Stroke in Young Patients: 5 New Things

December 24, 2018

In young patients with stroke without a clear cause, physicians should search for less common etiologies and treat accordingly.

Dr Wilner is Associate Professor of Neurology at the University of Tennessee Health Science Center and a staff physician at Regional One Health in Memphis, TN. His upcoming book is The Locum Life: A Physician's Guide to Locum Tenens. Website: andrewwilner.com. Twitter: @drwilner. Dr Wilner is an editorial board member of Neurology Times.

Every four minutes, a person in the US dies of stroke. In fact, stroke is the fifth leading cause of death in the US, affecting more than 795,000 people per year. While the risk of stroke increases with age, approximately 1 in 3 patients hospitalized for stroke are less than 65 years old. Stroke in adults aged 25 to 44 years (“young stroke”) accounts for approximately 10% to 12% of total stroke patients. In developed countries, the incidence of young stroke is 13/100,000.1 Similarly, while the incidence of stroke in people older than 65 years has decreased, the risk of ischemic stroke in young adults has increased.2

5 New Things

A recent paper in Neurology: Clinical Practice highlighted 5 new things regarding young stroke.2

1. Risk factors have increased for this population.

In the younger population, the prevalence of stroke risk factors such as hypertension, hyperlipidemia, obesity and smoking has increased from 2004 to 2012, nearly doubling in some cases. Cocaine use, another stroke risk factor, has increased nearly six-fold in young adults with ischemic stroke. Even cannabis users have more than twice the risk of developing ischemic stroke.

2. Complications From patent foramen ovale

Patent foramen ovale (PFO) is a common condition occurring in 25% of the population. In a minority of these patients, paradoxical embolism may occur, which can result in stroke. Patients with large interatrial shunts and/or the presence of atrial septal aneurysm may benefit from percutaneous PFO closure in order to prevent recurrent stroke.

3. Higher link of cervical artery dissection with stroke in younger stroke patients.

Cervical artery dissection can be either spontaneous/result from a medical condition or traumatic. In the general population, it is a less common cause of stroke, linked to only 2% of all cases. A review of stroke etiology in 2013 young adults with ischemic stroke revealed that cervical artery dissection (24%) was tied with cardiac embolism (24%) as the leading cause of stroke in this population.3

4. Genetics plays a role.

In young adults with ischemic stroke, particularly those without traditional atherosclerotic risk factors such as hypertension and smoking, a genetic cause may be responsible. Screening for inherited monogenic disorders such as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), cerebral amyloid angiopathy, Fabry disease, Marfan syndrome, and mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS) should be considered, although the yield may be <10%.

Mortality and morbidity rates, treatment issues >

5. High rates of mortality and morbidity

Mortality after 10 years in young adults with stroke is 10 times higher than the general population. Not surprisingly, the rates are even higher for young adults who experience recurrent strokes. A large retrospective study found that more than half of these young patients are unable to return to work after a stroke. Issues such as depression, sexual dysfunction, fatigue, post-stroke pain, and cognitive dysfunction plays a role in the high mortality rates for these patients, and thus should be assessed and addressed.

Treatment Issues

The 2018 American Heart Association (AHA)/American Stroke Association (ASA) Guidelines for the Early Management of Patients with Acute Ischemic Stroke do not itemize specific treatments for young adults.4 Young adults 18 years or older with stroke may be considered for tPA and thrombectomy if they fulfill standard inclusion and exclusion criteria.

In cases of stroke without an obvious etiology, other conditions should be considered (eg, antiphospholipid antibody syndrome, eclampsia, essential thrombocythemia, Factor V Leiden deficiency, migraine with aura, protein C deficiency, systemic lupus erythematosus and others).3.5 Treatment should be directed to the underlying cause of ischemic stroke, if it can be identified.

Conclusions

Stroke in young adults is increasing in incidence. In many cases, it is the result of an increased frequency of modifiable conventional risk factors, such as hypertension, hyperlipidemia, obesity, and smoking, all of which may result in early atherosclerosis. In patients without traditional stroke risk factors, other etiologies for stroke should be considered, such as cardioembolism, cervical artery dissection, eclampsia, migraine with aura, inherited monogenic disorders, hypercoagulable state, and substance abuse.

Ischemic stroke in young adults aged 18 years or older should be treated according to AHA/ASA Guidelines. In young patients with stroke without a clear cause, physicians should search for less common etiologies and treat accordingly.

References:

1. Martinez-Majander N, Aarnia K, Pirinen J, et al. Embolic strokes of undetermined source in young adults: baseline characteristics and long-term outcome. Eur J Neurol. 2018;25:535-541.

2. Bhatt N, Malik AM, Chaturvedi S. Stroke in young adults. Five new things. Neurology: Clinical Practice. 2018;8:501-506.

3. Nedeltchev K, der Maur TA, Georgiadis D, et al. Ischaemic stroke in young adults: predictors of outcome and recurrence. J Neurol Neurosurg Psychiatry. 2005;76:191-195.

4. Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines for the early management of patients with acute ischemic stroke. Stroke. 2018;49:e46-e99.

5. Alebeek MEV, Arntz RM, Ekker MS et al. Risk factors and mechanisms of stroke in young adults: The FUTURE study. J Cereb Blood Flow Metab. 2018;38:1631-1641.