Etiopathogenesis and prognosis of cerebral ischemia in young adults.

Etiology and long-term prognosis were prospectively investigated in 155 consecutive patients (96 men and 59 women), aged 16 to 45 years, referred to our Neurosurgical Unit with cerebral transient ischemic attacks or infarction during the period 1978-1988. All patients underwent neurological and medical-cardiological evaluation, cerebral computerized tomography scanning, electrocardiogram, and laboratory tests. Two-dimensional echocardiography was performed in 123 cases (79%), cerebral angiography in 147 (95%). Atherosclerosis was the leading etiology occurring in 48 patients (31%). A cardioembolic disorder was considered the probable cause of ischemia in 8 cases (5.1%). Further possible etiologies were contraceptive pill assumption (5.8% of the total, but 15.3% within the female group), spontaneous arterial dissection (4.5%), migraine (4%), puerperium (2.6%), cervical trauma (2.6%), and other, more uncommon conditions. Despite extensive evaluation, the cause of cerebral ischemia remained unknown in 40% of cases. All patients received antiplatelet medication and 16 underwent surgery. The long-term outcome at a mean follow-up of 5.8 years was favorable: 91% of subjects resumed their work on a full or part-time basis.     

Long-term prognosis in young adults after a cerebral ischemic episode

To asses long term prognosis in young adults with cerebral ischaemia a follow up study was performed. Eighty-four patients aged 18 to 45 years with the diagnosis of the first-ever ischaemic stroke or TIA were followed up. Four of them (4.8%) died within the first four weeks of cerebral ischaemia onset. Information about all but one patient (98.75%) who survived the first episode of cerebral ischaemia was obtained. The follow up time lasted 4 months till 8 years (mean 52 months +/- 20 months). Three of the patients died during the follow up (all--vascular deaths), twenty one others experienced second cerebral ischaemia one month to 80 months after the first one. Among the patients with first-ever ischaemic stroke the calculated incidence of vascular death or recurrent stroke in the patients who survived the first episode was 5.6% per year, and after 24 months--10.9%. Twenty-eight day mortality rate was in that group 5.6%. Twenty-eight day mortality rate, was in our group similar to the data from the literature, but recurrent stroke and vascular deaths appeared in our material twice as often as in the literature. It could be the effect of lifestyle and socioenvironmental determinants.     

Long-term prognosis of ischemic stroke in young adults

Prognostic information is provided for 74 young adults (age 16-40 yrs, mean age at stroke 29.5 yrs), who suffered from ischemic stroke and survived the first month after the stroke. The patients were followed for 13-26 yrs; in total for 1190 yrs after their stroke. At follow-up 12 of the patients were dead, mostly from severe underlying disease that was complicated by ischemic stroke. In 3 cases death was unrelated to cerebrovascular disease. Among the surviving 62 patients, 7 had experienced recurrent ischemic events (3 reinfarctions, 4 TIA:s). These 7 patients all had risk factors for cerebrovascular complications already at the time of their primary stroke. It is concluded that the long-term prognosis for ischemic stroke in the young adult is favourable. The recovery from neurological deficits is usually good (exceptions are occlusions within the internal carotid and middle cerebral arteries), the risk for recurrence is low (1.1-1.2% annually), and the social prognosis with respect to working capacity and family relation is fair.     

