Stroke will be South America's next epidemic. Therefore, information on stroke particularities in the region will help to overcome its impact burden. We evaluated prevalence, pattern of sub-types, and pathogenic mechanisms underlying stroke in Atahualpa, a village representative of rural coastal Ecuador. In a three-phase epidemiologic study, suspected cases were detected by a door-to-door survey (Phase I). Then, neurologists evaluated suspected cases and randomly selected negative persons (Phase II), and confirmed patients underwent complementary exams (Phase III). We found 20 stroke patients (mean age 70 years, 60% men) among 642 persons aged ≥40 years. Stroke prevalence was 31·15‰ that increased with age. Most patients had sub-cortical infarctions associated with leukoaraiosis or microbleeds. Hypertensive arteriolopathy was the most likely mechanism underlying strokes (55% patients). Intracranial arterial lesions were found in 47% cases. Extracranial atherosclerotic lesions or cardiac sources of emboli were not found in any case. Comparison of our findings with a previous survey performed in the same village showed an alarming increase in stroke prevalence (from 14·08‰ in 2003 to 31·15‰ in 2012, P = 0·03).