Semin Neurol 2005; 25(3): 290-299
DOI: 10.1055/s-2005-917665
Copyright © 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Stroke in the Tropics

Joao Gomes1 , Julio A. Chalela1 , 2
  • 1Neuroscience Critical Care Department, Johns Hopkins University Hospital, Baltimore, Maryland
  • 2Section on Stroke Diagnostics and Therapeutics, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
Further Information

Publication History

Publication Date:
19 September 2005 (online)


Similar to northern developed countries, cerebrovascular disease is a leading cause of morbidity and mortality in tropical countries. The epidemiology of stroke in the tropics is different from one tropical region to another and from the tropics to northern latitudes. In tropical regions, stroke is due to the conventional mechanisms encountered in other latitudes, as well as unusual causative mechanisms unique to the tropics. In tropical regions, infectious causes of stroke and nonatherosclerotic mechanisms are more common than in nontropical areas. Our current knowledge of stroke in the tropics is limited by the financial restrictions existing in such regions limiting health care delivery and epidemiological research.


  • 1 Murray C JL, Lopez A D. Mortality by cause for eight regions of the world: Global Burden of Disease Study.  Lancet. 1997;  349 1269-1276
  • 2 Ryan E T, Wilson M E, Kain K C. Illness after international travel.  N Engl J Med. 2002;  347 505-516
  • 3 Del Brutto O H. Enfermedad cerebrovascular en los tropicos.  Rev Neurol. 2001;  33 750-762
  • 4 Pradilla Ardila G, Vesga Angarita B E, Leon-Sarmiento F E. Study of neurological diseases prevalence in Aratoca, a rural area of eastern Colombia.  Rev Med Chil. 2002;  130 191-199
  • 5 Saposnik G, Del Brutto O H. for the Iberoamerican Society of Cerebrovascular Diseases . Stroke in South America: a systematic review of incidence, prevalence, and stroke subtypes.  Stroke. 2003;  34 2103-2108
  • 6 Uribe C S, Jimenez I, Mora M O et al.. Epidemiology of cerebrovascular disease in Sabaneta, Colombia.  Rev Neurol. 1997;  25 1008-1012
  • 7 Del Brutto O H, Mosquera A, Sanchez X, Santos J, Noboa C A. Stroke subtypes among Hispanics living in Guayaquil, Ecuador: results from the Luis Vernaza Stroke Registry.  Stroke. 1993;  24 1833-1836
  • 8 Siqueira Neto J I, Santos A C, Ramos Cebete Fabio S, Sakamoto A. Cerebral infarction in patients aged 15 to 40 years.  Stroke. 1996;  27 2016-2019
  • 9 Banerjee A K, Varma M, Vasista R K, Chopra J S. Cerebrovascular disease in north-west India: a study of necropsy material.  J Neurol Neurosurg Psychiatry. 1989;  52 512-515
  • 10 Bharucha N E, Bharucha A E, Bhise A V, Schoenberg B S. Prevalence of stroke in the Parsi community of Bombay.  Stroke. 1988;  19 60-62
  • 11 Abebe M, Haimanot R T. Cerebrovascular accidents in Ethiopia.  Ethiop Med J. 1990;  28 53-61
  • 12 Matenga J, Kitai I. Levy l. Strokes among black people in Harare, Zimbabwe: results of computed tomography and associated risk factors.  BMJ. 1986;  292 1649-1651
  • 13 Walker R W, Rolfe M, Kelly P J, George M O, James O FW. Mortality and recovery after stroke in The Gambia.  Stroke. 2003;  34 1604-1609
  • 14 Nyame P K, Bonsu-Bruce N, Amoah A G et al.. Current trends in the incidence of cerebrovascular accidents in Accra.  West Afr J Med. 1994;  13 183-186
  • 15 Walker R W, McLarty D G, Kitange H M et al.. Stroke mortality in urban and rural Tanzania.  Lancet. 2000;  355 1684-1687
  • 16 Beales P F, Brabin B, Dorman E et al.. Severe falciparum malaria.  Trans R Soc Trop Med Hyg. 2000;  94 S1-S90
  • 17 Marsden P D, Bruce-Sihwatt L J. Cerebral malaria. In: Hornabrook RW Topics on Tropical Neurology: Contemporary Neurology Series. Philadelphia; FA Davis Co 1975: 29-44