Long-term prognosis of ischemic stroke in young adults

Abstract Background There have been few studies of the long-term prognosis of young adults with ischemic stroke. The present study aimed to evaluate the long-term clinical outcome in a large series of young adults with ischemic stroke admitted to a tertiary medical center over the last 27 years, and to identify possible predictors for mortality, stroke recurrence and poor functional recovery. Methods We retrospectively reviewed 272 young adults (15–45 years) with a first-ever ischemic stroke admitted to the Neurology Department of University Hospital 12 de Octubre between 1974 and 2001. Follow-up assessments were performed by review of medical records and telephone interviews. Results Nine patients (3 %) died as the result of their initial stroke and follow-up information about the status of 23 (8%) patients was not available. The remaining 240 patients (89%) were followed. Two hundred and ten of them (88%) were alive with a mean follow-up of 12.3 years and 30 (12%) died during follow-up. The average annual mortality rate was 1.4%, being notably higher during the first (4.9%) than in the subsequent years (0.9 %) after the initial stroke. Ninety per cent of the followed patients were independent and 53% returned to work, although adjustments were necessary for 23% of them. The annual stroke recurrence rate during the first year was 3.6% dropping to 1.7 % in subsequent years. Age over 35 years, male gender, the presence of cardiovascular risk factors and large-artery atherosclerosis in the carotid territory were predictors of negative long-term outcome after the initial stroke. Conclusions The long-term prognosis for the ischemic stroke in the young is better than in the elderly, but the risk of mortality in young adults with ischemic stroke is much higher than in the general population of the same age. A bad prognosis is associated with an atherosclerotic risk profile, with a higher mortality and recurrent stroke rates and poorer functional recovery. The main functional limitation in the young survivors of their initial ischemic stroke occurs in work activity, since most patients are independent but almost half of them do not return to work.     

Long-term outcome of cerebral infarction in young adults

OBJECTIVES: We analysed the long-term outcome of 232 young adults aged 15-49 years with first-ever cerebral infarction in 1988-1997 in western Norway. MATERIAL AND METHODS: Mortality, recurrence, epilepsy, functional state as evaluated by modified Rankin scale (mRS), and employment were analysed at follow-up (mean time 5.7 years). RESULTS: Twenty-three (9.9%) patients had died. Recurrence occurred in 9.9%, and post-stroke seizures developed in 10.5%. Recurrence was associated with diabetes mellitus (P = 0.005). Favourable functional outcome (mRS = 2) was found in 77.9%. The functional outcome was better in posterior than anterior circulation infarctions (P = 0.011). Unfavourable functional outcome (mRS > 2) was associated with diabetes mellitus (P = 0.001) and severity of neurological deficits on admission for the index stroke (P < 0.001). Only 58.3% were employed at follow-up. CONCLUSION: This population-based study shows that, although the majority had favourable functional outcome, cerebral infarction had major long-term impact on young adults as evaluated by mortality, recurrence and employment status.     

Long-term prognosis of transient lone bilateral blindness in adolescents and young adults.

We describe a group of 14 patients aged 8-38 years at presentation who had one or more sudden transient attacks of bilateral blindness. Eight patients described bilateral blindness as their only symptom whereas six others experienced some mild associated symptoms. Visual loss always developed within seconds and attacks were often precipitated by exercise, stress, or postural change. Of 13 patients available for review, none suffered a major vascular event during a mean follow up of 10 years. When adolescents and young adults present with transient bilateral blindness, investigations are unlikely to reveal a cause and the long-term prognosis appears benign.     

Lupus anticoagulant and anticardiolipin antibodies in young adults with cerebral ischemia.

BACKGROUND AND PURPOSE: Our study evaluates in an unselected young population with cerebral ischemia the frequency of antiphospholipid antibodies; the relationship of antiphospholipid antibodies to conventional risk factors for and pathological mechanisms of cerebral ischemia; and the risk of recurrence of cerebral ischemia or systemic thrombotic events in patients with antiphospholipid antibodies compared with those without. METHODS: We prospectively tested for antiphospholipid antibodies in 55 of 59 young (aged 15-44 years) adults consecutively examined for ischemic stroke (n = 44) or transient ischemic attack (n = 11). These patients underwent a complete clinical and laboratory assessment for cerebral ischemia and had a 3-year mean follow-up. RESULTS: Ten patients (18%), all with stroke, had antiphospholipid antibodies. Antiphospholipid antibodies were significantly more frequent in women than in men (Fisher's test, p = 0.014). Two patients with antiphospholipid antibodies had a new diagnosis of systemic lupus erythematosus. On angiography, none of the patients with antiphospholipid antibodies had extracranial lesions. Patients with antiphospholipid antibodies had significantly more prior cerebral events (Fisher's test, p = 0.014), and, by survival analysis, higher probability of cerebral ischemic or systemic thrombotic events during follow-up than patients without (log rank test, p less than 0.005). CONCLUSIONS: We conclude that the prevalence of antiphospholipid antibodies is rather high in young adults with cerebral ischemia; that patients with cerebral ischemia and antiphospholipid antibodies may have unrecognized systemic lupus erythematosus; and that, among young patients with cerebral ischemia, patients with antiphospholipid antibodies constitute a subgroup at high risk of cerebral ischemic or systemic thrombotic recurrence. Prevention in this latter group may require close follow-up and treatment.     

