Brain Health in Stroke Care: From Modifiable Determinants to Clinical Translation

The concept of brain health has gained increasing relevance in stroke care. Beyond its traditional definition as optimal cognitive, emotional, and physical function, brain health is increasingly recognised as a determinant of stroke risk and long-term neurological outcomes. Preserving brain health supports cognitive reserve and may prevent vascular and neurodegenerative disease. Stroke and dementia represent a growing global health burden, particularly in ageing populations¹. Silent cerebral small vessel disease contributes early to disease development and can be detected by neuroimaging markers such as white matter hyperintensities (WMH) long before cognitive impairment becomes clinically apparent².

Evidence underscores the importance of modifiable risk factors in preserving brain structure and function. Up to 40 % of dementia cases are attributable to such factors, highlighting opportunities for early intervention.¹ Hypertension, diabetes, dyslipidaemia and smoking remain the most important, already well-established determinants of impaired brain health. Their cumulative effects accelerate cerebral small vessel disease and increase the risk of ischemic and hemorrhagic events. Identification and management of these factors remain the cornerstone of stroke prevention.³

As these mechanisms are well established, they are not discussed in detail here. Instead, the following section focuses on additional modifiable factors and their underlying pathophysiological mechanisms that complement vascular risk management and offer further opportunities to preserve brain health. Accumulating evidence indicates that regular physical exercise can improve learning and memory and attenuate neurodegeneration by enhancing neuroplasticity through alterations in synaptic structure and function, supporting angiogenesis and glial activity, and maintaining a cerebral microenvironment conducive to synaptic plasticity. All these mechanisms are thought to underlie exercise‑induced benefits for brain health.⁴ Even moderate levels of sustained activity are associated with meaningful neurocognitive benefits.⁵ Adequate sleep is equally important. Chronic sleep disruption is linked to cognitive impairment and an increased susceptibility to neurodegenerative processes.⁶ Nutrition influences brain health through modulation of neuroinflammation and oxidative stress, with dietary patterns such as the Mediterranean diet consistently associated with reduced cognitive decline.⁷ Stress represents an additional, often under-recognised modifier of brain health and chronic stress can contribute to vascular injury. Behavioral interventions including mindfulness-based strategies or cognitive-behavioural approaches may improve vascular risk factors.⁸

Despite growing evidence, practical implementation of brain health concepts in stroke care remains limited and translating these insights into individualised interventions is challenging. The Brain Care Score (BCS) was developed as a simple tool that offers a broader construct of brain health than conventional scores by integrating physiological, lifestyle and social determinants. Unlike other risk-based tools such as Framingham, CAIDE or ASCVD, it is structured as a “positive” health metric, with higher values indicating more favourable behavioural and physiological profiles, empowering patients to take actionable steps toward improvement.⁹

It has been shown that a higher BCS is associated with a reduced risk of both dementia and stroke, underscoring the overlap in targeted prevention.⁹ A higher BCS was also linked to reduced WMH load and attenuated progression of white matter microstructural changes over time¹⁰. Ongoing studies aim to examine its predictive value for structural brain changes and cognitive deficits.

In conclusion brain health is strongly influenced by modifiable factors across the lifespan. Tools such as the BCS may help patients identifying their risk for stroke and dementia and guide behaviour change.

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