Stroke at a young age

Strokes are always a somato-neurological problem. This applies not only to stroke in adulthood, but especially to strokes at a young age (according to the WHO classification in the range of 15 to 45 years). Ischemic strokes at a young age differ in etiological heterogeneity; they can be caused by vascular disease, cardiogenic embolism, hematologic disorders, drug abuse, oral contraceptives, migraine and many other more rare causes. Hemorrhagic strokes are manifested by subarachnoid, parenchymal and intraventricular hemorrhage and are caused by arterial hypertension, aneurysm, hemangioma, atherosclerosis, hemifilia, systemic lupus erythematosus, eclampsia, hemorrhagic vasculitis, venous thrombosis, Verlhof disease, cocaine abuse. In some cases, the cause of stroke remains unknown even with a comprehensive examination of the patient.

Here, the causes of stroke in childhood are not considered.

[1], [2],

The main causes of stroke at a young age

• Hypertensive disease (lacunar infarction)
• Cardiogenic embolism (endocarditis, atrial fibrillation, myocardial infarction, artificial valve, stenosis of the aortic valve, etc.)
• Vascular malformation
• Dissection of the carotid artery (pseudoaneurysm with trauma)
• Hypercoagulable conditions (systemic thromboses with antiphospholipid syndrome, Snedon syndrome, use of oral contraceptives, etc.)
• Fibromuscular dysplasia (non-inflammatory segmental angiopathy of unknown etiology)
• Moya-washing disease (non-inflammatory occlusal intracranial vasculopathy of unknown etiology)
• Migraine infarction (migraine with aura)
• Vasculitis
• Hematological disorders (polycythemia, dysglobulinemia, DVS-syndrome, etc.)
• Inflammatory diseases (rheumatoid arthritis, systemic lupus erythematosus, scleroderma, Sjogren's syndrome, nodular periarteritis, Wegener's granulomatosis, sarcoidosis, etc.)
• Infectious diseases (neuroborreliosis, neurocysticirosis, Herpes zoster, bacterial meningitis, chlamydia pneumonia, hepatitis C, HIV infection)
• Embolism with tumor cells
• Hereditary diseases (neurofibromatosis, epidermal nevus syndrome, autosomal dominant leukoencephalopathy with multiple deep small infarcts, Williams syndrome)
• Iatrogenic (treatment with high doses of female sex hormones, administration of L-asparagenase, high doses of immunoglobulin intravenously, interferon, etc.)

Hypertensive and symptomatic arterial hypertension is the most common cause of ischemic (lacunar infarction) and hemorrhagic strokes. The latter also develop with such vascular anomalies as aneurysms and vascular malformations. Less often, hemorrhagic strokes develop as a complication of coagulopathy, arteritis, amyloid angiopathy, moya-moya disease, TBI, migraine and the use of certain drugs (cocaine, fenfluramine, phentermine). Hereditary intracerebral hemorrhage (Dutch and Icelandic types) is described.

Differential diagnosis of the causes of stroke at a young age

Differential diagnosis of the causes of stroke at a young age requires a very careful study of the patient's anamnesis, targeted somatic examination and the use of special methods of studying the cerebral circulation and the cardiovascular system as a whole.

Currently, lacunar infarcts are diagnosed in vivo by computer tomography (but in the first 24 hours they may not be detected). Their size ranges from 1 mm to 2 cm. They develop due to destructive changes in the walls of penetrating (intracerebral) arteries in hypertensive disease and occur either asymptomatically or in the form of characteristic syndromes: "purely motor hemiplegia" ("isolated hemiplegia or hemiparesis"), "A purely sensitive insult" ("isolated hemygipesthesia"), "homolateral ataxia and the paracentesis" ("atactic hemiparesis"), "dysarthria and awkwardness in the hand". Less lacunar infarction can be manifested by other syndromes.

A cerebral infarction can develop as a result of prolonged angiospasm with subarachnoid hemorrhage from an aneurysm. Periodically described infarctions of the brain, developing at the height of migraine attack (migraine infarction).

