Stroke In The Young Adult

1. Stroke In The Young Adult Victoria E. Judd MD, MBA

3. What Is A Stroke ? • A stroke occurs when blood flow to the brain is interrupted by a blocked or a ruptured blood vessel. • A brain attack.

4. Stroke • Acute stroke is typically characterized by the sudden onset of a focal neurologic deficit, though some patients have a stepwise or gradual progression of symptoms.

5. Stroke Common deficits include: • Dysphasia (difficulty swallowing) • Dysarthria (difficulty speaking) • Hemianopia (difficulty with sight) • Weakness

6. Stroke Common Deficits • Ataxia • Sensory loss • Neglect • Consciousness is generally normal but maybe impaired

7. Stroke Warning Signs • Sudden weakness or numbness of the face, arm or leg, especially on one side of the body • Sudden confusion, trouble speaking or understanding • Sudden trouble seeing in one or both eyes

8. Stroke Warning Signs • Sudden trouble walking, dizziness, loss of balance or coordination • Sudden, severe headaches with no known cause (for hemorrhagic stroke)

9. Stroke Warning Signs • Acute loss of focal cerebral function • Abrupt onset • Symptoms occur in all affected areas at the same time • Symptoms resolve gradually • Symptoms are “negative”

10. Nature of Symptoms • Positive symptoms indicate active discharge from central nervous system neurons. Typical positive symptoms can be visual (e.g., bright lines, shapes, objects), auditory (e.g., tinnitus, noises, music), somatosensory (e.g., burning, pain, paresthesias), or motor (e.g., jerking or repetitive rhythmic movements). • Negative symptoms indicate an absence or loss of function, such as loss of vision, hearing, feeling, or ability to move a part of the body.

11. Annual Incidence of Ischemic Stroke • In young adults (15–45 years) has been estimated at approximately 2–11 per 100,000 in Caucasians, 22.8 per 100,000 in African Americans • 10/100,000 in a Mayo Clinic study of women ages 15 to 29 • About 2–12% of cerebral infarcts occur in young adult patients, with a higher frequency between 31 and 45 years

12. Annual Incidence of Ischemic Stroke • Stroke ranks second after ischemic heart disease as a cause of lost disability-adjusted life-years in high-income countries

13. Mortality of Strokes • Mortality in the first month after stroke has been reported to range from 2.5% in patients with lacunar infarcts to 78% in patients with space-occupying hemispheric infarction. • Lacunar stroke or lacunar infarct (LACI) is a type of stroke that results from occlusion of one of the penetrating arteries that provides blood to the brain's deep structures.

14. Stroke • Stroke in young adults is surprisingly common. • The differential diagnosis for potential etiologies is broader than that for older adults.

15. Stroke In children and young adults; • Congenital and acquired heart problems, • Hematologic conditions, • Vasculopathies, • Metabolic disorders, • Drug ingestion are more common.

16. Causes of Stroke • The largest series studies of young adults with ischemic stroke cite undetermined as the most frequent etiology (up to 35% of patients) • Ischemic stroke is much more common than hemorrhagic

17. Causes of Stroke • Up to 45% of strokes in young adults are due to spontaneous intracerebral hemorrhage. • Vascular malformations, aneurysms, hypertension, and illicit drug use are the main causes.

18. Causes of Ischemic Stroke in Young Adults Eur Neurol 2007;57:212–218

19. Cardiovascular Risk Factors in272 Young Patients % (n) Major cardiovascular risk factors 35 (96) • Arterial hypertension 22 (59) • Diabetes mellitus 8 (21) • Hypercholesterolemia 17 (46) • Atherosclerosis 5 (14) • Causes of Ischemic Stroke in Young Adults Eur Neurol 2007;57:212–218

20. Cardiovascular Risk Factors in272 Young Patients % (n) Minor cardiovascular risk factors 63 (172) • Cigarette smoking 49 (133) • Oral contraceptives 18 (17) • High alcohol intake 31 (84) • Causes of Ischemic Stroke in Young Adults Eur Neurol 2007;57:212–218

21. Prevention of Stroke • Control high blood pressure • Prevent heart disease • Stop cigarette smoking • Recognize signs of TIA • Reduce blood cholesterol levels

