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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
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