1. ARTERIAL ISCHEMIC
STROKE IN YOUNG
ADULTS
Ahmed Abdul Ghany

2. Annual incidence
• The annual incidence of AIS is 3.4 – 11.3 / 100.000
people / year While in Black adults is as high as
22.8/100.000

3. Risk factors
• A study of 324 patients undergoing standardized
clinical assessment traditional risk factors such as
Smoking 56%, Hypertension 23%, Dyslipidemia 15%,
and Diabetes 2% were not uncommon
• Oral contraceptives were used by 38% of women

4. One of the largest cohorts in
FILAND
Etiology
Cardioembolic 20%
Dissection 15%
Atherosclerosis 8%
Vasculopathies 14%
Undetermined 33%

6. Cardiac
Congenital
Endocarditis
Prosthetic
valve
replacement
Cardiomyopathy

7. Hematologic
Sickle cell
anemia
Antiphospholipid
Syndrome
Factor V
Leiden
mutation
Antithrombin
III deficency
Ptn C & S
deficency

8. Vasculopathy
Vasculitis
Dissection
1ry
2ry
Takayaso
SLE
Marfan
Syndrome
Moyamoya
Syndrome

9. Metabolic
MELAS
CADASIL
Fabry disease
Mitochondrial encephalopathy with lactic acidosis and stroke
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy

10. Initial management

11. Supportive measures
•
•
•
•
ABC
Maintain normoglycemia and normothermia.
Allow modest Hypertension.
Pneumatic compression and elastic stocking.

12. Thrombolysis (rt-PA)
Inclusion criteria
• Clinical diagnosis with
neurologic deficit.
• Onset ≤ 4.5 hours before
beginning treatment.
• Age ≥ 18 years
Exclusion criteria
• History of
stroke, ICH, tumor.
• Clinical: Systolic BP ≥ 185
or diastolic ≥ 110
• Active internal bleeding
• Lab: platelets ≤ 100.000 &
INR ≥ 1.7
• CT brain: ICH or
hypodensity ≥ 33% of the
cerebral hemisphere

13. Initial antithrombotic treatment
guidelines
• American Academy of chest physicians (ACCP)
recommend either unfractionated heparin or LMWH
or Aspirin until dissection and embolic causes have
been excluded.

14. • American heart association (AHA) stroke council
states that it may be reasonable to initiate
anticoagulation in patients with AIS pending
completion of diagnostic evaluation.
• Royal collage of physicians recommends initial
therapy with Aspirin.

15. • Aspirin 3-5 mg/kg day as initial therapy for all
patients except those with sickle cell disease or
intracranial hemorrhage.

16. • AIS due to confirmed cardioembolic source, arterial
dissection or hypercoagulable state: intravenous
unfractionated heparin( PTT 60 -85) or LMWH
subcutaneous (1 mg/kg q12 hr) for 5 – 7 days
followed by LMWH or warfarin.

17. • AIS with sickle cell disease: UK guidelines
recommends urgent IV hydration and blood
transfusion.

18. • AIS with vasculopathy: Aspirin +/immunosuppression for inflammatory vacuities.

19. • Decompressive hemicraniotomy: in patients with
mass effect or large (malignant) MCA territory
stroke.

20. Prognosis
Predictors of poor outcome:
• First year Mortality in • Young age
young adults 4 – 6 % • Fever at presentation
after AIS
• Altered consciousness at
presentation
• Bilateral ischemia
• MCA stroke volume ≥ 10 %

21. THANK YOU