22. Stroke Risk Factors That Can Be Treated • Hypertension/High Blood Pressure • Heart Disease • Cigarette Smoking • Transient Ischemic Attacks

23. Stroke Risk Factors That Can Be Treated • Diabetes • Elevated Blood Cholesterol/Lipids • Asymptomatic Carotid Bruits

24. Stroke Risk FactorsThat Cannot Be Treated • Age • Gender • Race • Prior stroke • Family history

25. Stroke Risk Factors Less Well-Documented • Geographical Location • Socioeconomic Factors • Excessive Alcohol Intake • Certain Kinds of Drug Abuse

26. What Are the Types of Stroke ? Ischemic Stroke (Blockage) • Caused by a blockage in blood vessels in brain Hemorrhagic Stroke (Bleeding) • Caused by ruptured or leaking blood vessels in brain

27. Stroke Background • Inadequate blood flow • Ischemic stroke • Focal – thrombotic or embolic occlusion of major artery • Global – inadequate cerebral perfusion • Hemorrhage • Parenchymal – into brain tissue • Subarachnoid – surrounding subarachnoid space

29. Causes of Stroke Some of the most common causes of ischemia in the young • Cardioembolism (20–35%), • Dissection of extracranial arteries (6–25%), • Migraine with aura (1–20%) • Drugs (10%) • Hypercoagulable states (5–10%) • Premature atherosclerosis (20-25%)

30. Ischemic Stroke • In patients younger than 55 years, only about 10% of strokes are caused by large-vessel atherosclerotic disease.

31. What Are the Causes of Ischemic Stroke? Large vessel disease • Premature atherosclerosis • Dissection (spontaneous or traumatic) • Inherited metabolic diseases (homocystinuria, Fabry’s, pseudoxanthoma elasticum, MELAS syndrome) • Fibromuscular dysplasia • Infection (bacterial, fungal, tuberculosis, syphilis, Lyme) • Vasculitis (collagen vascular diseases — systemic lupus erythematosus, rheumatoid arthritis, Sjögren’s syndrome, polyarteritis nodosa; Takayasu’s disease, Wegener’s syndrome, cryoglobulinemia, sarcoidosis, inflammatory bowel disease, isolated central nervous system angiitis) • Moyamoya disease: (Japanese, "puff of cigar smoke") is an inherited disease in which certain arteries in the brain are constricted • Radiation • Toxic (illicit drugs — cocaine, heroin, phencyclidine; therapeutic drugs — L-asparaginase, cytosine arabinoside, ephedra, phenylephrine)

32. What Are the Causes of Ischemic Stroke? • Cardiac disease (including congenital, rheumatic valve disease, mitral valve prolapse, patent foramen ovale, endocarditis, atrial myxoma, arrhythmias, cardiac surgery)

33. What Are the Causes of Ischemic Stroke? Small vessel disease • Vasculopathy (infectious, noninfectious, microangiopathy) • Independent predictors of arteriopathy are sickle cell disease and recent upper respiratory infection.

34. What Are the Causes of Ischemic Stroke? Hematologic disease • Sickle-cell disease • Leukemia • Hypercoagulable states (antiphospholipid antibody syndrome, deficiency of antithrombin III or protein S or C, resistance to activated protein C, increased factor VIII) • Disseminated intravascular coagulation • Thrombocytosis • Polycythemia vera • Thrombotic thrombocytopenic purpura • Venous occlusion (dehydration, parameningeal infection, meningitis, neoplasm, polycythemia, leukemia, inflammatory bowel disease)

35. Hematologic Disorders • Many hematologic disorders are associated with ischemic stroke. • The disorders most likely to cause ischemic stroke in patients younger than 45 years are: • Antiphospholipid antibody syndrome • Sickle cell anemia • Heparin induced thrombocytopenia

36. APS • Antiphospholipid syndrome (APS or APLS) or antiphospholipid antibody syndrome is a disorder of coagulation that causes blood clots (thrombosis) in both arteries and veins as well as pregnancy-related complications such as miscarriage, stillbirth, preterm delivery, or severe preeclampsia. The syndrome occurs due to the autoimmune production of antibodies against phospholipid (aPL), a cell membrane substance. In particular, the disease is characterized by antibodies against cardiolipin (anti-cardiolipin antibodies) and β2 glycoprotein.

