Aurora Semerano - An interview with a stroke neurologist

Andra: You trained as a neurologist with stroke subspecialty and worked on a cardiovascular study. How did that happen, and what drew you to the heart-brain connection?

Aurora: My path actually makes more sense than it first appears. As a stroke neurologist, you quickly realize that most of what you’re treating isn’t just a brain problem, but fundamentally a vascular one; stroke is, at its core, a disease of blood vessels. That naturally pulled me toward prevention. I became increasingly interested in what happens much earlier in the disease course, when people are still completely asymptomatic, but subtle vascular changes may already be affecting the brain.

That interest is what led me into cardiovascular research: trying to understand those early stages, years before clinical disease appears. Because if you think in terms of population impact, the greatest difference is probably made earlier through prevention.

Andra: The PESA study found that over 60% of seemingly healthy middle-aged people already had signs of atherosclerosis - and that this was quietly affecting their brains. What was your reaction when you saw that data? 

Aurora: The PESA study is a large, ongoing project that follows healthy middle-aged individuals over a period of 30 years to understand how atherosclerosis develops long before any symptoms appear. What really stood out early on was that over 60% of participants already had subclinical atherosclerosis despite being considered healthy, which already challenges how we define health.

But one of the most interesting findings, from work led by Marta Cortés (who is now my supervisor) was that this isn’t just a vascular issue. Individuals with a higher atherosclerotic burden also showed changes in brain glucose metabolism in specific regions, suggesting that the brain may be affected much earlier than we previously thought. 

This really shifts the perspective. Instead of seeing atherosclerosis only as something that leads to heart attacks or strokes later in life, it starts to look like a process that could already be subtly influencing brain function in midlife. These changes can be seen as a sign of brain vulnerability in midlife, potentially indicating a predisposition to future cognitive dysfunction.

The study is still ongoing, and the current focus is on understanding which brain networks are most vulnerable, how early these changes begin, and how they relate to cognitive outcomes.

Andra: If you had to explain to a patient what subclinical atherosclerosis is doing to the brain in midlife, what would you say?

Aurora: I’d say:

Even when people feel completely well, it’s actually quite common for small amounts of plaque to slowly build up in the arteries over time. Things like diet, genetics, cholesterol, blood pressure, or smoking can all contribute.

The key point is that this usually doesn’t cause symptoms, so it can go unnoticed. But over the years, it can make blood flow to the brain a bit less efficient. And if that happens gradually, it could start to have subtle effects on how the brain works: things like how quickly information is processed, attention, or how resilient the brain is with aging.

But I would also add that I really see this as an opportunity. Prevention plays a crucial role, and I think of it as support, not restriction.

Andra: Based on everything you've seen in your research and clinical practice, what are the most important things middle-aged people can do today to protect their brain health later in life - and is there anything on that list that might surprise them?

Aurora: From a research and clinical perspective, the key factors are quite consistent: sleep, physical activity, vascular health, cognitive engagement, stress regulation. These are the foundations that seem to support brain health over time.

What often surprises people is how everyday these factors are. It’s not only about specific interventions, but about patterns of living: how someone sleeps, manages risk factors, stays socially engaged, and keeps the brain mentally active across years. This also means it’s not about perfection. In the end, what really matters is the overall pattern over time, because brain health is shaped much more by habits than by individual moments.

Andra: If you could give every person in their 40’s and 50’s one prescription for brain health - beyond just eat well and exercise - what would it be?

Aurora: If I had to give one prescription for people in their 40’s and 50’s, it would be to take care of the brain’s environment. It’s really about not going on autopilot: staying curious, learning new things, and keeping meaningful relationships. It also means knowing how to switch off. Rest and recovery are not the opposite of a healthy life, they’re part of it, and the brain also needs proper downtime to consolidate and stay resilient.

I also think it’s important to see this not as a trade-off between present and future health, which sounds a bit transactional, but as something that supports both at the same time. Looking after these factors also shapes how people feel right now. In many ways, protecting long-term brain health and improving day-to-day wellbeing are the same thing: more energy, clearer thinking, better mood, and maintaining independence for longer.

Andra: Beyond this study, what do you think is the most underappreciated risk factor for brain disease that patients and even doctors tend to overlook?

Aurora: Beyond this study, I think two of the most under-appreciated risk factors for brain health are sleep and social isolation.

Sleep is still surprisingly overlooked in routine care, even though we now have strong evidence linking both sleep quality and duration to vascular health, neuro-degeneration, and cognitive performance. It’s really a core pillar of brain health (and even relates to conditions like atherosclerosis!), so it connects brain and body health quite closely.

The other big one is social connection. Being socially active, engaged, and mentally stimulated seems to be protective, while isolation is linked to faster cognitive decline. This is where ideas like social prescribing are interesting, where doctors can recommend community activities, not just medications.

Both are highly modifiable, but still not fully integrated into everyday preventive care, and I think there’s a lot of room to improve that in the next future.

Andra: Neurology has historically focused on treating disease once it appears. How is that philosophy shifting, and where do you think prevention in neurology is headed?

Aurora: It really feels like an exciting time to be in neurology: the field is opening up in a much more integrative and preventive direction, and that shift is something I personally find very motivating.

In everyday practice, this can be as simple as routinely checking in on sleep, diet, mood, physical activity, and social connection, small things that often get overlooked, but very relevant long term. In the neurology clinics too, these factors are starting to sit alongside traditional risk markers, not as extras, but as part of the core picture. To make this work in practice, we’ll need simple, usable tools, and I believe insights from wearables and personal devices will become increasingly helpful in capturing real-world patterns.

Ultimately, prevention shouldn’t feel like a one-off conversation, but more like an ongoing dialogue we return to over time, across both primary and specialist care.