Article In Brief
Dr. Vladimir Hachinski was honored with the Potamkin Prize at the 2022 AAN Annual Meeting for his groundbreaking research on multi-infarct dementia, which opened up a new way of thinking about the causes and treatment of the disease.
On July 27, 1974, TheLancet published a paper on something neurologists had never heard of at the time: “multi-infarct dementia.” According to the received wisdom of the time, most dementias were caused by cerebral atherosclerosis, not infarcts. The Lancet paper, however, opened up a whole new way of thinking about dementia.
“The term ‘cerebral atherosclerosis’ as applied to mental deterioration in the elderly is misleading and inaccurate,” the paper boldly declared. “When vascular disease is responsible for dementia it is through the occurrence of multiple small or large cerebral infarcts (multi-infarct dementia), demonstrating that few dementias were caused in that way, whereas many are associated with a multitude of tiny strokes.”
The young physician-scientist who was first author of that paper—Vladimir Hachinski, CM, MD, DSc, FAAN, now Distinguished University Professor at the University of Western Ontario—essentially discovered and defined vascular dementia and distinguished it from Alzheimer's disease. He then went on to describe leukoaraiosis, as seen with rarefaction of white matter on brain imaging, and to devise the eponymously named Hachinski Score, a scale used to differentiate dementia types. He also co-founded the world's first successful acute stroke unit.
And yet, Dr. Hachinski told Neurology Today, evidence for the role of multiple infarcts rather than cerebral atherosclerosis was already available before his 1974 paper was published, if only neurologists had taken the time to read neuropathology papers by C. Miller Fisher, a Canadian neurologist working at Harvard.
“Few neurologists read pathological reports, and all were subject to the belief that chronic ischemia from atherosclerosis-laden arteries was the main cause of dementia,” he said. “Pharmaceutical companies producing brain-vessel ‘vasodilators’ made sure that their products reached practitioners. One way was to monitor the number of prescriptions for a given vasodilator by a neurologist. If enough numbers were prescribed, the physician had all their expenses paid to go to a medical meeting.”
What's more, Dr. Hachinski said, “One condition for attending the meeting was that they also attend the drug company's symposia, where paid speakers promoted their products, reinforcing the unproved hypothesis. The lack of rigorous clinical trials and the vagueness of the term ‘vascular dementia’ helped to keep the hypothesis alive for years.”
For his many discoveries in this area and decades of clinical and research work, Dr. Hachinski was honored in Seattle at the AAN Annual Meeting with the Potamkin Prize for Research in Pick's, Alzheimer's and Related Diseases.
His pathway to that prize came with a few life detours. Born in 1941 into a once-prosperous family of Ukrainian landowners in the small city of Zhytomyr—which came under attack by Russia earlier this year—Dr. Hachinski learned early in life about the struggle between good and evil. His maternal grandfather was killed during one of Stalin's purges, and his father's family were exiled. After they managed to return to Ukraine, they lived in fear; when the opportunity arose during World War II, they escaped the advancing Russian armies through a war zone and ended up as refugees in Germany.
Hearing that Venezuela was offering land on good terms, his father managed to spirit the family there in the midst of World War II in hopes of becoming landowners again.
“We arrived in August,” Dr. Hachinski said. “By November there was a coup d'etat. No more land, no job, no money. My father didn't even know the language.”
Forced to become a laborer, his father taught Dr. Hachinski and his two younger brothers a lesson that has guided him through life.
“Your grandfather was rich,” his father told them. “I am lower poor. You boys will do well if you work hard. Remember, we're the same family. Everyone is equal in dignity.”
When he was 17, an uncle and aunt living in Canada sponsored Dr. Hachinski's family to move there. He graduated a year later at the top of his high-school class in Port Perry, Ontario. After receiving his medical degree in 1966 from the University of Toronto and serving his residency and fellowship, Dr. Hachinski was accredited in neurology in 1972 as a Fellow of the Royal College of Physicians and Surgeons of Canada.
A Pioneer and Innovator
Dr. Hachinski's research into vascular dementia began during a fellowship that brought him first to the National Hospital for Nervous Diseases in London, England, and then to Bispebjerg Hospital in Copenhagen.
One casualty of his obliteration of the atherosclerotic model of dementia was the market for vasodilators. “A whole industry had grown up around these vasodilators,” he said. “After we published what became a landmark article, that industry withered and died.”
In 1974, Dr. Hachinski returned to Toronto, where he and John W. Norris, MD, established what turned out to be the world's first successful acute stroke unit at Sunnybrook Medical Centre.
As stroke centers opened around the world, the pharmaceutical industry began developing what it called “neuroprotectants” for acute stroke treatment.
“Some of us said you cannot stop a cascade of abnormalities with a single treatment,” he said. “Nobody listened to us. After a number of major studies, none of these drugs showed any positive result. Except for acute stroke units, which remain the standard of care, we were left bereft of any treatment for stroke until thrombolysis came around.”
In 1980, he left Toronto for Western University in London, Ontario, where he is now professor of neurology and epidemiology in the department of clinical neurological sciences, as well as Distinguished University Professor.
“We've reached the point where we realize that the pathological changes in the brain are multifactorial, but that we have it in our power to change some of those factors,” Dr. Hachinski said.
While he remains hopeful that researchers will eventually find drugs that actually do block Alzheimer's pathology, for now the primary way to lower the risk of dementia is to lower the risk of stroke, through lifestyle changes and management of hypertension, he said.
“If you prevent stroke, you prevent dementia,” he said. “Here in Ontario, over a 12-year period, the incidence of stroke decreased by 32 percent, and of dementia by 7 percent. That means thousands of people have been spared dementia.”
Treatments at the individual level, however, are not enough, Dr. Hachinski said. “We know that environment is important, including air and water pollution,” he said. “We know socioeconomic factors are important. We have to address all of them.”
To catalyze the movement to prevent stroke and dementia, he is involved in planning for the World Congress of Neurology, to be held in Montreal from October 15-19, 2023.
“We hope to develop in Montreal a brain health manifesto,” he said. “We doctors can't do it alone. We need governments, union leaders, religious leaders, and corporate executives to focus on brain health.”
Contemplating the Potamkin prize, he said, “What's really encouraging to me is that some of the things I've been preaching for so many years are finally happening—that's why the Potamkin is so meaningful to me. It's thanks to my colleagues, my students, my patients.”
The medallion that comes with the Potamkin prize, he said, holds special meaning for him. “When I was at the University of Toronto, I was captain of the fencing team,” he said. “I was given the opportunity of trying out for the Olympics if I was willing to take a year out of medical school and train. I really thought about it. Finally, I said, well, I will not miss a year of medical school. So, I gave up forever the opportunity to get a medal. However, with the Potamkin prize medallion, I suppose I get a medal after all.”