青年型缺血性脑血管病特点

目的研究青年型缺血性脑血管病(ICVD)的特点。方法回顾性总结1990～1999年间我院收治的199例青年型ICVD患者。以46岁以上患者为对照组，分析青年型ICVD患者发病年龄、性别、脑血管病危险因素、血管影像学检查和预后特点。结果青年型ICVD患者男性比例显著高于女性，女性发病年龄早于男性。吸烟是青年型ICVD最常见的危险因素，有高血压、糖尿病、心肌梗死史的比例显著低于46岁以上患者；房颤、吸烟、酗酒、高甘油三脂和未发现危险因素的比例显著高于46岁以上患者。脑血管成像69．4％的患者存在血管狭窄。与46岁以上患者组比较，治疗后恶化和死亡的比例显著为低，而发生出血性梗死比例显著增高。结论男性更容易在青年期患ICVD，吸烟、酗酒等不良生活习惯在青年型ICVD的发病中具有更重要的作用。青年型脑梗死更容易发生出血性梗死。短期预后优于46岁以上患者。     

Headache in transient or permanent cerebral ischemia. Dutch TIA Study Group

We studied headache features in 3,126 patients with acute cerebral or retinal ischemia. Headache occurred in 18% of these patients (in 16% of all patients with transient ischemic attacks, in 18% of patients with reversible ischemic neurologic deficits, and in 19% of patients with minor strokes) and was mostly continuous in all types of attacks. Headache was present in 16% of patients with monocular visual symptoms. The occurrence of headache was not related to the mode of onset, mode of disappearance, or duration of the attack. Patients with headache more often were known to have heart disease. Headache was less frequent in patients with small deep infarcts, who were more often hypertensive, and in patients with infarcts in the anterior circulation; headache was more frequent in patients with cortical infarcts and in patients with infarcts in the posterior circulation. Patients with a relevant small deep infarct on computed tomographic scan and accompanying headache relatively often reported symptoms compatible with cortical ischemia, such as language disorders or a visual field defect. We conclude that headache is a frequent accompanying symptom in patients with acute cerebral and retinal ischemia and that the occurrence of headache is partly related to the underlying cause of the ischemic lesion.     

Elevated prothrombin is a risk factor for cerebral arterial ischemia in young adults

The prevalence of elevated prothrombin (PT) in the absence of the G20210A mutation has not been studied in patients with cerebral ischemia. We carried out a case-control study of PT G20210A and PT activity in 49 adult patients aged 45 years or less, with TIA or ischemic stroke without cardiac embolism or large vessel disease, and 87 controls from a group of blood donors. Five patients were heterozygous for PT 20210A (OR=2.3, 95% CI: 0.6–8.0). Even after exclusion of individuals with the PT gene variant, the PT activity was significantly higher in patients than in controls (1.11 vs. 0.97, P=0.0003). The relative risk of cerebral ischemia in patients within the fourth quartile of PT activity (1.10 U/ml or higher), was 3.2 fold (95% CI: 1.03–9.96), than in patients whose level of PT activity was in the second or third quartile. We conclude that, although PT 20210A may be a weak risk factor for TIA and ischemic stroke in young patients, increased PT activity, which is more frequent than the mutation, appears to be more strongly related to cerebral ischemia.     