  • 18 Edington G M. Cerebral malaria in the gold coast of Africa: four autopsy reports.  Ann Trop Med Parasitol. 1954;  48 300-306
  • 19 Thomas J D. Clinical and histopathological correlation of cerebral malaria.  Trop Geogr Med. 1971;  23 232-238
  • 20 Daroff R B, Deller J J, Kastl A J et al.. Cerebral malaria.  JAMA. 1967;  202 679-682
  • 21 Gilles H M, Lawson J B, Sibelas M et al.. Malaria, anemia, and pregnancy.  Ann Trop Med Parasitol. 1969;  63 245-263
  • 22 Toro G, Roman G. Cerebral malaria.  Arch Neurol. 1978;  35 271-275
  • 23 Warrell D A, Looareesuwan M J, Warrel P et al.. Dexamethasone proved deleterious in cerebral malaria.  N Engl J Med. 1982;  306 313-319
  • 24 Oo M M, Aikawa M, Than T et al.. Human cerebral malaria: a pathological study.  J Neuropathol Exp Neurol. 1987;  46 223-231
  • 25 Polder T W, Jerusalem C R, Eling W MC. Morphological characteristics of intracerebral arterioles in clinical (Plasmodium falciparum) and experimental (Plasmodium berghei) cerebral malaria.  J Neurol Sci. 1991;  101 35-46
  • 26 Schmid A H. Cerebral malaria: on the nature and significance of vascular changes.  Eur Neurol. 1974;  12 197-208
  • 27 Arietti S. Histopathological changes in cerebral malaria and their relation to psychotic sequels.  Arch Neurol Psychiatry. 1946;  56 79-104
  • 28 Krishnan A, Karmad D R, Limaye U, Siddarth W. Cerebral venous and dural sinus thrombosis in severe falciparum malaria.  J Infect. 2004;  48 86-90
  • 29 Wassmer S C, Combes V, Grau G E. Pathophysiology of cerebral malaria: role of host cells in the modulation of cytoadhesion.  Ann N Y Acad Sci. 2003;  992 30-38
  • 30 Jerusalem C, Polder T, Kubat K et al.. Comparative clinical and experimental study on the pathogenesis of cerebral malaria.  Contrib Microbiol Immunol. 1983;  7 130-138
  • 31 Jerusalem C, Polder T, Kubat K et al.. Brain edema in cerebral malaria: a comparative clinical and experimental, ultrastructural, and histochemical study. In: Go KG, Beathman A Recent Progress in the Study and Therapy of Brain Edema. New York; Plenum Press 1984: 127-135
  • 32 Silamut K, Phu N H, Whitty C et al.. A quantitative analysis of the microvascular sequestration of malaria parasites in the brain.  Am J Pathol. 1999;  155 395-410
  • 33 Cordoliani Y S, Sarrazin J L, Felten D et al.. MR of cerebral malaria.  AJNR Am J Neuroradiol. 1998;  19 871-874
  • 34 Cordoliani Y S, Sarrazin J L, Felten D et al.. MR of cerebral malaria.  AJNR Am J Neuroradiol. 1998;  19 871-874
  • 35 Kampfl A W, Birbamer G G, Pfausler B E et al.. Isolated pontine lesions in algid cerebral malaria: clinical features, management, and MRI findings.  Am J Trop Med Hyg. 1993;  48 818-822
  • 36 Saissy J M, Pats B, Renard J L, Dubayle P, Herve R. Isolated bulb lesion following mild Plasmodium falciparum malaria diagnosed by magnetic resonance imaging.  Intensive Care Med. 1996;  22 610-611
  • 37 Taylor T E, Wills B A, Kazembre P et al.. Rapid coma resolution with arthemeter in Malawian children with cerebral malaria.  Lancet. 1993;  341 661-662
  • 38 Huda S N, Shahab T, Ali S M et al.. A comparative clinical trial of artemether and quinine in children with severe malaria.  Indian Pediatr. 2003;  40 939-945
  • 39 Dastur D K, Lalitha V S, Udani P M, Parekh U. The brain and meninges in tuberculous meningitis: gross pathology in 100 cases and pathogenesis.  Neurol India. 1970;  18 86-100
  • 40 Udani P M, Pakekh U C, Dastur D K. Neurological and related syndromes in CNS tuberculosis: clinical features and pathogenesis.  J Neurol Sci. 1971;  14 341-357
