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The Recipient of a Prized Leadership Award in Stroke Takes the Road Less Traveled

Article In Brief

Dr. Alessandro Biffi's academic and clinical journeys down the road less traveled were recognized last spring when he was awarded AAN's 2019 Michael S. Pessin Stroke Leadership Prize. Here, he discusses his career path and the mentors who helped shape it.

Since graduating from medical school in 2008, Alessandro Biffi, MD, has pretty well ignored all the major trends in the study and treatment of stroke.

While research has tended to focus on prevention and acute care, he has focused on long-term treatment.

While ischemic stroke has been the subject of most studies, he has specialized in hemorrhagic stroke.

And while a majority of treatment efforts have been aimed at correcting the effects of stroke on movement, he has focused on the cognitive, emotional, and behavioral effects.

His academic and clinical journeys down the road less traveled were recognized last spring when he was awarded AAN's 2019 Michael S. Pessin Stroke Leadership Prize. Given each year to an emerging neurologist, the prize recognizes those who have demonstrated a passion for learning and expanding the field of stroke research, and who provide patients with the highest quality of compassionate care.

Roots in Italy

The roots of Dr. Biffi's interest in the cognitive, emotional, and behavioral effects of stroke date back to his youth in Milan, Italy, where a cousin of his had multiple sclerosis.

“She declined in front of my eyes when I was a teenager,” he said. “She was doing fairly well in the relapsing-remitting stage, but then it became progressive and included cognitive aspects that were not amenable to treatment. It affected me deeply.”

After graduating from the University of Milan School of Medicine, he was accepted into a research fellowship at Massachusetts General Hospital in Boston to study the genetics and clinical manifestations of stroke.

“I was being told by patients over and over again that just as important as not being able to move their left arm or leg were the things I couldn't see—the changes in their moods, their behaviors, their thinking,” Dr. Biffi said. “The field has been somewhat hyper-focused on the motor manifestations of stroke and has achieved great things in that area. But the emotional, cognitive and behavioral effects impact life terribly, and they're fairly difficult to handle.”

Bridging Psychiatry and Neurology

To bring greater attention to the psychiatric and cognitive effects of not only stroke but other age-related neurological disorders, Dr. Biffi, now an assistant professor of neurology at the Harvard University School of Medicine, has established the Aging and Brain Health Research Group at Mass General. The goal, he said, “is to be a force of change in the way research and clinical care are handled across the interface of neurology and psychiatry—to bridge the gap.”

Currently he is leading an observational trial, involving nearly 100 patients, called the Apathy and Depression Following Intracerebral Hemorrhage Study.

“Of all the stroke subtypes, hemorrhagic ones are the ones we know least about in terms of long-term expectations,” Dr. Biffi said. “Partly that's because, until recently, few people survived them. As our technology and treatments have allowed more and more people to live, we've noticed that these strokes are more likely than other kinds to result in depression and apathy. We're using scans, genetic data, and other tools to better understand the predictors of these problems and to leverage this knowledge to improve outcomes.”

Apathy, Dr. Biffi noted, is distinct from depression. “Depression is active,” he said. “You cry, you think sad thoughts. Apathy is the more passive component: you don't feel anything, you can't concentrate, you don't want to see anyone.”

Treatment differs for the two, he added. “Someone who has depression after stroke will usually get an SSRI,” he said. “Those are actually not good at treating apathy. In fact they make it worse. Venlafaxine, which increases the level of both serotonin and noradrenalin, is much better at treating apathy. But it requires greater clinical expertise, because it can increase blood pressure, which obviously you don't want to do in a stroke patient.”

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“The field has been somewhat hyper-focused on the motor manifestations of stroke and has achieved great things in that area. But the emotional, cognitive and behavioral effects impact life terribly, and theyre fairly difficult to handle.”—DR. ALESSANDRO BIFFI

Dr. Biffi traces the increased risk of depression and apathy following hemorrhagic, rather than ischemic, stroke to two factors.

“The primary reason,” he said, “is that usually the hemorrhage is just an acute manifestation of a chronic problem marked by progressive small-vessel disease. The stroke is really just the tip of the iceberg.”

The other factor, he said, is that the presence of blood inside the brain following a hemorrhage appears to trigger a more severe inflammatory reaction than does a blockage.

The Mentors

In accepting the Pessin prize, Dr. Biffi credited four mentors who have each played an important role in his work, beginning with Jonathan Rosand, MD, under whom Dr. Biffi did his postdoctoral fellowship. “He gave me the foundation of what it means to be a clinician-scientist and how each enriches the other. He has been a role model.”

He also paid tribute to Kevin N. Sheth, MD, FAAN; Steven M. Greenberg, MD; and Anand Viswanathan, MD, PhD, as mentors and colleagues. “They have all been supportive of the idea of this shift in focus toward some of the neglected aspects of stroke medicine.”

Although raised in Milan, Dr. Biffi was actually born in the southern Alps of Switzerland, in the small city of Lugano, where his ancestors have lived since the Middle Ages. His parents, however, both became physicians, studying at the University of Milan as he later did.

Married since 2011, with two young children, Dr. Biffi said that while he misses his extended family back in Italy, “I think I have found my calling here. While I do miss my roots, I really am reveling in the fact that I have found something that I am passionate about, something to be proud of, something that is helpful to people.”

Still early in his career, Dr. Biffi's journey down the road less traveled has already brought him far.

Link Up for More Information

• Kuramatsu JB, Biffi A, Gerner ST, et al. Association of surgical hematoma evacuation vs conservative treatment with functional outcome in patients with cerebellar intracerebral hemorrhage https://jamanetwork.com/journals/jama/fullarticle/2752468. JAMA 2019; 322(14):1392–1403.
    • Rodriguez-Torres A, Murphy M, Kourkoulis C, et al. Hypertension and intracerebral hemorrhage recurrence among white, black, and Hispanic individuals https://n.neurology.org/content/91/1/e37. Neurology 2018; 91(1):e37–e44.
      • Biffi A, Kuramatsu JB, Leasure A, et al. Oral anticoagulation and functional outcome after intracerebral hemorrhage https://onlinelibrary.wiley.com/doi/full/10.1002/ana.25079. Ann Neurol 2017; 82(5):755–765.