Lipid dysregulation as a convergent pathway linking environmental exposures to stroke

Stroke remains the second leading cause of death globally, yet traditional risk factors explain only 50-60 percent of cases. Emerging evidence indicates that lipid dysregulation is a central mechanism linking environmental exposures to cerebrovascular vulnerability. Aging, chronic inflammation, infections, diet, inactivity, stress, sleep disorders, and toxins are associated with disruption of lipid homeostasis through oxidative stress-induced lipid peroxidation, cytokine-mediated metabolic reprogramming, blood-brain barrier disruption, ER stress-triggered lipid droplet formation, and mitochondrial dysfunction. These associations are supported by a combination of mechanistic, epidemiological, and clinical data, the strength of which varies across exposures and is explicitly evaluated throughout this review. Neuronal lipid droplets actively fuel synapses under stress, while membrane PUFA composition determines ischemic resilience. Lipid droplet accumulation, a hallmark of acute stroke, represents the potential endpoint of chronic environmental insults, creating metabolic fragility in which neurons may be less able to survive transient ischemia. Similar patterns in neurodegenerative disorders predict elevated stroke risk. However, direct causal evidence linking neuronal lipid droplet accumulation to stroke outcomes in humans remains limited, and this review explicitly distinguishes mechanistic hypotheses from clinically validated relationships. These factors are modifiable. Interventions targeting lipid homeostasis range from established therapies (statins, PPAR agonists, omega-3 fatty acids) to emerging approaches (mitochondria-ER stabilization, autophagy enhancement). This framework shifts stroke prevention from managing isolated risks to addressing the cumulative environmental burden on lipid metabolism, enabling precision prevention through lipidomic profiling and targeted intervention.