Young Stroke Survivors

Young Stroke Survivors

Richard Leigh, M.D.Johns Hopkins University School of Medicine

Stroke in the Young

Generally stroke in a less than 40-45 years old Different from pediatric stroke

Unique causes that are more common in the young Cervical Artery Dissection Hypercoagulable States Vasospasm

Typical causes that are atypical in the young Hypertension Diabetes Hyperlipidemia

Cryptogenic

Stroke Worldwide

Appears to be trending toward younger populations.

This trend appears to be larger in the hemorrhagic stroke population.

Preferentially affecting lower socioeconomic classes.

Attributable to modifiable risk factors: hypertension, obesity and diabetes.

▪ Krishnamurthi et al., Lancet Global Health 2012

Differential Diagnosis

Hart & Miller, Stroke, 1983

Differential Diagnosis

Hart & Miller, Stroke, 1983

Differential Diagnosis

Hart & Miller, Stroke, 1983

Prognosis

Long-term prognosis for stroke in the young is better than the elderly but higher than the general population Mostly in the first year

after stroke A bad prognosis is

associated with an atherosclerotic risk profile

Varona et al., J Neurol, 2004

Overview – Common Causes

Dissection Cryptogenic with PFO Reversible vasoconstriction syndrome (RCVS)

Not vasculitis!

Dissection

Caused by separation of the arterial wall layers resulting in a false lumen. A history of trauma is often but not always elicited.

Can be associated with major, minor or trivial trauma Can be spontaneous or cryptogenic

Typically the dissection occurs at the skull base Can be diagnosed with CTA, angiogram typically not necessary

Often associated with fibromuscular dysplasia Rarer conditions also have an increased incidence▪ Ehlers-Danlos Syndrome Type IV▪ Marfans Syndrome

Often associated with headache/neck pain acutely and chronically Responds to migraine therapies

Heparin or ASA are reasonable treatments With heparin only for 3-6 months then switch to ASA

Dissection - Diagnosis

Can be detected with CT angiography and MR angiography

Conventional angiography is the gold standard

Dissection - Diagnosis

Angiography allows for detection of FMD in other vessels

Renal arteries can also be affected

Dissection - Prognosis

Prognosis is good Many dissections are asymptomatic Recurrent stroke after dissection is

rare with treatment Treat with Aspirin or Coumadin

Avoid anticoagulation of intracranial dissections▪ LP r/o SAH prior to a/c

Transition to ASA after 3-6 months Complications

Pseudo aneurysms

Cryptogenic Stroke with PFO

PFO (patent foramen ovale) 20-25% of adults have a PFO Some times associated with an ASA (atrial septal

aneurysm) PFO can serve as a source of paradoxical embolism

Venous clot (DVT) can traverse a right to left shunt and enter the arterial circulation.

Young people are felt to be at higher risk of paradoxical emboli due to heart chamber pressures that favor a right to left shunt.

Cryptogenic Stroke with PFO

There is an increase incidence of PFO and ASA in patients who have had a cryptogenic stroke.

There is no clear evidence that the PFO itself is the cause of the stroke. This has lead to many centers advocating not to close PFOs since they are

not the cause. Instead, underlying causes of venous embolism are evaluated and treated.▪ Hypercoagulable states treated with anticoagulation▪ Removal of triggers: Birth control, smoking

If no cause if found other than PFO, treat with Aspirin▪ Recurrent stroke very rare▪ Data on PFO with ASA conflicting▪ In the setting of recurrent stroke, PFO is closed

Vasculitis (Angiitis)

Primariy CNS Vasculitis? No! its almost never vasculitis Systemic rheumatologic diseases should be ruled out

Vasculitis mimicks Intracranial Athero RCVS reversible vasoconstriction syndrome PRES posterior reversible leukoencephelopathy Cerebral Amyloid Angiopathy Intravascular lymphoma and other malignancies

Never treat a primary CNS vasculitis without a positive brain biopsy Image guided biopsy is key

RCVS - Reversible Vasoconstriction Syndrome

Frequently misdiagnosed as vasculitis Vasculitis = smoldering

course Presents with

thunderclap HA Initial w/u is often negative Patients re-present with

ICH/SAH Can progress to ischemic

strokes

RCVS - Reversible Vasoconstriction Syndrome

RCVS triggers

Most common trigger at Hopkins:SSRI

Ducros et al., Brain 2007

RCVS - Reversible Vasoconstriction Syndrome

Does not respond to steroids Data suggests patients treated with steroids do worse

Treated by removing the trigger Calcium Channel Blockers Magnesium

MRA should normalize by 3 months Re-introduction of the offending agent can cause

recurrent RCVS Continuum?

RCVS <-> Migraine <-> PRES (posterior reversible encephalopathy syndrome)

Conclusions

Prognosis is good for young stroke survivors Better recovery Less recurrent stroke▪ Identifying the cause is key

Vascular risk factor associated stroke is on the rise in the young Preventative medicine