity of genomic data and other biomarkers.”

Merriam-Webster defines nidus as 1. a nest or breeding place, especially a place or substance in an animal or plant where bacteria or other organisms lodge and multiply; 2. a place where something originates, develops or is located.

The authors close by highlighting the inspirational aspect of the PMI and BRAIN initiatives, noting that the momentum it has created “converges with a digital health revolution that can handle the rich data gleaned from routine imaging of the brain.”

They write: “Crowdsourced endeavors may be used to rapidly and securely amass a unique resource of a million brains, refine stroke epidemiology with imaging profiles, study cerebrovascular health and tailor therapies rather than solely counting disabling stroke event rates.”