Strokes In The Young

Strokes in children younger 15 are often different from those found in adults. Brain infarcts tend to be limited more to the deeper regions of the cerebral hemispheres, especially the striatocapsular areas. Vascular occlusive lesions are more often intracranial and affect mostly the intracranial carotid and the middle cerebral and basilar arteries. Extracranial lesions are less common; when they occur, they usually involve the pharyngeal portions of the carotid and vertebral arteries rather than the arterial origins that are involved more commonly in adults. Vasoconstriction, dissection, fibromuscular dysplasia, trauma, and contiguous infection are the major diseases that affect the extracranial arteries of children. When the vascular occlusive process or embolism involves the middle cerebral artery, vascular compromise is maximal in the territory of the lenticulostriate branches. Because of the invariable absence of severe occlusive disease, collateral circulation over the convexities is abundant. This explains the striatocapsular localization of infarcts. Because atherosclerosis is very rare in youth, the types of vasculopathies that cause brain ischemia in children is much more diverse than in adults, and the differential diagnosis is very broad. Congenital cardiac disease is an important cause of stroke in children. T§Me.4.5.:9. lists the most important causes of brain ischemia in children younger than age 15 years.

Brain and subarachnoid hemorrhages, especially from aneurysms and vascular malformations, comprise a much higher percentage of strokes in children than they do in adults.y

In young adults, premature atherosclerosis and stroke risk factors are much more important than in youths. Cardiac

_TABLE 45-9 -- DIFFERENTIAL DIAGNOSIS OF PEDIATRIC BRAIN ISCHEMIA (1-15 YEARS)_

Migraine

Trauma: Dissection and other vascular injuries; abuse including whiplash-shake injuries; oral foreign body trauma to the internal carotid artery

Cardiac: Congenital heart disease with right-to-left shunts; tetralogy of Fallot; transposition of great vessels; tricuspid atresia; atrial and ventricular septal defects; cardiomyopathies; endocarditis; pulmonary arteriovenous fistula

Drugs: Especially cocaine and heroin

Infections: Bacterial meningitis, especially Hemophilus influenzae, pneumococci, and streptococci; facial, otitic, and sinus infections; AIDS; dural sinus occlusion and infection; tuberculous meningitis

Genetic and metabolic: Neurofibromatosis; hereditary disorders of connective tissue (Marfan's and Ehlers-Danlos syndromes, pseudoxanthoma elasticum); homocystinuria; Menkes' kinky hair syndrome; hypoalphalipoproteinemia; familial hyperlipidemias; methylmalonic aciduria; MELAS syndrome (mitochondrial myopathy, encephalopathy, lactic acidosis, strokes)

Hematological and neoplastic: Sickle cell anemia; purpuras; leukemia; L-asparaginase and aminocaproic acid (Amicar) treatment; radiation vasculopathy; hypercoagulable states (e.g., caused by decrease in natural inhibitors such as antithrombin III)

Arteritis: Collagen vascular disease; local infections; Takayasu's disease; Behcet's disease

Venous sinus thrombosis: Head and neck infections; dehydration; coagulopathy; paroxysmal nocturnal hemoglobinuria; puerperal or pregnancy-related Systemic disease: Rheumatic; gastrointestinal; renal; hepatic; pulmonary Moyamoya disease

From Caplan LR, Estol CE: Strokes in youths. In Adams HP (ed): Cerebrovascular Disease. New York, Marcel Dekker, 1993, pp 233-254.

disease and hematological diseases and cancer provide a higher proportion of infarcts in young adults than during the geriatric years. T§.ble.,4§.:10. lists the major differential considerations of brain ischemia in persons 15 to 40 years of age.

_TABLE 45-10 -- DIFFERENTIAL DIAGNOSIS OF ISCHEMIA IN YOUNG ADULTS (15-40 YEARS)_

Migraine

Arterial dissection

Drugs, especially cocaine and heroine

Premature atherosclerosis, hyperlipidemias, hypertension, diabetes, smoking, homocystinuria

Female hormone-related (oral contraceptives, pregnancy, puerperium): eclampsia; dural sinus occlusion; arterial and venous infarcts; peripartum cardiomyopathy

Hematological: Deficiency of antithrombin III, protein C, protein S; fibrinolytic system disorders; deficiency of plasminogen activator; antiphospholipid antibody syndrome; increased factor VIII; cancer; thrombocytosis; polycythemia; thrombotic thrombocytopenic purpura; disseminated intravascular coagulation

Rheumatic and inflammatory: Systemic lupus erythematosus; rheumatoid arthritis; sarcoidosis; Sjogrens syndrome; scleroderma; polyarteritis nodosa; cryoglobulinemia; Crohn's disease; ulcerative colitis

Cardiac: Interatrial septal defect; patent foramen ovale; mitral valve prolapse; mitral annulus calcification; myocardiopathies; arrhythmias; endocarditis Penetrating artery disease (lacunes); hypertension, diabetes

Others: Moyamoya disease; Behcets disease; neurosyphilis; Takayasus disease; Sneddon's disease; fibromuscular dysplasia; Fabry's disease; Cogan's disease From Caplan LR, Estol CE: Strokes in youths. In Adams HP (ed): Cerebrovascular Disease. New York, Marcel Dekker, 1993, pp 233-254.

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