The etiologies of ischemic stroke in the young are multiple and the outcome is good in most patients. New causes should now be identified.
Diagnostic work-up (additionally to the standard work-up as in older patients):
Intensive patient interview about the presence of headache, tinnitus, drug abuse, family history; careful skin examination; careful fundoscopic examination; and in selected patients serology for syphilis and HIV, electrophoresis of proteins, antiphospholipid antibodies and testing for thrombophilia. Causes:
• Large-vessel atherosclerosis
• Cardioembolism (see Table 14.1)
• Small-vessel occlusion such as CADASIL
• Diseases of large arteries:
• Cervical artery dissections
• Post-irradiation cervical arteriopathies
• Cervical fibromuscular dysplasia of cervical arteries in patients with von Recklinghausen disease or elastic tissue disorder
• Intracranial dissections
• Secondary vasculitis in the context of a systemic disorder such as panarteritis nodosa, systemic lupus erythematodes, Takayasu disease or Buerger disease or the context of infectious disorder
• Primary vasculitis of the central venous system
• Sneddon syndrome
• Post-partum cerebral angiopathy and eclampsia
• Unruptured aneurysms of intracranial arteries
• Hematological disorders
• Metabolic disorders such as Fabry disease, homo-cystinuria and MELAS syndrome
• Gas emboli, amniotic emboli or fat emboli
The most frequent cause in Western countries is cervical artery dissection, and in non-industrialized countries valvulopathies, but the cause of cerebral ischemia remains undetermined in up to 45% of patients.
Secondary prevention measures mainly depend on the presumed cause and consist of optimal management of vascular risk factors, an appropriate antithrombotic therapy (oral anticoagulation and antithrombotic agents, depending on the cause), and removal of the source in specific cases (severe internal artery stenosis, cardiac myxoma, etc.).
Specificities of stroke prevention in young adults: oral contraceptive therapy should be avoided in most cases; cervical artery dissections may be treated either by antiplatelet therapy or by anticoagulation (oral anticoagulation only for a few weeks); due to the low risk of recurrence in patients without any risk factor, the reasons for continuing antiplatelet therapy more than a few years are rather weak.
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