Etiology, prognosis, and hemostatic function after cerebral infarction in young adults

We retrospectively evaluated 66 patients younger than 40 years of age who presented with acute nonhemorrhagic cerebral infarction (n = 63) or transient ischemic attacks (n = 3) to determine the possible etiology and long-term outcome at a mean follow-up interval of 3 years after initial presentation. A probable cause for the stroke was identified in 24 patients (36%); this group included one woman with a history of recurrent spontaneous abortions and a positive test for the presence of the lupus anticoagulant. We performed detailed hemostatic investigations at follow-up in 38 (90%) of the remaining 42 patients in whom the cause of the stroke was unknown or uncertain; results of the basic hemostatic screening tests (including that for fibrinogen) were uniformly normal. All 38 patients demonstrated a normal fibrinolytic response as measured by tissue plasminogen activator release to a standard venous occlusion stress test; concentration of the inhibitor of tissue plasminogen activator was not increased. No abnormalities in the concentrations of the inhibitory proteins C or S or antithrombin III were identified, and none of the 38 patients had evidence of a lupus anticoagulant. Neurologic recovery was complete or the residual disability mild in 46 of 59 (78%) patients. Overall prognosis was excellent and independent of whether a precipitating factor for the stroke could be identified.     

Stroke in young adults: the role of paradoxical embolism

Stroke in young adults may be devastating and frequently no cause can be found. However, there is ample literature to suggest an association between cryptogenic stroke in young people and paradoxical embolisation via a venous to arterial circulation shunt (v-aCS), commonly due to patent foramen ovale (PFO). Although paradoxical embolisation is assumed to be a rare event, this review suggests that it is an important or even dominant cause of stroke in young people and that a transcranial Doppler (TCD) technique may be the investigation of choice to identify v-aCS.     

Isolated symptomatic middle cerebral artery stenosis in young adults: clinical prognosis and vascular change

Background and purpose: To investigate the clinical prognosis and vascular outcome of ischemic stroke patients with isolated symptomatic middle cerebral artery stenosis, and further analysis of the predictors associated with the results. Methods: Ischemic stroke patients aged 18–55 years old with isolated symptomatic middle cerebral artery stenosis were evaluated and followed up prospectively for six months. Logistic regression was used to detect predictors of ipsilateral stroke recurrence, and factors associated with the dynamic changes of lesion vascular were analyzed. Results: Eighty patients were included, with a mean age of 41.8 ± 8.3 years old. Males predominated in this cohort at a proportion of 78.8% (63/80). Twenty percent of patients presented with ipsilateral ischemic stroke recurrence during this time but mostly with a good outcome (70% mRS ≤ 1); multiple logistic regression indicated that diabetes mellitus is an independent predictor for stroke recurrence; 38.6% patients presented with significant vascular changes during the follow-up, with progression in 12 (17.1%) and regression in 15 (21.4%) patients individually. No variables were detected as predictors of cerebral vascular progression. Conclusion: Isolated symptomatic middle cerebral artery stenosis in young adults had unaccepted high rates of recurrence but comparatively good prognosis; despite the dramatic change of lesion artery in the short period after stroke, no factors were detected as the probable factors associated with the dynamic process.     

Stroke in young adults: analysis of 164 patients

We retrospectively analyzed the epidemiological features of 164 out-clinic patients with a first-onset stroke between 15 and 49 years old. Ischemic stroke occurred in 141 patients, hemorrhagic stroke in 16 patients, and venous thrombosis in 7 patients. Forty-eight percent of ischemic strokes were atherothrombotic, but no etiology was found in 32% of patients with ischemic stroke. Systemic arterial hypertension was the most frequent etiology in the hemorrhagic stroke group. The most frequent risk factors were systemic arterial hypertension, smoking, hypercholesterolemia, alcoholism and diabetes mellitus. Although stroke in young adults deserves some specific etiological investigation, we found that ordinary risk factors such as hypertension, tobacco use, hypercholesteremia and diabetes were prevalent in our population. It seems that prevention campaigns should be the target of our work.     

Antiphospholipid antibodies and cerebral artery dissection: Two frequent causes of brain ischemia in young adults

As part of a multicenter study on ischemic stroke in the young, we report the occurrence of high antiphospholipid antibody (aPLs) levels and cerebral dissection in 75 patients. These represent the two most frequent non-thromboembolic causes of cerebral ischemia in our population. Increased aPL titres were found in nine cases (12%); cerebral artery dissection in eleven (14%). Our data stress the need to modify the classical diagnostic approach to cerebral ischemia by including hematological assessments and new neuroimaging techniques as screening tests. Supported by National Research Council grant 93051602086