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Stroke in young adults
This document discusses stroke in young adults. It notes that the incidence of ischemic stroke is higher in black populations than white populations. The main causes of ischemic stroke are large vessel disease, small vessel disease, hematological diseases, and migraine. The main causes of hemorrhagic stroke are aneurysms and arteriovenous malformations. A thorough history, exam, and investigation including blood tests, imaging, and vascular studies are needed to determine the underlying cause in young adults since it is often not clear. Management is similar to older adults but prognosis is generally better.
Stroke in young adults
- 1. Stroke in YoungAdults Dr Frances Wood FY1 Acute Stroke Unit Royal Preston Hospital 16.01.13 1
- 2. Stroke in YoungAdults • Incidence • Aetiology/Risk factors • Clinical findings • Investigations • Management 2
- 3. Incidence • Ischaemic stroke – 3.4-11.3/100,000 white populations – Up to 22.8/100,000 black populations • Paediatric stroke – Males>females 3
- 4. Aetiology/Risk Factors • IschaemicStroke – Large vessel disease – Small vessel disease – Haematological disease – Migraine • Haemorrhagic Stroke – Subarachnoid haemorrhage – Intracerebral haemorrage 4
- 5. Large Vessel Disease •Premature atherosclerosis • Dissection (spontaneous/traumatic) • Inherited metabolic diseases – Homocysteinuria, MELAS syndrome etc • Fibromuscular dysplasia • Infection • Vasculitis – Collagen vascular diseases (SLE, Sjogren’s etc) • Toxic – Cocaine, heroin, phecyclidine, therapeutic drugs eg cytosine arabinosine 5
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- 7. Small Vessel disease •Vasculopathy – Infectious, noninfectious, microangiopathy 7
- 8. Haematologic Disease • Sickle-celldisease • Leukaemia • Hypercoagulable states – Protein C or S deficiency, antiphospholipid antibody syndromes, increased factor VIII etc • DIC • Polycythaemia vera • Thombotic thrombocytopenic purpura • Venous occlusion – Dehydration, meningitis, neoplasm etc 8
- 9. Migraine • Migraine inducedstroke rare (0.6%) – 13.7% ischaemic strokes in <45yo – Migraine with aura higher risk • Increase in cortical blood flow – Can stay above threshold for ischaemic injury • Endothelial dysfunction – Hypercoagulability, inflammation, vascular reactivity (posterior cerebral circulation) • Associated with PFO/ASD 9
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- 12. Intracerebral Haemorrhage • AVmalformation • Neoplasm – Primary CNS, metastatic, leukaemia • Haematologic – Thrombocytopenia, sickle-cell disease etc • Moyamoya disease • Drug use – Warfarin, amphetamines, cocaine etc • Iatrogenic – Peri-procedural 12
- 13. Clinical Findings • Presentation not unique to age group • Detailed hx • Full examination • Stroke mimics: – MS – Malignancy 13
- 14. Investigations • Routine bloods •Detailed coag profile – Lupus anticoagulants – Protein C and S – Activated protein C resistance – Antithrombin III • Toxicology screen – Even if drug use not acknowledged 14
- 15. Investigations • Homocysteine • Fibrinogen • Anti-nuclear antibody • Lipoprotein(a) • Serum protein electrophoresis • Haemoglobin electrophoresis • Sickle cell assay 15
- 16. Investigations • CT brain •MRI brain – DWI and PI • MRA brain • Carotid USS, MRA, Catheter angiography – Dissection/occlusion • TEE – 1/5 to 1/3 strokes in young attributed to cardioembolic phenomena 16
- 17. Carotid USS 17
- 18. Investigations • Cause ofstroke often remains undetermined in 20-30% cases even after full Ix 18
- 19. Management • Management similarto that of older adults • Prognosis better than older adults 19
- 20. Thank you 20
Editor's Notes
- #5 1/5 to 1/3 strokes in young attributed to cardioembolic phenomena
- #6 Dissection – extracranial internal carotid, vertebrobasilar system, less commonly intracranial carotid - assoc with trauma, chiropractic manipulation, marfan’s, ehlersdanlos type IV, drug abuseVasculitis – stroke with fever/encephalopathy multifocal symptomsMELAS - Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes
- #10 Impairedcerebrovascular reactivity in posterior cerebral circulation in those with migraine – ischaemic lesions in migraine patients occur mostly in this territory
- #13 45% strokes in young adults½ lobar¼ basal ganglia or internal capsule
- #14 Corneal arcus – hypercholesterolaemiaCorneal opacity – Fabry’s diseaseLisch nodules and optic atrophy – neurofibromatosisLens subluxation – Marfan’s, homocysteinuriaRetinal perivasculitis – sickle cell, syphilis, connective tissue diseases, IBDHamartoma – tuberous sclerosisSplinter haemorrhages, needle tracks – endocarditisXanthoma – hyperlipidaemiaCafé au lait spots, neurofibromas – neurofibromatosisPurpura – coagulopathyCapillary angiomata – cavernous malformation
- #15 Heparin can alter the results of these tests so send before any administered
- #17 DWI – diffusion weighted imagingPI – perfusion imagingThis is in order to distinguish between potentially salvageable tissue and irreversibly injured tissue
- #18 Common carotid artery dissection