Dr Wilner is Associate Professor of Neurology at the University of Tennessee Health Science Center and a staff physician at Regional One Health in Memphis, TN. His upcoming book is The Locum Life: A Physician's Guide to Locum Tenens. Website: andrewwilner.com. Twitter: @drwilner. Dr Wilner is an editorial board member of Neurology Times.
Every four minutes, a person in the US dies of stroke. In fact, stroke is the fifth leading cause of death in the US, affecting more than 795,000 people per year. While the risk of stroke increases with age, approximately 1 in 3 patients hospitalized for stroke are less than 65 years old. Stroke in adults aged 25 to 44 years (“young stroke”) accounts for approximately 10% to 12% of total stroke patients. In developed countries, the incidence of young stroke is 13/100,000.1 Similarly, while the incidence of stroke in people older than 65 years has decreased, the risk of ischemic stroke in young adults has increased.2
5 New Things
A recent paper in Neurology: Clinical Practice highlighted 5 new things regarding young stroke.2
1. Risk factors have increased for this population.
In the younger population, the prevalence of stroke risk factors such as hypertension, hyperlipidemia, obesity and smoking has increased from 2004 to 2012, nearly doubling in some cases. Cocaine use, another stroke risk factor, has increased nearly six-fold in young adults with ischemic stroke. Even cannabis users have more than twice the risk of developing ischemic stroke.
2. Complications From patent foramen ovale
Patent foramen ovale (PFO) is a common condition occurring in 25% of the population. In a minority of these patients, paradoxical embolism may occur, which can result in stroke. Patients with large interatrial shunts and/or the presence of atrial septal aneurysm may benefit from percutaneous PFO closure in order to prevent recurrent stroke.
3. Higher link of cervical artery dissection with stroke in younger stroke patients.
Cervical artery dissection can be either spontaneous/result from a medical condition or traumatic. In the general population, it is a less common cause of stroke, linked to only 2% of all cases. A review of stroke etiology in 2013 young adults with ischemic stroke revealed that cervical artery dissection (24%) was tied with cardiac embolism (24%) as the leading cause of stroke in this population.3
4. Genetics plays a role.
In young adults with ischemic stroke, particularly those without traditional atherosclerotic risk factors such as hypertension and smoking, a genetic cause may be responsible. Screening for inherited monogenic disorders such as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), cerebral amyloid angiopathy, Fabry disease, Marfan syndrome, and mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS) should be considered, although the yield may be <10%.
1. Martinez-Majander N, Aarnia K, Pirinen J, et al. Embolic strokes of undetermined source in young adults: baseline characteristics and long-term outcome. Eur J Neurol. 2018;25:535-541.
2. Bhatt N, Malik AM, Chaturvedi S. Stroke in young adults. Five new things. Neurology: Clinical Practice. 2018;8:501-506.
3. Nedeltchev K, der Maur TA, Georgiadis D, et al. Ischaemic stroke in young adults: predictors of outcome and recurrence. J Neurol Neurosurg Psychiatry. 2005;76:191-195.
4. Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines for the early management of patients with acute ischemic stroke. Stroke. 2018;49:e46-e99.
5. Alebeek MEV, Arntz RM, Ekker MS et al. Risk factors and mechanisms of stroke in young adults: The FUTURE study. J Cereb Blood Flow Metab. 2018;38:1631-1641.