The aim of this manuscript was to point out the relevance of the clinical aspects of stroke based on several clinical studies. We carried out a retrospective data collection study in 433 patients with cerebrovascular disease,which represent 7% of all patients admitted to our Service of Internal Medicine between 1979-1985. In this particular study the most frequent risk factor found was hypertension, 64.7% which represents the total median value (in men and women) of Transient Ischemic Attack (TIA), full stroke, and stroke in evolution. In another recent cross-sectional investigation carried out in 243 patients admitted with ischemic stroke, the most common modifiable risk factors were hypertension (72.1%), followed by diabetes (51.7%), and dyslipidemia(28.5%). Patients older than 60 years with isolated systolic hypertension constitutes a special group of population susceptible to disorders of the central nervous system. In our experience,a more effective antihypertensive treatment is needed to prevent this serious clinical situation in these patients.

Keywords: Hypertension; Stroke; Age; Risk factors; Cardiovascular disease; Cerebrovascular events; Ageing; Isolated Systolic Hypertension; Ischemic stroke; Intracerebral hemorrhage; Transient Ischemic Attack; Vascular neurologic dysfunction; Embolism; Thrombosis; Bleeding; Atherosclerosis; Diabetes mellitus; Dyslipidemia; Tobacco; Alcohol abuse; Obesity; Cardiac dysrhythmia; Semiology of stroke; Vascular dementia; Cerebral disease; Non modifiable risk factors; Arterial circle or Willis hexagon

Levels of Blood Pressure (BP) higher than normal (≤130/80 mmHg) is the most important public health problem in developed countries. It is important to realize that it is commonly asymptomatic, easy to detect, but difficult to control, and often leads to acute lethal complications, such as stroke. It is a devastating disease and is responsible for a transient or permanent neurologic dysfunction secondary to ischemic or hemorrhagic mechanisms of the Central Nervous System (CNS) [1]. Terminology and classification of stroke had already established according to the etiology [2]. There are several terms to define the presentation of this pathology in the clinical practice; the most adequate term should be cerebrovascular disease, mainly due to circulatory system problems (embolism, thrombosis, or hemorrhage) responsible for producing lesions occasionally irreversible. Arterial circle, polygon or Willis hexagon, supplies blood to the encephalon. It was described by the English clinician Thomas Willis (1622-1673).This author was also the first to describe myasthenia gravis and puerperal fev

At present, epidemiological analyses are able to quantify the risk factors responsible for cardiovascular diseases [3], age [4], hypertension, and history of previous heart disease [5-7]. Nevertheless, the principal etiology of stroke is atherosclerosis: a combination of circumstances affecting the arterial wall responsible for the inadequate supply of blood to the CNS. According to the general clinical opinion, the risk factors are classified into three categories: a) modifiable risk factors, (hypertension (72.1%), diabetes, dyslipidemia, arrhythmia, tobacco, alcohol abuse (>5 drinks daily) (8.1%), obesity (8.1%), and uncommon cause (25.6%); b) non modifiable risk factors (age, gender, ethnic groups, history of cardiovascular disease), and c) unknown circumstances.

Isolated Systolic Hypertension (ISH) is defined as Systolic Blood Pressure (SBP) >160 mmHg and Diastolic Blood Pressure (DBP) <90 mmHg. This situation affects 5% of the population older than 60 years, 13% of patients older than 70 years, and 24% of patients >80 years [8]. Some observational studies have demonstrated that the incidence of stroke and myocardial infarction in elderly people was strongly related to the levels of SBP; conversely, DBP levels do not represent an important predictor of risk [9]. However, the treatment of patients with both systolic and diastolic BP elevation reduces the incidence of cerebrovascular disease and all cardiovascular events combined. The hypothesis that antihypertensive drugs should also be prescribed to elderly population with ISH has been proven in at least three big clinical trials: SHEP (Systolic Hypertension in the Elderly Program), SYST-EUR Study (Systolic Hypertension in Europe), and HYVET (Hypertension in the Very Elderly Trial).

The SHEP trial showed a significant benefit for non-fatal stroke, but fatal strokes were not significantly reduced. The incidence of fatal strokes was rather low in the SHEP’s control group (14 of 159 strokes without including transient ischemic attacks, 9%). Whether the low incidence of fatal strokes in the The SHEP trial showed a significant benefit for non-fatal stroke, but fatal strokes were not significantly reduced. The incidence of fatal strokes was rather low in the SHEP’s control group (14 of 159 strokes without including transient ischemic attacks, 9%). Whether the low incidence of fatal strokes in the

This information is based on our large clinical experience in patients admitted to our Service of Internal Medicine and those referred from the Hypertension and Lipid Unit, as well as on several own studies [10-17]. In one of our researches [10] we analyzed retrospectively, 433 cases of stroke that represent 7% of all patients admitted to our Service of Internal Medicine between 1979 and 1985. The following were the conclusion of this investigation: most of the patients (men and women) were between 65 and 75 years old; the most frequent risk factors were hypertension 74.3%, 75.7%, and 54.2%, in men for TIA, full stroke, and stroke in evolution, respectively, and values of 70%, 62.2%, and 51.8% in women for TIA, full stroke, and stroke in evolution respectively; the median values for cardiac dysrhythmia were 35 % and 35.2% in men and women, respectively, and the median values for diabetes mellitus were 36.9% and 21.8% in men and women respectively [10] (Detailed values are shown in table 1). The prevalence of cerebral risk factors in our patients is shown in table 2). These previous discouraging results from our population were however, the motivation to create our Hypertension Unit in order to ameliorate this devastating clinical situation, not only in our region but also probably in everywhere. After that point and so far, we have treated thousands of patients with cardiovascular risk (hypertensive, diabetic, dyslipidemic patients and others) with the important and ambitious goal to improve this deteriorated situation. After that time, our group has also participated in more than 150 international clinical trials to improve the prognosis of this disease; even if the situation is now getting much better than three decades ago, there are still many problems to be resolved.

The recent study [11] was an observational cross-sectional investigation about the incidence of patients with ischemic cardiovascular disease carried out between June 2005 and June 2006. The study enrolled 243 patients in a referral population of 250,000 individuals from the province of Almeria (Spain). 172 individuals were diagnosed with acute ischemic stroke. All these patients with stroke were admitted to the Emergency and Critical Care Unit (1% of the population) because of ischemic cerebrovascular disease (neurological deficit lasting more than 24 hours of ischemic origin) with an incidence of 69 per 100,000 individuals per year. The semiology developed in the patients shown in table 3. The prevalence of stroke according to age shown in table 4. Although age is a risk factor for stroke events affecting mostly people older than 65 years, our experience reveals that this pathology is found in younger immigrants coming from the African continent (countries belonging to the Sub-Saharan region). The study was carried out according to the recommendations of the 59th General Assembly, Seul, 2008, and by the Convention for the Protection of Human Rights and Dignity of the Human Being.