Transcript Document
Richard Leigh, M.D.
Johns Hopkins University School of Medicine
Generally stroke in a less than 40-45 years old
Different from pediatric stroke
Unique causes that are more common in the young
Cervical Artery Dissection
Hypercoagulable States
Vasospasm
Typical causes that are atypical in the young
Hypertension
Diabetes
Hyperlipidemia
Cryptogenic
Appears to be trending toward younger
populations.
This trend appears to be larger in the
hemorrhagic stroke population.
Preferentially affecting lower socioeconomic
classes.
Attributable to modifiable risk factors:
hypertension, obesity and diabetes.
▪ Krishnamurthi et al., Lancet Global Health 2012
Hart & Miller, Stroke, 1983
Hart & Miller, Stroke, 1983
Hart & Miller, Stroke, 1983
Long-term prognosis
for stroke in the young
is better than the
elderly but higher
than the general
population
Mostly in the first year
after stroke
A bad prognosis is
associated with an
atherosclerotic risk
profile
Varona et al., J Neurol, 2004
Dissection
Cryptogenic with PFO
Reversible vasoconstriction syndrome (RCVS)
Not vasculitis!
Caused by separation of the arterial wall layers resulting in a false
lumen.
A history of trauma is often but not always elicited.
Can be associated with major, minor or trivial trauma
Can be spontaneous or cryptogenic
Typically the dissection occurs at the skull base
Can be diagnosed with CTA, angiogram typically not necessary
Often associated with fibromuscular dysplasia
Rarer conditions also have an increased incidence
▪ Ehlers-Danlos Syndrome Type IV
▪ Marfans Syndrome
Often associated with headache/neck pain acutely and chronically
Responds to migraine therapies
Heparin or ASA are reasonable treatments
With heparin only for 3-6 months then switch to ASA
Can be detected with CT
angiography and MR
angiography
Conventional angiography
is the gold standard
Angiography allows
for detection of FMD
in other vessels
Renal arteries can
also be affected
Prognosis is good
Many dissections are
asymptomatic
Recurrent stroke after dissection
is rare with treatment
Treat with Aspirin or Coumadin
Avoid anticoagulation of
intracranial dissections
▪ LP r/o SAH prior to a/c
Transition to ASA after 3-6 months
Complications
Pseudo aneurysms
PFO (patent foramen ovale)
20-25% of adults have a PFO
Some times associated with an ASA (atrial septal
aneurysm)
PFO can serve as a source of paradoxical
embolism
Venous clot (DVT) can traverse a right to left shunt and
enter the arterial circulation.
Young people are felt to be at higher risk of
paradoxical emboli due to heart chamber pressures
that favor a right to left shunt.
There is an increase incidence of PFO and ASA in patients
who have had a cryptogenic stroke.
There is no clear evidence that the PFO itself is the cause
of the stroke.
This has lead to many centers advocating not to close PFOs since
they are not the cause.
Instead, underlying causes of venous embolism are evaluated
and treated.
▪ Hypercoagulable states treated with anticoagulation
▪ Removal of triggers: Birth control, smoking
If no cause if found other than PFO, treat with Aspirin
▪ Recurrent stroke very rare
▪ Data on PFO with ASA conflicting
▪ In the setting of recurrent stroke, PFO is closed
Primariy CNS Vasculitis?
No! its almost never vasculitis
Systemic rheumatologic diseases should be ruled out
Vasculitis mimicks
Intracranial Athero
RCVS reversible vasoconstriction syndrome
PRES posterior reversible leukoencephelopathy
Cerebral Amyloid Angiopathy
Intravascular lymphoma and other malignancies
Never treat a primary CNS vasculitis without a
positive brain biopsy
Image guided biopsy is key
Frequently misdiagnosed
as vasculitis
Vasculitis = smoldering
course
Presents with
thunderclap HA
Initial w/u is often
negative
Patients re-present with
ICH/SAH
Can progress to ischemic
strokes
Most common trigger at
Hopkins:
SSRI
Ducros et al., Brain 2007
Does not respond to steroids
Data suggests patients treated with steroids do worse
Treated by removing the trigger
Calcium Channel Blockers
Magnesium
MRA should normalize by 3 months
Re-introduction of the offending agent can cause
recurrent RCVS
Continuum?
RCVS <-> Migraine <-> PRES (posterior reversible
encephalopathy syndrome)
Prognosis is good for young stroke survivors
Better recovery
Less recurrent stroke
▪ Identifying the cause is key
Vascular risk factor associated stroke is on the
rise in the young
Preventative medicine