Stroke in young adults

Management
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By Bartlomiej Piechowski-Jozwiak MD, Jorge Moncayo-Gaete MD, and Julien Bogousslavsky MD

So far, no evidence-based management guideline for stroke in young adults is available. In general terms, treatment in the acute phase of ischemic stroke is similar in both young and older patients (Singhal et al 2013). Even so, management should be individualized to the patient's diagnosis. Although the causes of stroke in children differ substantially from that in the adults, the vascular distributions and manifestations of stroke are similar in both groups. General supportive care is an appropriate primary step in treatment. Specific therapy directed at minimizing or treating the offending etiology should be pursued (Ning and Furie 2004). In patients with sickle cell disease between the age of 2 and 16 years, periodic transfusion is recommended in patients with abnormal transcranial Doppler study (Adams et al 1998a; Roach et al 2008). Thrombolytic, surgical, antiplatelet, and anticoagulation recommendations are not different from those of most other age groups (Roach et al 2008). To date, thrombolysis is approved for ischemic stroke in patients over 18 years of age. An ongoing trial of thrombolysis in children and adolescents may provide data about the safety and efficacy of thrombolysis in this age group. However, most stroke physicians support the use of intravenous tissue plasminogen activator in carotid dissection and other uncommon etiologies of stroke in young adults (Wagner and Lutsep 2005).

Recently, intravenous alteplase within 4.5 hours of stroke onset was found to be safer and more effective in around 3,250 young stroke patients (18 to 50 years old, median age of 45, median NIHSS score of 10) than in stroke patients 51 to 80 years old (median age of 70, median NIHSS score of 12). The subsets of other and undetermined stroke etiologies according to TOAST criteria were more frequent in young patients than in their older counterparts. Young patients had a better outcome at 3 months (52% with no or minimal disability and 72% with functional independence) than did older patients. Furthermore, symptomatic intracerebral hemorrhage and mortality were lower in younger patients compared to patients over 50 years of age (Toni et al 2012). Other therapeutic strategies in hyperacute stroke are being studied. Results of a randomized trial on the intraarterial treatment delivered on top of intravenous thrombolysis in a 6 hour time window in patients with proximal intracranial occlusion in the anterior circulation for the first time proved the efficacy and safety of intraarterial treatment. The studied population included patients from 23 to 96 years of age (mean age 65 years). The interventional arm had better odds for good recovery at 90 days, defined as a modified Rankin scale score of 0 to 2 (OR 1.66; 95% CI: 1.21-2.28). There was no difference in death rates or incidence of any symptomatic intracerebral hemorrhage. There were more ischemic events in other vascular territories though (Berkhemer et al 2015).

In This Article

Introduction
Historical note and nomenclature
Clinical manifestations
Clinical vignette
Etiology
Pathogenesis and pathophysiology
Epidemiology
Prevention
Differential diagnosis
Diagnostic workup
Prognosis and complications
Management
Pregnancy
Anesthesia
References cited
Contributors