William M. Feinberg Award for Excellence in Clinical Stroke

C linicians and patients tend to think of stroke as big acute brain injury, but small progressive vascular contributions to cognitive impairment and dementia (VCID) represent arguably a much greater societal burden. Dementia is certainly the preeminent public health threat of our time, estimated to affect 35.6 million individuals worldwide in 2010 and projected to double every 20 years to a staggering 115.4 million in 2050, 1 including >13 million Americans. Clinical-pathological correlation in ROS-MAP (Religious Orders Study and Rush Memory and Aging Project) shows that each level of greater severity of small or large vessel disease pathology confers higher likelihood of a clinical diagnosis of Alzheimer's disease (AD) and that these associations with vascular disease are independent of actual AD pathology. Similar findings are seen in clinical-radiological correlation: individuals with clinically silent brain infarcts in the Rotterdam Study have more than double the hazard of subsequent dementia. ealizing that most age-related dementia represents a mix of neurodegenerative and vascular pathologies 5 may sound like a reason to lose hope that this tsunami can be slowed, but should be considered the opposite: more contributors mean more opportunities to intervene. The very real possibility that improved vascular health has already reduced dementia incidence is highlighted by the Framingham Heart Study finding of a steady fall in the 5-year age-and sex-adjusted cumulative hazard rate for dementia per 100 persons from 3.6 for individuals with baseline exams in the 1978 to 1983 period to 2.8 for 1986 to 1991, 2.2 for 1992 to 1998, and 2.0 for 2004 to 2008. 6 Some of this decline may reflect important nonvascular factors such as improving education, but it coincides notably with sizable improvements in hypertension awareness and control, 7 offering a plausible reason for hope of further progress. The implications of bending the dementia curve are enormous, as delays of even a few years in dementia onset project to millions of Americans remaining dementia free. ecognizing the role of multiple pathologies in generating clinical dementia, the US National Alzheimer's Project Act of 2011 explicitly addressed not only AD itself but also the AD-related dementias (ADRDs) of frontotemporal, Lewy body, vascular, and mixed dementia. This effort led to National Institute of Health-sponsored ADRD summits in 2013 and 2016, bringing together scientific leaders in each of the ADRD fields and US government representatives, nongovernmental organizations, and the public to develop specific prioritized recommendations for future ADRD-related research. 9 These recommendations were formalized into milestones 10 for the National Plan to Address AD, a key element in annual National Institute of Health bypass budgets delivered to Congress.