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Young Stroke

Young Stroke. Peter Humphrey Walton Centre for Neurology and Neurosurgery, Liverpool. Young Stroke. Cardiac 20% Dissection 20% Idiopathic 30% Rare - including venous. Incidence. Cardiac Embolism 24% Cervical Artery Dissection 24% Small Vessel Disease 9% Large Artery Atheroma 4%

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Young Stroke

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  1. Young Stroke Peter Humphrey Walton Centre for Neurology and Neurosurgery, Liverpool

  2. Young Stroke • Cardiac 20% • Dissection 20% • Idiopathic 30% • Rare - including venous

  3. Incidence • Cardiac Embolism 24% • Cervical Artery Dissection 24% • Small Vessel Disease 9% • Large Artery Atheroma 4% • Undetermined Aetiology 33% • Others 6% • 203pts Zurich and Bern Stroke Registries • 11% aged 16 - 45 1997-2002

  4. Carotid and Vertebral Dissection

  5. Dissection • Headache/neck pain proceeding stroke • Horner’s syndrome • TIAs/stroke • MRI T1-Axial neck • MRA

  6. Carotid Dissection • Cranial Nerve Palsies (esp XII,IX,X) • Other cranial nerves eg III,V,VII etc • The Surgeon with Altered Taste-dysgeusia • Pulsatile Tinnitus, Objective Bruit • Scalp Tenderness • 60-75% TIAs/Stroke • Incidence 2.5 per100,000 per year • Recurrence Rate 1% pa

  7. Intracranial Dissection • More difficult to diagnose • Loss of elastic lamina • Present similar to extracranial dissection • Occasionally present as SAH esp.vertebral • Can affect any vessel

  8. Vertebral Dissection • Presents as ischaemic brain stem stroke eg Lat Medullary Syndrome • Occipital ischaemia • Spinal Cord ischaemia (high) • Unilateral pain and arm root lesion(C5/6) • Spinal Epidural Haematomas • SAH especially if intracranial

  9. Vertebral Dissection • Headache/Neck Pain • Can be in any of the 4 parts of the vertebral artery ; usually V2 and V3 • 10% spread intracranially (unlike carotid) • Intracranial - haemorrhage is common;consider in aneurysm -ve SAH • More likely to be multiple (25%)

  10. Basilar Dissection • Rare • Rapid Coma • SAH • Ischaemic Brain Stem Syndrome • Occasionally subacute • Probable account for ectatic basilar artery syndromes

  11. Trauma • Recent Series of 177 cases • Age 44yrs +/-11 • 74 (41.8%) history of trauma • Most sports,manipulations,sneezing,RTAs • Timing;median time from headache to other symptoms is 4 days

  12. Management • Risk stroke mainly in 1st month (occas late) • No randomised data • Extracranial dissection - most anticoagulate - stroke risk is embolic or ischaemic for 6m. • Intracranial - consider risk of haemorrhage especially if vertebral ;LP first • ??Antiplatelets if symptoms >1 month or just Horners

  13. Management of Dissection • Aneurysm - 30% heal • Late Risk of Rupture v. low; ?? never • Occasionally acts as source of emboli or as mass lesion • Observe; rarely need intervention • Dissection itself- 60-70% recanalise; sometimes within days-little change after 6m

  14. Venous Infarction • Pre-disposing cause - Pill, pregnancy, infection • Headache • Venous infarction - haemorrhagic - fits • Raised intracranial pressure- papilloedema • Fluctuating Focal Neurological Deficit • False Localising Signs eg VI n palsy • CT/MRI/MRV

  15. Venous Thrombosis - Causes • Pill/Pregnancy/Puerperium/Endocrine • Haematological eg Lupus,protein S/C etc • Malignancy Local/Systemic • Inflammatory eg Behcets,Inflammatory Bowel Disease,Sarcoid,Wegeners etc • Infective Local/Systemic

  16. Treatment/Prognosis • Anticoagulate if at all possible- even if haemorrhage; except if just BIH • 624pts 57% full recovery • 22% mRS grade1 • 7.5%mRS grade2 • 5.1%mRS grade3-5 • 8.3% died • 2.2% Recurrence (FU16m); 10% seizures

  17. Behcets • Arterial ischaemia • Venous thrombosis • Inflammatory • Venous Treatment - anticoagulant and steroids • Few causes of arterial and venous isch. - behcets, antiphospholipid syndrome

  18. SLE/Antiphospholipid Syndrome • Age • Miscarriage/DVT/Livido-reticularis • Migraine • Myelopathy • Dementia • Endocarditis (Leibmann Sachs) • IgG - anticardiolipin antibody • Thrombo-embolic/not arteritic usually

  19. Haematological Causes of Stroke • Polycythaemia • Thrombocythaemia • Antiphospholipid Syndrome • PNH • Sickel Cell Disease • Inherited Thrombophilias (usually venous) • Thrombocytopenias

  20. 36yrs Nurse Zimbabwe HIV -ve • 5 x Loss of use R arm/leg few mins • Loss of speech x1 • ESR 111: vasculitic screen -ve : MRI-N • LP normal except strongly +ve PCR to varicella zoster : other infection screen -ve • Hep ABC -ve: MRA : Rpt HIV

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