Arterial ischemic stroke in young adults

ARTERIAL ISCHEMIC STROKE IN YOUNG

ADULTSAhmed Abdul Ghany

Annual incidence • The annual incidence of AIS is 3.4 – 11.3 / 100.000

people / year While in Black adults is as high as

22.8/100.000

Risk factors• A study of 324 patients undergoing standardized

clinical assessment traditional risk factors such as

Smoking 56%, Hypertension 23%, Dyslipidemia 15%,

and Diabetes 2% were not uncommon

• Oral contraceptives were used by 38% of women

One of the largest cohorts in FILAND

Etiology

Cardioembolic 20%

Dissection 15%

Atherosclerosis 8%

Vasculopathies 14%

Undetermined 33%

Cardiac

Congenital Endocarditis Prosthetic

valve replacement

Cardiomyopathy

Hematologic

Sickle cell anemia

AntiphospholipidSyndrome

Factor V Leiden

mutation

AntithrombinIII deficency

Ptn C & S deficency

Vasculopathy

Vasculitis

1ry

Takayaso

2ry

SLE

Dissection

MarfanSyndrome

MoyamoyaSyndrome

Metabolic

MELAS CADASIL Fabry disease

Mitochondrial encephalopathy with lactic acidosis and strokeCerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy

Initial management

Supportive measures• ABC

• Maintain normoglycemia and normothermia.

• Allow modest Hypertension.

• Pneumatic compression and elastic stocking.

Thrombolysis (rt-PA)Inclusion criteria Exclusion criteria

• Clinical diagnosis with neurologic deficit.

• Onset ≤ 4.5 hours before

beginning treatment.

• Age ≥ 18 years

• History of

stroke, ICH, tumor.

• Clinical: Systolic BP ≥ 185

or diastolic ≥ 110

• Active internal bleeding

• Lab: platelets ≤ 100.000 &

INR ≥ 1.7

• CT brain: ICH or

hypodensity ≥ 33% of the

cerebral hemisphere

Initial antithrombotic treatment

guidelines• American Academy of chest physicians (ACCP)

recommend either unfractionated heparin or LMWH

or Aspirin until dissection and embolic causes have

been excluded.

• American heart association (AHA) stroke council

states that it may be reasonable to initiate

anticoagulation in patients with AIS pending

completion of diagnostic evaluation.

• Royal collage of physicians recommends initial

therapy with Aspirin.

• Aspirin 3-5 mg/kg day as initial therapy for all

patients except those with sickle cell disease or

intracranial hemorrhage.

• AIS due to confirmed cardioembolic source, arterial

dissection or hypercoagulable state: intravenous

unfractionated heparin( PTT 60 -85) or LMWH

subcutaneous (1 mg/kg q12 hr) for 5 – 7 days

followed by LMWH or warfarin.

• AIS with sickle cell disease: UK guidelines

recommends urgent IV hydration and blood

transfusion.

• AIS with vasculopathy: Aspirin +/-

immunosuppression for inflammatory vacuities.

• Decompressive hemicraniotomy: in patients with

mass effect or large (malignant) MCA territory

stroke.

Prognosis Predictors of poor outcome:

• First year Mortality in

young adults 4 – 6 %

after AIS

• Young age

• Fever at presentation

• Altered consciousness at

presentation

• Bilateral ischemia

• MCA stroke volume ≥ 10 %

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