Arterial ischemic stroke in young adults
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Transcript of 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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