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Stroke in Diabetic Patients: Is It Really a Macrovascular Complication?

2007; Lippincott Williams & Wilkins; Volume: 38; Issue: 10 Linguagem: Inglês

10.1161/strokeaha.107.492843

1524-4628

Luis Castilla‐Guerra, María del Carmen Fernández‐Moreno,

Acute Ischemic Stroke Management

HomeStrokeVol. 38, No. 10Stroke in Diabetic Patients: Is It Really a Macrovascular Complication? Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBStroke in Diabetic Patients: Is It Really a Macrovascular Complication? Luis Castilla-Guerra Maria del Carmen Fernandez-Moreno Luis Castilla-GuerraLuis Castilla-Guerra Department of Internal Medicine, Hospital de la Merced, Osuna, Seville, Spain Maria del Carmen Fernandez-MorenoMaria del Carmen Fernandez-Moreno Department of Neurology, Hospital Universitario de Valme, Seville, Spain Originally published23 Aug 2007https://doi.org/10.1161/STROKEAHA.107.492843Stroke. 2007;38:e106Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 23, 2007: Previous Version 1 To the Editor:We have read with interest the article by Wilcox et al,1 in which they demonstrated the positive effect of pioglitazone on stroke recurrence in patients with type 2 diabetes mellitus (DM). However, we would like to stress a particular concern regarding a basic concept in the difficult question of DM and stroke. In this study, as in other previous studies, stroke is considered a macrovascular event in diabetic patients, but is this statement true? Traditionally, retinopathy, neuropathy, and nephropathy have been designated microvascular complications of DM, and stroke, myocardial infarction and gangrene are termed macrovascular complications.2 However, we think it is time to change this commonly accepted concept.The pathophysiology of cerebrovascular disease in patients with DM is not fully characterized, but both large and small blood vessels seem to be affected. Thus, the etiology of strokes in diabetics is frequently microvascular disease from fibrinoid necrosis, which causes small subcortical infarcts or lacunar strokes.3Different studies have suggested that, though there is no doubt that diabetes is an important risk factor for ischemic stroke overall, the increase in relative risk must be similar for all subtypes of ischemic strokes. Most of the previous population-based studies have not suggested any hint of a particular association between DM and any subtype of ischemic stroke. Similar results have been obtained in a systematic review of all relevant hospital-based and population-based studies.3,4 Furthermore, in the Atherosclerosis Risk in Communities Study,5 a prospective study of 14 448 men and women, even the authors observed a positive association between lacunar strokes and diabetes, with a population-attributable fraction for DM of 26.3% for lacunar versus 11.3% for nonlacunar stroke. Finally, in a recent prospective study among 116 316 female registered nurses in a 24-year follow-up study, researchers found that the risk for large-artery infarction and lacunar stroke were similar in diabetic women.6In conclusion, it may be too simplistic to consider stroke a macrovascular complication of DM, as long as both microvascular and macrovascular factors operate simultaneously and intensively in diabetics' brain vascular damage. Given the significant public health impact of stroke and diabetes, further studies are required to identify all risk factors for vascular diabetic disease and apply appropriate preventive strategies.DisclosuresNone.1 Wilcox R, Bouser MG, Betteridge DJ, Schernthaner G, Pirags V, Kupfer S, Dormandy J. Effects of pioglitazone in patients with type 2 diabetes with or without previous stroke: results from PROACTIVE. Stroke. 2007; 38: 865–873.LinkGoogle Scholar2 Unger RH, Foster DW. Diabetes mellitus. In Wilson JD, Foster DW, Kronembenberg HM, Larsen PR, eds. Williams Textbook of Endocrinology. 1998; 973–1059.Google Scholar3 Rothwell PM. Prevention of stroke in patients with diabetes mellitus and the metabolic syndrome. Cerebrovasc Dis. 2005; 20: 24–34.CrossrefMedlineGoogle Scholar4 Jackson C, Sudlow C. Are lacunar strokes really different? A systematic review of different risk profiles between lacunar and nonlacunar infarcts. Stroke. 2005; 366: 29–36.Google Scholar5 Ohira T, Shahar E, Chambless LE, Rosamond WD, Mosley TH, Folsom AR. Risk factors for ischemic stroke subtypes. Stroke. 2006; 37: 2493–2502.LinkGoogle Scholar6 Janghorbani M, Hu FB, Willett WC, Li TY, Manson JE, Logroscino G, Rexrode KM. Prospective study of type 1 and type 2 diabetes and risk of stroke subtype: the Nurses' Health Study. Diabetes Care. 2007; 30: 1730–1735.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Sandech N, Jangchart R, Komolkriengkrai M, Boonyoung P and Khimmaktong W (2021) Efficiency of Gymnema sylvestre ‑derived gymnemic acid on the restoration and improvement of brain vascular characteristics in diabetic rats , Experimental and Therapeutic Medicine, 10.3892/etm.2021.10855, 22:6 Magnan E, Bolt D, Greenlee R, Fink J and Smith M (2016) Stratifying Patients with Diabetes into Clinically Relevant Groups by Combination of Chronic Conditions to Identify Gaps in Quality of Care, Health Services Research, 10.1111/1475-6773.12607, 53:1, (450-468), Online publication date: 1-Feb-2018. Ntaios G, Milionis H, Vemmos K, Makaritsis K, Ferrari J, Strbian D, Curtze S, Tatlisumak T, Michel P and Papavasileiou V (2016) Small-vessel occlusion versus large-artery atherosclerotic strokes in diabetics: Patient characteristics, outcomes, and predictors of stroke mechanism, European Stroke Journal, 10.1177/2396987316647856, 1:2, (108-113), Online publication date: 1-Jun-2016. Chehaibi K, Nouira S, Mahdouani K, Hamdi S, Rouis M and Slimane M (2014) Effect of the PPARγ C161T Gene Variant on Serum Lipids in Ischemic Stroke Patients with and Without Type 2 Diabetes Mellitus, Journal of Molecular Neuroscience, 10.1007/s12031-014-0326-3, 54:4, (730-738), Online publication date: 1-Dec-2014. Prakash R, Somanath P, El-Remessy A, Kelly-Cobbs A, Stern J, Dore-Duffy P, Johnson M, Fagan S and Ergul A (2012) Enhanced Cerebral but Not Peripheral Angiogenesis in the Goto-Kakizaki Model of Type 2 Diabetes Involves VEGF and Peroxynitrite Signaling, Diabetes, 10.2337/db11-1528, 61:6, (1533-1542), Online publication date: 1-Jun-2012. Hewitt J, Castilla Guerra L, Fernández-Moreno M and Sierra C (2012) Diabetes and Stroke Prevention: A Review, Stroke Research and Treatment, 10.1155/2012/673187, 2012, (1-6), . October 2007Vol 38, Issue 10 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.107.492843PMID: 17717304 Originally publishedAugust 23, 2007 PDF download Advertisement