stroke in young adults

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Stroke in Young AdultsDr Frances Wood

FY1Acute Stroke Unit

Royal Preston Hospital

16.01.13

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Stroke in Young Adults

• Incidence• Aetiology/Risk factors• Clinical findings• Investigations• Management

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Incidence

• Ischaemic stroke– 3.4-11.3/100,000 white populations– Up to 22.8/100,000 black populations

• Paediatric stroke– Males>females

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Aetiology/Risk Factors

• Ischaemic Stroke– Large vessel disease– Small vessel disease– Haematological disease– Migraine

• Haemorrhagic Stroke– Subarachnoid haemorrhage– Intracerebral haemorrage

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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

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ICA dissection

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Small Vessel disease

• Vasculopathy– Infectious, noninfectious, microangiopathy

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Haematologic Disease

• Sickle-cell disease• 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

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Migraine

• Migraine induced stroke 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

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Haemorrhagic Stroke

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Subarachnoid haemorrhage

Cerebral aneurysm

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Intracerebral Haemorrhage

• AV malformation• Neoplasm– Primary CNS, metastatic, leukaemia

• Haematologic– Thrombocytopenia, sickle-cell disease etc

• Moyamoya disease• Drug use– Warfarin, amphetamines, cocaine etc

• Iatrogenic– Peri-procedural

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Clinical Findings

• Presentation not unique to age group• Detailed hx• Full examination• Stroke mimics:– MS– Malignancy

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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

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Investigations

• Homocysteine• Fibrinogen• Anti-nuclear antibody• Lipoprotein(a)• Serum protein electrophoresis• Haemoglobin electrophoresis• Sickle cell assay

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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

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Carotid USS

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Investigations

• Cause of stroke often remains undetermined in 20-30% cases even after full Ix

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Management

• Management similar to that of older adults• Prognosis better than older adults

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Thank you