The source of cardiogenic embolism can be: endocarditis, atrial fibrillation, recent myocardial infarction, akinetic segment of myocardium, cardiomyopathy with dilatation, intracardiac thrombus or tumor, heart valve changes with non-bacterial thrombotic endocarditis, prosthetic heart valves, right-left shunt, heart aneurysm. Possible sources of embolism may also include: mitral valve prolapse, distant (in the past) myocardial infarction, left ventricular hypertrophy, hypokinetic segment of the myocardium, atrial septal defect, calcific aortic stenosis or mitral valve, sinus aneurysm of Valsalva.

Traumatic carotid artery dissection (dissection) can cause stroke in trauma (including light and hyperextension) and unsuccessful manual therapy. It is also described as a spontaneous phenomenon, with fibromuscular dysplasia, Marfan syndrome, type IV Ehlers-Danlo syndrome, migraine and some other rare diseases.

A rare cause of stroke is moya-washing disease, manifested as a characteristic neuroimaging picture.

When identifying vasculitis, it is necessary to clarify whether the process is limited only to the central nervous system (isolated central nervous system) or a systemic disease such as Takayasu disease, nodular periarteritis, etc. Occurs.

Hypercoagulable conditions (various variants of antiphospholipid syndrome, Sneddon syndrome, use of oral contraceptives, malignant neoplasm, insufficiency of antithrombin III, protein C, protein S, afibrinogenemia, pregnancy, malignant neoplastic syndrome, paroxysmal nocturnal hemoglobulinemia, diabetes mellitus, homocystinuria) and hematological disorders (polycythemia, dyslobulinemia, sickle-cell anemia, disseminated intravascular coagulation syndrome, leukoagglutination, thrombocytosis, thrombocytopenic purpura, protein C deficiency, protein deficiency S, fibrinolysis disorder) is a well-known cause of strokes at a young age. In the diagnosis of this range of diseases, hematological (and immunological) studies are crucial.

Inflammatory systemic diseases (rheumatism, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, Sjogren's syndrome, polymyositis, purpura Genoch-Schonlein, nodular periarteritis, Schurg-Strauss syndrome, Wegener's granulomatosis, sarcoidosis) and isolated angiitis of the central nervous system can lead to a stroke in as a complication of the underlying disease. Diagnosis is facilitated by the presence of symptoms of the current systemic disease, against which neurological cerebral symptoms are developing severely.

Strokes on the background of infectious lesions of the nervous system (neurocysticrosis, neuroborreliosis, bacterial meningitis, Herpes zoster, chlamydial pneumonia, hepatitis C, HIV infection) also develop against the background of already existing clinical manifestations of a somatic or neurological disease, the diagnosis of which is crucial for revealing the nature stroke.

Embolism by tumor cells refers to the rare causes of stroke (like fat embolism as well as air embolism) and in a significant percentage of cases remains unrecognized.

Hereditary diseases (homocystinuria, Fabry's disease, Marfan syndrome, Ehlers-Danlo syndrome, elastic pseudo-xanthoma, Rendu-Osler-Weber syndrome, neurofibromatosis, epidermal nevus syndrome, CADASIL syndrome, Williams syndrome, Sneddon syndrome, mitochondrial encephalopathy with lactic acidosis and strokes - so-called MELAS-syndrome), capable of leading to a stroke, are confirmed by clinical genetic analysis, characteristic neurological, skin and other somatic manifestations.

Iatrogenic forms of stroke develop sharply in response to the administration of certain drugs (high doses of female sex hormones, L-asparaginase, immunoglobulin, interferon and some others), which is the basis for suspicion of the iatrogenic origin of the stroke.

Investigating the history of stroke patients at a young age, it is important to pay attention to the presence of risk factors for certain diseases or the characteristic somatic symptoms that occurred in the past or detected during the examination.

Do not underestimate some of the eye and skin symptoms. The likelihood of atherosclerosis, as a possible cause of stroke, increases with risk factors such as smoking, hypertension, hyperlipidemia, diabetes, radiation therapy; Dissection of the carotid artery can be suspected in the presence of a history of injury or manual manipulation of the neck.

The cardiac cause of the stroke can be suspected if frequent intravenous drug use is detected, or the connection between stroke and physical activity is detected, deep vein thrombosis, heart murmur, heart valve surgery, bone marrow transplantation are detected.

