1. Stroke in Young Adults
Dr Frances Wood
FY1
Acute Stroke Unit
Royal Preston Hospital
16.01.13
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2. Stroke in Young Adults
• Incidence
• Aetiology/Risk factors
• Clinical findings
• Investigations
• Management
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3. 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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4. Aetiology/Risk Factors
• Ischaemic Stroke
– Large vessel disease
– Small vessel disease
– Haematological disease
– Migraine
• Haemorrhagic Stroke
– Subarachnoid haemorrhage
– Intracerebral haemorrage
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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
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6. ICA dissection
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7. Small Vessel disease
• Vasculopathy
– Infectious, noninfectious, microangiopathy
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8. 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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9. 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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10. Haemorrhagic Stroke
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11. Subarachnoid haemorrhage
Cerebral aneurysm
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12. 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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13. Clinical Findings
• Presentation not unique to age group
• Detailed hx
• Full examination
• Stroke mimics:
– MS
– Malignancy
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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
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15. Investigations
• Homocysteine
• Fibrinogen
• Anti-nuclear antibody
• Lipoprotein(a)
• Serum protein electrophoresis
• Haemoglobin electrophoresis
• Sickle cell assay
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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
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17. Carotid USS
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18. Investigations
• Cause of stroke often remains undetermined
in 20-30% cases even after full Ix
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19. Management
• Management similar to that of older adults
• Prognosis better than older adults
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20. Thank you
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