  • 41 Leiguarda R, Berthier M, Starkstein S et al.. Ischemic infarction in 25 children with tuberculous meningitis.  Stroke. 1988;  19 200-204
  • 42 Bhargava S, Gupta A K, Tandom P N. Tuberculous meningitis: a CT study.  Br J Radiol. 1982;  55 189-196
  • 43 Hsieh F Y, Chia L G, Shen W C. Locations of cerebral infarctions in tuberculous meningitis.  Neuroradiology. 1992;  34 197-199
  • 44 Rich A R, McCordock H A. The pathogenesis of tuberculous meningitis.  Bull Johns Hopkins Hosp. 1933;  52 5-37
  • 45 Dastur D K, Lalitha V S. The many facets of neurotuberculosis: an epitome of neuropathology. In: Zimmerman H Progress in Neuropathology. New York; Grune and Stratton 1973: 232-264
  • 46 Talamas O, del Brutto O H, Garcia Ramos G. Brain stem tuberculoma: an analysis of 11 patients.  Arch Neurol. 1989;  46 529-535
  • 47 Clark E G, Danbolt N. The Oslo study of the natural course of untreated syphilis.  Med Clin North Am. 1964;  48 613-620
  • 48 Nordenbo A M, Sorensen P S. The incidence and clinical presentation of neurosyphilis in greater Copenhagen, 1974-1978.  Acta Neurol Scand. 1981;  63 237-246
  • 49 Holland B A, Perret L V, Millis C M. Meningovascular syphilis: CT and MRI findings.  Radiology. 1986;  158 439-442
  • 50 Holmes M D, Brant-Zawadki M M, Simon R P. Clinical features of meningovascular syphilis.  Neurology. 1984;  34 553-556
  • 51 Aldrich M S, Burke J M, Gulati S M. Angiographic findings in a young man with recurrent stroke and positive fluorescent treponemal antibody (FTA).  Stroke. 1983;  14 1001-1004
  • 52 Landi G, Villani F, Anzalone N. Variable angiographic findings in patients with stroke and neurosyphilis.  Stroke. 1990;  21 333-338
  • 53 Shandera W X, White A C, Chen J C. Neurocysticercosis in Houston, Texas: a report of 112 cases.  Medicine (Baltimore). 1994;  73 37-52
  • 54 Alarcon F, Vanormelingen K, Moncayo J, Vinan I. Cerebral cysticercosis as a risk factor for stroke in young and middle-aged people.  Stroke. 1992;  23 1563-1565
  • 55 Sotelo J, Marin C. Hydrocephalus secondary to cysticercotic arachnoiditis: a long-term follow-up review of 92 cases.  J Neurosurg. 1987;  66 686-689
  • 56 McCormick G F, Zee C S, Heiden J. Cysticercosis cerebri: review of 127 cases.  Arch Neurol. 1982;  39 534-539
  • 57 Alarcon F, Hidalgo F, Moncayo J et al.. Cerebral cysticercosis and stroke.  Stroke. 1992;  23 224-228
  • 58 Barinagarrementeria F, Del Brutto O H. Neurocysticercosis and pure motor hemiparesis.  Stroke. 1988;  19 1156-1158
  • 59 Barinagarrementeria F. Causas no ateroescleroticas de isquemia cerebral.  Arch Inst Nal Neurol Neurocir (Mex). 1989;  1 33-35
  • 60 Barinagarrementeria F, del Brutto O H. Lacunar syndromes due to neurocysticercosis.  Arch Neurol. 1989;  46 415-417
  • 61 Barinagarrementeria F, Cantu C. Frequency of cerebral arteritis in subarachnoid cysticercosis: an angiographic study.  Stroke. 1998;  29 123-124
  • 62 Cantu C, Barinagarrementeria F. Cerebrovascular complications of neurocysticercosis-clinical and neuroimaging spectrum.  Arch Neurol. 1996;  53 233-239
  • 63 Martinez-Chamorro E, Muñoz A, Esparza J et al.. Focal cerebral involvement by neurobrucellosis: pathological and MRI findings.  Eur J Radiol. 2002;  43 28-30
  • 64 Povar J, Aguirre J M, Arazo P et al.. Brucelosis con afectacion del sistema nervioso.  An Med Interna. 1991;  8 387-390
  • 65 Koussa S, Chemaly R. Neurobrucellosis presenting with diffuse white matter lesions.  Eur Neurol. 2003;  50 121-123
  • 66 Bahemuka M, Shemena A R, Panayiotopolus C P et al.. Neurological syndromes of brucellosis.  J Neurol Neurosurg Psychiatry. 1988;  51 1017-1021
  • 67 Bodur H, Erbay A, Akinci E, Colpan A, Cevik M A, Balaban N. Neurobrucellosis in an endemic area of brucellosis.  Scand J Infect Dis. 2003;  35 94-97
