Review of stroke in young adults including etiology, physical exam, treatment, and prognosis

1. Stroke in Young Adults
Stroke in Young Adults

2. Epidemiology
10-15% of all Stroke patients
Among people 15 – 44 yo:
• 50% Ischemic Stroke
• 20% Intracerebral Hemorrhage
• 30% Subarachnoid
Hemorrhage
Increasing incidence of stroke in
younger age groups (Kissela et.
Al 2012)

3. Epidemiology

4. Epidemiology
• Racial and ethnic differences in stroke risk are even greater in younger populations
• Young blacks and Hispanics have a greater incidence of stroke than young whites (Jacobs et al.)
• Young black adults had a significantly higher hospitalization rate for stroke than whites and
Hispanics (Pathak et al.)

5. Risk Factors
Ischemic stroke in children
• cardiac abnormalities
• vascular lesions (focal cerebral
arteriopathy)
• hematologic abnormalities
• infection
• head and neck trauma
• genetic conditions
Ischemic stroke in young adults
• vasculopathy (ie. arterial dissection)
• cardiac defects
• recent pregnancy
• hypercoagulable states
• smoking
• illicit drug use
• premature atherosclerosis
• hypertension
• low physical activity
• metabolic disorders
• Migraine (possibly)

6. Modifiable Risk Factors
• Modifiable risk factors are the same for both younger and older
age groups.
• Prevalence of these risk factors not the same
• Hypertension, heart disease (including A fib), and diabetes
mellitus are the most common risk factors among the elderly.
• In contrast, among 1,008 young stroke patients in Finland, the
most common vascular risk factors were dyslipidemia (60%),
smoking (44%), and hypertension (39%).
• Putaala et al: 3,944 young stroke patients in Europe.
• The three most frequent risk factors were current smoking (49%),
dyslipidemia (46%), and hypertension (36%).

7. Etiology
• Range of potential etiologies for stroke in young
adults is broader than that for older adults
• Categorized as Ischemic or Hemorrhagic
• Ischemic includes Cardioembolic,
Atherosclerotic disease, and Non-
atherosclerotic vasculopathies
• Hemorrhagic includes Subarachnoid and
Intraparenchymal types

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13. Etiology
• Majority of teenage stroke patients have
undetermined etiology
• May be due to insufficient extent and timing of
the investigations.
• Younger patients are less likely to utilize 911
and do not appreciate they are at risk of
stroke.
• Diagnosis is often delayed or missed because
stroke is still considered a disease of the
elderly
• Also could be due to the way TOAST trial
classified etiologies

14. Clinical Manifestations
Symptoms often similar to stroke in older patients
Neurological symptoms localization to the brain
Focal manifestations
• Hemiparesis and hemifacial weakness in 67 to 90 percent
• Speech or language disturbance in 20 to 50 percent
• Visual disturbance in 10 to 15 percent
• Ataxia in 8 to 10 percent
Non-localizing manifestations
• Headache in 20 to 50 percent
• Altered mental status in 17 to 38 percent
• Vomiting in approximately 10 percent

15. Physical Exam
• Thorough Neuro Exam
• PE should also include dermatological and ophthalmologic assessment
Ophthalmologic Exam:
• Corneal arcus (hypercholesterolemia)
• Corneal opacity (Fabry’s disease);
• Lisch nodules, optic atrophy
(neurofibromatosis)
• Lens subluxation (Marfan’s,
homocystinuria)
Dermatologic Exam:
• Splinter hemorrhages or needle tracks
(endocarditis)
• Xanthoma (hyperlipidemia)
• Cafe-au-lait spots, neurofibromas
(neurofibromatosis)
• Purpura (coagulopathy)
• Capillary angioma (cavernous malformations)

16. Investigations
• Emergent treatment of younger stroke patients same as older patients
• Physiologic management:
• blood pressure, temperature, glucose, and oxygenation, and potential thrombolysis
• CT Head – initial imaging
• High sensitivity for acute hemorrhage
• CTA Head and Neck
• Most patients should get MRI
• DWI: very sensitive for acute ischemia
• TTE w/ bubble study
• Telemetry Monitoring
• Blood work: lipid panel, hemoglobin A1c, TSH, ESR, CRP, RPR, HIV, and
toxicology screen

17. Investigations
• When appropriate, SCD screen and pregnancy test
• Low threshold to obtain blood cultures or a lumbar puncture.
• indicated for cases suspicious for infectious, vasculitic, or occult hemorrhage origins.
• Toxicologic studies are useful, even when drug use is not acknowledged.
• Other blood tests may include:
• Hypercoagulable labs, fibrinogen, ANA, serum protein electrophoresis, hemoglobin electrophoresis.
Cause of stroke in young patients may remain
undetermined in 20% - 30% of cases

18. Prognosis
• Better outcomes
• 330 patients with first stroke or TIA (followed for an average of 96 months)
• 8% died, 3% had another stroke, and 3% had a myocardial infarction.
• Approximately 16% were dependent; 56% had returned to work.
• Only a minority of those who smoked at the time of their stroke subsequently stopped using
tobacco.
• The overall annual recurrence rate is less than 1%.
• Prognosis is often closely associated with the underlying cause