Ischemic stroke in young adults.

PURPOSE OF REVIEW: Although the clinical approach to the young adult stroke patient is similar to that of an older adult, several important differences exist. The purpose of this article is to concisely review the epidemiology, pathophysiology, risk factors, clinical manifestations, diagnostic methods and current treatment options for the young adult ischemic stroke patient. RECENT FINDINGS: Evidence clearly indicates that the incidence ischemic stroke in young adults is on the rise. A variety of factors are implicated, including an increased burden of classic and emerging vascular risk factors, and improved stroke detection, among other causes. Improved awareness, prevention and successful treatment of the young adult stroke patient is of great importance, particularly given the major long-term socioeconomic impact strokes have on the patient, their family and society at large. SUMMARY: In this review, we focus on the latest epidemiologic, diagnostic and treatment paradigms to improve physician awareness and optimize outcomes in young adult ischemic stroke patients. An overview of the clinical presentations of various stroke syndromes is described, emphasizing key causes physicians should consider, as well as providing recommendations regarding evaluation and treatment. Important causes including dissection and inflammatory and noninflammatory vasculopathies are emphasized. The diagnoses of cerebral venous thromboses, cardioembolic stroke and paradoxical emboli are also discussed. The effects of established and emerging risk factors on large and small vessel disease, as well as genetic contributions, are also highlighted.

A Diagnostic Approach to Stroke in Young Adults.

OPINION STATEMENT: Optimal diagnosis and management of stroke in young adults benefit from a multidisciplinary team, including a vascular neurology specialist. In addition to the "standard" vascular risk factors including smoking, hypertension, diabetes, and hyperlipidemia, one needs to consider alternative etiologies including substance abuse, carotid/vertebral artery dissections, and rare genetic conditions among others. Once a young patient is determined to have had a stroke, the next question a clinician should ask is why did this patient have a stroke? A "heart to head" diagnostic approach is recommended. A thorough history is performed, including a detailed family history with specific annotations on each family member. A thorough physical examination is necessary including a careful evaluation of the patient's general appearance, noting any joint laxity, and/or abnormalities of the skin, eyes, and heart. Findings across multiple organ systems in the patient and/or their family may indicate a genetic etiology. After an initial head CT rules out hemorrhagic stroke, additional testing should include a brain MRI, neck and cerebral vascular imaging (e.g., CTA for head and neck), transthoracic echocardiogram with a bubble study, telemetry monitoring, basic risk factor blood work (e.g., lipid panel, hemoglobin A1c, TSH, ESR, CRP, RPR, HIV, and toxicology screen), and, when appropriate, sickle screen and pregnancy test. There should be a low threshold to obtain blood cultures or a lumbar puncture. The acute treatment of ischemic stroke in young adult patients does not differ from treatment of older adults, using intravenous alteplase within 4.5 h, assuming no contraindications. In suspected proximal large artery occlusive disease, interventional clot extraction procedures should be employed in patients deemed eligible. Long-term secondary prevention strategies aimed to reduce recurrent stroke risk by targeting and modifying vascular risk factors should be instituted. The mainstay of preventative therapy is aspirin for most etiologies; however, for atrial fibrillation, anticoagulation is recommended. Statin therapy is another pharmacologic intervention recommended in most stroke patients. Other measures employed are blood pressure reduction, smoking cessation, optimal glucose control in diabetic patients, the initiation of a healthy diet and regular exercise, and lastly, substance abuse counseling in appropriate patients.