On the hematologic cause of stroke can say: sickle cell anemia, deep vein thrombosis, reticular livedo, bone marrow transplantation. Sometimes the key to unraveling the nature of the stroke is information on the use of oral contraceptives, alcohol abuse, recently transferred (within one week) fever, pregnancy, HIV infection, myocardial infarction in the past, indications of a stroke in a family history.

The presence of a "corneal arch" around the iris indicates hypercholesterolemia; corneal opacity may reflect Fabry's disease; the identification of Lisch nodules allows one to suspect neurofibromatosis; subluxation of the lens - Marfan's disease, homocystinuria; retinal perivasculitis - seropovidnocellular anemia, syphilis, connective tissue disease, sarcoidosis, inflammatory bowel disease, Behcet's disease, Iles disease (Eales). Occlusion of the retinal artery can accompany embolism of cerebral vessels and multiple infarcts; Retinal angioma - cavernous malformation, Gippel-Lindau disease; atrophy of the optic nerve - neurofibromatosis; retinal hamartoma - tuberous sclerosis.

A simple examination of the skin sometimes suggests or directly points to this or that somatic or neurological pathology. Osler's nodules and traces of hemorrhage sometimes accompany endocarditis; xanthoma indicates hyperlipidemia; spots of coffee color and neurofibroma - on neurofibromatosis; vulnerable skin with easy bruising and blue sclera - on the Ehlers-Danlos syndrome (type IV); telangiectasias cause exclusion of Osler-Weber-Randu disease (hereditary hemorrhagic telangiectasia) and scleroderma; purple hemorrhage - coagulopathy, Henoch-Schonlein's disease, cryoglobulinopathy; aphthous ulceration - Behcet's disease; angiokeratosis - Fabry's disease; livedo reticularis - Sneddon's syndrome; facial angiofibroma - tuberous sclerosis.

NV: Cerebral vein thrombosis is a rare complication of various diseases. Cerebral vein thrombosis can be aseptic and septic (infections of frontal paranasal and other sinuses, otitis, pregnancy, carcinoma, dehydration, marasmus, androgen therapy, cisplatin, aminocaproic acid, intravenous catheterization, nodular periarteritis, systemic lupus erythematosus, Wegener's granulomatosis, Behcet's disease , Degos disease, sarcaidosis, nephrotic syndrome, chronic lung diseases, diabetes, TBI, some hematologic diseases, disseminated intravascular Arteriovenous malformation, Sturga-Weber disease, idiopathic thrombosis of cerebral veins.

[3], [4]

Diagnostic studies in young adults with stroke

Clinical blood count (platelet count, hemoglobin, red and white blood cell count, ESR), urinalysis, biochemical blood test (including potassium and sodium electrolytes, glucose, kreotinin, urea, bilirubin, liver tests, ACT and ALT, cholesterol , triglycerides, etc.), plasma osmolality, blood gas composition, acid-base balance, pregnancy test, HIV infection, antibodies to phospholipids, lupus anticoagulant, cryoglobulins; a coagulogram with the determination of fibrinogen, fibrinolytic activity, thrombin time, prothrombin, hematocrit, clotting time, antithrombin III, and erythrocyte aggregation capacity, blood viscosity, blood and urine toxicology, Wasserman reaction, blood test for HB antigen, CT or MRI, ECG (sometimes ECG monitoring by Holter), EEG, radioisotope scanning of the brain and investigation of blood flow, ophthalmoscopy, various methods of dopplerography, lumbar puncture, blood culture, n indications - carotid or vertebral angiography, immunological blood tests, chest X-ray. The consultation of the therapist is shown.

When implementing a differential diagnosis, it is important to remember that some other diseases with stroke-like course may also occur under the mask of a stroke: multiple sclerosis, partial ("hemiparetic") epileptic seizures, brain tumor, brain abscess, subdural hematoma, brain contusion, migraine with aura, Dismetabolic disorders in diabetes mellitus.

Syndrome of chronic progressive hemiplegia is not considered here.

[5], [6], [7], [8], [9], [10], [11]