RELATIONSHIP

DIABETICDiabetic BETWEEN DIABETES

neuropathy
NEUROPATHY

AND ISCHAEMIC STROKE

Neurologic Complication of Diabetes

JUMRAINI TAMMASSE

Department of Neurology
Faculty of Medicine – Hasanuddin University
 Introduction
Diabetes and ischemic stroke are common diseases that
frequently occurring together
Diabetes is an independent risk factor for stroke disease
diabetic patients have at least twice the risk forstroke, and
approximately 20% of diabetic patients will die from stroke,

Diabetes duration has also been shown to increase the risk

of ischaemic stroke disease, with every year of diabetes
duration increasing the risk by 3%

Hyperglycaemia has been shown to increase the size of

ischaemic stroke and worsen the clinical outcome following
a stroke

Tuttolomondo et al., J Diabetes Metab 2015, 6:5

 Estimations of the Prevalence of
Cerebrovascular Disease among People with
Diabetes
diabetes is present in about 10–25%
of people with stroke disease

stress related hyperglycaemia is found in up to two-

DIABETES
thirds of people with an acute stroke

Barzilay and colleagues prevalence of cerebrovascular

disease was 12.6% for men and 12.7% for women

the Minnesota Heart Survey

prevalence of diabetes hospitalized for stroke, 22.4% STROKE
in men and 24.7% in women

Tuttolomondo et al., J Diabetes Metab 2015, 6:5

 What is Stroke ?
• Stroke is defined by focal
neurological signs or symptoms
thought to be of vascular origin
that persisted for >24 h

The two broad categories of stroke are

ischemic stroke due to thrombosis, embolism,
or systemic hypoperfusion

hemorrhagic stroke due to Intracerebral

Hemorrhage (ICH) or Subarachnoid
Hemorrhage (SAH)
 Risk Factors of Stroke Associated
with Diabetes
• hyperglycemia
• vascular risk
factors
– hypertension
– dyslipidemia
• Genetic
• demographic,
• lifestyle factors

Bangalore S, Kumar S, Lobach I, Messerli FH (2011)

 Role of Chronic Hyperglycemia
 prolonged hyperglycemia
is associated with
 microvascular
complications such as
o retinopathy,
o neuropathy,
o and nephropathy,
 macrovascular
complications such as
o cerebrovascular
o cardiovascular
events
o Peripheral Arterial
Disease (PAD)
caused by
atherosclerosis
 Role of Hyperglycemia in Acute
Ischemic Stroke
Hyperglycemia arises in 30–40% of people with
acute ischemic stroke both in patients with
diabetes mellitus than in patients without a
previous history of diabetes
resulting in the increased production of stress
hormones such as cortisol and epinephrine
following the activation of the hypothalamic-
pituitary-adrenal axis and the autonomic
nervous system which finally results in an
increased production of glucose through the
gluconeogenesis, glycogenolysis, lipolysis and
proteolysis.
hyperglycemia consistently increased infarct
size and several mechanisms have been
identified through which hyperglycemia could
aggravate cerebral damage in ischemic stroke.
relationship between hyperglycemia and p
outcome in patients with ischemic stroke
arouses the question of whether the outco
may be improved by glucose-lowering
treatment. In fact, although it is true that t
concentrations of glucose can be
there is evidence suggesting that that glucos
lowering treatment improves clinical outcom
in patients with acute ischemic stroke and to
date uncertainty persists about the issue of
whether glucose-lowering treatment for ear
stroke can improve clinical outcome
 The Pathological Effects of Hyperglycaemia on
the Cardiovascular (CV) System and Brain
• Indirect pathways promoted by
• hyperglycaemia include worsening of
dyslipidaemia, especially the
development of atherogenic
dyslipidaemia (small dense low-
density lipoproteins, reduced high-
density lipoproteins, and increased
triglyceride levels) and sympathetic
nervous system dysfunction
• Direct acceleration of the
atherosclerotic process by
hyperglycaemia is in part related to
the development of endothelial
dysfunction which in turn promotes
vasoconstrictive, proinflammatory,
and prothrombotic processes that
contribute to plaque development
and rupture

The pathophysiology of cerebrovascular disease in patients with DM is not fully

characterized, but both large and small blood vessels seem to be affected
 Prevention of Stroke Disease in
Diabetic People
• Glycaemic Control :Improved • Antiplatelet Therapy: Platelets
glycaemic control has been have a “key role” in atherogenesis
shown to reduce the incidence of and its thrombotic complications
other common complications of in subjects with diabetes
diabetes, such as retinopathy, • Atrial Fibrillation :predisposes to
nephropathy, and neuropathy embolic stroke disease
• Hypertension :mproved • Surgical Treatments :Carotid
hypertensive management has endarterectomy
been shown to reduce the • Smoking and Lifestyle Advice
incidence of stroke in diabetic
people
• Cholesterol :any diabetic person
who has suffered stroke disease
should routinely be prescribed
cholesterol lowering therapy
regardless of their initial
cholesterol level.
Jonathan Hewitt,1 et all 2012, Diabetes and Stroke Prevention
 Conclusions

• Stroke disease is common in people with diabetes

• aggressively treating hyperglycaemia has not been
shown to have beneficial outcomes in either primary or
secondary prevention in stroke disease.
• Aggressive management of hypertension, however, has
been shown to be particularly efficacious in diabetic
people
• Cholesterol should be reduced, regardless of its
starting point and other common and established
primary and secondary stroke risk factors managed in
diabetic people.