Stroke in young adults

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

Stroke prevention is of paramount importance in young individuals because of its high impact on productivity and future quality of life. Unfortunately, no single preventative measure can reduce the general risk of stroke in young adults. As many risks are modifiable, general prevention strategies (as in the older population) may lessen the impact of stroke in this population. A risk factor study found diabetes (odds ratio 11.6), hypertension (odds ratio 6.8), heart disease (odds ratio 2.7), current tobacco use (odds ratio 2.5), and long history of alcohol use (odds ratio 15.3) to be risk factors in patients aged 15 to 45 years with first onset stroke (You et al 1997). Neither heavy alcohol use just prior to stroke or history of oral contraceptive use was associated with an increased risk of stroke in this study. Tobacco use, elevated triglycerides, and alcohol abuse were more common in men whereas migraine was more frequent in women. Arterial hypertension and elevated cholesterol and triglycerides are more common in patients older than 35 years. In patients below 35 years, oral contraceptive use is more prevalent (Carolei et al 1993). Tobacco use and arterial hypertension were especially noted in young African-American patients (Rohr et al 1996). The amount and type of alcohol can influence stroke risk, with light to moderate alcohol consumption reducing stroke risk in young women (Malarcher et al 2001).

In general, reduction of modifiable risk factors is the single best preventative action to lessen strokes in both younger and older individuals (Ning and Furie 2004). Primary stroke prevention guidelines recommend regular screening and appropriate treatment of hypertension and diabetes, smoking cessation for all current smokers, weight reduction in overweight persons, a healthy diet, and regular exercise (Furie et al 2011). No similar recommendations have been specifically directed at the younger stroke patient population (Meschia et al 2014). It is recommended that female sufferers of migraine, particularly with aura, stop smoking and replace hormonal contraception (especially those containing estrogen) with other methods. Attempting to reduce migraine frequency through treatment, particularly in the case of the aural type, may be a reasonable step, although there is no evidence that this will reduce stroke occurrence (Meschia et al 2014). Patients with a history of stroke related to drug abuse (cocaine and amphetamines) should be referred to an appropriate therapeutic program. Treatment of Fabry disease with enzyme replacement therapy has not proven to reduce stroke risk (Meschia et al 2014).

In a retrospective Norwegian study, the risk of recurrent stroke or myocardial infarction was proportional to the number of risk factors, being as high as 30% with 4 risk factors and 67% with 5 risk factors, and as low as 2.1% in patients with no risk factors (Naess et al 2005). The authors suggest that long-term stroke preventive measures may not be warranted in young stroke patients with no identifiable risk factors. Risk factor control can be challenging in the young population: in the French PFO-ASA study, greater than 50% to 60% of young stroke patients continued smoking or had poorly controlled blood pressure after their stroke (Arguizan et al 2005). Prevention has a major role in a few diseases that predispose to stroke in the young: for example, timely blood transfusions have been shown to reduce the risk for stroke in patients with sickle cell disease (Adams et al 1998b). It was also shown that periodic red cell transfusion (target reduction of hemoglobin S to less than 30%) has been shown to effectively reduce the risk for stroke in patients with sickle cell disease (Meschia et al 2014). A history of illicit and licit (including over-the-counter) drug use should be sought during patient encounters and appropriate counseling initiated as needed. Caution has also been recommended in women using oral contraceptives with additional risk factors (cigarette smoking or prior thromboembolic events) in the setting of migraine (Bousser et al 2000).

As has been stated previously, the burden of stroke is increasing among the young worldwide. In a recent comprehensive review of stroke in young adults and adolescents, Singhal and colleagues emphasized the need to implement educational, preventive, and support strategies, particularly in high-risk groups and young stroke survivors and their families (Singhal et al 2013). They also highlighted the need to promote research on the topic of stroke in young adults to gather reliable epidemiological data and provide feedback for planning and service delivery by stroke professionals and policymakers (Singhal et al 2013).

Investment in research and educational campaigns on this topic may be insufficient or negligible in countries with middle- and, particularly, low-income economies where other health problems are considered priorities. Nevertheless, these countries can benefit from successful educational strategies, stroke survivor support experiences, and prevention and rehabilitation interventions targeted at young adults with stroke that have been developed in high-income economies but are adaptable to local facilities.

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