37. Hematologic disorders • Most of the common hereditary hypercoagulable disorders, such as factor V Leiden/activated protein C resistance, the prothrombin gene mutation (G20210A), antithrombin III deficiency, protein C deficiency, and protein S deficiency, typically cause venous thrombosis much more often than they cause arterial thrombosis.

38. What Are the Causes of Ischemic Stroke? Migraine: especially with aura

39. Embolism: • Cardiogenic (atrial fibrillation, mural thrombus, myxoma, valvular vegetations) • Artery-to-artery • Fat • Air • Paradoxical (emboli of venous origin passing through a patent foramen ovale)

40. Cardiogenic Embolism • Major risk factors: Anticoagulation Indicated • Atrial fibrillation • Mitral stenosis • Prosthetic cardiac valve • Recent MI • Thrombus in LV or LA appendage • Atrial myxoma • Infective endocarditis (No anticoagulation) • Dilated cardiomyopathy

41. Cardiogenic Embolism • Minor risk factors: Best treatment unclear • Pathologic Mitral valve prolapse (2% of population) • Mitral annular calcification • Patent foramen ovale (25% 0f population) • Atrial septal aneurysm • Calcific aortic stenosis • LV regional wall motion abnormality • Aortic arch atheromatous plaques • Spontaneous echocardiographic contrast

42. Cardiogenic Embolism • One-fifth to one-third of strokes in the young may be caused by cardioembolic phenomena.

43. Cardiogenic Embolism • Paradoxical embolization from the right heart to the left is believed to occur via a patent foramen ovale or atrial septal defect (which can be found on autopsy in up to one fourth of all people. • Atherosclerosis of the aorta or carotid arteries can be a source of both atheroemboli and thromboemboli

44. Cardiogenic Embolism • Left atrial thrombi account for nearly half of cardiac thromboemboli. The most common cause is atrial fibrillation; other causes are dilated cardiomyoapthy, mitral valve stenosis, and some hypercoagulable states.

45. Left atrium Left atrium Right atrium Valsalva Figure 1. Transesophageal Echocardiograms of a Patent Foramen Ovale. In Panel A, a transesophageal echocardiogram in the longitudinal plane shows a separation between the primum septum (arrowhead) and the secundum septum — a finding consistent with the presence of patent foramen ovale. Panel B shows a transesophageal echocardiogram, also in the longitudinal plane, obtained during the injection of agitated-saline contrast material through an antecubital vein with use of the Valsalva maneuver. There is complete opacification of the right atrium, and passage of a cloud of bubbles between the primum and secundum septa into the left atrium is visible. Right atrium

46. RA LA Figure 2. Transesophageal echocardiogram showing a thrombus (arrows) passing from right atrium (RA) to left atrium (LA) through a patent foramen ovale.

47. Left atrium Left atrium Right atrium Right atrium Left ventricle Right ventricle Figure 2. Transesophageal Echocardiograms of an Atrial Septal Aneurysm. In Panel A, a transesophageal echocardiogram (in the horizontal plane) shows an atrial septal aneurysm protruding into the right atrium (arrow). Atrial septal aneurysm is defined as either sustained bowing of a 15-mm segment of interatrial septal membrane in the fossa ovalis of at least 11 mm (or at least 15 mm by a more conservative definition) beyond the plane of the interatrial septum or as phasic excursion to either side totaling the same distance. Panel B shows a transesophageal echocardiogram showing the same atrial septal aneurysm (arrow) viewed in the longitudinal plane.

48. PFO • Figure 3. Percutaneous Closure of a Patent Foramen Ovale. • With use of a femoral approach, a transvenous sheath is advanced across the foramen into the left atrium, where a folded disk is expanded and pulled back, apposing the primum and secundum septa closed. This step is followed by deployment of a right-sided disk, at which time the two-disk device is released. Clopidogrel and aspirin are recommended for a period of three months to prevent thrombus formation on the device, with aspirin therapy continued for an additional three months, when endothelialization is complete. Antibiotic prophylaxis for six months is recommended. Complete late closure of the foramen has been reported in 80 to 95 percent of patients.