In light of their position paper on ‘stroke prevention in the longevity era’ published recently in Stroke, Gustavo Saposnik (Toronto, Canada) and Conrado E Estol (Buenos Aires, Argentina) discuss the potential benefit of showing patients their own brain scans as well as outlining a future clinical study evaluating this approach further.
A 74-year-old man’s blood pressure reads 146/84mmHg. His general practitioner (GP) knows the target, decides to recheck in a year, and moves on. It is a defensible call. You would make the same call the next year, and the next. Ten years and ten appointments later he arrives in an emergency department with weakness down one side. That is where we meet him. We meet almost all of them there.
Our field has become extraordinarily good at the last four hours of a stroke and has largely stopped arguing about the preceding thirty years. Thrombectomy works, and the trial evidence behind it is among the most persuasive in medicine. It is also—every time—a prevention failure that reached us too late. In a position paper recently published in Stroke, we argue that a stroke is better understood not as an isolated vascular event but as accelerated biological ageing becoming visible in the brain.
“This reframing also reminds us that the goal of prevention is not only to avoid a stroke—it is to help people in a more positive way to preserve brain health, maintain independence, and enhance quality of life for as long as possible.”
Mitchell Elkind, chief science officer for the American Heart Association (AHA)
There are now 104.8 million people living with stroke worldwide and 13.2 million incident strokes a year, with incidence rising in older populations and, separately, in adults in their 40s and 50s.
Nothing in that man’s decade looked like a mistake, and that is the part worth sitting with. Consider the asymmetry his physician faced at every visit. Intensify treatment, and he becomes dizzy and falls, and the harm is immediate, visible and unmistakably yours. Do nothing, and he has a stroke in four years, and the harm is deferred, diffuse and belongs to no one. Every incentive favours waiting. We call this therapeutic inertia, and it is not ignorance—the physicians it affects can recite the guideline. It is structural. Humans weigh a visible present against an invisible future, and rising risk has no witness.
This is why 50 years of guidelines, conferences and patient education have moved behaviour so little. Hypertension carries the highest population-attributable risk for stroke—close to 48%. A 10mmHg reduction in systolic pressure prevents roughly a quarter of strokes, with the benefit holding past 80 years. None of this is contested; it is simply not happening at scale.
There is a body of evidence—small and imperfect—suggesting the problem is not what people know but what they can see.
Existing evidence
In the VIPVIZA trial, 3,532 middle-aged Swedish adults were randomised; 1,749 received a pictorial carotid ultrasound showing their own plaque and vascular age, with a copy sent to their GP and a nurse follow-up call. A year later, their cardiovascular risk scores had fallen while the comparison group’s had risen, and the separation persisted at three years. The intervention was not a new drug or a new target. It was the same information, made visible.
A 2022 systematic review in PLOS Medicine, updating a Cochrane review, pooled 21 randomised trials and 9,248 participants of interventions showing people medical images of their own bodies. Systolic pressure fell by 1.58mmHg (95% confidence interval [CI], 0.74–2.41) and smoking cessation improved (risk ratio [RR], 1.11; 95% CI, 1.01–1.23). The authors translate that blood-pressure effect into roughly 0.8% fewer cardiovascular events, or 127 people being shown an image in order to prevent one of these events.
We want to be unambiguous about how thin that is. Not one of the 21 trials was at low risk of bias. Only the smoking outcome reached moderate certainty; most were rated low or very low. Showing people their own arteries did nothing measurable for medication adherence (standardised mean difference [SMD], 0.04; 95% CI, -0.24–0.32), the outcome we would most have wanted to move. Epigenetic clocks—the other route to a number for biological age—predict mortality across populations but have never been shown to change an individual’s outcome, which is why our position paper declines to recommend them for patient management outside research settings.
Here is the gap that should interest us specifically. Of those 21 trials, not one imaged the brain. They showed people arteries, skin, teeth and retinas. Nobody has tested the organ patients are most afraid of losing, and the one where damage accumulates silently for decades—a systematic review in The Lancet Neurology has revealed that, among older adults with elevated cardiovascular risk, 30–50% carry a covert infarct visible only on magnetic resonance imaging (MRI).
We are also sitting on an underused instrument. Carotid and femoral plaque burden is inexpensive, already measured in many of our clinics, and prognostically meaningful. In the BioImage study, the highest plaque tertile carried an adjusted hazard ratio of 2.36 (95% CI, 1.13–4.92) for major cardiovascular events with reclassification beyond conventional risk factors. We treat that image as a diagnostic output. The VIPVIZA result suggests it may also be a therapeutic one, yet we have never tested it that way.
Meanwhile, demand for biological age measurement has run well ahead of the evidence supporting it. The useful distinction is not between clinics and consumers, but between measures with outcome data behind them and measures without. Epigenetic panels remain prognostic rather than actionable. Carotid and femoral plaque burden is inexpensive, validated, prognostically meaningful and already installed in our vascular laboratories—where we use it for one purpose only.
Future directions
So, this is a call for a trial, not a practice change, and we would not want it read as anything stronger. The study is straightforward: randomise patients with incidental small-vessel disease or covert infarction to standard risk counselling versus structured visual feedback of their own imaging, copied to their primary physician, with risk-factor control and event rates as outcomes. The comparator arm matters, because the discriminating question is whether the effect comes from seeing an image at all or from seeing one’s own. Salience and ownership make different predictions, and nobody has separated them.
“We now have unprecedented access to biological age estimates, biomarkers, and data from wearable devices, yet information alone rarely changes behaviour or risk trajectories. We already know that controlling blood pressure, staying active, eating well, avoiding smoking and managing conditions such as diabetes can reduce stroke risk. The bigger challenge is helping people adopt and sustain these proven strategies in their daily lives. In this context, longevity clinics may help by encouraging people to pay closer attention to their health. However, their greatest value will come not from collecting more data, but from supporting people to act on what we already know works.”
Moira Kapral, chair of the Department of Medicine at the University of Toronto
However, there are also three things that do not require that trial in order to be recommended. Ask patients for a number and a date—‘am I okay?’ is unanswerable, while ‘what is my target, are we at it, and when do we act if we are not?’ converts reassurance into a commitment. Record what currently goes unrecorded; physical activity is quantified in fewer than 5% of specialist encounters. And, when imaging already exists, show it to the patient rather than summarising it.
For the man whose pressure read 146/84mmHg, the calendar could not be slowed, but his biology could. By the time he reached us, we were very good at what we do, and thirty years too late to do the thing that mattered.
Gustavo Saposnik is professor of neurology at the University of Toronto and director of the Stroke Outcomes and Decision Neuroscience Research Unit at Unity Health in Toronto, Canada. He is also the vice-president of the World Stroke Organization (WSO) and the founder of NeuroRise.
Conrado E Estol is medical director of the stroke unit at Sanatorio Güemes in Buenos Aires, Argentina, and the founder of Xtend—a longevity and cardiovascular prevention clinic.
Saposnik disclosed receipt of a grant from Hoffmann-La Roche Ltd. Estol reported no relevant disclosures.