  • 68 McLean D R, Russell N, Khan M Y. Neurobrucellosis: clinical and therapeutic features.  Clin Infect Dis. 1992;  15 582-590
  • 69 Kirchhoff L V. Trypanosoma species: biology of trypanosomes. In: Mandell GL, Bennet JE, Dolin R Principles and Practice of Infectious Disease. New York; Churchill Livingstone 1995: 2442-2450
  • 70 Kirchhoff L V. American trypanosomiasis (Chagas' disease): a tropical disease now in the United States.  N Engl J Med. 1993;  329 639-644
  • 71 Rassi Jr A, Rassi A, Little W C. Chagas' heart disease.  Clin Cardiol. 2000;  23 883-889
  • 72 Pitella J E. Ischemic cerebral changes in chronic Chagasic cardiomyopathy.  Arq Neuropsiquiatr. 1984;  42 105-115
  • 73 Samuel J, Oliveira M, Correa De Araujo R R, Navarro M A, Muccillo G. Cardiac thrombosis and thromboembolism in chronic Chagas' heart disease.  Am J Cardiol. 1983;  52 147-151
  • 74 Carod-Artal F J, Vargas A P, Melo H M, Toran T A. American trypanosomiasis (Chagas' disease) an unrecognized cause of stroke.  J Neurol Neurosurg Psychiatry. 2003;  74 516-518
  • 75 Petkova S B, Huang H, Factor S M et al.. The role of endothelin in the pathogenesis of Chagas' disease.  Int J Parasitol. 2001;  31 499-511
  • 76 Shi F L, Hart R G, Sherman D G, Tegeler C H. Stroke in the people's republic of China.  Stroke. 1989;  20 1581-1585
  • 77 Del Brutto O H, Sanchez J, Campos X, Mosquera A. Non-traumatic intracerebral hemorrhage in young adults living in Guayaquil, Ecuador (South America): analysis of 151 patients.  Funct Neurol. 1999;  14 21-28
  • 78 Shi F, Hart R G, Sherman D G, Tegeler C H. Stroke in the People's Republic of China.  Stroke. 1989;  20 1581-1585
  • 79 Enria D A, Pinheiro F. Rodent-borne emergent viral zoonosis: hemorrhagic fevers and Hantavirus infections in South America.  Infect Dis Clin North Am. 2000;  14 167-184
  • 80 De Bracco M ME, Rimoldi M T, Cossio P M et al.. Argentine hemorrhagic fever: alterations of the complement system and anti-Junin virus humoral response.  N Engl J Med. 1978;  299 216-221
  • 81 Child P L, MacKenzie R B, Valverde L R, Johnson K M. Bolivian hemorrhagic fever: a pathologic description.  Arch Pathol. 1967;  83 434-445
  • 82 Enria D A, de Damilano A J, Briggiler A M et al.. Sindrome neurologico tardio en enfermos de fiebre hemorragica Argentina tratados con plasma inmune.  Medicina (B Aires). 1985;  45 615-620
  • 83 Kilgore P E, Ksiazek T G, Rollin P E et al.. Treatment of Bolivian hemorrhagic fever with intravenous ribavirin.  Clin Infect Dis. 1997;  24 718-722
  • 84 Enria D A, Pinheiro F. Rodent-borne emerging viral zoonosis: hemorrhagic fevers and hantavirus infections in South America.  Infect Dis Clin North Am. 2000;  14 167-184
  • 85 Koide K. [Japanese clinical statistical data of patients with aortitis syndrome.]  Nippon Rinsho. 1992;  50 343-354
  • 86 Bleck T P. Takayasu's disease. In: Toole JF Handbook of Clinical Neurology. London; Elsevier 1989: 335-340
  • 87 Ishikawa K. Survival and morbidity after diagnosis of occlusive thromboaortopathy (Takayasu's disease).  Am J Cardiol. 1981;  47 1026-1032
  • 88 Deyu Z, Dijun F, Lisheng L. Takayasu arteritis in China: a report of 530 cases.  Heart Vessels. 1992;  50(suppl) 343-354
  • 89 Asaoka Y. Takayasu's disease. In: Bogousslavsky J, Caplan L Uncommon Causes of Stroke. 2nd ed. Cambridge; Cambridge University Press 2001: 37-42
  • 90 Kumral E. Behcet's disease. In: Bogousslavsky J, Caplan L Uncommon Causes of Stroke. 2nd ed. Cambridge; Cambridge University Press 2001: 150-156
  • 91 Yazi H. Behcet's syndrome. In: Klippel JH, Dieppe PA Mosby Year Book of Rheumatology. London; Mosby 1994: 24-36
  • 92 Wolf S M, Scotland D L, Phillips L L. Involvement of the nervous system in Behcet's syndrome.  Arch Neurol. 1965;  12 315-325
  • 93 Tsutsui K, Hasegawa M, Takata M, Takeahara K. Increased plasma granulocyte elastase levels in Behcet's disease.  J Rheumatol. 1998;  25 326-328
  • 94 Rougemont D, Bousser M G, Wechsler B, Bletry O, Castaigne P, Godeau P. Manifestations neurologiques de la maladie de Behcet.  Rev Neurol (Paris). 1982;  138 493-505
  • 95 Shakir R A, Sulaiman K, Kahn R A, Rudwan M. Neurological presentation of neuro-Behcet's syndrome: clinical categories.  Eur Neurol. 1990;  30 249-253
  • 96 Shimizu T, Ehrlich G E, Inaba G, Hayashi K. Behcet's disease.  Semin Arthritis Rheum. 1979;  8 223-260
  • 97 Uruyama A, Sakuragi S, Sakai F. Angio-Behcet syndrome. In: Lehner T, Barnes CG Behcet Syndrome: Clinical and Immunological Features. London; Academic Press 1979: 54-63
  • 98 Zelenski J D, Capraro J A, Holden D, Calabrese L H. Central nervous system vasculitis in Behcet's syndrome: angiographic improvement after therapy with cytotoxic agents.  Arthritis Rheum. 1989;  32 217-220
  • 99 Matsumoto T, Uekusa T, Fukuda Y. Vasculo-Behcet's disease: a pathologic study of eight cases.  Hum Pathol. 1991;  22 45-51
  • 100 Adams H P. Moya-moya. In: Bogousslavsky J, Caplan L Uncommon Causes of Stroke. 2nd ed. Cambridge; Cambridge University Press 2001: 241-257
  • 101 Wakai K, Tamakoshi A, Ikesaki K et al.. Epidemiological features of moya-moya disease in Japan: findings from a nation-wide study.  Clin Neurol Neurosurg. 1997;  99 S1-S5
  • 102 Fukui M. Current state of study on moyamoya disease in Japan.  Surg Neurol. 1997;  47 138-143
  • 103 Chiu D, Sheddon P, Bratina P, Grota J C. Natural history of moyamoya disease in the United States.  Stroke. 1998;  29 1347-1351
  • 104 Bruno A, Yuh W T, Biller J. Magnetic resonance imaging findings in young adults with cerebral infarction due to moyamoya.  Arch Neurol. 1988;  45 303-306
  • 105 Hung C C, Tu Y K, Lin L S, Shih C J. Epidemiological study of moyamoya disease in Taiwan.  Clin Neurol Neurosurg. 1997;  99 S23-S25
  • 106 Kaufman M, Little B W, Berkowitz B W. Recurrent intracranial hemorrhage in an adult with moyamoya disease.  Can J Neurol Sci. 1988;  15 430-434
  • 107 Kawaguchi S, Sakaki T, Morimoto T et al.. Characteristics of intracranial aneurysms associated with moyamoya disease.  Acta Neurochir (Wien). 1996;  138 1287-1294
  • 108 Kodama N, Sato M, Sasaki T. Treatment of ruptured cerebral aneurysms in moyamoya.  Surg Neurol. 1996;  46 62-66
  • 109 Yamada I, Himeno Y, Suzuki S, Matsushima Y. Posterior circulation in moyamoya disease: angiographic study.  Radiology. 1995;  197 239-246
  • 110 Kuroda S, Kamiyama H, Isobe M et al.. Cerebral hemodynamics and “re-build-up” phenomenon on electroencephalogram in children with moyamoya disease.  Childs Nerv Syst. 1995;  11 214-219
  • 111 Smadja D, Cabre P, May F et al.. ERMANCIA: epidemiology of stroke in Martinique, French West Indies-part 1, methodology, incidence, and 30-day case fatality rate.  Stroke. 2001;  32 2741-2747
  • 112 Hernandez-Hernandez R, Armas-Padilla M C, Armas-Hernandez M J, Velasco M. Hypertension and cardiovascular death in Venezuela and Latin American countries.  J Hum Hypertens. 2000;  14(suppl 1) S2-S5
  • 113 Collaborative Stroke Group for Latin America . Attitudes in the management of acute ischemic cerebrovascular accident and cerebral hemorrhage in Latin America.  Acta Neurol Scand. 1989;  79 300-305
  • 114 Imam I. Stroke: a review with an African perspective.  Ann Trop Med Parasitol. 2002;  96 435-445

Julio A ChalelaM.D. 

Section on Stroke Diagnostics and Therapeutics, NINDS/NIH

10 Center Drive, Room B1D733

Bethesda, MD 20892